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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ciprofloxacin / Bactrim / Erythromycin Base / Keflex / Latex /
Vancomycin / Doxycycline / Cyclobenzaprine / linezolid / Codeine
/ Penicillins
Attending: ___
Chief Complaint:
Fever, sore throat, and epigastric pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F PMH significant for severe atopic disease with prior
episodes of MSSA bacteremia related to likely skin source,
elevated IgE levels, and eosinophiila who presents with ongoing
fevers, abdominal pain, and cough after recent hospitalization
for likely viral gastroenteritis.
The patient initially admitted on ___ for influenza-like
symptoms of fevers/chills, sore throat, n/v, and significant GI
symptoms of diarrhea. She did not endorse any respiratory
symptoms of SOB or productive cough, but CXR did show a RML
infiltrate. She was initially managed for PNA and influenza with
aztreonam, clindamycin, and oseltamivir. Per ID's
recommendations, antibiotics were discontinued given low
likelihood of PNA and the oseltamivir was stopped after her
influenza DFA returned negative. Her symptoms improved quickly
with conservative management and she was discharged on ___.
She was seen in ___ clinic by Dr. ___ f/u and reported
continued although improved fevers, but new nasal congestion.
Her sore throat and GI symptoms were resolved. F/u labs on ___
showed a persistent leukocytosis of 14.8. The patient reported
to Dr. ___ that she developed epigastric abdominal pain
after dinner yesterday evening which radiated up her L rib cage
and developed a temperature to 101.4 last night. She reports
that her abdominal pain was associated with acid reflux. Because
of these symptoms, she was instructed to come to the ED for
repeat CXR to rule out PNA.
In the ED, initial VS 98, 60, 127/70, 18, 100% on RA. She was
without abdominal pain on exam, but reported intermittent chest
tightness. Labs were notable for WBC 13.3, wnl Chem7,
LFTs/lipase were normal, UA negative, troponin < 0.01, CXR
showed resolution of her previous infiltrate and no new focal
consolidations. EKG showed NSR.
Blood cultures x 2 were drawn and the patient was started on
aztreonam and clindamycin, given her multiple antibiotic
allergies.
This morning, patient reports persistent sore throat but her
fever and abdominal pain have subsided.
Past Medical History:
- Atopic dermatitis
- Eosinophilia
- Elevated IgE level
- Osteopenia
- Mild high-frequency hearing loss
- Corneal dystrophy
- Vocal cord polyps
Social History:
___
Family History:
- Father with HTN, CAD, SCD due to MI
- Mother with HTN
- Sister with colon cancer
- Uncle with CAD
Physical Exam:
ADMISSION AND DISCHARGE EXAM
Vitals: 98.2, 85, 131/43, 18, 98% RA
General: Well-appearing elderly-appearing female lying in bed
HEENT: Sclera anicteric, MMM, oropharynx clear
CV: RRR, nl S1/S2, no MRG
Lungs: CTAB, no wheezes/rales/rhonchi
Abdomen: Soft, NTND, normoactive bowel sounds
GU: No Foley
Ext: Warm, well-perfused, 1+ pitting edema bilaterally
Neuro: CN II-XII grossly intact
Skin: Erythematous macular/papular confluent rash over face,
chest, upper back, and upper and lower extremities. Small
healing scab over lateral left thigh.
Pertinent Results:
ADMISSION LABS
___ 12:55PM BLOOD WBC-13.3* RBC-4.14* Hgb-12.3 Hct-39.5
MCV-95 MCH-29.7 MCHC-31.1 RDW-13.3 Plt ___
___ 12:55PM BLOOD Neuts-75.5* Lymphs-10.1* Monos-7.8
Eos-6.1* Baso-0.5
___ 12:55PM BLOOD Glucose-94 UreaN-14 Creat-0.9 Na-133
K-4.3 Cl-97 HCO3-27 AnGap-13
___ 12:55PM BLOOD ALT-28 AST-25 AlkPhos-92 TotBili-0.3
___ 12:55PM BLOOD Lipase-43
___ 12:55PM BLOOD cTropnT-<0.01
___ 12:55PM BLOOD Albumin-3.9
___ 01:09PM BLOOD Lactate-1.6
___ 01:25PM URINE Color-Straw Appear-Clear Sp ___
___ 01:25PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
DISCHARGE LABS
___ 06:20AM BLOOD WBC-9.4 RBC-3.83* Hgb-12.1 Hct-36.0
MCV-94 MCH-31.5 MCHC-33.6 RDW-12.8 Plt ___
___ 06:20AM BLOOD Glucose-94 UreaN-15 Creat-0.7 Na-143
K-4.2 Cl-107 HCO3-29 AnGap-11
___ 06:20AM BLOOD Calcium-9.0 Phos-4.4# Mg-2.3
MICROBIOLOGY: Blood cultures pending on discharge.
IMAGING
CXR (___): Partial resolution of the previously seen right
middle lobe pneumonia with some persistent opacity. Continued
followup until resolution is suggested. No new consolidation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO DAILY
2. Calcium Carbonate 1500 mg PO DAILY
3. Fish Oil (Omega 3) 1000 mg PO DAILY
4. Hydrocortisone Cream 2.5% 1 Appl TP BID itchy rash
5. HydrOXYzine 50 mg PO Q4H:PRN patient request
6. Mupirocin Ointment 2% 1 Appl TP BID
7. Nystatin Cream 1 Appl TP BID
8. Vitamin D 1000 UNIT PO BID
9. Glutamine 500 mg PO BID
10. Cyanocobalamin 1000 mcg PO DAILY
11. Hydrocerin 1 Appl TP TID:PRN patient request
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
2. Calcium Carbonate 1500 mg PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
4. Fish Oil (Omega 3) 1000 mg PO DAILY
5. Hydrocerin 1 Appl TP TID:PRN patient request
6. Hydrocortisone Cream 2.5% 1 Appl TP BID itchy rash
7. HydrOXYzine 50 mg PO Q4H:PRN patient request
8. Mupirocin Ointment 2% 1 Appl TP BID
9. Nystatin Cream 1 Appl TP BID
10. Vitamin D 1000 UNIT PO BID
11. Glutamine 500 mg PO BID
12. Clindamycin 300 mg PO Q8H
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every eight (8)
hours Disp #*18 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Viral syndrome NOS
Secondary diagnosis: Atopic dermatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST, TWO VIEWS.
HISTORY: ___ female with fevers and chills and abdominal pain.
COMPARISON: ___.
FINDINGS: Compared to prior, there has been interval improvement of the right
basilar opacity which is now less extensive, but still present. There is no
new region of consolidation nor effusion. Cardiomediastinal silhouette is
within normal limits. Mild biapical scarring is noted. No acute osseous
abnormality is identified.
IMPRESSION: Partial resolution of the previously seen right middle lobe
pneumonia with some persistent opacity. Continued followup until resolution
is suggested. No new consolidation.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever, Abd pain, Cough
Diagnosed with CHEST PAIN NEC, PNEUMONIA,ORGANISM UNSPECIFIED, LEUKOCYTOSIS, UNSPECIFIED , FEVER, UNSPECIFIED
temperature: 98.0
heartrate: 60.0
resprate: 18.0
o2sat: 100.0
sbp: 127.0
dbp: 70.0
level of pain: 4
level of acuity: 3.0 | ___ yo F with PMH of severe atopic dermatitis complicated by MSSA
bacteremia, eosinophilia, elevated IgE, osteopenia, and
depression/anxiety who presents with likely viral illness.
ACTIVE ISSUES
# Fevers: Most likely continuation of viral illness. Attributed
last week to a brief viral gastroenteritis. Resolved rapidly
with IV fluids after which patient was discharged. On follow-up
with ID on ___ patient was feeling better with the exception of
fatigue. Labs drawn at that time remarkable for leukocytosis to
14.8. The patient subsequently developed fever to 101.4, sore
throat, and burning epigastric pain. On the recommendation of
ID, she presented to the ED. CXR with interval improvement in
RML opacity. UA negative. Rapid respiratory viral screen sent
but specimen was inadequate. Patient was treated with 1 day of
aztreonam and clindamycin IV for possible pneumonia. She was
never febrile in the hospital and reported that her symptoms
improved overnight. Given resolution of the opacity on CXR and
resolution in symptoms with the exception of sore throat and
nasal congestion, antibiotics discontinued on HD#2. Per ID,
patient was discharged on 6 days of clindamycin 300 mg PO Q6H to
cover for possible bacterial infection. Follow-up with Dr. ___
was scheduled.
# Sore throat: Likely viral syndrome. Treated as above.
# GERD: Epigastric pain on admission most likely due to GERD vs.
mild gastritis. Symptoms resolved spontaneously.
CHRONIC ISSUES
# Severe atopic dermatitis: Extensive confluent maculopapular
rash. Continued home skin regimen.
# Osteopenia: Continued home calcium and vitamin D.
# Multiple allergies: Continued home hydroxyzine.
TRANSITIONAL ISSUES
- Discharged on clindamycin 300 mg PO Q8H for 6 days
- Consider PPI if patient has further issues with abdominal pain
- Follow-up with ID scheduled
- Follow-up with PCP scheduled |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
IV contrast
Attending: ___.
Chief Complaint:
Abdominal pain, nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with unclear history of
Crohns disease and previous partial SBOs managed conservatively.
He presents today with 3 days of abdominal pain, nausea, and
low-grade fevers to 100.4F. Yesterday evening he had a syncopal
episode, which he says happens whenever he has an obstruction.
He presented to ___ following his syncopal episode. A CT A/P
was performed, which showed dilated small bowel and stomach with
a decompressed colon and mild ascites. There is no evidence of
perforation or pneumatosis. He had on ___ surgery was
consulted for management of partial SBO.
Upon initial assessment by ___ surgery, Mr. ___ denies
chest pain, shortness of breath, diarrhea, hematochezia, or
dysuria. He endorses continued passage of flatus, nausea, and
hiccups.
Past Medical History:
Past Medical History:
-TMJ
-gastritis
-recurrent severe abd pain a/w syncopal episode
-? Crohns disease, terminal ileitis, ulceration and granulation
tissue on colonoscopy & pathology, no evidence of disease on
MRE.
-IPMN
-pSBO managed conservatively
Past Surgical History:
-lap ccy (___), pathology benign (cholelithiasis),
-bilateral knee surgery
-right inguinal hernia repair
Social History:
Marital status: Married
Children: Yes
Lives with: ___
Sexual activity: Present
Sexual orientation: Female
Contraception: None
Tobacco use: Never smoker
Alcohol use: Denies
drinks per week: <1
Recreational drugs Denies
(marijuana, heroin,
crack pills or
other):
Depression: Based on a PHQ-2 evaluation, the patient
does not report symptoms of depression
Exercise: Activities: walking
Diet: regular
Seat belt/vehicle Always
restraint use:
Family History:
Child with severe Crohns disease
Physical Exam:
T 97.8 P 81 BP 146/84 RR 18 02 96%RA
General: no acute distress, alert and oriented x 3
Cardiac: regular rate and rhythm, no murmurs appreciated
Resp: clear to auscultation, bilaterally
Abdomen: soft, non-tender, non-distended, no rebound tenderness
or gaurdign
Ext: no lower extremity edema or tenderness, bilaterally
Pertinent Results:
LABS:
___ 03:00AM BLOOD WBC-13.6*# RBC-4.96 Hgb-15.5 Hct-43.1
MCV-87 MCH-31.3 MCHC-36.0 RDW-12.5 RDWSD-39.3 Plt ___
___ 06:33AM BLOOD WBC-5.3 RBC-4.10* Hgb-12.3* Hct-35.9*
MCV-88 MCH-30.0 MCHC-34.3 RDW-12.0 RDWSD-38.7 Plt ___
___ 03:25AM BLOOD ALT-15 AST-19 AlkPhos-55 TotBili-0.7
___ 03:25AM BLOOD Lipase-13
___ 03:00AM BLOOD cTropnT-<0.01
___ 03:00AM BLOOD proBNP-33
___ 03:25AM BLOOD CRP-43.5*
___ 03:29AM BLOOD Lactate-1.9
IMAGING:
CT ABD & PELVIS W/O CONTRAST
Small-bowel obstruction with transition point in the right lower
quadrant and associated small amount of ascites and mesenteric
edema. No free air.
CHEST (PORTABLE AP)
Enteric tube terminates overlying the expected location of
stomach.
MR ENTEROGRAPHY (___) SBFT:
1. Resolving partial small bowel obstruction. Edematous loops of
small bowel just proximal to the transition in the right lower
quadrant which likely relates to obstruction. No convincing MR
evidence of inflammatory bowel disease.
2. Persistent but decreased interloop fluid and mesenteric
edema.
3. Distended stomach without mechanical obstruction notably
stomach was also distended on prior CT, when small-bowel
obstruction resolved, consider gastric emptying study to
evaluate for underlying gastroparesis.
4. Small bilateral pleural effusions.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. mometasone 0.1 % topical ASDIR
2. Ranitidine 150 mg PO QHS
3. Cyanocobalamin 1000 mcg IM/SC ONCE
Discharge Medications:
1. Cyanocobalamin 1000 mcg IM/SC ONCE
2. mometasone 0.1 % topical ASDIR
3. Ranitidine 150 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
Partial small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: +PO contrast; History: ___ with abdominal pain+PO contrast//
evaluate for intra-abdominal pathology
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.0 s, 54.4 cm; CTDIvol = 15.3 mGy (Body) DLP = 830.0
mGy-cm.
Total DLP (Body) = 830 mGy-cm.
COMPARISON: MRI abdomen from ___.
FINDINGS:
LOWER CHEST: Subsegmental atelectasis.
ABDOMEN: The unenhanced liver, pancreas, spleen, adrenal glands and kidneys
are unremarkable. The previously seen pancreatic cystic lesion is not
demonstrated on this noncontrast exam. Cholecystectomy changes are again
noted
GASTROINTESTINAL: There are moderately dilated loops of small bowel with a
transition point in the right hemiabdomen concerning for a small bowel
obstruction. The distal ileum is collapsed. There is a small amount of
ascites and mesenteric edema. No free air visualized
PELVIS: There is a small amount of free fluid in the pelvis.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: An umbilical hernia containing fat is noted.
IMPRESSION:
Small-bowel obstruction with transition point in the right lower quadrant and
associated small amount of ascites and mesenteric edema. No free air.
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: ___ with small bowel obstruction. Evaluate placement of
nasogastric tube.
TECHNIQUE: Portable frontal AP radiograph of the chest.
COMPARISON: None available.
FINDINGS:
Enteric tube and its side port terminates below the left hemidiaphragm in the
expected location of the stomach.
There is no consolidation, pneumothorax, or pleural effusion. Heart size
exaggerated by AP view. There is no acute fracture.
IMPRESSION:
Enteric tube terminates overlying the expected location of stomach.
Radiology Report
EXAMINATION: MR ___
INDICATION: ___ year old man with ? crohn's disease, partial bowel
obstruction// evaluate for crohn's/ extent of 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 (8 cc). Oral contrast consisted of 900 mL of VoLumen. 1.0
mg of Glucagon was administered IM to reduce bowel peristalsis.
COMPARISON: CT abdomen and pelvis ___, MR enterography ___
FINDINGS:
MR ENTEROGRAPHY:
The stomach is distended, as seen previously without evidence of mechanical
obstruction. There are persistent, but improved now mildly dilated loops of
small bowel in the mid abdomen measuring up to 3.3 cm. There is a transition
to decompressed loops of bowel in the right lower quadrant. There remains
interloop fluid and mild mesenteric fluid, although also improved from prior.
Oral contrast has extended into the large-bowel. There is a loop of ileum in
the right mid abdomen just proximal to the transition which demonstrates
serosal edema and mild serosal hyperenhancement (series 8, image 11). There
is no mucosal abnormality to suggest inflammatory bowel disease. No
intra-abdominal fluid collection or fistulous tracts are seen.
Although not optimized for evaluation, views of the large bowel are
unremarkable. The appendix is well-visualized and normal.
There is small volume ascites.
MRI OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST:
There are small bilateral pleural effusions with associated atelectasis.
Views of the liver are unremarkable without focal lesion. Gallbladder is
surgically absent. No intra or extrahepatic biliary duct dilation. Adrenal
glands are unremarkable. Spleen is normal in size and signal intensity. The
pancreas is normal in signal intensity. Previously seen 6 mm cystic lesion in
the pancreatic body, not well seen on this examination. Kidneys are symmetric
in size. No suspicious renal lesion is identified. There is no
hydroureteronephrosis. There is no enlarged mesenteric or retroperitoneal
adenopathy.
There is no abdominal aortic aneurysm. Hepatic arterial anatomy is
conventional. Portal vein is patent.
MRI OF THE PELVIS WITH AND WITHOUT IV CONTRAST:
The bladder is distended and unremarkable. There is a small amount of pelvic
free fluid. There is no pelvic sidewall or inguinal adenopathy. The prostate
is unremarkable.
IMPRESSION:
1. Resolving partial small bowel obstruction. Edematous segment of ileum just
proximal to the transition in the right lower quadrant is likely related to
obstruction. No specific or convincing MR evidence of inflammatory bowel
disease.
2. Persistent but decreased interloop fluid and mesenteric edema.
3. Distended stomach without mechanical obstruction. Notably stomach was also
distended on prior CT. When small-bowel obstruction resolves consider gastric
emptying study to evaluate for underlying gastroparesis.
4. Small bilateral pleural effusions.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, R Shoulder pain, Syncope
Diagnosed with Unspecified intestinal obstruction
temperature: 98.6
heartrate: 75.0
resprate: 18.0
o2sat: 97.0
sbp: 119.0
dbp: 75.0
level of pain: 0
level of acuity: 2.0 | The patient presented to the Emergency Department on ___.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with either intravenous
morphine or hydromorphone. The patient's pain resolved entirely
prior to discharge.
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 and ambulation were encouraged throughout
hospitalization.
GI/GU/FEN: The patient was initially placed on bowel rest with a
___ tube in place for decompression. On HD 3, given
evidence of resolving obstruction, the NGT was removed. On HD
4, he underwent MR ___ to evaluate for evidence of
crohn's disease. The MR was suggestive of resolving partial
bowel obstruction without definitive evidence of active
inflammation, but did not possible delayed gastric emptying.
Additionally, per the radiology fellow, there was no evidence of
stricture suggesting chronic inflammation. Following the MR,
the patient's diet was resumed and advanced to low residue per
gastroenterology, which he tolerated without pain, nausea or
vomiting. Given po tolerance, he was discharged to home and
will follow-up with his gastroenterologist and surgeon as an
output for further work-up of possible crohn's disease.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
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: NEUROSURGERY
Allergies:
morphine
Attending: ___
Chief Complaint:
L ___
Major Surgical or Invasive Procedure:
___ L craniotomy for ___ evacuation
History of Present Illness:
___ year old male with no significant medical hx presents
with headache, right sided weakness. Patient reports that he has
been "feeling off " and persistent headache for the past 5
weeks.
He states that today he developed right arm weakness and having
difficulty using his right hand. He reports falling on ___
without head strike. On that day was helping his son build a
shed, he tripped and fell onto his right leg. He was evaluated
at
OSH where CT head revealed large left SDH with apprx 11mm MLS.
He
was medflighted to ___ for further evaluation. Neurosurgery
was
consulted.
On arrival, patient is awake alert and oriented. Denies nausea,
vomiting. Patient states he was started on aspirin 81mg two days
ago for right groin thrombophlebitis, Last taken ___ AM.
Past Medical History:
BPH
Right groin thrombophlebitis
Social History:
___
Family History:
NC
Physical Exam:
On admission:
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3mm to 2mm
bilaterally.
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. Right pronator without drift
TrapDeltoidBicepTricepGrip
Right 4 4+ 4 4
Left 5 5 5 5
IPQuadHamATEHLGast
Right 4 4 4+ 5 5 5
Left 5 5 5 5 5 5
Sensation: Intact to light touch
Handedness Right
On discharge:
Exam:
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: PERRL 3-2mm
EOM: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]No
Tongue Midline: [x]Yes [ ]No
Pronator Drift: [ ]Yes [x]No
Speech Fluent: [x]Yes [ ]No
Comprehension intact: [x]Yes [ ]No
Motor:
TrapDeltoidBicepTricepGrip
IPQuadHamATEHLGast
[x]Sensation intact to light touch
Wound: L crani - OTA with staples
Pertinent Results:
Please refer to OMR for pertinent lab and imaging results.
Medications on Admission:
ibuprofen prn pain
81mg aspirin
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Docusate Sodium 100 mg PO BID
3. LevETIRAcetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*5 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Left subdural hematoma
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: ___ year old man with left acute on chronic ___ s/p craniotomy for
___ evacuation// Evaluate for bleeding s/p L craniotomy for acute on chronic
___ evacuation
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.0 s, 20.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
934.3 mGy-cm.
Total DLP (Head) = 934 mGy-cm.
COMPARISON: CT head ___ from outside hospital, with report
indicating frontotemporoparietal subdural hematoma containing both
hyperdensity isodense component measuring up to 1.8 cm in thickness causing
marked compression of the left lateral ventricle and rightward subfalcine
herniation by 1.1 cm.
FINDINGS:
The patient is status post left-sided craniotomy for chronic subdural hematoma
drainage. Subfalcine herniation has improved. There is a drain present in the
left frontotemporal region. In the region of the prior chronic subdural,
there is pneumocephalus and an air-fluid level, with blood products. There is
a small hyperdense region within the area of older blood products (02:16),
demonstrating newer blood products in the evacuated region, likely secondary
to drainage placement. Interval decrease in midline shift from 1.6 cm to 0.7
cm.
Craniotomy screws in place without 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.
There are postsurgical changes in the soft tissue of the left posterior head.
IMPRESSION:
1. The patient is status post left-sided craniotomy for drainage of chronic
subdural. Improvement in subfalcine herniation.
2. There postoperative changes, including pneumocephalus, and blood products
of variable age in the area of the evacuated subdural.
Gender: M
Race: WHITE
Arrive by HELICOPTER
Chief complaint: SDH, Transfer
Diagnosed with Nontraumatic acute subdural hemorrhage, Altered mental status, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: ua
level of acuity: 2.0 | # L ___
Mr. ___ is a ___ male on ASA 81mg with history of fall,
no headstrike, with presented to OSH with 5 weeks of headache
and feeling off. OSH CT head showed large L acute on chronic
SDH. He was transferred to ___ for neurosurgical evaluation.
He was admitted to the neuro step down unit and consented for
surgery. He went to the OR on ___ for left craniotomy for ___
evacuation. A subdural drain was placed. patient tolerated the
procedure well. He was extubated in the OR and transferred to
the PACU for recovery. He was alert and joking with family on
post-op check with improvement in right sided weakness. He was
straight cathed x1 for urinary retention. He remained
neurologically and hemodynamically stable and transferred to
___ for further monitoring. Post-op ___ showed
pneumocephalus, but with improvement in midline shift. He was
started on a nonrebreather mask for 24hrs. Subdural drain was
removed on POD#2. He remained neurologically and hemodynamically
stable. He was evaluated by physical therapy who recommended
discharge home. He was discharged home in stable condition on
POD#4. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
vancomycin / Zosyn / levofloxacin
Attending: ___.
Chief Complaint:
Confusion, s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx ___ Disease and a recent admission for LLL
PNA/Empyema s/p decortication, recent discharge ___ for acute
renal failure felt to be AIN in combination w DRESS from zosyn,
who presents with altered mental status and fall. Patient was
brought in by his home health aide who reports that over the
past week he has had a change from his baseline mental status
with episodes of confusion. She reports today he was not using
his walker instead picked up multiple items from his bedroom and
brought him into the kitchen for no apparent reason. He then
fell to the ground as he was not using his walker. He has
additionally noted some cough but no fevers or chest pain. No
fevers, chills, n/v/d, abd pain, sputum production, dysuria. He
is not quite sure why he is here, denies any knowledge of
confusion at home, does endorse falls ___ mechanical reasons.
In the ED initial vitals were: 97.5 80 156/79 100% ra
- Labs were significant for HCT 31 at baseline. No fevers, no
leukocytosis or left shift. CXR w possible LLL consolidation, ED
gave ctx/azithro. No UA was sent.
Past Medical History:
___ Disease (Diagnosed ___, Followed by ___
MD, PhD at ___, ___, ___
Thyroid nodule s/p partial thyroidectomy
Hypothyroidism
Orthostatic Hypotension
Social History:
___
Family History:
Sibling deceased from Hodgkin's lymphoma. He has 2 sons who are
alive and healthy.
Physical Exam:
INITIAL PHYSICAL EXAM
===============
Vitals - afebrile, 140/85 75 14 99%RA
GENERAL: NAD, pleasant, interactive, appropriate
HEENT: AT/NC, EOMI, PERRL
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
NEURO: CN II-XII intact. Mental status is AOx3, oriented to
current events. Performs ___ backwards, ___ backwards and serial
7s effortlessly. Does occasionally have some tangential
thinking.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
=================
Vitals - T 98.4 140/71 ___ 18 100%RA
GENERAL: NAD, pleasant, interactive, appropriate
HEENT: AT/NC, EOMI, PERRL
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB
ABDOMEN: nondistended, +BS, nontender in all quadrants
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
NEURO: Alert and oriented, answers all questions appropriately
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
INITIAL LAB RESULTS
=============
___ 09:35PM BLOOD WBC-9.4 RBC-3.45* Hgb-9.8* Hct-31.3*
MCV-91 MCH-28.5 MCHC-31.4 RDW-16.6* Plt ___
___ 09:35PM BLOOD Neuts-65.2 ___ Monos-4.7 Eos-5.7*
Baso-0.6
___ 09:35PM BLOOD Glucose-138* UreaN-16 Creat-0.8 Na-139
K-3.5 Cl-98 HCO3-30 AnGap-15
___ 09:35PM BLOOD ALT-5 AST-18 AlkPhos-96 TotBili-0.2
___ 09:35PM BLOOD Albumin-3.6 Calcium-9.0 Phos-2.9 Mg-2.0
___ 09:35PM BLOOD TSH-0.095*
___ 11:06PM BLOOD Lactate-1.7
IMAGING
======
___ CXR
IMPRESSION:
Continued interval improvement of the bilateral parenchymal
opacities and
essentially resolved bilateral pleural effusions. More
conspicuous opacity
projecting over the heart on the lateral view potentially within
the right
middle lobe may be atelectasis although infection is not
excluded.
___ CT Head
FINDINGS: There is no evidence of acute intracranial
hemorrhage, mass, mass
effect, or large territorial infarction. Prominent ventricles
and sulci are
likely related to age-related involutional changes.
Periventricular and
subcortical deep white matter hypodensities are likely secondary
to chronic
small vessel ischemic disease. The basal cisterns are patent
and there is
otherwise good preservation of gray-white matter
differentiation.
No acute fracture is identified. The visualized paranasal
sinuses, mastoid
air cells, and middle ear cavities are clear. The globes are
unremarkable.
IMPRESSION: No acute intracranial abnormality identified.
___ CT C Spine
IMPRESSION:
1. No acute cervical spine fractures identified.
2. Left 5-mm apical lung nodule, overall unchanged compared to
the prior
exam. A CT in six months is recommended for further evaluation.
DISCHARGE LAB RESULTS
================
___ 07:15AM BLOOD WBC-10.1 RBC-3.34* Hgb-9.4* Hct-30.5*
MCV-91 MCH-28.0 MCHC-30.7* RDW-16.5* Plt ___
___ 07:15AM BLOOD Neuts-76.9* Lymphs-15.9* Monos-3.1
Eos-3.8 Baso-0.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Carbidopa-Levodopa (___) 1 TAB PO Q3H
2. Docusate Sodium 100 mg PO DAILY
3. Selegiline HCl 5 mg PO BID
4. Tasmar (tolcapone) 50 mg ORAL Q3H
5. Aspirin 81 mg PO DAILY
6. Mirapex ER (pramipexole) 1.125 mg oral @9pm
7. Levothyroxine Sodium 100 mcg PO DAILY
8. Senna 8.6 mg PO HS
9. Cyanocobalamin 500 mcg PO DAILY
10. Vitamin D 1000 UNIT PO DAILY
11. Fludrocortisone Acetate 0.1 mg PO BID
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Carbidopa-Levodopa (___) 1 TAB PO Q3H
3. Docusate Sodium 100 mg PO DAILY
4. Selegiline HCl 5 mg PO BID
5. Tasmar (tolcapone) 50 mg ORAL Q3H
6. Mirapex ER (pramipexole) 1.125 mg oral @9pm
7. Cyanocobalamin 500 mcg PO DAILY
8. Fludrocortisone Acetate 0.1 mg PO BID
9. Vitamin D 1000 UNIT PO DAILY
10. Levothyroxine Sodium 88 mcg PO DAILY
RX *levothyroxine 88 mcg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*0
11. Senna 8.6 mg PO HS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
1. Fall
SECONDARY DIAGNOSIS
1. ___ Disease
2. Orthostatic Hypotension
3. Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with altered mental status, fall from standing // eval for
trauma
TECHNIQUE: Chest AP and lateral
COMPARISON: ___
FINDINGS:
There has been continued interval improvement in the bilateral opacities in
the right upper and left mid to lower lung. On the lateral, however there is
a new opacity projecting over the heart potentially localizing to the right
middle lobe. Effusions have also decreased in size. The cardiomediastinal
silhouette is within normal limits. Healed posterior left rib fractures are
again noted.
IMPRESSION:
Continued interval improvement of the bilateral parenchymal opacities and
essentially resolved bilateral pleural effusions. More conspicuous opacity
projecting over the heart on the lateral view potentially within the right
middle lobe may be atelectasis although infection is not excluded.
Radiology Report
INDICATION: History of altered mental status, fall from standing. Please
evaluate for trauma.
COMPARISONS: Head CT from ___.
TECHNIQUE: ___ MDCT images were obtained through the brain without the
administration of IV contrast. Multiplanar reformatted images in coronal and
sagittal axis were generated and reviewed.
FINDINGS: There is no evidence of acute intracranial hemorrhage, mass, mass
effect, or large territorial infarction. Prominent ventricles and sulci are
likely related to age-related involutional changes. Periventricular and
subcortical deep white matter hypodensities are likely secondary to chronic
small vessel ischemic disease. The basal cisterns are patent and there is
otherwise good preservation of gray-white matter differentiation.
No acute fracture is identified. The visualized paranasal sinuses, mastoid
air cells, and middle ear cavities are clear. The globes are unremarkable.
IMPRESSION: No acute intracranial abnormality identified.
Radiology Report
INDICATION: History of altered mental status, fall from standing. Please
evaluate for trauma.
COMPARISONS: CT and MRI C-spine from ___.
TECHNIQUE: ___ MDCT images were obtained through the cervical spine without
the administration of IV contrast. Multiplanar reformatted images in coronal
and sagittal axes were generated and reviewed.
FINDINGS: There is no evidence of fracture or malalignment. There is no
prevertebral soft tissue swelling.
Multilevel, multifactorial degenerative changes are seen throughout the
cervical spine with anterior and posterior osteophytosis, worst at C6/C7 with
mild thecal sac narrowing. Mild-to-moderate neural foraminal narrowing is
seen on the right, worst from C5/C6. At least moderate canal narrowing seen
at C3/C4 due to a disc bulge and thickening of the ligamentum flavum as on
prior.
The thyroid is normal. A 5-mm left apical lung nodule, series 2, image 60, is
unchanged compared to the prior exam. Mild biapical pleural scarring, right
greater than left, is also unchanged.
IMPRESSION:
1. No acute cervical spine fractures identified.
2. Left 5-mm apical lung nodule, overall unchanged compared to the prior
exam. A CT in six months is recommended for further evaluation.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 97.5
heartrate: 80.0
resprate: nan
o2sat: 100.0
sbp: 156.0
dbp: 79.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ w/ ___ dz, hypothyroidism,
multiple recent admissions for PNA/empyema s/p decortication and
acute renal failure (AIN) likely from DRESS syndrome ___ zosyn,
who presents from home with possible confusion and falls.
ACUTE ISSUES
#History of Fall/Pre-syncope:
From the patient's history, his fall was secondary to not using
his walker at home which he uses at baseline due to ___
disease and bradykinesia. He reports no trauma, and his CT head,
and CT C spine were negative. He was evaluated by physical
therapy, and discharged home with recommendations for discharge
home with 24 hour assistance.
#Encephalopathy:
On arrival to the general medicine floor, the patient had no
signs of reduced attention; there was concern for infection in
the ED due to a possible LLL infiltrate on CXR, however the pt
did not meet SIRS criteria, and had a normal CBC and
differential and normal lung exam. All of his electrolytes were
normal, in addition to renal and liver functions testing. Thus
antibiotics were held on admission.
A TSH on admission was low at 0.095. After speaking to his
nurse, his medications were reconciled, and he has been taking
Levothyroxine 100mcg QD. Given his reduced TSH, his
Levothyroxine dose was decreased to 88 mcg QD, which was
verbally communicated to his nurse, and he should have repeat
TSH testing with his PCP.
#Lung nodule:
Incidentally found on imaging. Discussed with patient. 6 month
follow up recommended
CHRONIC ISSUES
#Parkinsons dz:
The patient was continued on his home medications including
Carbidopa-Levodopa and Pramiprexole.
#Hypothyroidism:
The patient's home Levothyroxine dose was decreased to 88 mcg as
described above.
#Orthostatic Hypotension:
The patient was discharged to continue his home Fludrocortisone.
TRANSITIONAL ISSUES
-please check repeat TSH as levothyroxine dose was decreased to
88 mcg given low TSH of 0.095 on admission. Prior dose was
100mcg
-pls consider bed alarm at night to avoid future falls.
-pls institute fall precautions and monitor pt at all times
during the day to avoid falls. Pls ensure pt uses walker or
wheel chair at all times
-Pt was found to have a Left 5-mm apical lung nodule, overall
unchanged compared to the prior exam. A CT in six months is
recommended for further evaluation. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
C3-C6 spinal cord compression
Major Surgical or Invasive Procedure:
___: Posterior bilateral laminectomy C3-C4, C5-C6, and
superior C7; also, proximal foraminotomies C3-4 on the left,
C5-6 on the right, and C6-7 on the left.
History of Present Illness:
Mr. ___ is a ___ year old gentleman s/p fall on ___
while vacationing
in ___. Per report, he was getting ready to leave his
friend's house and while putting on his shoes fell forward.
Immediately after the fall was unable to move his extremities.
When the patient arrived to the ___, he was able
to move arms (proximally) but was unable to move hands. MRI
C-spine
revealed severe degenerative changes with severe cord
compression at C3-7 with T2 signal changes. The patient was
inpatient for approx. 8 days and received physical
therapy/occupational therapy. Per the patient, insurance would
no
longer cover therapies and was transported back to the ___ for
further treatment. He subsequently presented to ___
___ and then transferred to ___ for spine evaluation.
Patient denies neck pain. Patient does have paraesthesias in all
extremities with decreased sensory from T8 level to ___
area. Patient states has had difficulty with urinating, a trial
was given to patient prior to discharge from OSH facility
however he
was unable to void and required catheter. Patient also states
difficulty with bowel movements at first however was able to
have
bowel movement at OSH.
Past Medical History:
HTN
GERD
Social History:
___
Family History:
Non-contributory
Physical Exam:
On Admission:
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: ___ EOMs intact
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T WE WF G IP Q H AT ___ G
Sensation: Intact to light touch. + paraesthesias in all
extremities. decreased sensory from T8 to ___ area.
Reflexes: B T Br Pa Ac
Right 2----------
Left 2----------
Propioception intact
Rectal exam normal sphincter control
negative hoffmans.
negative clonus (R ankle fused)
ON DISCHARGE:
Gen: WD/WN, comfortable, NAD.
HEENT:
Pupils: ___
EOMs: intact
Neck: Supple. In hard Aspen collar
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
D B T G IP Q H AT ___ G
Sensation: Intact to light touch. + paraesthesias in all
extremities.
Propioception intact
Rectal exam normal sphincter control
Patient feels when his foley catheter is tugged, and also felt
insertion of catheter. He is able to feel normally when he wipes
his anus.
He is able to feel the urge to urinate, just unable to initiate
stream.
Pertinent Results:
___ MR CERVICAL SPINE W/O CONTRAST:
1. Mild prevertebral soft tissue edema in the C4 through C5
levels with
minimal heterogeneity of the anterior longitudinal ligament, may
be
degenerative in nature, though given the history of trauma,
ligamentous injury cannot be excluded, though no frank tear is
seen.
2. Heterogeneous bone marrow signal and edema spanning the C3
through the C6 levels is likely degenerative, though fracture is
difficult to assess given the background signal abnormality.
3. Severe spinal cord impingement with cord signal abnormality
spanning the C3-C4 through C5-C6 levels compatible with edema or
myelomalacia.
4. Severe multilevel cervical spondylosis, as described, with
severe spinal canal narrowing and cord compression at multiple
levels and severe neural foraminal narrowing at multiple levels.
5. Millimetric bilateral thyroid nodules measure up to 3 mm. No
further
evaluation is necessary.
___ CT C-SPINE W/O CONTRAST:
1. Suggestion of hairline nondisplaced fracture right C1
transverse process.
2. There is severe degenerative arthritis of the cervical spine
with severe central canal narrowing, cord flattening at C3-C4,
C4-C5, C5-C6 levels.
___ XR C-SPINE
Surgical instrumentation in place. Tubes in place. Advanced
degenerative
changes cervical spine
___ XR C-SPINE
No previous images or image of the type of catheter involved.
No evidence of abnormal opaque catheter on the single frontal
view presented.
___ MR THORACIC AND LUMBAR SPINE W/O CONTRAST:
Preliminary read: Marked degenerative changes of the lower
thoracic and lumbar spines. Diffuse disc bulge at L2-L3 flattens
the anterior thecal sac with crowding of the nerve roots. No
severe spinal canal narrowing at any level. No abnormal signal
abnormalities in the thoracic spinal cord.
MRI reviewed with Neurosurgeon on-call, consistent with
epidermal lipomatosis.
Medications on Admission:
- Lisinopril 5mg
- HCTZ 25mg
- Fish Oil
- MVI
- Vitamin B12
- Calcium
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Ciprofloxacin HCl 500 mg PO Q12H Duration: 4 Days
4. Diazepam 2 mg PO Q6H:PRN muscle spasm
5. Docusate Sodium 100 mg PO BID
6. Heparin 5000 UNIT SC BID
7. HydrALAZINE 10 mg IV Q6H:PRN SBP > 160
8. Morphine Sulfate ___ mg IV Q3H:PRN BREAKTHROUGH PAIN
9. Omeprazole 20 mg PO DAILY
10. Ondansetron 4 mg IV Q8H:PRN nausea/vomiting
11. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Senna 8.6 mg PO QHS
14. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
15. Hydrochlorothiazide 25 mg PO DAILY
16. Lisinopril 5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___)
Discharge Diagnosis:
C3-C6 spinal cord compression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: MR CERVICAL SPINE W/O CONTRAST ___ MR ___ SPINE
INDICATION: Fall on ___ with report of C3 through C7 central cord
syndrome per MRI in ___ with persistent arm and leg weakness. Evaluate for
cord compression.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 and gradient echo imaging were next performed. Sagittal diffusion
weighted imaging was then performed.
COMPARISON: None.
FINDINGS:
There is millimetric retrolisthesis of C3 on C4, C4 on C5, and C5 on C6,
likely degenerative. There is mild prevertebral soft tissue edema spanning
the C3 through C5 levels with minimal irregularity of the anterior
longitudinal ligament at this level, though no frank tear is identified.
There is marrow edema and heterogeneous bone marrow signal spanning the C3
through C6 levels, likely degenerative. No definite fracture line is
identified, however this is difficult to assess given the background
degenerative change.
Vertebral body heights are otherwise relatively well preserved. Focal fat is
noted in the superior endplate of the T4 vertebral body. There is loss of T2
signal of the intervertebral disc, a manifestation of degenerative disc
disease. There is severe intervertebral disc height loss from the levels of
C3-C4 through C5-C6.
There is cord compression from the levels of C3-C4 through C5-C6, with
associated central cord T2 hyperintensity, compatible with edema or
myelomalacia. There is some associated high signal within the spinal cord on
diffusion images, though no definite ADC correlate is seen.
At C2-C3, there is no significant spinal canal or neural foraminal narrowing.
At C3-C4, large disc bulge, endplate osteophytes and ligamentum flavum
thickening produce severe spinal canal narrowing with focal cord impingement.
Facet and uncovertebral osteophytes produce severe bilateral neural foraminal
narrowing.
At C4-C5, large disc bulge, endplate osteophytes and ligamentum flavum
thickening produce severe spinal canal narrowing with severe cord impingement.
Facet and uncovertebral osteophytes produce severe bilateral neural foraminal
narrowing.
At C5-C6, large disc bulge, endplate osteophytes and ligamentum flavum
thickening produce severe spinal canal narrowing with cord impingement. Facet
and uncovertebral osteophytes produce severe right and moderate to severe left
neural foraminal narrowing.
At C6-C7, disc bulge, endplate osteophytes produce mild spinal canal
narrowing. Facet and uncovertebral osteophytes produce severe left and
moderate to severe right neural foraminal narrowing.
At C7-T1, there is no significant spinal canal or neural foraminal narrowing.
At T1-T2, there is no significant spinal canal or neural foraminal narrowing.
Sagittal view of the T2-T3 and T3-T4 demonstrate no significant spinal canal
or neural foraminal narrowing.
Scattered millimetric T2 hyperintense thyroid nodules are seen bilaterally,
measuring up to 3 mm.
IMPRESSION:
1. Mild prevertebral soft tissue edema in the C4 through C5 levels with
minimal heterogeneity of the anterior longitudinal ligament, may be
degenerative in nature, though given the history of trauma, ligamentous injury
cannot be excluded, though no frank tear is seen.
2. Heterogeneous bone marrow signal and edema spanning the C3 through the C6
levels is likely degenerative, though fracture is difficult to assess given
the background signal abnormality.
3. Severe spinal cord impingement with cord signal abnormality spanning the
C3-C4 through C5-C6 levels compatible with edema or myelomalacia.
4. Severe multilevel cervical spondylosis, as described, with severe spinal
canal narrowing and cord compression at multiple levels and severe neural
foraminal narrowing at multiple levels.
5. Millimetric bilateral thyroid nodules measure up to 3 mm. No further
evaluation is necessary.
RECOMMENDATION(S):
1. If there is continued concern for fracture, consider further evaluation
with CT or comparison to priors, if available.
2. 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: CHEST (SINGLE VIEW)
INDICATION: Preoperative planning // Preoperative planning; cervical spinal
cord compression Surg: ___ (Cervical decompression)
TECHNIQUE: Chest single view
COMPARISON: None
FINDINGS:
Shallow inspiration. Mild left infrahilar opacity, likely atelectasis.
Shallow inspiration accentuates heart size. Normal pulmonary vascularity. No
edema. No pneumothorax. No pleural effusion.
IMPRESSION:
Mild left infrahilar opacity, likely atelectasis.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: ___ year old man with cervical stenosis (C3-6 spinal cord
impingement and signal change on MRI); evaluate for bony pathology // ___ year
old man with cervical stenosis (C3-6 spinal cord impingement and signal change
on MRI); evaluate for bony pathology ___ year old man with cervical
stenosis (C3-6 spinal cord impingement and signal change on MRI); evaluate for
bony pathology
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 4.8 s, 18.8 cm; CTDIvol = 36.6 mGy (Body) DLP = 690.1
mGy-cm.
Total DLP (Body) = 690 mGy-cm.
COMPARISON: MRI cervical spine ___
FINDINGS:
There is mild retrolisthesis of C3 on C4, C4-C5, C5 on C6, likely
degenerative, similar to prior. Alignment is otherwise normal. There is
chronic ununited fracture of the distal C7 transverse process. Suggestion of
a hairline nondisplaced acute fracture of the right C1 transverse process,
lateral to the foramen transversarium series 2, image 11. There are no other
fractures. There is no prevertebral soft tissue swelling. There is no
evidence of infection or neoplasm.
There is multilevel advanced degenerative changes with disc space narrowing
C3-C4, C4-C5, C5-C6, C6-C7, and reactive degenerative type sclerosis involving
vertebral bodies. Endplate cystic changes are likely degenerative.
Multilevel disc osteophyte complexes at above levels causes severe central
canal narrowing at C3-C4, C4-C5, C5-C6 levels, with cord flattening. There is
probably moderate central canal narrowing at C6-C7 level. There is multilevel
moderate to severe foraminal narrowing, better seen on MRI exam.
IMPRESSION:
1. Suggestion of hairline nondisplaced fracture right C1 transverse process.
2. There is severe degenerative arthritis of the cervical spine with severe
central canal narrowing, cord flattening at C3-C4, C4-C5, C5-C6 levels.
Radiology Report
EXAMINATION: CERVICAL SINGLE VIEW IN OR
INDICATION: Fusion, laminectomy
TECHNIQUE: Single lateral radiograph cervical spine
COMPARISON: Cervical spine CT ___
FINDINGS:
Surgical instrumentation in place. Tubes in place. Advanced degenerative
changes cervical spine
IMPRESSION:
Images obtained for surgical purposes
Radiology Report
EXAMINATION: C-SPINE SGL 1 VIEW
INDICATION: ___ year old man s/p drain removal // evaluate for retained
catheter evaluate for retained catheter
IMPRESSION:
No previous images or image of the type of catheter involved. No evidence of
abnormal opaque catheter on the single frontal view presented.
Radiology Report
EXAMINATION: MRI THORACIC AND LUMBAR PT6 MR SPINE
INDICATION: ___ year old man with cervical spinal cord compression with T2
signal change, status post posterior laminectomy at C3-C4 and C5-C6
bilaterally and superior C7 laminectomy; proximal foraminotomies at C3-C4 on
the left, at C5-C6 on the right, and C6-7 on the left. Evaluate thoracic and
lumbar spine for any cause of urinary retention.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and IDEAL technique,
followed by axial T2 imaging.
COMPARISON: Cervical spine MRI and CT from ___ are available for
correlation.
FINDINGS:
There are 7 cervical, 12 rib-bearing, and 4 lumbar-type vertebrae. L5 is
partially sacralized. The numbering is documented on images 3:9, 5:3, 5:6,
and 11:12. Thoracolumbar scoliosis is not optimally assessed on the localizer
sequences, but appears to be convex to the right in the upper thoracic spine
and convex to the left in the lumbar spine.
CERVICAL:
The sagittal T1 weighted "counting" sequence through the cervical and thoracic
spine, which is not intended for diagnostic purposes, demonstrates evidence of
laminectomies from C3 through either C6 ; C7 superior laminectomy changes are
not adequately demonstrated. Extensive discogenic marrow changes in the C5
vertebral body, as well as in the C4 inferior endplate and C6 superior
endplate, are again seen. Kyphotic curvature of the cervical spine is again
noted. Disc disease is not assessed on this limited sequence. No gross
compression of the spinal cord is seen on limited evaluation. Previously
noted focus of myelomalacia at C4 is faintly visible.
THORACIC:
Bone marrow signal is relatively low. There are Schmorl's nodes in the
endplate at extensive discogenic bone marrow changes in the lower thoracic
spine, as well as scattered hemangiomas or focal fat deposits in the bone
marrow. No thoracic cord signal abnormalities are seen. The conus medullaris
terminates at T12-L1 and appears unremarkable.
There is a mild disc bulge plus/minus tiny right paracentral disc protrusion
at T5-T6, and mild disc bulges from T8-T9 through T11-T12 without significant
spinal canal narrowing.
At T10-T11, there is a small left foraminal disc protrusion and bilateral
facet arthropathy, causing moderate left and mild right neural foraminal
narrowing.
LUMBAR:
Bone marrow signal is relatively low. There are Schmorl's nodes in the
endplate at extensive discogenic bone marrow changes from T12-L1 through
L4-L5. L5 is partially sacralized, as stated above.
T12-L1: There is a disc bulge with endplate osteophytes, and facet
arthropathy, mildly narrowing the right subarticular zone with possible mass
effect on the traversing right L1 nerve root. The thecal sac is mildly
narrowed without mass effect on the intrathecal nerve roots. There is
moderate right neural foraminal narrowing.
L1-L2: Due to posterior endplate osteophytes, it is not clear whether minimal
retrolisthesis may be present. Disc bulge with endplate osteophytes and mild
facet arthropathy cause abutment of bilateral traversing L2 nerve roots in the
subarticular zones, and mild narrowing of the thecal sac without significant
mass effect on the intrathecal nerve roots. There is mild to moderate right
and moderate left neural foraminal narrowing.
L2-L3: Due to posterior endplate osteophytes, it is not clear with a minimal
retrolisthesis may be present. Disc bulge with endplate osteophytes, mild
facet arthropathy, and prominent posterior epidural fat cause moderate to
severe narrowing of the thecal sac with crowding of the intrathecal nerve
roots, as well as impingement of bilateral traversing L3 nerve roots in the
subarticular zones. There is also moderate right neural foraminal narrowing
with abutment of the exiting right L2 nerve root, and mild to moderate left
neural foraminal narrowing.
L3-L4: Due to posterior endplate osteophytes, it is not clear with a minimal
retrolisthesis may be present. There is a disc bulge with endplate
osteophytes and mild facet arthropathy, as well as prominent posterior
epidural fat, causing left greater than right subarticular zone narrowing with
impingement of the traversing left L4 nerve root, and moderate narrowing of
the thecal sac with mild crowding of the intrathecal nerve roots. There is
also moderate to severe bilateral neural foraminal narrowing with abutment of
the exiting L3 nerve roots.
L4-L5: There is a mild retrolisthesis with a disc bulge and a small central
disc protrusion, as well as moderate facet arthropathy and mildly prominent
posterior epidural fat. Traversing L5 nerve roots are abutted in the
subarticular zones with possible impingement on the left. There is mild to
moderate narrowing of the thecal sac with mild crowding of the intrathecal
nerve roots. There is also severe bilateral neural foraminal narrowing with
abutment and likely impingement of the exiting L4 nerve roots by facet
osteophytes.
L5-S1: There is a disc bulge with a possible superimposed central disc
protrusion, as well as moderate facet arthropathy. Bilateral traversing S1
nerve roots are contacted in the subarticular zones. The thecal sac is mildly
narrowed without mass effect on the intrathecal nerve roots. There is mild to
moderate bilateral neural foraminal narrowing.
IMPRESSION:
1. Relatively low bone marrow signal suggests some degree of red marrow
reconversion, which may be secondary to anemia, smoking, or chronic systemic
illness, including chronic cardiac, liver, or renal disease. An infiltrative
process is less likely. Please correlate with clinical history and laboratory
data.
2. Incompletely evaluated postsurgical changes in the cervical spine.
Myelomalacia at C4 is again noted.
3. Normal appearance of the thoracic spinal cord. No significant thoracic
spinal canal narrowing.
4. Partially sacralized L5.
5. Thoracolumbar scoliosis.
6. Multilevel degenerative disease and prominent posterior epidural fat and
lumbar spine, as detailed above, with moderate to severe thecal sac narrowing
at L2-L3, moderate thecal sac narrowing at L3-L4, and mild to moderate thecal
sac narrowing at L4-L5, and with mass effect on multiple traversing and
exiting nerve roots in the lumbar spine, as detailed above.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with Unspecified cord compression
temperature: 97.4
heartrate: 74.0
resprate: 20.0
o2sat: 99.0
sbp: 128.0
dbp: 90.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a pleasant ___ year old gentleman who was
transferred to ___ from ___ on ___ for
evaluation of cervical spinal cord compression after a fall
sustained on ___.
#Cervical Spine Compression: He was admitted to the Neurosurgery
service for preoperative assessment. His cervical spine was
immobilized in an Aspen collar. He underwent a posterior
bilateral laminectomy C3-C4, C5-C6, and superior C7 with
proximal foraminotomies left C3-4, right C5-6, and left C6-7 on
___. Please see separately dictated operative report by Dr.
___ for full detail. Hemovac drain was left in place
following surgery. The patient was instructed to continue Aspen
cervical collar at all times when out of bed for 10 days
following surgery. His neurologic examination was stable
postoperatively and remained notable for four-extremity
paresthesias as well as decreased grip strength. The patient was
evaluated by physical and occupational therapy who recommended
acute rehabilitation following discharge.
#Urinary Tract Infection: Preoperative urinalysis was consistent
with urinary tract infection. The patient was initiated on 7-day
course of ciprofloxacin, which he will plan to complete
following discharge.
#Urinary Retention
The patient was admitted with foley catheter in place given
urinary retention. He underwent repeat voiding trial on
___ and was unable to void. The foley was replaced with
plans for follow-up with Urology in one week. An MRI of the
thoracis and Lumbar spine was performed to rule out neurologic
cause for urinary retention. It showed diffuse disc bulge at
L2-L3 flattens the anterior thecal sac with crowding of the
nerve roots. No severe spinal canal narrowing at any level. No
abnormal signal abnormalities in the thoracic spinal cord. MRI
reviewed with Neurosurgeon on-call, consistent with epidermal
lipomatosis.
At the time of discharge, the patient's vital signs were within
normal limits and neurologic examination remained stable. He
stated that his pain was adequately controlled. He was able to
tolerate oral intake without nausea and vomiting. The patient
was ambulating with supervision. Foley catheter was in place.
Patient feels when his foley catheter is tugged, and also felt
the insertion of catheter. He is able to feel normally when he
wipes his anus. He is able to feel the urge to urinate, just
unable to initiate stream. He will plan to follow up with Dr.
___ Urology following discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___
Chief Complaint:
s/p fall, pneumonia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yoF with h/o ischemic CVA not on AC, COPD, lung cancer s/p
lobectomy, and ___ transferred from ___ for
evaluation of T4 compression fracture s/p mechanical fall. She
lost her balance while trying to get into car and fell. She
struck the back of head. She denies LOC but daughter notes she
was somewhat dazed and confused after fall. She denies chest
pain, palpitations, lightheadedness/dizziness, sweating,
numbness/tingling or any unusual symptoms prior to the fall. Her
laceration was stapled at ___. She normally uses a walker,
lives with her family at home.
In the ED, initial vital signs were: 97.6 79 164/74 16 94%RA
- She was noted to be dizzy with low blood pressure upon
standing
- Labs were notable for: CBC and chem-7 nl, trop neg x2, UA neg
- CXR showed small region of possible PNA or bronchiolitis of
RLL
- OSH Imaging:
CT torso: smooth indentation in superior endpoint of T4,
patchy tree in ___ nodules in RLL, no dominant mass.
Head CT: negative
CT c spine: called ___- negative
- Patient was given: 2L NS, ASA 162, levofloxacin 750 IV
- NSGY was consulted and recommended f/u in 2 weeks with Dr.
___
On Transfer ___ were: 97.2 75 161/54 14 98%RA
On the floor, patient endorses some dizziness when sitting her
bed up. She also endorses productive cough and shortness of
breath which is chronic from COPD and not worse than usual. She
denies back pain. She states she was recently discharged from
the hospital 1.5 weeks ago for pneumonia.
Past Medical History:
COPD
CVA in ___, ischemic with residual RLE weakness
NIDDM
Hyperlipidemia
Lung cancer s/p lobectomy
Hypothyroidism
Social History:
___
Family History:
Brother died of heart attack, other brother had MI yesterday
Mother with DM
Father with bone cancer
Physical Exam:
ON ADMISSION:
Vitals: 97.4 152/51 68 20 97RA
Wt: 79kg
General: Well appearing, in NAD
HEENT: PERRL, laceration R scalp with staples and dried blood,
has nodule on R eyelid and beneath eye, MMM, no cervical LAD
CV: RRR, no m/r/g
Lungs: Intermittent rhonchi, no crackles or wheezing
Abdomen: Soft, nontender, nondistended, no hepatsplenomegaly
GU: No foley
Ext: WWP, trace pedal edema, RLE swelling > LLE, distal pulses
palpable
Neuro: AAOx3, ___ strength in RLE compared to LLE which is
chronic
Skin: No rashes or venous stasis changes
ON DISCHARGE:
Vitals: 98 150s/40s-50s ___ 92-97RA
General: Well appearing, in NAD
HEENT: PERRL, laceration R scalp with staples and dried blood,
has nodule on R eyelid and beneath eye, MMM, no cervical LAD
CV: RRR, no m/r/g
Lungs: Intermittent rhonchi, no crackles or wheezing
Abdomen: Soft, nontender, nondistended, no hepatsplenomegaly
GU: No foley
Ext: WWP, trace pedal edema, RLE swelling > LLE, distal pulses
palpable
Neuro: AAOx3, ___ strength in RLE compared to LLE which is
chronic
Skin: No rashes or venous stasis changes
Pertinent Results:
ON ADMISSION:
___ 03:25AM BLOOD WBC-9.1 RBC-3.94 Hgb-11.2 Hct-35.5 MCV-90
MCH-28.4 MCHC-31.5* RDW-14.3 RDWSD-46.8* Plt ___
___ 03:25AM BLOOD Neuts-62.9 ___ Monos-8.1 Eos-3.8
Baso-1.1* Im ___ AbsNeut-5.72 AbsLymp-2.16 AbsMono-0.74
AbsEos-0.35 AbsBaso-0.10*
___ 03:25AM BLOOD Glucose-73 UreaN-28* Creat-1.0 Na-135
K-4.3 Cl-103 HCO3-24 AnGap-12
___ 03:25AM BLOOD cTropnT-<0.01
___ 12:48PM BLOOD cTropnT-<0.01
___ 07:50AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.6
ON DISCHARGE:
___ 07:50AM BLOOD WBC-8.2 RBC-3.65* Hgb-10.5* Hct-32.6*
MCV-89 MCH-28.8 MCHC-32.2 RDW-14.2 RDWSD-46.4* Plt ___
___ 07:50AM BLOOD Glucose-67* UreaN-25* Creat-1.0 Na-139
K-4.4 Cl-106 HCO3-25 AnGap-12
___ 07:50AM BLOOD Calcium-8.2* Phos-3.1 Mg-1.6
___ 07:50AM BLOOD TSH-0.77
MICROBIOLOGY:
___ 11:28AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 11:28AM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-8
___ CULTUREBlood Culture,
Routine-PENDINGEMERGENCY WARD
___ CULTUREBlood Culture,
Routine-PENDINGEMERGENCY WARD
IMAGING:
CXR ___:
1. SMALL REGION OF POSSIBLE PNEUMONIA OR BRONCHIOLITIS, RIGHT
LOWER LOBE,
BEST APPRECIATED ON OUTSIDE CT PERFORMED ___.
2. SEVERE EMPHYSEMA, PULMONARY FIBROSIS, AND BRONCHIECTASIS.
UNIT LOWER EXT VEINS ___: No evidence of deep venous
thrombosis in the right lower extremity veins.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Levothyroxine Sodium 125 mcg PO DAILY
3. Citalopram 20 mg PO DAILY
4. Omeprazole 20 mg PO BID
5. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
6. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
prn sob
7. Simvastatin 80 mg PO QPM
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Simvastatin 80 mg PO QPM
3. Omeprazole 20 mg PO BID
4. Citalopram 20 mg PO DAILY
5. Levothyroxine Sodium 125 mcg PO DAILY
6. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
prn sob
7. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 CAP IH
once a day Disp #*30 Capsule Refills:*0
8. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 100 mcg-50 mcg/dose 1
IH INH twice daily Disp #*1 Disk Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
Mechanical fall with T4 compression fracture
SECONDARY:
CVA ___ with residual right lower extremity weakness
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: History: ___ with weakness, fall // evidence of pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: Outside torso CT from ___.
FINDINGS:
There is mild cardiomegaly. Multiple surgical clips project over the left
mediastinum. HYPERINFLATION IS DUE TO SEVERE EMPHYSEMA. DIFFUSE reticular
opacities, present on prior outside CT ARE felt to reflect chronic
interstitial lung changes AND, INCLUDING PULMONARY FIBROSIS, BRONCHIECTASIS,
AND INFLAMMATORY EMPHYSEMA. There is a however a focal area of increased
nodular opacities IN THE RIGHT LOWER LOBE which corresponds to tree in ___
nodularities on prior outside CT. In the appropriate clinical setting, these
findings could reflect an acute infectious process. Blunting of the left
costophrenic angle is likely secondary to a small amount of pleural fluid.
There is no pneumothorax.
IMPRESSION:
1. SMALL REGION OF POSSIBLE PNEUMONIA OR BRONCHIOLITIS, RIGHT LOWER LOBE,
BEST APPRECIATED ON OUTSIDE CT PERFORMED ___.
2. SEVERE EMPHYSEMA, PULMONARY FIBROSIS, AND BRONCHIECTASIS.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS
INDICATION: ___ year old woman with R > L lower extremity swelling, RLE
weakness ___ CVA // e/o DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the right common
femoral, femoral, and popliteal veins. Normal 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 lower extremity veins.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Head injury
Diagnosed with Oth fracture of fourth thoracic vertebra, init for clos fx, Unspecified fall, initial encounter
temperature: 97.6
heartrate: 79.0
resprate: 16.0
o2sat: 94.0
sbp: 164.0
dbp: 74.0
level of pain: 1
level of acuity: 2.0 | ___ yoF with h/o ischemic CVA not on anticoagulation, COPD, lung
cancer s/p lobectomy, and ___ transferred from
___ for evaluation of T4 compression fracture s/p
mechanical fall, admitted for presumed pneumonia based on chest
x-ray findings and reported cough and shortness of breath.
Patient's fall was thought to be secondary to progressive
weakness of her right lower extremity, which she has had since
CVA in ___. She appears to have had multiple falls over the
past month due to buckling sensation of her right leg upon
walking. Other etiologies to fall, including orthostatic
hypotension, cardiac event, and infection, were ruled out.
Neurosurgery evaluated her in the ED and recommended outpatient
follow-up in 2 weeks. Physical therapy evaluated her and
recommended discharge to rehab to increase strength and
mobility. However the patient declined and would prefer home ___.
Patient was also evaluated by speech and swallow and found to be
aspirating on thin liquids. The patient was given information on
thickening liquids.
Patient was admitted for pneumonia given report of cough and
shortness of breath, as well as CXR and CT torso showing signs
suggestive of pneumonia. However, she clinically did not appear
to have pneumonia given lack of fever, hypoxia, leukocytosis, or
new shortness of breath or cough. She stated that her current
cough and dyspnea were chronic from her COPD. Of note, she was
admitted at OSH from ___ for pneumonia and treated with
levofloxacin. It was therefore thought that radiographic
findings were residual from her recent pneumonia and not
indicative of an active infection.
Given her COPD patient was started on tiotropium and advair. She
should follow up further titration. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Neck pain, difficulty with upper extremity movement
Major Surgical or Invasive Procedure:
None: Placed into ___ J collar for comfort
History of Present Illness:
___ gentleman with history of alcohol
abuse who presents after a fall down 15 stairs while
intoxicated.
He was assessed by the trauma service yesterday evening and his
collar was cleared. This morning, after regaining sobriety, he
complained of severe hand weakness as well as lower extremity
weakness limiting his ability to ambulate. He has since
ambulated with physical therapists, however, he continues to
have
subjective leg weakness as well as numbness and tingling on the
soles of his feet. He denies any incontinence of bowel or
bladder or saddle anesthesia. He has severe weakness in his
hands and states that he is unable to cross his fingers, his
hand
grip is weak and his finger extension is also weak. He has
numbness and tingling which is worse on his bilateral middle,
ring, and small fingers. He denies significant neck pain. He
does endorse a history of mild, chronic neck pain for the past ___
years which has been diagnosed as degenerative disc disease. He
denies pain other problems or joints.
Past Medical History:
HTN, Ulcerative colitis
Social History:
___
Family History:
Noncontributory
Physical Exam:
VS ___ ___ Temp: 99.1 PO BP: 165/90 L Lying HR: 98 RR: 18
O2 sat: 96% O2 delivery: Ra
BMI: 27.5.
NAD, A&Ox4
nl resp effort
RRR
Sensory:
UE
C5 C6 C7 C8 T1
(lat arm) (thumb) (mid fing) (sm finger) (med arm)
R SILT SILT SILT SILT ___
L SILT SILT SILT SILT ___
___
L2 L3 L4 L5 S1 S2
(Groin) (Knee) (Med Calf) (Grt Toe) (Sm Toe) (Post Thigh)
R SILT SILT SILT SILT SILT SILT
L SILT SILT SILT SILT SILT SILT
Motor:
UE Dlt(C5) Bic(C6) WE(C6) Tri(C7) WF(C7) FF(C8)FinAbd(T1)
R 5 5 5 5 4 4 4
L 5 5 5 5 4 4 4
___ Flex(L1) Add(L2) Quad(L3) TA(L4) ___ ___
R 5 5 5 5 5 5 5
L 5 5 5 5 5 5 5
Medications on Admission:
Amlodipine
Lisinopril
HCTZ
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. Lisinopril 20 mg PO DAILY
3. Amlodipine
4. HCTZ
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Central Cord
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Trauma status post fall
COMPARISON: None
FINDINGS:
Portable AP upright chest radiograph provided. Overlying EKG leads are
present. There is no consolidation, large effusion or pneumothorax seen.
Cardiomediastinal silhouette is normal. No definite bony abnormalities.
IMPRESSION:
No acute findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ s/p fall// ? traumatic injury
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or discrete mass. Left
basal ganglia calcifications are noted.. The ventricles and sulci are normal
in size and configuration.
Subcutaneous foci of subcutaneous air at the left vertex is consistent with
laceration. No underlying fractures. The paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST
INDICATION: ___ s/p fall// ? traumatic injury
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: Total DLP (Head) = 585 mGy-cm.
COMPARISON: None.
FINDINGS:
No fractures are identified. There is no evidence of facial swelling.
Minimal mucosal thickening is noted within the right inferior maxillary sinus
though otherwise the imaged paranasal sinuses are well aerated.
There is no evidence of abnormal fluid collections. Bilateral mastoids appear
normal. The globes, extraocular muscles, optic nerves, and retrobulbar fat
appear normal. The visualized upper aerodigestive tract appears normal. The
mandible and temporomandibular joints appear normal. There is lucency
surrounding the right maxillary canine tooth, series 2 image 76 through 79,
which should be correlated clinically for loosening.
IMPRESSION:
1. No acute fracture.
2. Relative lucency surrounding the right maxillary canine which should be
correlated for possible loosening.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ s/p fall// ? traumatic injury
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Total DLP (Body) = 543 mGy-cm.
COMPARISON: None.
FINDINGS:
Alignment is normal. No fractures are identified.There are multilevel
degenerative changes of the cervical spine worse at the C6-7 level where there
is disc height loss, endplate sclerosis, and anterior posterior intervertebral
osteophytes. Posterior intervertebral osteophytes cause mild canal narrowing
at C6-7. Facet arthropathy uncovertebral hypertrophy cause moderate severe
neural foraminal narrowing at several levels, worst at the left C3-4 level,
left C4-5 level, and left C5-6 level.There is no prevertebral soft tissue
swelling.Lung apices are clear. Thyroid gland is unremarkable.
IMPRESSION:
No acute fracture or traumatic malalignment.
Radiology Report
EXAMINATION: CT torso
INDICATION: ___ s/p fall// ? traumatic injury
TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and
pelvis following intravenous contrast administration with split bolus
technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 1,711 mGy-cm.
COMPARISON: None.
FINDINGS:
CHEST:HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury. The heart, pericardium, and great vessels are
within normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Mild dependent atelectasis bilaterally. Lungs are otherwise
clear. Evaluation of the airways is limited by motion artifact, especially at
the bases, however they appear patent to at least the segmental levels.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesion or laceration. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder is within
normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesion or laceration.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal. There is no
evidence of mesenteric injury.
There is no free fluid or free air in the abdomen.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: 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.
Minimal atherosclerotic disease is noted.
BONES: There is no acute fracture. No focal suspicious osseous abnormality.
Mild-to-moderate degenerative changes of the lower lumbar spine are noted.
Few chronic appearing anterior left-sided rib fractures are noted.
SOFT TISSUES: Bilateral fat containing inguinal hernias are noted. Fat
containing umbilical hernia is noted. Vasectomy surgical clips are noted.
IMPRESSION:
No acute sequelae of trauma.
Radiology Report
EXAMINATION: MR ___ WAND W/O CONTRAST ___ MR ___ SPINE
INDICATION: History: ___ with hand weakness, bilateral, after traumaIV
contrast to be given at radiologist discretion as clinically needed// eval for
central cord syndrome
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 and gradient echo imaging were next performed. After administration
of Gadavist intravenous contrast, sagittal and axial T1 weighted imaging was
performed.
COMPARISON: CT ___ dated ___
FINDINGS:
There is mild anterolisthesis of C4 on C5 and mild retrolisthesis C6 on C7.
Vertebral body heights are preserved. Endplate STIR hyperintensity along the
inferior endplate of C6 and superior endplate of C7 could be secondary to
___ type changes however bony contusion in the trauma setting cannot be
excluded. There is loss of signal intensity within the intervertebral discs
at C4-5 and C5-6, suggestive of disc desiccation. There is loss of
intervertebral disc space C6-7.
C2-3: There is no substantial spinal canal or neural foraminal narrowing.
C3-4: Posterior osteophytes and uncovertebral and facet osteophytes contribute
to mild spinal canal narrowing and severe bilateral neural foraminal
narrowing.
C4-5: Uncovertebral and facet osteophytes contribute to mild spinal canal
narrowing and severe bilateral neural foraminal narrowing.
C5-6: Uncovertebral and facet osteophytes contribute to moderate left and mild
to moderate right neural foraminal narrowing.
C6-7: Posterior disc bulge and uncovertebral and facet osteophytes contribute
to severe spinal canal narrowing with effacement of the CSF and severe
bilateral neural foraminal narrowing.
C7-T1: Posterior left disc protrusion contributes to moderate left neural
foraminal narrowing. No significant spinal canal narrowing is seen.
There is T2/stir signal intensity prevertebral space from C2 through at least
T3, though most pronounced from C3-C5. There is no clear disruption of the
anterior longitudinal ligament. There is also T2 hyperintensity along the
posterior paraspinal muscles from C2 through C6 suggesting strain, and within
the left facet joints at C4-5 and C5-6, likely secondary to bony contusion.
There is focal T2 signal intensity within the spinal cord at C6-7.
IMPRESSION:
1. Prevertebral edema extending from C2 through at least T3, most pronounced
from C3 through C5, with suggestion of anterior longitudinal ligament strain,
without clear disruption.
2. Disc herniation at ___ be traumatic in etiology contributing to severe
spinal canal stenosis at this level. There is edema of the spinal cord at
this level secondary to trauma.
3. T2 hyperintensity along the posterior paraspinal muscles from C2 through C6
is suggestive of interspinous ligament strain.
4. Multilevel degenerative changes as described above. Possible ___ changes
at C6-C7 versus bony contusion in the setting of trauma.
Radiology Report
INDICATION: ___ year old man with hand pain and weakness s/p fall// fracture?
dislocation?
TECHNIQUE: Bilateral hands, 6 total images, three views of each
COMPARISON: None.
FINDINGS:
Right wrist: No acute fracture or dislocation is seen. There are moderate to
severe osteoarthritic change at the first carpometacarpal joint and MCP joint.
Faint chondrocalcinosis at the TFCC is seen.
Left wrist: No acute fracture or dislocation is seen. Moderate to severe
osteoarthritic changes are seen at the first carpometacarpal joint, including
joint space narrowing, marginal sclerosis, and proliferative change.
IMPRESSION:
No acute fracture or dislocation. Degenerative changes, as above.
Radiology Report
INDICATION: ___ year old man with hand pain and weakness s/p fall// fracture?
dislocation?
TECHNIQUE: Bilateral hands, three views of each
COMPARISON: None
FINDINGS:
Right hand: No acute fracture or dislocation is seen. There are moderate
osteoarthritic changes at the first carpometacarpal joint and at the first MCP
joint. Spurring is noted at the head of the third metacarpal. Faint
chondrocalcinosis is noted at the TFCC.
Left hand: No acute fracture or dislocation is seen. There are moderate to
severe osteoarthritic changes at the first carpometacarpal joint, including
joint space narrowing, marginal sclerosis, and proliferative change. Mild
degenerative changes seen at the triscaphe joint. Spurring is noted at the
heads of the second and third metacarpals.
IMPRESSION:
No acute fracture or dislocation of the bilateral hands. Degenerative
changes, as above.
Radiology Report
EXAMINATION: CR - CHEST PORTABLE AP
INDICATION: ___ year old man with fever// fevers
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___. CT chest ___.
FINDINGS:
There is no focal consolidation, pleural effusion or pneumothorax. The
cardiomediastinal silhouette is within normal limits. No acute osseous
abnormalities are identified.
IMPRESSION:
No pneumonia or acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with Laceration without foreign body of nose, initial encounter, Fall (on) (from) unspecified stairs and steps, init encntr, Syncope and collapse, Alcohol abuse with intoxication, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | Patient was admitted to the ___ Spine Surgery Service for
observation to ensure that he recovered from his injury.
pnemoboots were used for DVT prophylaxis. Pain was controlled
with IV and PO pain medications. Diet was advanced as
tolerated. The patient was transitioned to oral pain medication
when tolerating PO diet. Physical therapy was consulted for
mobilization OOB to ambulate. 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: SURGERY
Allergies:
Penicillins / phenobarbital / Sulfa (Sulfonamide Antibiotics) /
oxycodone
Attending: ___.
Chief Complaint:
pelvic pressure
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ year-old woman with an inflammatory bowel
disease felt to be Crohn's who had an abdominal colectomy with
end ileostomy in ___ at an OSH, s/p ileostomy revision due to
prolapse in ___ and now ___ s/p lap proctectomy who presents
with pain and swelling at her perineal incision. She was
evaluated by her PCP 1 day prior and started on Keflex and cipro
for concern of cellulitis. On exam, she reports feeling
generally
unwell for the past few days and a new pressure sensation near
her incision. She notes her drain has ~80 cc of serosanguinous
output each day. She denies fevers, chills, chest pain,
shortness
of breath, nausea, vomiting, changes in ileostomy output, or
difficulty voiding.
Past Medical History:
Past Medical History:
INDETERMINATE COLITIS
SEIZURE DISORDER
OSTEOPOROSIS
FIBROMYALGIA
? INFLAMMATORY ARTHOPATHY
ANXIETY
Past Surgical History:
ILEOSTOMY REVISION
COLECTOMY WITH END ILEOSTOMY
Social History:
___
Family History:
Family history positive for colitis
Physical Exam:
Physical Exam
VS: 98.5F HR:108 BP:92/63 RR:18 98% on room air
Gen: Uncomfortably appearing, A&Ox3, pleasant, conversant
CV: RRR
Resp: Breathing comfortably on room air
Abd: Ostomy with gas & stool, abdomen soft, non-tender,
non-distended, drain with thin serosanguinous drainage
Perineum: Incision well-approximated, mild erythema, no
expressible purulence, no fluctuance appreciated, tender to
palpation
Ext: Warm, well-perfused
Pertinent Results:
___ 01:02PM BLOOD Lactate-1.5
___ 08:02AM BLOOD WBC-6.9 RBC-2.91* Hgb-8.8* Hct-28.2*
MCV-97 MCH-30.2 MCHC-31.2* RDW-12.3 RDWSD-43.4 Plt ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 600 mg PO TID
2. LevETIRAcetam 500 mg PO BID
3. TraZODone 50 mg PO QHS:PRN insomina
4. desvenlafaxine succinate 100 mg oral DAILY
5. Multivitamins 1 TAB PO DAILY
6. Vitamin D ___ UNIT PO DAILY
7. Denosumab (Prolia) 60 mg SC Q6MOS
8. Acetaminophen 1000 mg PO Q8H
9. Enoxaparin Sodium 40 mg SC DAILY
Discharge Medications:
1. Fluconazole 150 mg PO Q72H yeast infection
RX *fluconazole 150 mg 1 tablet(s) by mouth every 72 hours Disp
#*3 Tablet Refills:*0
2. Acetaminophen 1000 mg PO Q8H
3. Denosumab (Prolia) 60 mg SC Q6MOS
4. desvenlafaxine succinate 100 mg oral DAILY
5. Enoxaparin Sodium 40 mg SC DAILY
For 28 days post-op
6. Gabapentin 600 mg PO TID
7. LevETIRAcetam 500 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. TraZODone 50 mg PO QHS:PRN insomina
10. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Crohn's disease with retained rectum
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old woman with Crohn's disease s/p lap proctectomy ___
presents with 5 days of increased perineal wound pain and redness* Perform
study with PO and IV contrast *// * Perform study with PO and IV contrast
*evaluate for infection/collection near perineal wound
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2
mGy-cm.
2) Stationary Acquisition 5.0 s, 1.0 cm; CTDIvol = 11.6 mGy (Body) DLP =
11.6 mGy-cm.
3) Spiral Acquisition 12.3 s, 42.4 cm; CTDIvol = 7.2 mGy (Body) DLP = 295.3
mGy-cm.
Total DLP (Body) = 322 mGy-cm.
COMPARISON: MR enterography ___
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are normal in size with asymmetric abnormal nephrogram.
No hydronephrosis. There is a 3 mm nonobstructing stone within the right
inferior pole renal collecting system. There is a millimetric simple cyst
within the interpolar left kidney, too small to characterize by CT but likely
representative of a simple cyst. No suspicious lesions.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel demonstrates
normal caliber and enhancement. No small-bowel obstruction. There is a right
lower quadrant ostomy. The patient is status post colectomy and proctectomy.
PELVIS: The urinary bladder is within normal limits. The uterus is normal. A
left adnexal cyst measures up to 3.5 cm and a right adnexal cyst measures up
to 2.8 cm, similar in size and appearance to the prior study, though both
adnexal cysts are shifted posteriorly due to proctectomy.
Inferiorly to the adnexal cysts, there is a slightly hypodense heterogeneous
collection with soft tissue stranding measuring up to 2.3 x 1.4 cm (series 6,
image 21). No organized collection is demonstrated. The surgical drain
courses just inferior to the hypodense collection.
LYMPH NODES: There are scattered prominent lymph nodes which are likely
reactive, predominately within the periportal and bilateral upper periaortic
spaces. No lymphadenopathy by CT size criteria.
VASCULAR: There is no abdominal aortic aneurysm. No substantial
atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Right lower quadrant ostomy as described above. Postsurgical
changes along the anterior midline as well as a left lower quadrant surgical
drain.
IMPRESSION:
1. Postoperative changes in the presacral space with soft tissue stranding and
heterogeneous hypodense non organized fluid measuring up to 2.0 cm in the
postsurgical bed, likely a seroma. No organizing or rim enhancing fluid
collections.
2. Of note, physiologic bilateral adnexal cysts are noted superior to the
presacral postoperative changes, and should not be mistaken for fluid
collections.
3. No bowel obstruction.
4. Nonobstructing right renal stone measuring 3 mm.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Wound eval
Diagnosed with Other specified diseases of anus and rectum
temperature: 98.5
heartrate: 108.0
resprate: 18.0
o2sat: 98.0
sbp: 92.0
dbp: 63.0
level of pain: 5
level of acuity: 3.0 | Ms. ___ presented to ___ ED on ___ for pain and
swelling along her incision s/p lap proctectomy. She was
admitted for further workup.
Neuro: Pain was well controlled on Tylenol and tramadol for
breakthrough pain.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulm: The patient remained stable from a pulmonary standpoint;
oxygen saturation was routinely monitored. He/She had good
pulmonary toileting, as early ambulation and incentive
spirometry were encouraged throughout hospitalization.
GI: The patient was initially kept NPO. Patient's intake and
output were closely monitored.
GU: At time of discharge, the patient was voiding without
difficulty. Urine output was monitored as indicated.
ID: The patient was closely monitored for signs and symptoms of
infection and fever. CT imaging did not reveal a drainable fluid
collection. Examination of the incision site did not indicate
active infection. She was initially started on Cipro and flagyl
empirically which was discontinued. She had concern for a yeast
infection predating the admission and exacerbated by the
antibiotic infusion.
Heme: The patient received subcutaneous heparin and ___ dyne
boots during this stay. She was encouraged to get up and
ambulate as early as possible. The patient is being discharged
on prophylactic Lovenox.
On ___, the patient was discharged to home. At discharge,
She will follow-up in the clinic. This information was
communicated to the patient directly prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M with h/o EtOh abuse brought in intoxicated complainting
of chest pain radiating down L arm for the past several hours.
He has had this kind of chestp ain before. Also feels short of
___. Admits to EoH use.
In the ED, went in to afib with RVR, which converted back to
sinus after 1L NS. He was intiially agitated and received haldol
5mg IM and ativan 2mg IM. Also received 10mg valium PO for etoh
withdrawal symptoms. CXR clear.
On arrival to the floor, patient c/o ___ pain.
Past Medical History:
1. ETOH abuse as above
2. Hepatitis C: He has never been treated and is followed by
his PCP.
3. s/p cholecystectomy in ___
4. s/p bariatric surgery in ___
5. h/o PUD in ___
6. h/o C. diff in ___
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
summden cardiac death; otherwise non-contributory.
Physical Exam:
Admission physical exam:
VS: T 98.1, BP 134/82, HR 110, RR 16 O2 Sat 99%2L
Weight 122.6kg
GEN:A&Ox3, tired
HEENT: NCAT, EOMI, PERRL, MMM. no LAD, no JVD, neck supple
CV: RRR. normal S1/S2, no murmurs, rubs, or gallops. No thrills,
lifts. No S3 or S4. PMI located in ___ intercostal space,
midclavicular line.
Lung: CTAB, no wheezes, rales, or rhonchi, respirations were
unloabored, no accessory muscle use. No chest wall deformities,
scoliosis, or kyphosis
ABD: RQU pain to palp, otherwise NT/ND. BS+
EXT: W/WP, no edema, no C/C. No femoral bruits
SKIN: W/D/I. No stasis dermatitis, ulcers, scars, xanthomas
NEURO: CNs II-XII intact. ___ strength in U/L extremities.
Sensation intact to LT.
PULSES:
Right: DP2+ PT2+
Left DP2+ PT2+
Discharge physical exam:
Unchaged from admission physical exam.
Pertinent Results:
Admission labs:
___ 11:50PM BLOOD WBC-8.0 RBC-4.71 Hgb-13.1*# Hct-41.8#
MCV-89# MCH-27.8# MCHC-31.4 RDW-14.6 Plt ___
___ 11:50PM BLOOD Neuts-55.3 ___ Monos-5.9 Eos-2.2
Baso-0.9
___ 11:50PM BLOOD ___ PTT-36.4 ___
___ 11:50PM BLOOD Glucose-86 UreaN-13 Creat-0.7 Na-142
K-3.6 Cl-107 HCO3-21* AnGap-18
___ 11:50PM BLOOD ALT-173* AST-388* CK(CPK)-379*
AlkPhos-315* TotBili-0.2
___ 11:50PM BLOOD Albumin-4.0 Cholest-112
___ 11:50PM BLOOD %HbA1c-5.7 eAG-117
___ 11:50PM BLOOD Triglyc-131 HDL-41 CHOL/HD-2.7 LDLcalc-45
___ 11:50PM BLOOD TSH-2.4
___ 11:50PM BLOOD Free T4-0.94
Discharge labs:
___ 05:53AM BLOOD Glucose-82 UreaN-13 Creat-0.6 Na-141
K-3.7 Cl-107 HCO3-23 AnGap-15
___ 05:53AM BLOOD ALT-134* AST-207* CK(CPK)-363*
AlkPhos-273* TotBili-0.4
___ 11:50PM BLOOD CK-MB-4
___ 11:50PM BLOOD cTropnT-<0.01
___ 05:53AM BLOOD CK-MB-4 cTropnT-<0.01
___ 05:53AM BLOOD Albumin-3.6 Calcium-8.3* Phos-2.6*
Mg-1.4*
___ 11:50PM BLOOD HCV Ab-POSITIVE*
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Omeprazole 20 mg PO DAILY
2. Naproxen 500 mg PO Q12H:PRN pain
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
2. Naproxen 500 mg PO Q12H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Alcohol intoxication
Multifocal atrial tachycardia
Secondary diagnosis:
Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
PORTABLE CHEST: ___.
HISTORY: ___ male with chest pain.
FINDINGS: Single portable view of the chest is compared to previous exam from
___. Low lung volumes seen on the current exam. The lungs are
grossly clear without evidence of large consolidation or effusion.
Cardiomediastinal silhouette is stable given differences in positioning and
technique. Osseous and soft tissue structures are unremarkable.
IMPRESSION: No definite acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: CP
Diagnosed with ALCOHOL ABUSE-UNSPEC, ATRIAL FIBRILLATION
temperature: 100.0
heartrate: 106.0
resprate: 16.0
o2sat: 98.0
sbp: 134.0
dbp: 90.0
level of pain: 10
level of acuity: 2.0 | Patient left against medical adivce. He was able to voice that
he was leaving against medical advice and understood the risks
of leaving against medical advice. He was advised that if his
symptoms worsened, then he should return to the ED to be
re-evaluated.
#Atrial fibrillation/atrial multifocal tacyhcardia: Patient has
a history of paroxysmal atrial fibrillation and has presented to
ED in RVR previously. Converted to sinus after 2L NS. The
patient reports that drinking can exacerbate his heart rhythm.
It was planned for him to received metoprolol 12.5mg QID, but
the patient left AMA. Of note, cardiac enzymes were negative.
#History of alcohol abuse: Patient was placed on CIWA scale upon
admission. He was given a banana bag as well. The patient also
had LFTs that were elevated likely due to his recent alcohol
ingestion. The patient's LFTs were noted to be downtrending. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Nortriptyline
Attending: ___.
Chief Complaint:
Leg swelling
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ female with PMH significant
for CAD, CHF with preserved ejection fraction, Gold Stage IV
COPD on 2L O2 baseline, diabetes type 2 on insulin, morbid
obesity, sleep apnea, h/o hypercarbic respiratory failure ___,
recurrent b/l lower extremity ulcers, h/o cocaine use, ___ heavy
alcohol use, who presented from clinic today for unilateral L
leg swelling x 2 weeks. She reports gradual swelling, left
greater than right. No fevers/chills, no significant burning or
pain, just increased pressure. She reports a discomfort at the
bottom of her feet, left greater than right. No trauma, no rash.
She also reports a single episode of chest pressure in her left
chest that came on at rest with no inciting features, lasted 5
seconds, and did not recur. She never has anginal symptoms while
climbing stairs or otherwise exerting herself.
At her PCP office, her left leg was noted to be enlarged
compared to the right and she was referred to the ED for lower
extrem doppler.
In the ED initial vitals were: 97.5 70 121/80 18 98% 2LNC. Note
was made of weeping RLE concerning for cellulitis.
Past Medical History:
- Morbid obesity
- Coronary artery disease
- Obstructive sleep apnea
---> Noncompliant with CPAP
- Obesity Hypoventilation Syndrome
- Chronic Diastolic Heart Failure
---> EF 55% in ___.
---> BNP during last CHF exacerbation 23,000
- Atrial Fibrillation
- Chronic obstructive pulmonary disease
---> Last FEV1 31% predicted\
- Diabetes Mellitus 2
- Hypertension
- Prior intubations for respiratory failure -- last ___
- Polysubstance abuse - currently smoking
- Alcoholism
- Upper gastrointestinal bleed
- Depression
- Migraines
- Gallstones
- Hysterectomy
- Macrocytosis
Social History:
___
Family History:
- Significant for DM & HTN
Physical Exam:
Admission and Discharge Physical Exam:
Vitals- Tm 98.1 BP 94/66 (90s-150s/60s-80s) P 77 (70s-80s) RR 22
(___) 96-97% on 2L
General- Alert, oriented, AAOx3, no acute distress, obese female
HEENT- Sclera anicteric, MMM, nasal cannula in place
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, no JVP, ___ reflux
Abdomen- obese, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly. No
CVAT
Ext- warm, well perfused, 2+ pulses, 2+ pitting edema L>R
Skin- lower extremities erythematous, warm to touch L>R, with
chronic lichenification changes as well as some pus noted under
skin on left side in medial shin area
Pertinent Results:
Admission Labs:
___ 06:23PM BLOOD WBC-8.6 RBC-4.01* Hgb-12.2 Hct-39.5
MCV-99* MCH-30.3 MCHC-30.8* RDW-14.4 Plt ___
___ 06:23PM BLOOD Neuts-61.4 ___ Monos-6.4 Eos-3.6
Baso-0.8
___ 06:23PM BLOOD Glucose-97 UreaN-39* Creat-1.1 Na-139
K-5.3* Cl-96 HCO3-32 AnGap-16
___ 06:31PM BLOOD Lactate-2.8*
Pertinent Labs:
___ 06:50AM BLOOD CK(CPK)-141
___ 06:50AM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:23PM BLOOD cTropnT-<0.01 proBNP-84
Discharge Labs:
___ 06:50AM BLOOD WBC-6.7 RBC-3.69* Hgb-11.3* Hct-35.5*
MCV-96 MCH-30.7 MCHC-31.9 RDW-14.2 Plt ___
___ 06:50AM BLOOD Glucose-132* UreaN-34* Creat-0.9 Na-140
K-4.1 Cl-99 HCO3-31 AnGap-14
___ 03:34PM BLOOD Lactate-1.7
Imaging:
- ___ ___ Impression: Less than optimal due to body habitus.
The peroneal veins were not seen bilaterally. Otherwise, no
evidence of deep venous thrombosis in the bilateral lower
extremities.
- CXR ___ impression: Persistent prominence of the hila
suggesting pulmonary vascular engorgement/enlargement of the
central pulmonary arteries, similar to prior, with possible mild
increase in vascular congestion as compared to prior study.
Micro:
- Urine cx ___: pnding
- Blood cx x ___: pnding
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H
2. Artificial Tears 1 DROP BOTH EYES BID
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PR PRN constipation
5. Bisacodyl 10 mg PO DAILY:PRN constipation
6. Cepacol (Menthol) 1 lozenge Other q4h:prn sore throat
7. Docusate Sodium 100 mg PO BID
8. Fleet Enema 1 Enema PR PRN constipation
9. Guaifenesin 10 mL PO Q4H:PRN cough
10. Ibuprofen 200 mg PO Q8H:PRN pain
11. Lactulose 30 mL PO DAILY:PRN constipation
12. MetFORMIN (Glucophage) 1000 mg PO BID
13. Metoprolol Tartrate 6.25 mg PO BID
14. Milk of Magnesia 30 mL PO PRN constipation
15. Polyethylene Glycol 17 g PO BID
16. Potassium Chloride 20 mEq PO DAILY
17. Senna 17.2 mg PO QHS
18. Simvastatin 40 mg PO QPM
19. DuoNeb (ipratropium-albuterol) 0.5 mg-3 mg(2.5 mg base)/3 mL
inhalation q4h:prn dyspnea
20. Cyanocobalamin 100 mcg PO DAILY
21. Acetaminophen 650 mg PO Q6H:PRN pain/fever
22. Albuterol Inhaler 2 PUFF IH Q2H PRN wheeze sob
23. Hydrocerin 1 Appl TP TID:PRN dry/irritated skin
24. Lisinopril 2.5 mg PO DAILY
25. Omeprazole 20 mg PO DAILY
26. Fluoxetine 40 mg PO DAILY
27. GlipiZIDE 5 mg PO BID
28. Tiotropium Bromide 1 CAP IH DAILY
29. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
30. Ipratropium-Albuterol Neb 1 NEB NEB QID
31. Fluticasone Propionate NASAL 1 SPRY NU DAILY
32. Torsemide 80 mg PO DAILY
33. TraMADOL (Ultram) 50 mg PO Q6H:PRN severe pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
2. Albuterol Inhaler 2 PUFF IH Q2H PRN wheeze sob
3. Artificial Tears 1 DROP BOTH EYES BID
4. Bisacodyl 10 mg PR PRN constipation
5. Bisacodyl 10 mg PO DAILY:PRN constipation
6. Cyanocobalamin 100 mcg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Fluoxetine 40 mg PO DAILY
9. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
10. Guaifenesin 10 mL PO Q4H:PRN cough
11. Hydrocerin 1 Appl TP TID:PRN dry/irritated skin
12. Ipratropium-Albuterol Neb 1 NEB NEB QID
13. Lactulose 30 mL PO DAILY:PRN constipation
14. Lisinopril 2.5 mg PO DAILY
15. Metoprolol Tartrate 6.25 mg PO BID
16. Milk of Magnesia 30 mL PO PRN constipation
17. Omeprazole 20 mg PO DAILY
18. Polyethylene Glycol 17 g PO BID
19. Senna 17.2 mg PO QHS
20. Simvastatin 40 mg PO QPM
21. Tiotropium Bromide 1 CAP IH DAILY
22. Torsemide 80 mg PO DAILY
23. Cephalexin 500 mg PO Q6H Duration: 4 Days
RX *cephalexin 500 mg 1 tablet(s) by mouth every six (6) hours
Disp #*24 Tablet Refills:*0
24. Acetaminophen 650 mg PO Q6H:PRN pain/fever
do not exceed 3 g/day
25. Cepacol (Menthol) 1 lozenge Other q4h:prn sore throat
26. Fleet Enema 1 Enema PR PRN constipation
27. Fluticasone Propionate NASAL 1 SPRY NU DAILY
28. GlipiZIDE 5 mg PO BID
29. Potassium Chloride 20 mEq PO DAILY
Hold for K >
30. MetFORMIN (Glucophage) 1000 mg PO BID
31. TraMADOL (Ultram) 50 mg PO Q6H:PRN severe pain
32. Aspirin 81 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses: Chronic venous statis, venous stasis ulcer,
cellulitis
Secondary diagnoses: Paroxysmal a fib, copd, obesity, DM
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 ___ swelling, chest pain //
TECHNIQUE: Chest Frontal and Lateral
COMPARISON: ___
FINDINGS:
There is persistent prominence of the hila suggesting vascular engorgement
with possible mild increase in vascular congestion as compared to the prior
study. No new focal consolidation is seen. There is no large pleural effusion
or pneumothorax. The cardiac and mediastinal silhouettes are stable.
IMPRESSION:
Persistent prominence of the hila suggesting pulmonary vascular
engorgement/enlargement of the central pulmonary arteries, similar to prior,
with possible mild increase in vascular congestion as compared to prior study.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with worsening bilateral ___ swelling // DVT?
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: Left lower extremity Doppler ultrasound from ___. No
prior right lower extremity ultrasound available for comparison.
FINDINGS:
Suboptimal due to body habitus. There is compressibility and wall to wall
color flow of the bilateral common femoral, superficial femoral, and popliteal
veins. Color flow is demonstrated in the posterior tibial veins. The peroneal
veins were not visualized.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
Less than optimal due to body habitus. The peroneal veins were not seen
bilaterally. Otherwise, no evidence of deep venous thrombosis in the bilateral
lower extremities.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Leg swelling
Diagnosed with CELLULITIS OF LEG
temperature: 97.5
heartrate: 70.0
resprate: 18.0
o2sat: 98.0
sbp: 121.0
dbp: 80.0
level of pain: 8
level of acuity: 3.0 | ___ AAF with diabetes, CHF, COPD, recurrent multi-drug resistant
UTI and multiple comorbidities presents with lower exrem
swelling, L>R, as well as dysuria with pyuria on U/A. ___
grossly negative for PE but not conclusive. CXR shows
potentially mild increase in pulmonary vascular congestion but
exam less concerning for fluid overload as cause and patient
satting well on baseline oxygen. Exam showed chronic venous
stasis changes with developing ulcer on left medial leg and some
erythema concerning for possible overlying cellulitis. Pt
overall afebrile, satting ___ home oxygen, vital signs
stable, deemed safe for discharge home on antibiotics for
cellulitis and to follow-up management of chronic venous
insufficiency. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right elbow/forearm pain/swelling/erythema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ PMH notable for HTN/HLD, IDDM, and RCC s/p nephrectomy
(___) c/b CKD that presents w/ 5days of pain/swelling/erythema
of R forearm/elbow. ___
Past Medical History:
HTN
Hyperlipidemia
DM (diabetes mellitus), type 2
CKD (chronic kidney disease) stage 3, GFR ___ ml/min
Renal cell cancer s/p L nephrectomy ___
Hemorrhoid
Diverticulitis
Anemia
Sickle Cell trait
Substance Dependence
Colonic adenoma
Cervical radiculopathy
Back pain
s/p rotator cuff repair ___
Social History:
___
Family History:
Mother died age ___ colon cancer dx age ___. Also with DM, HTN.
Father unknown hx. No known history of early MIs, arrhythmia,
cardiomyopathies, sudden deaths.
Physical Exam:
Right upper extremity:
-Painless A/PROM of elbow - flex/ext, pronosupination
-Fires EPL, FPL, DIO
-SILT r/m/u
-Palpable radial artery
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Chlorthalidone 25 mg PO DAILY
2. Lisinopril 5 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Glargine 35 Units Bedtime
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. cefaDROXil 500 mg oral BID Duration: 10 Days
RX *cefadroxil 500 mg 1 capsule(s) by mouth twice a day Disp
#*20 Capsule Refills:*0
3. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN
BREAKTHROUGH PAIN
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*15 Tablet Refills:*0
4. Glargine 35 Units Bedtime
5. Atorvastatin 20 mg PO QPM
6. Chlorthalidone 25 mg PO DAILY
7. Lisinopril 5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Right forearm cellulitis and potential septic olecranon bursitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with elbow effusion, erythema.// Evaluate for
effusion, fracture.
TECHNIQUE: Right elbow, three views
COMPARISON: None.
FINDINGS:
No definite acute fracture or dislocation. Marked degenerative changes of the
humeral ulnar and humeral radial joints with osteophyte formation, joint space
narrowing, and probable intra-articular loose bodies. Enthesophyte is seen at
the insertion of the triceps upon the olecranon. No suspicious lytic or
sclerotic osseous abnormalities. No radiopaque foreign bodies. Mild soft
tissue swelling about the elbow without soft tissue gas.
IMPRESSION:
Mild soft tissue swelling about the elbow without joint effusion. No acute
fracture or dislocation.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: R Elbow pain
Diagnosed with Cellulitis of right upper limb
temperature: 98.3
heartrate: 88.0
resprate: 16.0
o2sat: 99.0
sbp: 144.0
dbp: 98.0
level of pain: 6
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the hand surgery team. The patient was found to
have a Right forearm cellulitis and potential septic olecranon
bursitis and was admitted to the hand surgery service. The
patient was started on IV ancef, which resulted in improvement
in symptoms. The patient was given anticoagulation per routine,
and the patient's home medications were continued throughout
this hospitalization. The ___ hospital course was
otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, and the patient was voiding/moving bowels
spontaneously. The patient is weight bearing as tolerated in the
Right upper extremity. He will take oral cefadroxil for 7 days
for antibiotic therapy. The patient will follow up with Dr.
___ routine. A thorough discussion was had with the
patient regarding the diagnosis and expected post-discharge
course including reasons to call the office or return to the
hospital, and all questions were answered. The patient was also
given written instructions concerning precautionary instructions
and the appropriate follow-up care. The patient expressed
readiness for discharge. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
shortness of breath, chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ year-old gentleman with a PMH of non-ischemic
dilated cardiomyopathy (EF 20%), COPD, previous PNAs, now
admitted with dypsnea and chest pain. Of note, he was admitted
to ___ for acute decompensation of CHF ___.
Patient reports that he has been experiencing shortness of
breath over the past 4 days, and this has been associated with
substernal chest pain that was exertional and cough productive
of whitish sputum. His chest pain resolved prior to arrival in
the ED. He has been compliant with his torsemide 60 mg PO daily
(took it in the morning prior to presentation). He also took
aspirin 162 mg PO prior to presentation.
On arrival to the ___ ED, initial vital signs were: T97.5
HR101 BP116/79 RR22 O294% on 4LNC. Labs were remarkable for:
proBNP 4028, troponin 0.06; WBC 7.5 with 75%N; K 5.5, BUN 28, Cr
1.7; lactate 2.0. UA showed no evidence of infection. Blood
culture was sent. EKG showed sinus tachycardia at 100 bpm, NA/NI
(QTc 421 msec), with possible interventricular conduction delay
(QRS ~110 bpm), no ST elevations/depressions or Q waves. Chest
x-ray (portable AP) showed moderately increased lung markings
with lower zone predominance, suggestive of pulmonary fibrosis
without much change from prior. He was given nitroglycerin SL
and aspirin 162 mg (for a total of 325 mg for today). He was
placed on CPAP for increased work of breathing, with settings Vt
400-500, RR ___, PEEP 5, PS 5, FiO2 50%. He tolerated CPAP
well. Vitals on transfer were: 97.2 105 ___ 93% NC. Prior
to transfer, he was given furosemide 120 mg IV x1.
On arrival to the floor, the patient appeared stable. On
interview, he denied any recent illnesses or symptoms such as
fevers, chills, night sweats. He can walk about 1 mile without
getting short of breath when he is not having an acute
exacerbation. He sleeps on ___ pillows at night and does not
wake up short of breath. He does not typically have leg
swelling. He also have not had any hemoptysis, hematemesis,
nausea, vomiting, abdominal pain, or diarrhea.
REVIEW OF SYSTEMS
Negative in addition to above
Past Medical History:
1. CARDIAC RISK FACTORS: (+)Diabetes, (+)Dyslipidemia,
(+)Hypertension
2. CARDIAC HISTORY:
- ischemic cardiomyopathy (EF ___ as of ___, likely
cocaine-related, with last hospitalization for acute
decompensated CHF from ___ to ___.
3. OTHER PAST MEDICAL HISTORY:
- Insulin-dependent diabetes
- Hyperlipidemia
- HTN
- hepatitis C antibody positive
- h/o MRSA pneumonia (requiring trach)
- COPD
- Schizophrenia (functioning well on no medications)
- Substance abuse (cocaine, alcohol, weed)
- Tobacco abuse
- Anxiety
- cocaine induced pneumonitis
- restrictive lung disease
Social History:
___
Family History:
Father: DM, ___, deceased. Mother with breast CA. No
family history of pulmonary disease.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: T=97.5 BP=105/73 HR=107 RR=20 O2 sat=94% on 4L NC
General: sitting in bed, in mild respiratory distress
Neck: supple
CV: RRR, no M/R/G
Lungs: bibasilar crackles up ___ of lung fields, no wheezing,
generally poor air movement
Abdomen: normal bowel sounds, soft, non-tender, non-distended
Ext: warm, well-perfused, trace to 1+ lower extremity edema up
to mid shins bilaterally
Neuro: alert and oriented x3
Skin: no rashes or lesions
Pulses: 2+ radial and carotid pulses bilaterally; DP and ___
pulses doppler-able bilaterally
DISCHARGE PHYSICAL EXAM
VS: 98.2/98.2, BP 115/78, HR 99, RR 18 96% 3L NC
I/O 24H: 1120 in/3850 out
(590 in/150 out on floor; 530 in/3.7L out on CCU)
I/O 8H: NR
Weight: 85.3kg
General: NAD
Neck: supple
CV: RRR, no M/R/G
Lungs: bibasilar crackles, diffuse coarse inspiratory sounds, no
wheezing, generally poor air movement
Abdomen: normal bowel sounds, soft, non-tender, non-distended
Ext: warm, well-perfused, trace to 1+ lower extremity edema to
ankles
Neuro: alert and oriented x3
Skin: no rashes or lesions
Pulses: 2+ radial and carotid pulses bilaterally; DP and ___
pulses doppler-able bilaterally
Pertinent Results:
ADMISSION LABS
___ 08:42AM BLOOD WBC-7.4 RBC-4.55* Hgb-11.5* Hct-35.8*
MCV-79* MCH-25.3* MCHC-32.1 RDW-18.1* Plt ___
___ 08:42AM BLOOD Neuts-75.0* Lymphs-15.2* Monos-5.4
Eos-3.3 Baso-1.1
___ 08:42AM BLOOD ___ PTT-31.0 ___
___ 08:42AM BLOOD Glucose-58* UreaN-38* Creat-1.7* Na-138
K-5.5* Cl-102 HCO3-24 AnGap-18
___ 05:10PM BLOOD CK(CPK)-375*
___ 08:42AM BLOOD CK-MB-9 proBNP-4028*
___ 08:42AM BLOOD cTropnT-0.06*
___ 08:42AM BLOOD Calcium-8.6 Phos-4.2 Mg-1.7
___ 04:16AM BLOOD Digoxin-0.7*
___ 08:50AM BLOOD Lactate-2.0
___ 11:10AM URINE Color-Straw Appear-Clear Sp ___
___ 11:10AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 11:10AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
DISCHARGE LABS:
___ 05:30AM BLOOD WBC-7.1 RBC-4.31* Hgb-11.0* Hct-34.7*
MCV-81* MCH-25.5* MCHC-31.6 RDW-17.5* Plt ___
___ 05:30AM BLOOD Glucose-167* UreaN-38* Creat-1.4* Na-138
K-4.6 Cl-98 HCO3-26 AnGap-19
___ 05:30AM BLOOD Calcium-9.1 Phos-4.1 Mg-2.2
MICROBIOLOGY:
___ Blood cultures x2: no growth to date
EKG (___): sinus tachycardia at 100 bpm, NA/NI (QTc ~470
ms), with possible interventricular conduction delay (QRS ~110
bpm), no ST elevations/depressions or Q waves
___ CXR (portable AP): Severe cardiomegaly with tortuosity
of the aorta is unchanged from prior study. Hilar contours are
unremarkable. Again appreciated are moderate increased
interstitial lung markings with lower zone predominance, similar
to prior examination given difference of technique. There is no
focal consolidation. There is no pleural effusion or
pneumothorax.
IMPRESSION: Similar appearance of moderately increased
interstitial lung markings suggestive of pulmonary fibrosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath or
coughing
2. Aspirin EC 81 mg PO DAILY
3. Atorvastatin 20 mg PO HS
4. Digoxin 0.125 mg PO DAILY
5. Glargine 48 Units Breakfast
Glargine 48 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Lorazepam 0.5 mg PO Q8H:PRN anxiety
7. Losartan Potassium 25 mg PO DAILY
8. Omeprazole 20 mg PO BID
9. Torsemide 40 mg PO DAILY
10. TraMADOL (Ultram) 50 mg PO BID:PRN severe pain only
11. traZODONE 100 mg PO HS
12. HumaLOG KwikPen (insulin lispro) 100 unit/mL Subcutaneous
TID
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath or
coughing
2. Aspirin EC 81 mg PO DAILY
3. Atorvastatin 20 mg PO HS
4. Digoxin 0.125 mg PO DAILY
5. Glargine 48 Units Breakfast
Glargine 48 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
RX *blood sugar diagnostic [FreeStyle Test] as directed TID
before meals Disp #*1 Box Refills:*3
6. Losartan Potassium 25 mg PO DAILY
7. Omeprazole 20 mg PO BID
8. Torsemide 60 mg PO DAILY
9. traZODONE 100 mg PO HS
RX *trazodone 100 mg one tablet(s) by mouth hs Disp #*30 Tablet
Refills:*2
10. Nicotine Patch 14 mg TD DAILY
11. HumaLOG KwikPen (insulin lispro) 100 unit/mL Subcutaneous
TID
12. TraMADOL (Ultram) 50 mg PO BID:PRN severe pain only
Discharge Disposition:
Home
Discharge Diagnosis:
Acute on chronic systolic heart failure
Acue on chronic kidney injury
Restrictive lung disease
Diabetes Mellitus
Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: CHF with dyspnea.
COMPARISON: ___.
TECHNIQUE: Portable frontal chest radiograph, single view.
FINDINGS: Severe cardiomegaly with tortuosity of the aorta is unchanged from
prior study. Hilar contours are unremarkable. Again appreciated are moderate
increased interstitial lung markings with lower zone predominance, similar to
prior examination given difference of technique. There is no focal
consolidation. There is no pleural effusion or pneumothorax.
IMPRESSION: Similar appearance of moderately increased interstitial lung
markings suggestive of pulmonary fibrosis.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dyspnea, Chest pain
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS, HYPERLIPIDEMIA NEC/NOS
temperature: 97.5
heartrate: 101.0
resprate: 22.0
o2sat: 94.0
sbp: 116.0
dbp: 79.0
level of pain: 5
level of acuity: 2.0 | Mr. ___ is a ___ year-old gentleman with a PMH of non-ischemic
dilated cardiomyopathy (EF 20%), COPD, previous PNAs, admitted
with dypsnea and chest pain.
ACTIVE ISSUES
# Dyspnea: Dyspnea was thought to be multifactorial from acute
on chronic systolic HF, cocaine induced pulmonary fibrosis, and
COPD flare. He has a baseline LVEF of ___ from his previous
echo. On physical exam, he demonstrates all the classic signs of
heart failure (elevated JVP, crackles in the lungs, and lower
extremity edema). Patient is not on a beta-blocker due to
ongoing cocaine use, and not on spiranolactone due to
non-compliance. He was diuresed with IV lasix and continued on
home losartan, digoxin, atorva and aspirin. He required 3L
nasal cannula, which was weaned off with diuresis. For his
subjective SOB he was given nebs, which improved his symptoms.
At discharge, his weight was 85.3 kg.
# Chest Pain: His chest pain was unlikely to be ischemic in
nature given that his troponin is around his baseline level of
0.04 to 0.10 and an ECG showing no signs of ischemia. It was
described as chronic and intermittent. He was monitored on
telemtry without any events.
CHRONIC ISSUES
# CKD: His baseline creatinine level is around 1.3 to 1.5 with
elevations to 2 occasionally. Usually, he presents with an
elevated creatinine from baseline on presentation and trend down
during the course of hospitalization. He presented with Cr 1.7
which trended down to his baseline and was thought that in the
setting of decompensated heart failure, he had poor forward flow
to the kidneys.
# COPD: Stable. Continued albuterol nebs at needed.
# Diabetes: Stable. His last HbA1c was 7.9 on ___. Continued
reduced regimen of insulin glargine 40 units at breakfast and
bedtime and titrated up to home regimen with insulin sliding
scale AC and HS
# GERD: Stable. Continued home omeprazole.
# Anxiety: Continued home lorazepam as needed.
TRANSITIONAL ISSUES:
- At discharge, patient was referred to ___
___/ ___ Counseling as part of discharge plan.
- At the time of discharge, blood cultures x2 from ___ had
not finalized. As of ___, there was still no growth to date.
- CODE: confirmed FULL
- EMERGENCY CONTACT: ___ (sister), ___,
alternatively, ___ (sister), ___,
___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
linezolid / allopurinol
Attending: ___.
Chief Complaint:
swollen, red leg, altered mental status and fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ is a ___ year old woman w/PMH progressive MS, HTN,
lymphedema, recurrent cellulitis (admitted ___ for LLE
cellulitis), NHL in remission (NOT on therapy), who presents
with
altered mental status and fever.
Per patient's husband, she was not acting like herself this
morning. He found her covered in urine and noticed redness of
the
right leg. He says she is baseline AAOx3, ambulates with walker
at home. He checked her temp and it was 102.9. He reports she
has
had low PO intake over the last 24 hours as well. He reports no
new cough or SOB.
The patient is more alert on my assessment and does not have any
acute complaints. Husband thinks she is not back at full
baseline
but much better. She describes a upper left quadrant pain which
she attributes to rib fractures from ___ years ago, not a new
issue. Denies other abdominal or suprapubic pain.
Of note, she had a recent admission here for cellulitis of the
left leg due to a traumatic injury, and has had this wound
managed by wound care upon discharge. She also has h/o UTIs due
to neurogenic bladder. She has fecal incontinence as well and
follows with CRS.
For her NHL, she is off rituximab but is still supposed to be
getting IVIG, but due to shortage has not received in months.
She
is scheduled tomorrow for appt for this.
In the ED:
- Initial vital signs were notable for: T 99.6 HR 86 BP 132/74
RR
18 SpO2 97% RA
- Exam notable for: redness overlying right shin with bullae
noted, legs nontender to palpation.
- Labs were notable for: WBC 11.7 Hgb 9.9 CRP 65.7 K 6.5
(hemolyzed) repeat K 3.7, flu negative, UA with 15 WBC
- Studies performed include:
CXR - small to moderate b/l pleural effusions
CT RLE - soft tissue edema involving entire calf and knee, skin
thickening posteriorly c/w cellulitis, no evidence of
necrotizing
fasciitis.
R ___ - right calf veins not visualized due to pain, no DVT in
right femoral or popliteal veins, significant soft tissue
swelling in R popliteal fossa.
- Patient was given:
IVF LR
IV Piperacillin-Tazobactam
IV Vancomycin
Pregabalin 150 mg
Baclofen 25 mg
- Consults: none.
Past Medical History:
- Progressive MS ___ frequent UTI ___ neurogenic bladder, and
fecal incontinence)
- Chronic Pain
- Chronic Raynaud's
- Hypertension
- b/l venous stasis
- ___ lymphoma - s/p auto SCT in ___ with recurrence
on maintenance Rituxan (q12w)/IVIG(q6w)
- Neurogenic bladder
- Breast cancer (___)
- Macular degeneration
- ___
- Depression
Social History:
___
Family History:
Grandmother with diabetes. MGF had bowel cancer.
Uncle with ___ lymphoma and Aunt with NHL.
Physical Exam:
ADMISSION PHYISCAL EXAM:
============================
ADMISSION PHYSICAL EXAM:
VITALS: Per POE
GEN: pleasant elderly female in NAD
HEENT: MM slightly dry
CV: Heart regular, no murmur, rubs or gallops
RESP: Lungs with reduced BS bibasilar, clear to auscultation
bilaterally otherwise, no respiratory distress
GI: Abdomen soft, non-distended, non-tender to palpation
MSK: Neck supple, moves all extremities. Port site CDI inright
chest wall
EXT: large area of erythema overlying right shin/calf within
margins of marker, cool to touch. LLE wrapped with ACE, upon
unwrapping has small well healing wound over left shin with zinc
powder covering the area.
NEURO: AAOx3, able to complete days of week backwards, face
symmetric, gaze conjugate with EOMI,speech fluent, moves all
limbs
PSYCH: pleasant, appropriate affect
DISCHARGE PHYISCAL EXAM:
============================
___ 0728 Temp: 98.2 PO BP: 172/66 HR: 71 RR: 18 O2 sat: 92%
O2 delivery: Ra
GENERAL: Pleasant, lying in bed comfortably
HEENT: Normocephalic, atraumatic, PERRLA, EOMI, sclerae
anicteric, no conjunctival discharge
CARDIAC: Regular rate and rhythm, normal S1+S2, systolic
ejection
murmur best heard at the apex
LUNG: Normal work of breathing, clear to auscultation in upper
lung fields bilaterally, diminished breath sounds bilateral
lower
lung fields
ABD: Nontender, nondistended, normal bowel sounds
EXT: Warm, bilateral lower extremity edema L>R, left lower
extremity wrapped, right lower extremity erythema largely within
drawn borders, bullae more tense today, warm to touch, nontender
to palpation
NEURO: Alert, oriented, CN II-XII intact, moving all
extremities, more detail exam deferred
SKIN: As above, port in R upper chest wall
Pertinent Results:
ADMISSION LABS:
====================
___ 12:32PM BLOOD WBC-11.7* RBC-3.87* Hgb-9.9* Hct-31.4*
MCV-81* MCH-25.6* MCHC-31.5* RDW-16.9* RDWSD-49.2* Plt ___
___ 12:32PM BLOOD Neuts-81.6* Lymphs-7.8* Monos-9.5
Eos-0.3* Baso-0.4 Im ___ AbsNeut-9.56* AbsLymp-0.92*
AbsMono-1.11* AbsEos-0.04 AbsBaso-0.05
___ 12:32PM BLOOD ___ PTT-38.0* ___
___ 12:32PM BLOOD Glucose-91 UreaN-17 Creat-1.0 Na-137
K-6.5* Cl-103 HCO3-23 AnGap-11
___ 12:32PM BLOOD Calcium-8.2* Phos-3.9 Mg-2.0
___ 12:32PM BLOOD CRP-65.7*
___ 12:35PM BLOOD Lactate-0.8 K-3.7
PERTINENT IMAGING:
====================
LOWER EXTREMITY DOPPLERS
IMPRESSION:
1. Right calf veins were not evaluated due to patient pain.
Otherwise, no
deep venous thrombosis visualized in the right femoral and
popliteal veins.
2. Significant soft tissue swelling in the right popliteal
fossa.
CT LOWER EXTREMITY
IMPRESSION:
1. Soft tissue edema involving the entire calf and visualized
knee, and skin
thickening, predominantly posteriorly is most consistent with
cellulitis.
2. No evidence for necrotizing fasciitis.
3. Trace knee joint effusion.
PERTINENT MICRO:
====================
___ 3:20 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 12:32 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
DISCHARGE LABS:
====================
___ 06:00AM BLOOD WBC-5.3 RBC-3.74* Hgb-9.6* Hct-31.5*
MCV-84 MCH-25.7* MCHC-30.5* RDW-17.1* RDWSD-52.0* Plt ___
___ 06:00AM BLOOD Glucose-81 UreaN-22* Creat-1.1 Na-146
K-4.3 Cl-105 HCO3-28 AnGap-13
___ 06:00AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO BID:PRN Pain - Mild/Fever
2. Amphetamine-Dextroamphetamine 15 mg PO BID
3. Baclofen 25 mg PO BID
4. Baclofen 20 mg PO QHS
5. DULoxetine ___ 120 mg PO DAILY
6. LOPERamide 2 mg PO QID:PRN loose stool
7. Pregabalin 150 mg PO TID
8. Vitamin D 1000 UNIT PO DAILY
9. Vitamin E 200 UNIT PO DAILY
10. Culturelle (Lactobacillus rhamnosus GG) 10 billion cell oral
DAILY
11. Digest Probiotic (S.boulardii) (Saccharomyces boulardii) 250
mg oral DAILY
12. Psyllium Powder 1 PKT PO QAM
Discharge Medications:
1. Cephalexin 500 mg PO Q6H
2. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days
3. Acetaminophen 650 mg PO BID:PRN Pain - Mild/Fever
4. Amphetamine-Dextroamphetamine 10 mg PO TID
5. Baclofen 25 mg PO BID
6. Baclofen 20 mg PO QHS
7. Culturelle (Lactobacillus rhamnosus GG) 10 billion cell oral
DAILY
8. Digest Probiotic (S.boulardii) (Saccharomyces boulardii) 250
mg oral DAILY
9. DULoxetine ___ 120 mg PO DAILY
10. LOPERamide 2 mg PO QID:PRN loose stool
11. Pregabalin 150 mg PO TID
12. Psyllium Powder 1 PKT PO QAM
13. Vitamin D 1000 UNIT PO DAILY
14. Vitamin E 200 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
___:
PRIMARY DIAGNOSIS
=================
Right lower extremity cellulitis
SECONDARY DIAGNOSIS
===================
___ Lymphoma
Multiple sclerosis
Lymphedema
Fecal incontinence
Discharge Condition:
Mental Status: Alert and oriented.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with weakness, cough // ?PNA
COMPARISON: Prior CT ___
IMPRESSION:
Right-sided vascular access catheter tip at the cavoatrial junction.
Cardiomediastinal silhouette is at upper limits for normal for size.
Small-to-moderate bilateral pleural effusions with compressive atelectatic
changes. Bilateral atelectatic changes. There are no pneumothoraces. Mild
degenerative changes the left shoulder joint.
Radiology Report
EXAMINATION: CT LOWER EXT W/C RIGHT
INDICATION: ___ year old woman with R leg cellulitis. ?Nec fasc: please obtain
knee and below.
TECHNIQUE: Axial images were obtained of the knee through the foot with bone
algorithm as well as standard algorithm. Coronal and sagittal reformats were
obtained and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 7.7 s, 60.6 cm; CTDIvol = 22.6 mGy (Body) DLP =
1,372.9 mGy-cm.
Total DLP (Body) = 1,373 mGy-cm.
COMPARISON: None.
FINDINGS:
Knee joint in soft tissue stranding and edema involving the entire calf,
mostly involving the medial posterior compartment. No emphysema to suggest
necrotizing fasciitis. No fracture or dislocation is identified. There is
substantial skin thickening of the calf.
IMPRESSION:
1. Soft tissue edema involving the entire calf and visualized knee, and skin
thickening, predominantly posteriorly is most consistent with cellulitis.
2. No evidence for necrotizing fasciitis.
3. Trace knee joint effusion.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: ___ with right leg swelling. Question of DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins. Patient denied imaging of the right calf
veins due to tenderness.
COMPARISON: Same day CT of the right lower extremity.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the right
common femoral, femoral, and popliteal veins. Due to patient pain, right calf
veins were not evaluated. There is significant soft tissue swelling involving
the right popliteal fossa.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1. Right calf veins were not evaluated due to patient pain. Otherwise, no
deep venous thrombosis visualized in the right femoral and popliteal veins.
2. Significant soft tissue swelling in the right popliteal fossa.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status, Fever
Diagnosed with Altered mental status, unspecified
temperature: 99.6
heartrate: 86.0
resprate: 18.0
o2sat: 97.0
sbp: 132.0
dbp: 74.0
level of pain: 0
level of acuity: 2.0 | TRANSITIONAL ISSUES
===================
[] Patient was not able to attend IVIG appointment for NHL.
Please ensure this is rescheduled (per oncologist, defer until
infection has resolved).
[] CXR demonstrated stable pleural effusions since CT chest from
___. Please f/u for symptoms and repeat CXR to assess for
resolution.
[] Patient and husband reported desire to re-establish care with
a psychiatrist/therapist and may need assistance to accomplish
this.
[] Patient should re-establish care with cognitive neurology.
[] Patient should be referred to ___ wound clinic
# CODE: FULL
# CONTACT/HCP: Husband (___) ___
(cell) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R lower extremity limb ischemia
Major Surgical or Invasive Procedure:
___ - R angiojet thrombolysis & popliteal stent placement
History of Present Illness:
___ with a history of acute RLE ischemia due to popliteal
occlusion, s/p most recently in ___, angiojet angioplasty
and
popliteal stent placement. He has been intermittently compliant
with medications. His last episode of rest pain in ___
resulted after discontinuing his aspirin. After his ___
procedure, he was discharged on ASA81 and Plavix x1 month and
lifelong xarelto. He stopped his aspirin "months ago" and
stopped
his xarelto on ___. On ___ he noted severe rest pain that woke
him up from sleep, in the RLE calf. This resolved when he moved
his extremity and bent his leg to the side. He resumed his
xarelto the following day and his pain has since improved but
has
not resolved. He is now able to walk ___ yards, and was able
to
take the bus to the hospital without pain. He intermittently
will
have rest pain which will shortly resolve.
Of note, ABI in the ED was 0.81.
Past Medical History:
PMH:
HTN
peripheral artery disease
etoh abuse
tobacco dependence
anemia
PSH:
___ finger surgeries
___ RLE angiogram-lysis check
___ RLE angiogram- AKpop occlusion s/p intraarterial tpa
___ bilateral lower extremity angiogram
Social History:
___
Family History:
Non-contributory
Physical Exam:
afebrile, vital signs stable
General: well appearing, NAD
HEENT: normocephalic, atraumatic, no scleral icterus
Resp: breathing comfortably on room air
CV: regular rate and rhythm on monitor
Abdomen: soft, NT, ND
Extremities: Warm and Well perfused. Palpable right ___ pulse, 2+
Doppler signal in R DP
Medications on Admission:
atorvastatin 40', losartan 50', xarelto 20', ASA81
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Atorvastatin 40 mg PO QPM
3. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*29
Tablet Refills:*0
4. Losartan Potassium 50 mg PO DAILY
5. Rivaroxaban 20 mg PO DAILY
you must take this medication DAILY, life long. If you stop this
medication, you risk limb ischemia
RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*9
6. Aspirin 81 mg PO DAILY
start this medication on ___ after you stop the Plavix
RX *aspirin 81 mg 1 tablet(s) by mouth Daily Disp #*90 Tablet
Refills:*4
Discharge Disposition:
Home
Discharge Diagnosis:
right limb ischemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man pre-op // pre-op Surg: ___ (angio )
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
The lungs are clear of airspace or interstitial opacity. The
cardiomediastinal silhouette is unremarkable. No pleural effusions or
pneumothorax. No acute or aggressive osseus changes.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: ART DUP EXT LO UNI;F/U RIGHT
INDICATION: ___ year old man with claudication symptoms, cold R foot, ABI
0.81, // eval for arterial flow
TECHNIQUE: Grayscale, color, and spectral Doppler ultrasound images were
obtained of the right lower extremity arteries and stent.
COMPARISON: None
FINDINGS:
The right lower extremity arteries have peak systolic velocities and waveforms
as follows:
Common femoral: 138 cm/s, triphasic
Deep femoral: 117 cm/s, triphasic
Proximal SFA: 87 cm/s, multi phasic
Mid SFA: 90 set cm/s, multi phasic
Distal SFA: 33 cm/s, monophasic
The popliteal artery stent is essentially occluded with minimum internal flow.
Anterior tibial: 17 cm/s, monophasic (parvus tardus waveform)
Posterior tibial: 26 cm/s, monophasic
Peroneal: 10 cm/s, monophasic
Dorsalis pedis: 5 cm/s
IMPRESSION:
Essentially occluded right popliteal artery stent with minimal flow in the
calf vessels.
NOTIFICATION: Findings were communicated via phone at 10:00 AM on the day of
the study by the sonographer to the ordering physician.
Radiology Report
EXAMINATION: ART EXT (REST ONLY)
INDICATION: ___ year old man with claudication symptoms, cold R foot, ABI
0.81, // eval for signs of PAD
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.
COMPARISON: None
FINDINGS:
On the right side, multiphasic Doppler waveforms are seen in the right
femoral, and superficial femoral arteries. Monophasic waveforms are seen in
the popliteal, posterior tibial and dorsalis pedis arteries.
The right ABI was 0.18.
On the left side, multiphasic Doppler waveforms are seen in the left femoral,
and superficial femoral arteries. Monophasic waveforms are seen in the
popliteal, posterior tibial and dorsalis pedis arteries.
The left ABI was 0.91.
Pulse volume recordings showed dampened amplitudes in right ankle metatarsal
compared to the left.
IMPRESSION:
On the right, outflow arterial disease at the level of the popliteal artery
with severely decreased resting ABI.
On the left, outflow arterial disease at the level of the popliteal artery
with mildly decreased resting ABI.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: R Foot pain
Diagnosed with Other disorder of circulatory system, Pain in right ankle and joints of right foot
temperature: 98.7
heartrate: 68.0
resprate: 18.0
o2sat: 99.0
sbp: 138.0
dbp: 63.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ M w/ hx of PAD and right lower extremity
limb ischemia who was admitted to the ___
___ on ___. The patient was taken to the
endovascular suite and underwent R angiojet thrombolysis &
popliteal stent placement. For details of the procedure, please
see the surgeon's operative note. The patient tolerated the
procedure well without complications and was brought to the
post-anesthesia care unit in stable condition. After a brief
stay, the patient was transferred to the vascular surgery floor
where he remained through the rest of the hospitalization.
Post-operatively, he did well without any groin swelling. he was
able to tolerate a regular diet, get out of bed and ambulate
without assistance, void without issues, and pain was controlled
on oral medications alone. He was deemed ready for discharge,
and was given the appropriate discharge and follow-up
instructions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Fentanyl / Lasix
Attending: ___.
Chief Complaint:
Hypoglycemia
Confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with history of insulin-dependent
diabetes mellitus, cerebrovascular accident, dementia, diastolic
heart failure, and recent admission for complete heart block
with permanent pacemaker placement and possible seizure who was
transported from her assisted living facility after she was
noted to be confused and hypogylcemic to ___ despite oral
glucose. In the ED, she was afebrile (98.8), normotensive, and
mildly bradycardic (58) and received 25g of D50, with
improvement in fingerstick blood glucose to 125. Rectal
temperature less than 1 hour later was documented as 93, but she
was otherwise hemodynamically stable. EKG at that time showed
atrioventricular pacing at 59. Bair hugger was applied and
warmed normal saline infused. Blood cultures were drawn, and she
was started on vancomycin/levofloxacin for possible retrocardiac
opacity. Noncontrast head CT was negative. Temperature and
fingerstick blood glucose had normalized by the time of transfer
to the floor.
On arrival to the floor, she was comfortable and oriented to
person and place. She attributed her admission to "stomachache"
in association with nausea, nonbloody/nonbilious emesis, and
nonbloody diarrhea x3 days in the absence of fever/chills or
clear sick contacts. She denies shortness of breath, cough, or
myalgias during this period, but does endorse poor appetite. She
believes that an aide at her assisted living facility
administers her medications and injects her insulin, and she is
uncertain as to whether her regimen has changed recently or in
the setting of her acute illness, though she reportedly stated
at one point that she had self-discontinued insulin due to poor
oral intake. She has no recollection of low fingerstick blood
glucose and thus is unable to describe how she felt at that
time. She denies chest pain, shortness of breath, abdominal
pain, recurrent nausea/vomiting, or any other source of
discomfort. She does endorse intermittent peripheral edema at
baseline without paroxysmal nocturnal dyspnea or orthopnea.
Past Medical History:
Insulin-dependent type II diabetes mellitus
Hypertension
Hyperlipidemia
Diastolic heart failure
Cerebrovascular accident (right internal capsule lacunar stroke)
Dementia
Depression
Right breast cancer status post lumpectomy and radiotherapy
(___)
Uterine cancer status post hysterectomy and oophorectomy (___)
Complete heart block status post permanent pacemaker placement
(___)
Social History:
___
Family History:
Her brother was diagnosed recently with "memory loss" and is
being treated with Aricept. Her father has a history of
depression.
Physical Exam:
On admission:
VS: 98.2 162/87 82 20 96% RA
GENERAL: elderly woman in NAD
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, no JVD
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: obese, NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES: WWP, 1+ pitting edema bilaterally, palpable pulses
NEURO: awake, A&Ox1, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
At discharge:
VS: AF/98.4, 149/90 (140s-150s/60s-80s), 78 (60s-70s), 20, 98%
RA (95-98% RA)
FSBG: 140s-280s
GENERAL: elderly woman in NAD
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, no JVD (though obesity limits exam)
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: obese, NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES: WWP, 1+ pedal edema bilaterally, palpable pulses
NEURO: awake, alert, grossly oriented, CNs II-XII grossly
intact, muscle strength ___ throughout, sensation grossly intact
throughout, mild intention tremor bilaterally
Pertinent Results:
On admission:
___ 08:40PM BLOOD WBC-12.2* RBC-3.93* Hgb-10.8* Hct-34.1*
MCV-87 MCH-27.4 MCHC-31.7 RDW-13.5 Plt ___
___ 08:40PM BLOOD Neuts-87.4* Lymphs-8.9* Monos-2.5 Eos-0.9
Baso-0.3
___ 08:40PM BLOOD Glucose-166* UreaN-10 Creat-1.3* Na-137
K-3.8 Cl-102 HCO3-27 AnGap-12
___ 08:40PM BLOOD ALT-13 AST-19 AlkPhos-89 TotBili-0.4
___ 08:40PM BLOOD proBNP-3761*
___ 08:40PM BLOOD cTropnT-<0.01
___ 06:40AM BLOOD CK-MB-3 cTropnT-<0.01
___ 08:40PM BLOOD Albumin-3.4*
___ 08:57PM BLOOD Lactate-1.2
___ 08:30PM URINE Color-Straw Appear-Clear Sp ___
___ 08:30PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-150 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 08:30PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
At discharge:
___ 07:53AM BLOOD WBC-6.2 RBC-3.52* Hgb-9.8* Hct-30.2*
MCV-86 MCH-27.9 MCHC-32.5 RDW-13.5 Plt ___
___ 07:53AM BLOOD Glucose-158* UreaN-14 Creat-1.6* Na-139
K-4.1 Cl-104 HCO3-27 AnGap-12
___ 07:53AM BLOOD Calcium-8.9 Phos-3.9 Mg-1.8 Iron-32
___ 07:53AM BLOOD calTIBC-295 VitB12-___* Ferritn-44
TRF-227
Microbiology:
Urine culture (___): No growth.
Blood cultures x2 (___): No growth to date.
Imaging:
EKG (___):
A-V sequential pacing. Compared to the previous tracing of
___ no definite change.
IntervalsAxes
___
___
EKG (___):
A-V sequential pacing. Compared to the previous tracing no
change.
IntervalsAxes
___
___
EKG (___):
A-V sequential pacing. Compared to the previous tracing no
change.
IntervalsAxes
___
___
Noncontrast head CT (___):
No acute intracranial process.
Portable CXR (___):
Mild congestive heart failure with small bilateral pleural
effusions and retrocardiac atelectasis.
CXR PA/lateral (___):
As compared to the previous radiograph, the lung volumes are
unchanged. Unchanged position of the left pectoral pacemaker,
unchanged course of the pacemaker leads. The transparency of
the lung parenchyma has increased as compared to the previous
examination, an improved ventilation. There is no evidence of
pneumonia. However, lateral radiograph now documents
mild-to-moderate bilateral pleural effusions. Unchanged mild
cardiomegaly persists. No pulmonary edema.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 20 mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. Donepezil 10 mg PO HS
4. Glargine 10 Units Breakfast
NPH 34 Units Breakfast
NPH 34 Units Lunch
NPH 34 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
5. Memantine 5 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Simvastatin 10 mg PO DAILY
8. Vitamin D 400 UNIT PO DAILY
9. Niaspan Extended-Release *NF* (niacin) 500 mg Oral daily
10. Aspirin 81 mg PO DAILY
11. Labetalol 300 mg PO BID
Hold for HR <60, SBP <100
12. Calcium Carbonate 1500 mg PO BID
13. CloniDINE 0.1 mg PO BID
Hold for SBP <100
14. NIFEdipine CR 30 mg PO DAILY
Hold for HR <60, SBP <100
15. Lisinopril 10 mg PO DAILY
Hold for SBP <100
16. Spironolactone 25 mg PO DAILY
Hold for SBP <100
17. Metoprolol Tartrate 12.5 mg PO BID
Hold for HR <60, SBP <100
Discharge Medications:
1. Citalopram 20 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 1000 mg PO DAILY
4. Cyanocobalamin 1000 mcg PO DAILY
5. Donepezil 10 mg PO HS
6. Glargine 5 Units Breakfast
7. Labetalol 300 mg PO BID
Hold for HR <60, SBP <100
8. Lisinopril 10 mg PO DAILY
Hold for SBP <100
9. Memantine 5 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Simvastatin 10 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. Niaspan Extended-Release *NF* (niacin) 500 mg Oral daily
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Hypoglycemia
Hypothermia
Discharge Condition:
Mental Status: Confused - sometimes (however, back to baseline
per friend/healthcare proxy who visited)
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH
INDICATION: Questionable consolidation.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the lung volumes are
unchanged. Unchanged position of the left pectoral pacemaker, unchanged
course of the pacemaker leads. The transparency of the lung parenchyma has
increased as compared to the previous examination, an improved ventilation.
There is no evidence of pneumonia. However, lateral radiograph now documents
mild-to-moderate bilateral pleural effusions. Unchanged mild cardiomegaly
persists. No pulmonary edema.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: HYPOGLYCEMIA
Diagnosed with IDDM W SPEC MANIFESTATION, ALTERED MENTAL STATUS
temperature: 98.8
heartrate: 58.0
resprate: 18.0
o2sat: 97.0
sbp: 130.0
dbp: 60.0
level of pain: 0
level of acuity: 1.0 | Ms. ___ is a ___ with history of insulin-dependent
diabetes mellitus, cerebrovascular accident, dementia, diastolic
heart failure, and recent admission for complete heart block
with permanent pacemaker placement and possible seizure who was
transported from her assisted living facility after she was
noted to be confused and hypogylcemic to ___ despite oral
glucose. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left sided weakness
Major Surgical or Invasive Procedure:
tPA at ___ on ___
History of Present Illness:
___ is a ___ male with a PMHx AF on ASA, HTN, HL,
systolic dysfunction, and lumbar stenosis s/p
decompression/fusion L2/3 and L3/4 who presents with left
face/arm/leg weakness.
His symptoms began at 10:00am at which time he was walking to
the
dining room. He stumbled on his left leg, hit a table with his
felt like his left leg was going to "give out." He denies
falling. He also had a headache (on the left, per patient).
Later, he noticed that his arm buckled when he tried to lean his
head on it while his elbow was resting on the table. He also had
some left arm paresthesias. He did not notice a facial droop. He
also reports some intermittent blurry vision (denies diplopia)
in
all visual fields; he did not attempt to close either eye to see
if there was improved. Also, his wife's voice seemed "far away."
He presented to ___, where he was noted to
have an NIHSS of 6 and subsequently 4 on telestroke (scored for
LUE/LLE weakness, L facial droop, and LUE ataxia). He received
tPA at ___ (noon to 2pm) and was transferred to ___
for post-tPA care. His exam reportedly did not improve after
tPA.
On neuro ROS, the pt denies diplopia, dysarthria, dysphagia,
lightheadedness, vertigo, tinnitus. Denies difficulties
producing
or comprehending speech. Denies No bowel or bladder
incontinence
or retention.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation,
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Problems (Last Verified ___ by ___:
LUMBAR SPINAL STENOSIS
___ L4-L5, L5-S1 bilateral laminectomies and
foraminotomies. Instrumentation L3-L4. Arthrodesis L3-S1 with
Dr. ___. Revision decompression and fusion at L2-L3 on
___. He previously had undergone decompression and
fusion at L3-L4, the adjacent segment in the past. Third lumbar
spine laminectomy.
Atrial fibrillation
Atrial flutter ablation on ___
Depressed left ventricular systolic function with LVEF
estimated 25 to 30% with global hypokinesis by echocardiogram
___
Patent foramen ovale
Hypertension
Hyperlipidemia
Chronic idiopathic pancreatitis, acute presentation ___
GERD, chronic
bilateral arthroscopic knee surgeries
work-related injury to his cervical spine, which was repaired
surgically
hernia repair
appendectomy
cholecystectomy
ankle surgery
Surgical History (Last Verified - None on file):
As above
PCP:
___, MD
--------------- --------------- --------------- ---------------
Active Medication list as of ___:
ASA 325mg daily
Metop 125mg BID
Atorva 40
Creon 24k-76k-120k U ___ ___ meals
___ 5 TID (muscle relaxanat)
Losartan 100--HCTZ 12.5 qd
Omeprazole 40
Zofran 4 distintegrating tab prn N/V
Oxy-Acet ___ 2 tabs q6-8
--------------- --------------- --------------- ---------------
Allergies (Last Verified ___ by ___:
Lisinopril--MI-like symptoms
Social History:
___
Family History:
NC
Physical Exam:
Admission Physical Exam:
Vitals: T: 98.3F P: 106 R: 16 BP: 128/85 SaO2: 96RA
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple
Pulmonary: no WOB
Cardiac: irreg irreg
Abdomen: soft
Extremities: No C/C/E bilaterally
Neurologic:
Please see top of note for NIHSS.
-Mental Status: Alert, oriented x ___ (except date ___ but knew
day of week, month, and year). Able to relate history without
difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt was able to
register 3 objects and recall ___ at 5 minutes ___ with
prompts). There was no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and ___. Initially did not
appear to look all the way to left with either eye but he was
able to do so on repeat testing. Normal saccades. VFF except
?altitudinal field cut (could not see numbers to finger
controntation with right eye closed/left eye open in upper
field).
V: Decreased facial sensation 60-70% L side
VII: L NLFF. Normal forehead wrinkling.
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 and tone. LUE drift without pronation. No
adventitious movements, such as tremor, noted. No asterixis
noted.
[___]
[C5] [C5] [C7] [C6] [C7] [T1][L2] [L3] [L5] [L4] [S1][L5]
L 4 5 4+ 4+ 4 3 4+ 5- 4+ 5 5 5
R 5 5 5 5 5 5 5 5 5 5 5 5
-Sensory: Decreased sensation to LT in LUE (40% normal) and LLE
___ normal) and to PP (LUE normal, LLE 0%). LT and PP in
RUE/RLE normal. No deficits to temperature sensation. LLE
impaired proprioception to small movements, RLE all
proprioceptive movements impaired. No extinction to DSS.
-DTRs: ___ bilaterally. Plantar response was flexor
bilaterally.
-Coordination: Mild LUE dysmetria on FNF. Unable to participate
in HKS testing on left.
-Gait: Deferred
================================================================
Discharge Exam:
Vitals: Tmax 99.3, Tcurrent 98.1, BP 110-136/75-89, HR 87-104,
RR 16, O2% 96RA
General: awake, alert, NAD
Neuro:
MS: alert and oriented x3. Normal language without dysarthria or
paraphasic errors
CNs: EOM intact, face symmetric, tongue protrudes in the midline
Motor: left sided exam significantly limited by pain, but
4-to-4+ in the proximal and distal upper and lower left
extremities. ___ in the right
Sensory: reports "complete numbness" in the left lateral thigh
and around the knee
Pertinent Results:
___ 06:20AM BLOOD WBC-6.4 RBC-4.58* Hgb-13.7 Hct-40.9
MCV-89 MCH-29.9 MCHC-33.5 RDW-14.4 RDWSD-46.1 Plt ___
___ 06:20AM BLOOD ___ PTT-29.9 ___
___ 06:20AM BLOOD Glucose-69* UreaN-12 Creat-1.0 Na-141
K-3.3 Cl-103 HCO3-25 AnGap-16
___ 06:20AM BLOOD ALT-12 AST-16 LD(LDH)-142 CK(CPK)-43*
AlkPhos-45 TotBili-0.7
___ 06:20AM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:20AM BLOOD %HbA1c-5.8 eAG-120
___ 06:20AM BLOOD Triglyc-95 HDL-39 CHOL/HD-3.2 LDLcalc-66
___ 06:20AM BLOOD TSH-2.1
___ 06:20AM BLOOD CRP-3.3
___ 02:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-POS* Barbitr-NEG Tricycl-NEG
====================
IMAGING:
CTA Head and Neck (___):
1. No acute intracranial abnormality.
2. Patent intracranial vasculature without significant stenosis,
occlusion, or aneurysm.
3. Patent cervical vasculature without significant stenosis,
occlusion, or
dissection.
4. Minimal areas of white matter hypodensity likely reflecting
chronic small vessel ischemic disease.
5. Minimal paranasal sinus disease
MRI Brain (___):
FINDINGS: There is no evidence of hemorrhage, edema, masses,
mass effect, midline shift or infarction. The ventricles and
sulci are normal in caliber and configuration. There are
scattered white matter hyperintensities on the FLAIR images.
Although nonspecific, these are often attributed to chronic
small vessel ischemia
IMPRESSION: White matter hyperintensities suggesting chronic
small vessel ischemia. Otherwise normal study.
Echocardiogram (___):
The left atrial volume index is moderately increased. No left
atrial mass/thrombus seen (best excluded by transesophageal
echocardiography). The right atrium is moderately dilated. With
maneuvers, there is early appearance of agitated
saline/microbubbles in the left atrium/left ventricle most
consistent with a patent foramen ovale. The estimated right
atrial pressure is ___ mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is severe
global left ventricular hypokinesis (biplane LVEF = 23 %).
Systolic function of apical segments is relatively preserved.
The estimated cardiac index is borderline low (2.0-2.5L/min/m2).
The right ventricular cavity is mildly dilated with mild global
free wall hypokinesis. The ascending aorta and aortic arch are
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
mildly thickened. There is no mitral valve prolapse. Mild to
moderate (___) mitral regurgitation is seen. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
severe global hypokinesis in a pattern most c/w a non-ischemic
cardiomyopathy. Mild-moderate mitral regurgitation. Right
ventricular cavity dilation with free wall hypokinesis. Dilated
thoracic aorta.
Compared with the prior study (images reviewed) of ___,
the findings are new (including atrial fibrillation).
CLINICAL IMPLICATIONS:
The left ventricular ejection fraction is <40%, a threshold for
which the patient may benefit from a beta blocker and an ACE
inhibitor or ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Metoprolol Tartrate 125 mg PO BID
3. Atorvastatin 40 mg PO QPM
4. Creon 12 2 CAP PO TID W/MEALS PRN heavy meals
5. Diazepam 5 mg PO Q8H:PRN Muscle relaxant
6. losartan-hydrochlorothiazide 100-12.5 mg oral Other
7. Omeprazole 40 mg PO DAILY
8. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/vomiting
9. oxyCODONE-acetaminophen ___ mg oral Other Pain
10. Tamsulosin 0.4 mg PO QHS
11. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
12. DULoxetine 30 mg PO BID
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet by mouth twice daily Disp
#*60 Tablet Refills:*3
2. Cyclobenzaprine 5 mg PO TID:PRN muscle spasms
RX *cyclobenzaprine 5 mg 1 tablet by mouth three times a day
Disp #*60 Tablet Refills:*0
3. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % Place one patch on affected area daily Disp
#*30 Patch Refills:*0
4. Metoprolol Succinate XL 300 mg PO DAILY
RX *metoprolol succinate 100 mg 3 tablets by mouth every morning
Disp #*90 Tablet Refills:*3
5. Polyethylene Glycol 17 g PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Creon 12 2 CAP PO TID W/MEALS PRN heavy meals
8. Diazepam 5 mg PO Q8H:PRN Muscle relaxant
9. DULoxetine 30 mg PO BID
10. losartan-hydrochlorothiazide 100-12.5 mg oral Other
11. Omeprazole 40 mg PO DAILY
12. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/vomiting
13. oxyCODONE-acetaminophen ___ mg oral Other Pain
14. Tamsulosin 0.4 mg PO QHS
15. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
TIA, chronic left-sided weakness
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: Post tPA for stroke. Evaluate for thromboembolism.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of mL of Omnipaque intravenous contrast material. Three-dimensional
angiographic volume rendered, curved reformatted and segmented images were
generated on a dedicated workstation. This report is based on interpretation
of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 7.2 s, 18.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
1,009.3 mGy-cm.
2) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 70.8 mGy (Head) DLP =
35.4 mGy-cm.
3) Spiral Acquisition 5.3 s, 41.9 cm; CTDIvol = 32.0 mGy (Head) DLP =
1,342.9 mGy-cm.
Total DLP (Head) = 2,388 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of no evidence of infarction, hemorrhage, edema, or mass.
The ventricles and sulci are normal in size and configuration. Subtle areas
of subcortical and deep white matter hypodensity are in a configuration most
suggestive of chronic small vessel ischemic disease.
There is moderate mucosal wall thickening in the left frontoethmoidal recess.
There is trace mucosal thickening in the floors of the maxillary sinuses. The
remainder of the paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. The visualized portion of the orbits are unremarkable.
CTA HEAD:
The vessels of the circle of ___ and their principal intracranial branches
appear patent without stenosis, occlusion, or aneurysm formation. The dural
venous sinuses are patent.
CTA NECK:
The carotid and ertebral arteries and their major branches appear patent with
no evidence of dissection, stenosis or occlusion. There is no evidence of
internal carotid stenosis by NASCET criteria.
OTHER:
The visualized portion of the lungs are clear. The visualized portion of the
thyroid gland is within normal limits. There is no lymphadenopathy by CT size
criteria. There is severe multilevel cervical spondylosis.
IMPRESSION:
1. No acute intracranial abnormality.
2. Patent intracranial vasculature without significant stenosis, occlusion, or
aneurysm.
3. Patent cervical vasculature without significant stenosis, occlusion, or
dissection.
4. Minimal areas of white matter hypodensity likely reflecting chronic small
vessel ischemic disease.
5. Minimal paranasal sinus disease, as described.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T9113 MR HEAD
INDICATION: ___ year old man with LUE face/arm/leg weakness and LUE ataxia.
// ?Stroke
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON Head CTA ___.
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. The ventricles and sulci are normal in caliber and
configuration. There are scattered white matter hyperintensities on the FLAIR
images. Although nonspecific, these are often attributed to chronic small
vessel ischemia
IMPRESSION:
1. White matter hyperintensities suggesting chronic small vessel ischemia.
Otherwise normal study.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with concern for stroke // ?PNA ?PNA
IMPRESSION:
Comparison to ___. Mild elevation of the left hemidiaphragm with
subsequent left basilar atelectasis. Mild elongation of the descending aorta.
No pneumonia, no pulmonary edema. Borderline size of the cardiac silhouette.
Radiology Report
EXAMINATION: LEFT LOWER EXT VEINS
INDICATION: ___ year old man with hx chronic pain, trf from OSH for neuro w/u
facial droop (MRI negative) now with L calf pain (no swelling) // r/o DVT in L
calf
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: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Weakness, Transfer
Diagnosed with Cerebral infarction, unspecified
temperature: 98.3
heartrate: 106.0
resprate: 16.0
o2sat: 96.0
sbp: 128.0
dbp: 85.0
level of pain: 8
level of acuity: 1.0 | ___ is a ___ year old man with hypertension,
hyperlipidemia, atrial fibrillation L (on ASA), and chronic
spine disease with resultant baseline left-sided weakness. He
presented to an OSH on ___ with acute worsening of his
baseline left arm and leg weakness. There, he was found to also
have left-sided facial weakness and his initial ___ stroke scale
was 5. He was given tPA and then transferred to the ___
neurology stroke service.
His MRI brain did not show evidence of an acute stroke. His left
facial weakness resolved but his left arm and leg weakness
persisted. Altogether, we were suspicious of a TIA as the cause
of his worsening symptoms, but an acute worsening of his chronic
left limb weakness secondary to pain was also considered.
He has several factors that puts him at risk for having strokes
in the future, including:
- Atrial fibrillation
- Hypertension
- Hyperlipidemia, although this has been well controlled with
Atorvastatin (LDL 66)
Because of his atrial fibrillation, we discontinued his home
aspirin and started apixaban (5 mg BID).
He was in atrial fibrillation throughout his admission,
occasionally in RVR. His PO metoprolol was increased and then
converted to Toprol XL. He required one dose of IV diltiazem for
RVR.
He had an echocardiogram as a part of his stroke work-up which
showed a severely decreased LVEF of 23%.
He developed severe left neck and shoulder pain while in the
hospital which seemed to be musculoskeletal in nature, as he had
spasms of his cervical paraspinal and trapezius muscles. He was
continued on his home pain medications as well as lidocaine
patches and Flexiril. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
adhesive bandage / Benzoin / Mastisol Stertip / Compazine /
gabapentin / Neurontin
Attending: ___.
Chief Complaint:
s/p Motor vehicle crash
Major Surgical or Invasive Procedure:
1. Irrigation and debridement down to and inclusive of bone
of open ulna and radius fracture.
2. Open reduction internal fixation both-bones forearm
fracture including segmental radius and ulnar shaft.
3. Examination under anesthesia distal radioulnar joint for
joint stability.
History of Present Illness:
___ yo M with a PMH significant for
tardive dyskinesia (? secondary to prolonged Clozapine
exposure),
bipolar disorder, multiple abdominal surgeries (Roux-en-Y
gastric
bybass, distal pancreatectomy, splenectomy, revision of
gastrectomy/choledochojejunostomy), Vit D/Vit B12/testosterone
deficiency, and anemia of chronic disease who presents as
unrestrained driver in ___. Per report he was unrestrained
driver who struck the highway barrier whereafter his car spun
around 180 degrees. The patient was found on the passenger side
of the car. EMS found the patient confused and unable to answer
questions. They could not obtain IV access and found the patient
to be hypotensive with a systolic pressure blood pressure of 80.
For this an interosseous access was established. Upon arival he
was initially noted to have GCS of 14 with slow speech and was
somnolent. Patient was initially found to not be responsive to
commands, and he did not remember the event. He complained of
left forearm pain, nose pain (fracture nose last week with
planned surgical repain in ___ in ___ weeks), and headache.
Dicussion and history per his brother and sister, he had been
recently "stable" with all his medical problems, and returned
from a trip to ___ this past ___. He had been living
alone and has a tendencey to either over take medication or
undertake medication when not supervised. He was supposed to go
to physical therapy and had missed his appointment this morning
prior to the accident. His brother states that he had tried to
call him this morning without success. For the past several
months he has been eating very little secondary to nausea and
has
had occasional tongue swelling with taste amplification. He was
recently hospitalized ___ for altered mental status
and confusion. At that time, he had been experiencing frequent
falls in which he would hit his head. Remeron and Trileptal
were
tapered out of concern that these medications could be
contributing to his altered mental status. Since the patient has
no indication for being on Trileptal with the exception of a
possible history of basilar migraines, we conferred with his
psychiatrist who agreed that this medication was unnecessary and
could be contributing to the patient's falls. Also, a neurology
note from ___ stated explicitly that the patient did not have
basilar migraines. Prior notes have also felt like there was a
large functional component to his neurologic deficits. Also it
is likely that the patient's numerous psychotropic medications
in the setting of his leukocytosis have been attributed to his
unsteady gate. A series of labs were sent off for the workup of
a
toxic metabolic syndrome or a nutritional deficiency which could
cause a peripheral neuropathy. These results came back
negative.
The patients mental status dramatically improved with
antibiotics
and IV hydration during this admission. The patient has been
seen by Dr. ___ Neurology for follow-up of Tardive
Dyskinesia. He was last seen in the Movement Disorders Clinic
on
___. At that time, the patient described persistent teeth
grinding, abnormal movmements of the face and tongue, and
slurred, high pitch speech that worsens at the end of the day.
The patient also reported abnormal leg movements with give-way
weakness throughout his legs. At that time, he had recently
stopped tetrabenazine , which had worked well in the past, due
to
insurance changes.
.
Past Medical History:
1. Roux-en-Y gastric bypass surgery with bile duct injury
complicated by stricture
2. S/P revision with total gastrectomy and
choledochojejunostomy.
3. S/P distal pancreatectomy, splenectomy, and ventral hernia
repair
4. Surgery for islet cell hyperplasia of the pancreas
5. MSSA endocarditis
6. recurrent line sepsis
7. circumferential abdominoplasty
8. hypoglycemia thought to be from nesidioblastosis
9. Osteomalacia ___ vitamin D deficiency
10. Vitamin B12 deficiency
11. Testosterone deficiency
12. Anemia of chronic disease
13. uvulectomy and tonsillectomy
14. lumbar spinal fusion at L4-L5
15. bilateral shoulder surgeries
16. right ankle fusion
17. hx of TB - treated with 4 drug therapy for 9 mo
18. basilar migraines
19. Bipolar disorder
Social History:
___
Family History:
Significant for CAD in his father and a sister w/ SLE.
Pertinent Results:
___ 06:55PM GLUCOSE-105* UREA N-14 CREAT-0.7 SODIUM-138
POTASSIUM-4.7 CHLORIDE-110* TOTAL CO2-25 ANION GAP-8
___ 06:55PM ALT(SGPT)-48* AST(SGOT)-57* ALK PHOS-94 TOT
BILI-0.3
___ 06:55PM CALCIUM-8.0* PHOSPHATE-3.7 MAGNESIUM-1.8
___ 06:55PM LITHIUM-0.7
___ 06:55PM WBC-24.0* RBC-3.18* HGB-9.0* HCT-28.3* MCV-89
MCH-28.2 MCHC-31.8 RDW-16.8*
___ 06:55PM PLT COUNT-372
Imaging:
CXR: Bilateral upper lobe opacities (R>L), similar compared to
___ studies, no effusion/pneumothorax
CT head: No acute intracranial process. Buckled right nasal bone
fracture.
CT C-spine: No fracture or malalignment
CT Torso: No intrathoracic or intraabdominal injury
Plain Film Forearm: Dispalced segmental fracture of the radius
and fracture of the mid-to-distal ulna.
Plain Film of Hand: Minimally displaced transverse fracture of
the proximal middle finger phalanx with volar displacement of
the distal fracture fragment. Evidence of old hand surgery with
an anchor in the middle phlanx of right thumb
Medications on Admission:
1. dronabinol 10 mg Capsule Sig: One (1) Capsule PO BID (2 times
a day).
2. ZOFRAN ODT 8 mg Tablet, Rapid Dissolve Sig: One (1) Tablet,
Rapid Dissolve PO three times a day: With meals .
3. clonazepam 0.5 mg Tablet Sig: One (1) Tablet PO three times a
day.
4. hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO three
times a day as needed for nausea.
5. acetaminophen 325 mg Tablet Sig: ___ Tablets PO every six (6)
hours as needed for pain.
6. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Four (4)
Capsule, Ext Release 24 hr PO DAILY (Daily).
7. zolpidem 5 mg Tablet Sig: Two (2) Tablet PO HS (at bedtime).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
10. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
11. multivitamin Tablet Sig: One (1) Tablet PO DAILY
(Daily).
12. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
13. ergocalciferol (vitamin D2) 50,000 unit Capsule Sig: One (1)
Capsule PO EVERY OTHER DAY (Every Other Day).
14. thiamine HCl 100 mg Tablet Sig: 2.5 Tablets PO DAILY
(Daily).
15. tramadol 50 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for pain.
16. lithium carbonate 450 mg Tablet Extended Release Sig: One
(1) Tablet Extended Release PO HS (at bedtime).
17. Adderall XR 20 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO once a day.
18. Calcium Citrate + D 315-200 mg-unit Tablet Sig: Three (3)
Tablet PO twice a day.
19. Pancrelipase 5000 5,000-17,000 -27,000 unit Capsule, Delayed
Release(E.C.) Sig: Twelve (12) Capsule, Delayed Release(E.C.) PO
three times a day: Take with meals .
20. Fish Oil 1,000 mg Capsule Sig: One (1) Capsule PO once a
day.
21. vitamin E 600 unit Capsule Sig: Two (2) Capsule PO once a
day.
22. cyanocobalamin (vitamin B-12) 1,000 mcg/mL Solution Sig: One
(1) ml Injection once a month.
23. Miralax 17 gram/dose Powder Sig: One (1) PO once a day as
needed for constipation.
24. guaifenesin 100 mg/5 mL Syrup Sig: ___ ml PO every six (6)
hours as needed for cough.
25. DuoNeb 0.5 mg-3 mg(2.5 mg base)/3 mL Solution for
Nebulization Sig: One (1) inhalation Inhalation every six (6)
hours as needed for shortness of breath or wheezing
ALL: ___ bandage / Benzoin / Mastisol Stertip /
Compazine /
gabapentin / Neurontin
Discharge Medications:
1. lipase-protease-amylase 5,000-17,000 -27,000 unit Capsule,
Delayed Release(E.C.) Sig: Three (3) Cap PO TID W/MEALS (3 TIMES
A DAY WITH MEALS).
2. venlafaxine 75 mg Capsule, Ext Release 24 hr Sig: Four (4)
Capsule, Ext Release 24 hr PO DAILY (Daily).
3. hydroxyzine HCl 25 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day).
4. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours).
5. senna 8.6 mg Tablet Sig: ___ Tablets PO DAILY (Daily).
6. oxybutynin chloride 5 mg Tablet Sig: Three (3) Tablet PO BID
(2 times a day).
7. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
9. lithium carbonate 450 mg Tablet Extended Release Sig: One (1)
Tablet Extended Release PO DAILY (Daily).
10. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ Puffs Inhalation Q6H (every 6 hours) as needed for shortness
of breath or wheezing.
11. heparin (porcine) 5,000 unit/mL Solution Sig: One (1) ml
Injection TID (3 times a day).
12. amphetamine-dextroamphetamine 20 mg Capsule, Ext Release 24
hr Sig: Two (2) Capsule, Ext Release 24 hr PO daily ().
13. ciprofloxacin 250 mg Tablet Sig: Three (3) Tablet PO Q12H
(every 12 hours) for 2 days.
14. silver sulfadiazine 1 % Cream Sig: One (1) Appl Topical BID
(2 times a day): Apply to blisters on left forearm BID .
15. tramadol 50 mg Tablet Sig: One (1) Tablet PO QID (4 times a
day).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
s/p Motor vehicle crash
Injuries:
Nasal bone fracture
Left ulnar & radius fractures
Right ___ phalanx fracture
Pneumonia
Discharge Condition:
Awake and alert, conversant w/ some dysathria
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: MVC and trauma.
COMPARISON: Chest radiograph on ___.
FINDINGS: Again seen are bilateral upper lobe opacities, right greater than
left, similar compared to ___. No effusion or pneumothorax.
Cardiac, mediastinal and hilar contours are normal.
IMPRESSION: Bilateral upper lobe right greater than left opacities, similar
compared to prior study.
Radiology Report
INDICATION: Trauma, MVC.
COMPARISON: None available.
TECHNIQUE: Contiguous axial images were obtained through the brain. No
contrast was administered.
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or
acute territorial infarction. The ventricles and sulci are normal in size and
configuration for the patient's age. There are mucous retention cysts in the
maxillary sinuses bilaterally. The patient has antrectomies bilaterally. The
mastoid air cells are well aerated. There is a buckled right nasal bone
fracture.
IMPRESSION: No acute intracranial process. Buckled right nasal bone
fracture.
These findings were discussed with the surgical team at 12:45 p.m. on ___ in person.
Radiology Report
INDICATION: MVC and trauma.
COMPARISON: None available.
TECHNIQUE: Helical MDCT images obtained through the cervical spine without
contrast. Coronal and sagittal reformations were performed.
FINDINGS: There is no acute fracture or malalignment. Incidental note is
made of 6 mm calcified right thyroid lobe nodule. Prevertebral and
paravertebral soft tissues are unremarkable. The aerodigestive tract is
unremarkable.
IMPRESSION: No acute fracture or malalignment.
These findings were discussed with surgical team at 12:45 p.m. on ___ in person.
Radiology Report
INDICATION: MVC trauma.
COMPARISON: CT chest on ___, CT abdomen and pelvis on ___, and chest radiograph on ___.
TECHNIQUE: MDCT images were obtained through the chest, abdomen, and pelvis
following the administration of IV contrast. Coronal and sagittal
reformations were performed.
FINDINGS: There is a 6-mm calcified nodule in the right lobe of the thyroid.
Otherwise, the thyroid is unremarkable. The aorta is normal in caliber
throughout. There is no evidence of aortic dissection, aneurysm, or other
abnormality. The heart and pericardium are unremarkable. There are no
filling defects seen within the pulmonary arteries to the subsegmental level.
The airways are patent to the subsegmental level. No evidence of pleural
effusion, pneumothorax, or pulmonary contusion or laceration. The vague
ground-glass opacities in the bilateral upper lobes are again seen and not
significantly changed since CT chest on ___. In addition to the
ground-glass opacities, there are also some nodular opacities in the bilateral
upper lungs that are unchanged compared to prior. These lung findings likely
represent residual scarring from prior infection, however, acute infection
cannot be excluded. There is bibasilar atelectasis.
ABDOMEN AND PELVIS: The liver is unremarkable. The patient is status post
splenectomy. There are cysts in the kidneys bilaterally. The ureters are
unremarkable. The bladder is unremarkable. The adrenal glands are
unremarkable. The remaining head and proximal body of the pancreas are
unremarkable. Patient is status post distal pancreatectomy. Patient is
status post total gastrectomy and choledochojejunostomy. There is no evidence
of small or large bowel injury. The rectum is unremarkable.
The prostate and seminal vesicles are unremarkable. There is no free fluid in
the pelvis. There is no free air. Patient is status post ventral hernia
repair.
The intra-abdominal vasculature is patent.
There are mild degenerative changes of the lumbar spine, most prominent at
L5/S1. The patient is status post L5 laminectomy. The posterior left healed
rib fractures are again seen and unchanged compared to CT chest on ___. On the scout view, a segmental fracture of the radius and fracture
of the ulna are seen, better seen on dedicated films of the forearm.
IMPRESSION:
1. No acute intrathoracic injury. No acute intra-abdominal injury.
2. Bilateral upper lung opacities with nodularity, likely represent scarring
from prior infection; however, acute infection in this area cannot be ruled
out. This is similar in appearance compared to CT chest on ___.
3. Segmental fracture of the radius and fracture of the ulna better described
on concurrent radiographs of the forearm.
4. Incidental note is made of 6-mm calcified right thyroid nodule.
5. Bilateral renal cysts.
Radiology Report
INDICATION: MVC. Question of fracture.
COMPARISON: None available.
FINDINGS: Evaluation of the study is limited due to overlying cast or splint
material. Five views of the forearm and wrist. There is a segmental fracture
of the left radius, with the distal fragment of the radius displaced
posteriorly and the mid segment displaced medially. There is also a likely
fracture of the distal portion of the proximal segment of the radius as well
as the proximal portion of the distal fragment. There is a fracture of the
mid-to-distal portion of the left ulna with lateral displacement of the distal
fragment. Limited evaluation of the wrist does not demonstrate any
dislocation or obvious fracture. A more subtle fracture may be more difficult
to assess.
IMPRESSION: Dispalced segmental fracture of the radius and fracture of the
mid-to-distal ulna as described above. Evaluation of the wrist is limited due
to overlying cast or splint material.
Radiology Report
HISTORY: ORIF of left forearm.
TECHNIQUE: Six spot fluoroscopic images obtained in the OR without
radiologist present for a total screening time of 22.3 seconds.
FINDINGS: Limited images obtained during open reduction internal fixation of
the comminuted ulnar and comminuted radial fractures demonstrate adequate
reduction of the fragments with near anatomic alignment. Please see the
intraoperative report for additional information.
IMPRESSION: Intraoperative images from ORIF of a comminuted radius and ulna
fracture.
Radiology Report
HISTORY: Splinted right hand.
TECHNIQUE: A single fluoroscopic image was obtained without a radiologist
present.
FINDINGS: There is nondisplaced fracture of the base of the right long finger
proximal phalanx. No additional fractures are seen. Please see
intraoperative note for additional information.
IMPRESSION: Nondisplaced fracture of the base of the right long finger
proximal phalanx.
Radiology Report
HISTORY: ___ man with possible fracture of the proximal phalanx of
the left middle finger.
TECHNIQUE: Three views of the right thumb, index and middle finger.
FINDINGS: There is a nondisplaced fracture through the base of the proximal
phalanx of the long finger. No other fractures are seen. No soft tissue
swelling. No degenerative changes are identified on this limited study.
There has been prior surgical intervention at the base of the thumb proximal
phalanx, likely an ulnar collateral ligament repair.
IMPRESSION: Nondisplaced fracture of the base of the right long finger
proximal phalanx.
Radiology Report
INDICATION: OR.
COMPARISON: ___.
A single fluoroscopic spot image is submitted for review demonstrating
placement of wires transfixing the long finger proximal phalangeal fracture.
A suture anchor is noted within the base of the thumb proximal phalanx. For
further details, please consult the intraoperative report.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Acute respiratory failure, intubated patient. Bilateral
upper extremity fractures.
Comparison is made with prior study ___.
Cardiac size is top normal. New opacities in the lower lobes bilaterally and
worsening consolidations in the perihilar regions right greater than left and
right upper lobe are consistent with aspiration. There is some component of
basilar atelectasis. ET tube is in a standard position 4.5 cm above the
carina. There is no pneumothorax or pleural effusion.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Assess line.
Comparison is made with prior study performed a day earlier.
Left IJ catheter tip is at the cavoatrial junction. There is no pneumothorax.
ET tube is in standard position. Cardiomediastinal contours are unchanged.
Multifocal consolidations in the upper lobe right greater than left perihilar
region and medially in the lower lobes bilaterally are unchanged. These are
consistent with aspiration with a component of atelectasis in the lower lobes.
Small left pleural effusion is stable.
Radiology Report
INDICATION: ___ male status post motor vehicle collision and multiple
surgeries with respiratory distress.
COMPARISON: ___.
TECHNIQUE: Axial CT images through the chest were acquired before and after
administration of intravenous contrast. Coronal, sagittal, and bilateral
oblique reformatted images were reviewed.
FINDINGS: A small acute non-occlusive thrombus is seen in a right upper lobe
subsegmental pulmonary artery (4:67-74). The heart and great vessels are
normal in caliber without pericardial effusion. Coronary artery
calcifications are moderate in severity. A left internal jugular catheter
terminates in the region of the cavoatrial junction. Small hilar and
subcarinal lymph nodes have increased in size. Right thyroid calcification is
again noted.
Bilateral lower lung consolidations have substantially increased compared to
prior. Endotracheal tube terminates in the high trachea. Small bilateral
pleural effusions are present. No pneumothorax is detected. Left apical
consolidation persists but is decreased since ___.
Suture material is seen in the upper abdomen.
Rib fractures are noted on the left.
IMPRESSION:
1. Small non-occlusive right upper lobe subsegmental acute pulmonary embolus.
2. Substantially increased bilateral lower lobe consolidations, which likely
include a large component of atelectasis, but superiorly are concerning for
pneumonia or aspiration.
3. Right thyroid calcification.
These findings were reported to Dr. ___ by Dr. ___ by telephone at
10:36 a.m. on ___ at the time of discovery of these findings.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Assess NG tube.
Comparison is made with prior studies performed earlier the same day.
NG tube tip is at the level of the hemidiaphragm and should be advanced for
more standard position. This finding was discussed by phone on ___ at
3:30 p.m. with ___. ET tube tip is 6.5 cm above the carina. Left IJ
catheter tip is in the lower SVC. There is no pneumothorax or pleural
effusion. Large bibasilar consolidations and opacities in the upper lobes
bilaterally are better seen in prior CT performed the same day earlier in the
morning.
Radiology Report
STUDY: AP chest ___.
CLINICAL HISTORY: Patient with tardive dyskinesia and bipolar disease with
multiple abdominal surgeries.
FINDINGS: Comparison is made to prior study from ___.
Endotracheal tube has been removed. There remains a left IJ central venous
line with the distal lead tip at the cavoatrial junction. Cardiac silhouette
is enlarged. There are diffuse airspace opacities bilaterally, more confluent
within the right lung. Findings are consistent with pulmonary edema, although
multifocal pneumonia should also be considered.
Radiology Report
CLINICAL HISTORY: ___ man with subsegmental PE on CTA. Evaluate for
DVT.
FINDINGS: Grayscale and color Doppler sonograms with spectral analysis of the
bilateral common femoral, superficial femoral, popliteal, posterior tibial and
peroneal veins was performed. There is normal compressibility, flow and
augmentation.
IMPRESSION: No bilateral lower extremity DVT.
Radiology Report
CHEST RADIOGRAPH
INDICATION: History of pneumonia, evaluation for effusion.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the lung volumes have
slightly increased. The pre-existing, predominantly perihilar opacities have
substantially decreased in extent and severity. The remaining opacities are
now predominating in the upper lobes and are located around the upper aspects
of the left and right hilus.
No newly appeared opacities. The left internal jugular vein catheter has been
removed, the lateral radiograph shows evidence of a small left effusion,
obliterating the dorsal aspects of the costophrenic sinus.
Radiology Report
STUDY: Right hand three views ___.
CLINICAL HISTORY: ___ man now with right hand fracture.
FINDINGS: Comparison is made to the previous study from ___.
There are percutaneous pins fixating a fracture involving the base of the
third proximal phalanx. Percutaneous pins are in place and without
hardware-related complications. Minimal if any bridging callus is seen at the
site of the injury.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: MVC
Diagnosed with FX FOREARM NOS-CLOSED, MV COLLISION NOS-DRIVER, TETANUS-DIPHT. TD DT, BARIATRIC SURGERY STATUS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | He was admitted to the Acute Care Surgery team. Orthopedics
consulted for the fractures in his left forearm and he was taken
to the operating room for repair of these injures.
Postoperatively he was noted to have significant swelling and
was monitored closely for compartment syndrome. His compartments
on exam did remain soft and the swelling decreased significantly
with elevation using a stockinette attached to IV pole.
His right middle finger fracture was evaluated by Hand Surgery.
His finger remained splinted while discussions for operative
repair were underway. Occupational therapy was consulted for
splinting of his extremities.
He was taken to the operating room again on ___ for repair
of his finger fractures and nasal fracture (of note, was an
exacerbation of an old nasal fracture and elective repair had
been scheduled prior to this injury). Following the procedure,
he desaturated in the PACU requiring re-intubation. This is
believed to be from residual anesthetic. He was admitted to the
SICU. Over the next ___ hours, he was weaned from the ventilator
and extubated without incident. He was bronched prior to
extubation and purulent secretions were found. His chest x-ray
at that time showed bilateral atelectasis with mild hilar
congestion. He was started on Cipro which will continue through
___.
He was transferred to the floor the following day
hemodynamically stable. He did require intermittent nasal oxygen
once transferred form the ICU and was continued on nebulizer
treatments.
He was noted with pain control issues postoperatively and was
initially started on MS ___ with oral ___ for
breakthrough pain. Because of some mental status changes felt
likely from the narcotics these were stopped and he was started
on around the clock Tylenol and standing Ultram.
He was also seen by Physical therapy given his history of
frequent falls. It is being recommneded that he go to rehab
after his acute hospital stay. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Trauma: MVC:
left orbital floor blowout fracture
sacral fracture
bifrontal subdural hematoma
subarachnoid hematoma
Major Surgical or Invasive Procedure:
none
History of Present Illness:
This patient is a ___ year old male who complains of MVC,
EJECTION. ___ yo male transferred from outside hospital where
he presente after rollover MVC with ejection fom vehicle.
Was ambulaory at scene. Found to have SDH, orbital and
pelvic fractures. Multiple abrasions. Patient denies LOC. No
abdominal pain. Negative C spine CT prior to transfer.
+ETOH.
Past Medical History:
none
Social History:
___
Family History:
non-contributory
Physical Exam:
PHYSICAL EXAMINATION: ___: upon admission
Constitutional: Comfortable
HEENT: L orbital swelling and ecchymosis, EOMI
C collar in place
Chest: Clear to auscultation
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds
Abdominal: Soft, Nontender, Nondistended
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema, + pulses
Skin: multiple abrasions, L elbow laceration
Neuro: Speech fluent, GCS 15, no focal weakness
Psych: Normal mood, Normal mentation
___: No petechiae
Physical examination upon discharge: ___:
vital signs: t=98, hr85, bp=141/63, rr=18, 100% room air
General: Patient sitting in bed, NAD
HEENT: left eye scleral injection, full EOM's bil. suture left
upper eyelid
CV: ns1, s2, -s3, -s4
LUNGS: clear
ABDOMEN: soft, non-tender
EXT: no pedal edema bil., no calf tenderness bil., mild edema
left patella, left elbow laceration
NEURO: alert and oriented x 3, speech clear
Pertinent Results:
___ 01:30PM BLOOD WBC-9.5 RBC-3.80* Hgb-11.8* Hct-35.3*
MCV-93 MCH-31.2 MCHC-33.5 RDW-13.2 Plt ___
___ 06:00AM BLOOD WBC-10.1 RBC-3.65* Hgb-11.3* Hct-33.7*
MCV-92 MCH-30.8 MCHC-33.4 RDW-12.9 Plt ___
___ 10:36AM BLOOD WBC-17.8* RBC-4.32* Hgb-13.4* Hct-40.2
MCV-93 MCH-31.0 MCHC-33.3 RDW-13.0 Plt ___
___ 10:36AM BLOOD Neuts-87.5* Lymphs-5.4* Monos-6.5 Eos-0.5
Baso-0.2
___ 01:30PM BLOOD Plt ___
___ 10:36AM BLOOD ___ PTT-25.2 ___
___ 06:00AM BLOOD Glucose-118* UreaN-6 Creat-0.6 Na-141
K-3.5 Cl-104 HCO3-29 AnGap-12
___ 10:36AM BLOOD Glucose-99 UreaN-8 Creat-1.0 Na-147*
K-3.5 Cl-109* HCO3-24 AnGap-18
___ 06:00AM BLOOD Calcium-8.7 Phos-1.8* Mg-1.9
___ 10:36AM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___: chest x-ray:
No acute intrathoracic abnormality.
___: cat scan of the head:
1. No evidence of intracranial hemorrhage or infarction.
2. Extensive ethmoidal air cell opacification suggestive of
hemorrhage in the setting of a facial bone fracture, not well
visualized on this non-dedicated examination.
___: cat scan of the sinus:
Left orbital floor blow-out fracture with resultant it
opacification of the bilateral ethmoidal air cells and air-fluid
level within the left maxillary sinus. No evidence of ocular
muscle entrapment.
___: x-ray of the pelvis:
A markedly distended bladder filled with iodinated contrast
partially obscures the sacrum. Fracture through the left
hemisacrum extending to the sacroiliac joint with mild left
sacroiliac diastasis seen on the preceding CT is not well
appreciated on the current radiographs. There is mild widening
of the pubic symphysis. Elevated appearance of the bladder is
likely related to mass effect from a retropubic hematoma noted
on CT.
___: left shoulder:
IMPRESSION: No obvious fracture or dislocation. If symptoms
persist,
consider followup radiographs for further assessment with MRI.
Medications on Admission:
none
Discharge Medications:
1. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
hold for diarrhea
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*30 Capsule Refills:*0
3. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Trauma: motor vehicle accident
left orbital floor blowout fracture
sacral fracture
bifrontal subdural hematoma
subarachnoid hematoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane)(crutches)
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with trauma // trauma
TECHNIQUE: A single portable AP supine view of the chest was obtained.
COMPARISON: None
FINDINGS:
Trauma board partially obscures the view. Cardiomediastinal silhouette is
within normal limits. Lungs are grossly clear. There is no pleural effusion
or pneumothorax. Bones are grossly unremarkable.
IMPRESSION:
No acute intrathoracic abnormality.
Radiology Report
INDICATION: ___ man with sacral fracture, evaluate.
COMPARISON: CT abdomen and pelvis from earlier today.
PELVIS, 3 VWS
FINDINGS: A markedly distended bladder filled with iodinated contrast
partially obscures the sacrum. Fracture through the left hemisacrum extending
to the sacroiliac joint with mild left sacroiliac diastasis seen on the
preceding CT is not well appreciated on the current radiographs. There is
mild widening of the pubic symphysis. Elevated appearance of the bladder is
likely related to mass effect from a retropubic hematoma noted on CT.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with SDH and facial trauma with orbital floor fx //
eval SDH and orbit fracture
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Reformatted coronal, sagittal and
thin section bone algorithm-reconstructed images were then generated.
DOSE: CTDIvol: 48.28 mGy
DLP: 891.93 mGy-cm
COMPARISON: Comparison is made to reference CT head dated ___, and
CT facial bones performed ___.
FINDINGS:
There is no evidence of intracranial hemorrhage, edema, mass effect, or
infarction. The ventricles and sulci are normal in size and configuration. The
basal cisterns appear patent and there is preservation of gray-white matter
differentiation.
There is extensive opacification of the bilateral anterior and posterior
ethmoidal air cells, as well as mucosal thickening within the frontal and
maxillary sinuses. Although no definitive fracture line is visualized on these
non dedicated views, a concomitant CT facial bone examination demonstrates a
left orbital floor blow-out fracture. The mastoid air cells are clear
bilaterally.
IMPRESSION:
1. No evidence of intracranial hemorrhage or infarction.
2. Extensive ethmoidal air cell opacification suggestive of hemorrhage in the
setting of a facial bone fracture, not well visualized on this non-dedicated
examination.
NOTIFICATION: Findings were conveyed by Dr. ___ to Dr. ___
telephone at 13:22 on ___, 1 min after interpretation.
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST
INDICATION: History: ___ with SDH and facial trauma with orbital floor fx //
eval SDH and orbit fracture
TECHNIQUE: Helical axial MDCT images were acquired through the paranasal
sinuses. Coronal reformatted images were prepared.
DOSE: CTDIvol: 25.67 mGy
DLP: 523.13 mGy-cm
COMPARISON: Comparison is made to reference head CT and CT head both dated ___.
FINDINGS:
A comminuted left orbital floor blow-out fracture is noted with several
osseous fragments displaced inferiorly into the left maxillary sinus. There is
no evidence of ocular muscle entrapment. There is associated left preorbital
soft tissue swelling and subcutaneous air.
There is extensive opacification of the bilateral anterior and posterior
ethmoidal air cells. An air-fluid level is seen within the left maxillary
sinus. There is mucosal thickening within the bilateral sphenoid sinuses,
right maxillary sinus, and bilateral frontal sinuses. The bilateral mastoid
air cells are clear.
The ostiomeatal units are obstructed bilaterally due to a combination of
mucosal thickening and hemorrhage. The anterior clinoid processes are not
pneumatized. The nasal septum is deviated towards the right. The
temporomandibular joints are symmetric and unremarkable.
Allowing for helical acquisition, reconstruction algorithm, and section
thickness, the visualized brain is grossly unremarkable.
IMPRESSION:
Left orbital floor blow-out fracture with resultant it opacification of the
bilateral ethmoidal air cells and air-fluid level within the left maxillary
sinus. No evidence of ocular muscle entrapment.
NOTIFICATION: Findings were conveyed by Dr. ___ to Dr. ___ at 13:29
on ___, 1 min after discovery.
Radiology Report
HISTORY: left shoulder pain s/p MVC, rule out fracture or dislocation.
LEFT SHOULDER, THREE VIEWS.
Technologist note "patient unable to stand or rotate body for Grashey view due
to pain in other areas of body, x-ray angled to provide Grashey view. Some
distortion can be seen, best films possible. Patient could not perform
axillary position due to pain."
No fracture or dislocation is detected about the left shoulder. The AC and
glenohumeral joints remain congruent, allowing for the distortion described.
No focal lytic or sclerotic lesion is detected. Possible small soft tissue
calcification posterior to the scapula on the Y view is unlikely related to an
acute injury.
IMPRESSION: No obvious fracture or dislocation. If symptoms persist,
consider followup radiographs for further assessment with MRI.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: MVC, EJECTION
Diagnosed with SUBDURAL HEMORR-COMA NOS, FX SACRUM/COCCYX-CLOSED, FX ORBITAL FLOOR-CLOSED, LAC EYELID SKN/PERIOCULR, OPEN WOUND OF LIP, MV TRAFF ACC NEC-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 admitted from an outside hospital after being
involved in a motor vehicle accident. He reportedly sustained a
loss of consciousness. On imaging studies, he was reported to
have sustained a left orbital floor blowout fracture, a sacral
fracture, a bi-frontal subdural hematoma and a subarachnoid
hematoma. He also sustained a laceration to his eye lid and lip.
Because of the head injuries, he was evaluated by the
Neurosurgery service. The patient was placed on neuro checks
and was started on a course of keppra for seizure prophalaxis.
During his hospital course, the patient remained neurologically
intact. He was evaluated by occupational therapy and no
out-patient cognitive evaluation was warrented.
Additional injuries to the face included a left orbital floor
blowout fracture. The patient was evaluated by the Plastic
surgery service who determined that there was no facial
instability and no need for surgical intervention at this time.
The patient was placed on sinus precautions and the laceration
to his upper eyelid and lip were sutured.
Upon admission, the patient reported low back pain. Cat scan
imaging was done and showed an oblique fracture of the left
sacrum. For this, the patient was evaluated by the Orthopedic
service. Serial hematocrits remained stable. To further
evaluate this, the patient underwent pelvic films which showed a
pelvic fracture with a sacral component but no anterior ring
injury. This was treated in a closed manner without
manipulation. The patient was instructed in TDWB by the
physical therapist and was cleared for discharge home. Prior to
discharge, the patient met with the social worker who offered
referrals for substance abuse resources.
On HD #4, the patient was discharged home in stable condition.
His vital signs were stable and he was afebrile. He was
tolerating a regular diet and his pain was controlled with oral
analgesia. He was instructed to follow-up with his primary care
provider if he continued to have left knee swelling.
Appointments for follow-up were made with the Orthopedic,
Neurosurgery, and Plastic Surgery service. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
R leg pain
Major Surgical or Invasive Procedure:
1. Operative treatment right tibia fracture with intramedullary
nail.
2. Closed treatment right fibula fracture without manipulation.
3. Washout and debridement open fracture, right ___ toe.
4. Closed treatment right metatarsophalangeal dislocation right
great toe.
5. Closed treatment ___ and ___ metatarsal fractures with
manipulation.
6. Closed treatment right ___ toe with metatarsophalangeal
dislocation with manipulation.
History of Present Illness:
___ s/p fall from 12 foot ladder while attempting to cut tree
branches at his house. He landed on his right leg and noted
immediate pain and inability to weight bear. No headstrike or
LOC. He was taken to ___ where xrays demonstrated
multiple RLE fractures for which he was transferred to ___.
There was also a question of a possible open fracture due to a
small plantar poke hole at his foot in close proximity to a ___
digit fracture. He was given ancef and tetanus at the OSH.
Past Medical History:
DM, HTN
Social History:
___
Family History:
NC
Physical Exam:
Discharge Exam:
VS: 99.4 87 156/82 20 95RA
Gen: NAD, AAOx3
Wound: dressing c/d/i
RLE exam: in short aircast boot, fires ___, SILT SP/DP/T,
WWP
Medications on Admission:
lisinopril 20, actos 30, simvastatin 10
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
RX *acetaminophen 325 mg ___ tablet(s) by mouth every 6 hours
Disp #*60 Tablet Refills:*2
2. Cephalexin 500 mg PO Q8H
RX *cephalexin 500 mg 1 tablet(s) by mouth every 8 hours Disp
#*30 Capsule Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*30 Capsule Refills:*2
4. Senna 1 TAB PO BID *AST Approval Required*
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice daily Disp
#*30 Tablet Refills:*2
5. Vitamin D 400 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 1 tablet(s) by mouth
daily Disp #*60 Capsule Refills:*3
6. Simvastatin 10 mg PO DAILY
7. Pioglitazone 30 mg PO DAILY
8. OxycoDONE (Immediate Release) ___ mg PO Q3H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every 3 hours Disp
#*61 Tablet Refills:*0
9. Lisinopril 20 mg PO DAILY
10. Enoxaparin Sodium 40 mg SC DAILY Duration: 14 Days
RX *enoxaparin 40 mg/0.4 mL 40 mg SC daily Disp #*14 Syringe
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Right tibia/fibular fracture.
2. Open right ___ metatarsophalangeal dislocation, great toe.
3. ___ and ___ proximal phalanx fractures, right foot.
4. ___ interphalangeal toe dislocation.
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: Right tib/fib and foot fractures.
Seven views right tibia and fibula and right foot. Compared to the prior study
of ___ there has been no significant interval change in the
transverse fractures through the distal tibia and fibula with approximately
50% anterior displacement. The ankle mortise is congruent.
There is a fracture dislocation of the first metatarsophalangeal joint with
additional fractures of the heads of the second, third, and fourth
metatarsals. Alignment of the fourth metatarsophalangeal joint is difficult
to assess on this study.
Radiology Report
INDICATION: Right tibial fracture.
COMPARISON: ___
13 total fluoroscopic spot images are provided for localization of the right
tibia and fibula as well as the right foot. There has been placement of a
long intramedullary rod with interlocking screws transfixing the known spiral
distal tibial fracture. The distal fibular fracture is again visualized.
Fractures of the metatarsals are best evaluated on the same-day radiograph.
There appears to be improved alignment of the first MTP joint. The total
fluoroscopic spot time is 132.7 seconds.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: TIB/FIB TOE FX
Diagnosed with FX SHAFT FIB W TIB-CLOS, FX PHALANX, FOOT-OPEN, FALL-1 LEVEL TO OTH NEC, FX METATARSAL-CLOSED
temperature: 98.0
heartrate: 83.0
resprate: 18.0
o2sat: 93.0
sbp: 170.0
dbp: 80.0
level of pain: 0
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have R tibial shaft fracture and multiple R foot fractures
and was admitted to the orthopedic surgery service. The patient
was taken to the operating room on ___ for IM nail of the R
tibia and closed reduction and washouts of the R foot fractures,
which the patient tolerated well (for full details please see
the separately dictated operative report). The patient was taken
from the OR to the PACU in stable condition and after recovery
from anesthesia was transferred to the floor. The patient was
initially given IV fluids and IV pain medications, and
progressed to a regular diet and oral medications by POD#1. The
patient was given perioperative antibiotics and anticoagulation
per routine. The patients home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to home with services 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 heel weightbearing as tolerated in
the right lower extremity in a short aircast boot, and will be
discharged on Lovenox for DVT prophylaxis. He will be
discharged on a 10 day course of Keflex for his open fracture.
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: ORTHOPAEDICS
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
Left ___ digit laceration with tendon and nerve injury
Major Surgical or Invasive Procedure:
___:
1. Irrigation and debridement of flexor tendon sheath.
2. Repair of the flexor digitorum profundus tendon in zone 2.
3. Repair of the radial digital nerve to the index using the
operating room microscope.
History of Present Illness:
Ms. ___ is a ___ y/o female RHD who was cutting an avacado
on ___ and sustained a laceration for the volar surface of
her
left index just distal to the PIP joint. She states she went to
___ where she recieved a tetanus shot, had her
hand washed-out and sutured. She states within the first 24
hours
she developed spreading erythema and swelling which was
significantly worsened over the last 12 hours and thus she
presented to the ED. We are consulted by the ED for possible
tenosynovitis of the left hand.
She states she has decreased sensation at the tip of her finger
both radial and ulnar sides although she can feel pressure. She
has had some yellow drainage. She denies any fevers, chills,
nausea, vomiting, rigors, diarrhea. She states that she was not
discharged on any oral anti-biotics.
Past Medical History:
Denies
Social History:
___
Family History:
NC
Physical Exam:
AFVSS
LUE: WWP. Incision C/D/I. Improving edema and erythema of ___
digit. Stable sensory exam. <2 sec cap refill all digits.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 12 Days
2. Docusate Sodium 100 mg PO BID
3. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q3H:PRN pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Left index finger laceration with flexor tendon and digital
nerve injury complicated by infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Left index finger pain and swelling and erythema, assess for foreign
body.
COMPARISON: None.
FINDINGS:
3 views were obtained of the left hand. No fracture, dislocation or
significant degenerative disease is identified. Mild soft tissue swelling is
seen of the index finger without radiopaque foreign body or abnormal soft
tissue calcifications.
IMPRESSION:
No fracture, dislocation or evidence of radiopaque foreign body with diffuse
swelling of the index finger.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: HAND INFECTION
Diagnosed with SYNOVITIS NOS
temperature: 99.4
heartrate: 99.0
resprate: 16.0
o2sat: 100.0
sbp: 141.0
dbp: 90.0
level of pain: 5
level of acuity: 3.0 | Ms. ___ was admitted to the Orthopaedic Hand Surgery service
following I&D of her left ___ digit with repair of FDP tendon
and radial digital nerve on ___. She tolerated the procedure
well and was taken to the PACU in stable condition.
Intra-operative cultures were taken, which ultimately grew H.
influenza and Coag + S. aureus. While in-house, she was given IV
Unasyn for empiric antimicrobial coverage. She was given an
orthoplast radial gutter splint POD #2. She remained afebrile
during her stay. At time of discharge, she was tolerating a
regular diet, her pain was well-controlled with oral medications
and her clinical exam continued to show improvement. She was
discharged home on POD #1 with plan to continue on PO Augmentin
for another 12 days. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
BuSpar / Benzodiazepines / lorazepam / propofol
Attending: ___
Chief Complaint:
confusion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ with PMH significant for cryptogenic
cirrhosis c/b variceal bleeding s/p TIPS (___), ascites,
hepatic encephalopathy requiring high doses of lactulose, and
recurrent right hepatic hydrothorax (used to have to get weekly
thoracentesis) on diuretic presenting with confusion and
lethargy.
Per patient's wife, he has had increasing encephalopathy
symptoms (confusion, poor sleep, tremors) despite lactulose Q2h
and frequent bowel movements. Has also had worsening pain in his
back from a recent fall in the bathroom and has increased fluid
retention.
In the ED, initial vitals were: 97.4 97 115/68 16 99% RA
Labs were notable for: WBC 7.7, H/H 7.3/23.3, plt 82, INR 1.5,
normal chemistries with Cr 0.9, lactate 1.7, AST/ALT 67/65 with
tbili 1.1, alb 2.5. Serum tylenol level 15, urine tox and rest
of serum tox negative. UA unremarkable.
Consults: Hepatology was consulted and agreed with infectious
work-up and increase in lactulose to treat HE. Admission to
liver.
Vitals prior to transfer: 97.9 89 129/75 16 98% RA
Currently, vitals 97.9 131/54 86 20 100%. Patient floridly
delirious, repeating his own name over and over again.
ROS: per HPI. Unable to assess further due to HE.
Past Medical History:
- Cryptogenic Cirrhosis
- Esophageal varices, 3 cords s/p variceal bleed ___: No
varices on repeat EGD after TIPS; TIPS ___
- Hepatic encephalopathy, requires high doses of lactulose to
have ___ BM's day
- Recurrent right hepatic hydrothorax: used to get weekly
thoracentesis but now on diuretics post TIPS
- Hyperlipidemia
- GERD
Social History:
___
Family History:
No known family history of cirrhosis.
Physical Exam:
========================
ADMISSION EXAM:
========================
VS: 97.9 131/54 86 20 100%RA. Weight 74.8kg
General: Confused Caucasian male lying in bed in NAD, repeating
his first and last name over and over.
HEENT: NC, sclerae anicteric. OP clear.
Neck: Supple, no ___.
CV: RRR, normal s1/s2. ___ systolic murmur
Lungs: CTAB, No appreciable wheeze or crackles anteriorly
Abdomen: Soft, mildly distended with mild ttp throughout without
guarding though difficult to assess entirely as patient bothered
by all intervention this morning.
Ext: WWP, DP pulses 2+ bilaterally. 1+ edema to knees
bilaterally. Neuro: Oriented to self only, + asterixis, moving
all 4 extremities with purpose
=========================
DISCHARGE EXAM:
=========================
VS: 98.1, 119/72, 89, 18, 98RA
I/O: 9BM (___)
General: alert, middle aged man, lying in bed, comfortable, NAD
HEENT: NC/AT, PERRL, EOMI, sclerae anicteric. MMM, OP clear.
Neck: Supple
CV: RRR, normal s1/s2. ___ systolic murmur
Lungs: CTAB, No appreciable wheeze or crackles anteriorly
Abdomen: Soft, nondistended, nontender to palpation, negative
murphys sign, no rebound, no guarding
Back: no point tenderness along spinal processes, full range of
motion
Ext: WWP, DP pulses 2+ bilaterally. no edema bilaterally.
Neuro: AOx3, able to say days of the week backwards, CN II-XII
grossly intact, moving all extremities, gait stable
Skin: no rash or excoriations
Pertinent Results:
==========================
ADMISSION LABS:
==========================
___ 12:30AM WBC-7.7 RBC-2.64* HGB-7.3* HCT-23.3* MCV-88
MCH-27.7 MCHC-31.3* RDW-20.2* RDWSD-63.7*
___ 12:30AM NEUTS-75.2* LYMPHS-11.5* MONOS-11.3 EOS-1.2
BASOS-0.3 IM ___ AbsNeut-5.77 AbsLymp-0.88* AbsMono-0.87*
AbsEos-0.09 AbsBaso-0.02
___ 12:30AM PLT COUNT-86*
___ 12:30AM ___ PTT-24.2* ___
___ 12:30AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 12:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 12:30AM ALT(SGPT)-65* AST(SGOT)-67* ALK PHOS-124 TOT
BILI-1.1
___ 12:30AM ALBUMIN-2.5* CALCIUM-8.1* PHOSPHATE-3.3
MAGNESIUM-2.5
___ 12:30AM ASA-NEG ETHANOL-NEG ACETMNPHN-15 bnzodzpn-NEG
barbitrt-NEG tricyclic-NEG
___ 12:30AM GLUCOSE-116* UREA N-17 CREAT-0.9 SODIUM-139
POTASSIUM-4.4 CHLORIDE-106 TOTAL CO2-25 ANION GAP-12
___ 12:34AM LACTATE-1.7
============================
DISCHARGE LABS:
============================
___ 05:29AM BLOOD WBC-7.7 RBC-2.83* Hgb-7.9* Hct-25.6*
MCV-91 MCH-27.9 MCHC-30.9* RDW-19.2* RDWSD-62.0* Plt Ct-62*
___ 05:29AM BLOOD ___ PTT-65.0* ___
___ 05:29AM BLOOD Glucose-95 UreaN-20 Creat-0.7 Na-136
K-4.4 Cl-108 HCO3-25 AnGap-7*
___ 05:29AM BLOOD ALT-49* AST-42* AlkPhos-123 TotBili-1.2
___ 05:31AM BLOOD calTIBC-213* VitB12-1797* Folate-12.7
___ Ferritn-44 TRF-164*
================
STUDIES:
================
CXR PA/L ___: IMPRESSION:
No significant change since ___, with small right pleural
effusion and
likely small left pleural effusion.
___: Duplex abdominal US Prelim report:
Severely technically limited evaluation of the abdomen.
1. Patent TIPS of wall-to-wall color flow with increased
velocities compared to the prior study of ___, however
this may be secondary to suboptimal velocity measurement
conditions.
2. Patent hepatopetal flow in the main portal vein.
3. Cirrhotic liver with small amount of perihepatic ascites and
a right pleural effusion.
___ LIVER OR GALLBLADDER US (SINGLE ORGAN)
1. High velocities within the TIPS, which have been
progressively increasing compared to earlier in ___ and in
___. These findings are concerning for progressive
narrowing of the TIPS lumen.
2. Small right pleural effusion and trace perihepatic ascites.
Lumbar spine ___: IMPRESSION:
Mild compression deformity at T12 appears to be new when
compared to the prior study and acute fracture cannot be
excluded. Recommend correlation with clinical examination
findings a tenderness in this area to exclude an acute fracture.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: Evaluate for portal vein thrombosis.
TECHNIQUE: Gray scale, color and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: Liver Doppler ultrasound from ___
FINDINGS:
Please note that this study is severely technically limited.
Liver: The hepatic parenchyma is coarsened and nodular. Nofocal liver
lesions are identified. There is mild ascites and a right pleural effusion.
Bile ducts: There is no intrahepatic biliary ductal dilation. The common
hepatic duct measures 2 mm.
Gallbladder: The gallbladder is contracted.
Pancreas: The pancreas is completely obscured by overlying bowel gas.
Spleen: The left upper quadrant is not visualized at all.
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate direction.
Main portal vein velocity is 33 cm/sec.
The TIPS is patent with wall to wall flow. Again noted is apparent focal
narrowing in the mid TIPS (image 22).
Proximal TIPS velocity is 110 centimeter/second, previously 85
centimeter/second on ___, 225 centimeter/second on ___ at
100 centimeter/second on ___.
Mid TIPS velocity is 237 cm second, previously 117 centimeter/second on ___, 219 centimeter/second on ___, and 130 centimeter/second on
___.
Distal TIPS velocity is 194 centimeter/second, previously 98
centimeter/seconds on ___, 200 centimeter/second on ___, and
137 centimeter/second on ___.
Right anterior portal vein is reversed as expected.
Right hepatic artery is patent with appropriate waveforms.
IMPRESSION:
Severely technically limited evaluation of the abdomen.
1. Patent TIPS of wall-to-wall color flow with increased velocities compared
to the prior study of ___, however this may be secondary to
suboptimal velocity measurement conditions.
2. Patent hepatopetal flow in the main portal vein.
3. Cirrhotic liver with small amount of perihepatic ascites and a right
pleural effusion.
Radiology Report
EXAMINATION: L-SPINE (AP AND LAT)
INDICATION: ___ year old man with cryptogenic cirrhosis c/b variceal bleeding
s/p TIPS (___), ascites, hepatic encephalopathy, coming in for hepatic
encephalopathy. Patient fell on back a few weeks ago. Continues to have pain.
Has been on long courses of prednisone for adrenal insufficiency. // Evidence
of fracture?
TECHNIQUE: AP and lateral views of the lumbar spine.
COMPARISON: CT abdomen ___
FINDINGS:
There are 5 non-rib-bearing lumbar-type vertebrae. There is preservation of
the normal lumbar lordosis. There is a mild compression deformity at T12,
this is at the periphery of the image and there are degenerative changes which
may falsely exaggerated this compression, nonetheless there appears to be
approximately20% loss of anterior vertebral body height. This was not clearly
seen on the prior study. A TIPS stent is in-situ in appearance compared to
the prior study. Mild degenerative changes in the bilateral hip joints.
IMPRESSION:
Mild compression deformity at T12 appears to be new when compared to the prior
study and acute fracture cannot be excluded. Recommend correlation with
clinical examination findings a tenderness in this area to exclude an acute
fracture.
NOTIFICATION: Findings were discussed with Dr. ___ by telephone at
4.05pm on ___ at the time of discovery.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Confusion, Lethargy
Diagnosed with ALTERED MENTAL STATUS
temperature: 97.4
heartrate: 97.0
resprate: 16.0
o2sat: 99.0
sbp: 115.0
dbp: 68.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ with PMH significant for cryptogenic
cirrhosis c/b variceal bleeding s/p TIPS (___), ascites,
hepatic encephalopathy requiring high doses of lactulose, and
recurrent right hepatic hydrothorax (used to have to get weekly
thoracentesis) on diuretic presenting with confusion and back
pain.
# HEPATIC ENCEPHALOPATHY: On arrival to ED, pt AOx0. No signs of
infections (bl cx NGTD, Urine cx NGTD, no ascites), no portal
vein thrombosis seen on US. Started on 60mL lactulose Q2H, with
resolution of encephalopathy in 24 hours. Transitioned to 30mL
Lactulose QID with ___ daily and no signs of encephalopathy.
Some concern that patient was not taking lactulose at home as
directed. Wife and pt adamant about compliance with medications.
Discharged on lactulose 30mL QID with close updates to the liver
center. Dr. ___ was contacted and suggested possibly reducing
size of TIPS in the future if hepatic encephalopathy continued
to be a problem.
# ANEMIA: Pt noted to have worsening anemia of Hgb 6.8 from
baseline ~8. Given 2U rbc with appropriate bump. No melena,
BRBPR. Vit B12, folate, iron, ferritin wnl. Needs outpatient
followup. Endoscopy in ___ with grade 2 varices and portal
gastropathy, no evidence of bleeding. Colonoscopy in ___
without polyps or evidence of bleeding.
# T12 COMPRESSION DEFORMITY: Pt had ongoing back pain from
previous hospitalization when he fell off the toilet. XRAY
showed T12 anterior compression. No neurologic symptoms. Likely
___ osteoperosis from chronic steroids used to treat adrenal
insufficiency. Instructed to take acetaminophen 650mg TID prn,
hot packs, ___. Can consider MRI in the future. Pt already set up
with outpaitent ___.
# Variceal bleed s/p TIPS: Last EGD in ___ with GEJ
varices which did not require intervention.
# Ascites: h/o TIPS in ___. Recent diagnostic
paracentesis on ___ was without evidence of SBP or
malignancy. No history of SBP. Lasix and spironolcatone
discontinued on recent admission due to hyponatremia. RUQ US
without significant ascites in ED.
# Cirrhosis: Cryptogenic. MELD 11 on admission, trended up to
16. Patient is on transplant list.
# COAGULOPATHY: INR up to 1.9 on ___. Likely from decreased PO
intake and frequent bowel movements. Given Vitamin K 5mg once on
___. Received heparin SC as platelets were over 50.
# Adrenal insufficiency: Continued home hydrocortisone 15mg TID.
No stress dose steroids were given since no signs of infection
or hemodynamic instability. Spoke to outpatient endocrinologist,
Dr. ___ suggested close followup to reassess steroids.
# GERD: Continued home pantoprazole q12h and calcium carbonate.
======================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine / Tree Nut
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of COPD, on 4L home O2, presents with dyspnea
over the past ___ days. Increased dyspnea is associated with
worsening cough and subjective fevers and chills at home. She
reports that she can barely ambulate from DOE. She had to sit
down when trying to move from her kitchen to her bathroom which
is only a shoert distance away. Reports she was hospitalized for
pneumonia two weeks ago and is continuing to take a low dose of
azithromycin at home as per her pulmonologist's recommendation.
Reports a chronic cough but no change in sputum characteristics.
Denies chest pain.
Additionally reports a new rash over her eyes. Denies any
associated vision changes or pain with EOMs.
ED Course:
Time Pain Temp HR BP RR Pox Glucose
Triage 12:41 0 98.2 108 122/87 18 97% 4L Nasal Cannula
Today 13:26 0 104 124/84 16 96% Nasal Cannula
Today 14:50 0 109 122/87 21 97% Nasal Cannula
Today 15:02 0 109 119/98 21 97% Nasal Cannula
]CXR -> no obvious consolidation.
abs were relatively unremarkable. Dimer was negative. ECG showed
sinus tachycardia.
Labs showed: Hgb 11.8, normal D-dimer, normal lactate, HCO3 35
Micro: blood cx
done in ED. CXR (my read): large body habitus, no clear pleural
effusions as the costophrenic angles are indistinct likely due
to redundant soft tissue. Increased vascular markings
predominantly in the lower lungs. No consolidation. No
lymphadenopathy on lateral.
Received:
IV Ondansetron 4 mg
IH Albuterol 0.083% Neb Soln 1 NEB
IH Ipratropium Bromide Neb 1 NEB
PO Azithromycin 500 mg
PO PredniSONE 60 mg
On arrival to the floor she was in no acute distress. She
confirmed the report above.
Past Medical History:
-COPD: PFT ___: FEV1 12% predicted (250cc FEV1), FVC 35%
predicted, FEV1/FVC 34% predicted; on home O2 since ___,
currently 4L by NC; h/o intubation and tracheostomy x 2
-History of melanoma
-Osteoporosis; history of multiple vertebral fractures due to
chronic corticosteroid use
-Hypertension
-Anxiety
-History of positive PPD s/p 6mos of isoniazid
Social History:
___
Family History:
Great uncle had MI in ___, Maternal & Paternal GMs had CVAs in
___. Mother with COPD.
Physical Exam:
On Admission:
-------------
VS - Temp 98.9, BP 117/81, HR 110, RR 20, O2 sat 95% 4L NC
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: 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, no excoriations or lesions, no
rashes
At Discharge:
-------------
VS - 98.6, 107/60 (90-110s/50s-70s), 106 (80s-100s), 18 (___),
99/4L (94-99/4L = baseline O2)
GENERAL: NAD
HEENT: rash around eyes bilaterally, with some mild scaling,
pink conjunctiva, MMM
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: moderate air movement, with some wheezes
ABDOMEN: obese, +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, no excoriations or lesions, no
rashes
Pertinent Results:
Labs on Admission:
-------------------
___ 01:15PM WBC-8.1 RBC-3.84* HGB-11.8* HCT-36.3 MCV-94
MCH-30.6 MCHC-32.4 RDW-14.0 PLT COUNT-395
___ 01:15PM WBC-8.1 RBC-3.84* HGB-11.8* HCT-36.3 MCV-94
MCH-30.6 MCHC-32.4 RDW-14.0
___ 01:15PM GLUCOSE-127* UREA N-6 CREAT-0.6 SODIUM-139
POTASSIUM-3.6 CHLORIDE-93* TOTAL CO2-35* ANION GAP-15
___ 01:18PM LACTATE-1.9
___ 03:14PM D-DIMER-445
___ 01:15PM ___ PTT-31.4 ___
DISCHARGE LABS
--------------
___ 05:40AM BLOOD WBC-10.7 RBC-3.59* Hgb-10.9* Hct-33.9*
MCV-94 MCH-30.5 MCHC-32.3 RDW-13.9 Plt ___
___ 05:40AM BLOOD Glucose-101* UreaN-12 Creat-0.6 Na-138
K-4.1 Cl-93* HCO3-34* AnGap-15
___ 05:40AM BLOOD Calcium-9.3 Phos-4.3 Mg-1.8
PERTINENT LABS
--------------
___ 03:14PM D-DIMER-445
___ 01:18PM BLOOD Lactate-1.9
IMAGING
-------
CXR ___:
No radiographic evidence of pneumonia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
2. Azithromycin 250 mg PO Q24H
3. Benzonatate 100 mg PO TID
4. Captopril 12.5 mg PO TID
5. Escitalopram Oxalate 20 mg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. Furosemide 20 mg PO DAILY
8. ipratropium bromide 0.06 % nasal QID
9. Lorazepam 1 mg PO QID
10. Dulera (mometasone-formoterol) 200-5 mcg/actuation
inhalation BID
11. Omeprazole 20 mg PO DAILY
12. TraZODone 50 mg PO QHS
13. Verapamil SR 240 mg PO BID
14. Vitamin D ___ UNIT PO DAILY
15. Senna 8.6 mg PO BID
16. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation 2 puffs twice daily
17. Tudorza Pressair (aclidinium bromide) 400 mcg/actuation
inhalation 1 inhalation twice daily
Discharge Medications:
1. Benzonatate 100 mg PO TID
2. Escitalopram Oxalate 20 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Furosemide 20 mg PO DAILY
5. Lorazepam 1 mg PO QID
6. Omeprazole 20 mg PO DAILY
7. Senna 8.6 mg PO BID
8. TraZODone 50 mg PO QHS
9. Verapamil SR 240 mg PO BID
10. Vitamin D ___ UNIT PO DAILY
11. Lisinopril 5 mg PO DAILY
12. PredniSONE 30 mg PO DAILY Duration: 7 Days
Rx 1 of 3: starting ___.
Take 30mg prednisone for 7d.
13. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
14. Dulera (mometasone-formoterol) 200-5 mcg/actuation
inhalation BID
15. ipratropium bromide 0.06 % nasal QID
16. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
INHALATION 2 PUFFS TWICE DAILY
17. Tudorza Pressair (aclidinium bromide) 400 mcg/actuation
inhalation 1 inhalation twice daily
18. Azithromycin 250 mg PO Q24H
19. Hydrocortisone Cream 1% 1 Appl TP TID
20. PredniSONE 20 mg PO DAILY Duration: 7 Days
Rx 2 of 3: starting ___.
Take 20mg prednisone for 7d.
21. PredniSONE 10 mg PO DAILY Duration: 7 Days
Rx 3 of 3: starting ___.
Take 10mg prednisone for 7d.
22. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
------------------
- COPD exacerbation
- Emphysema/COPD - GOLD stage 4
- Chronic hypoxemic-hypercarbic respiratory failure
SECONDARY DIAGNOSIS:
--------------------
- Hypertension, essential
- Essential tremor
- Periocular dermatitis
- anxiety
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with cough anddyspnea // r/o acute infectious process
EXAMINATION: CHEST (PA AND LAT)
TECHNIQUE: Chest radiograph, AP and lateral views
COMPARISON: Chest radiograph ___
FINDINGS:
There is no pleural effusion, or pneumothorax. Mild bibasilar atelectasis is
similar compared to ___. Emphysematous changes are noted in bilateral
lungs. Cardiomediastinal and hilar silhouettes are normal size.
IMPRESSION:
No radiographic evidence of pneumonia.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION
temperature: 98.2
heartrate: 108.0
resprate: 18.0
o2sat: 97.0
sbp: 122.0
dbp: 87.0
level of pain: 0
level of acuity: 2.0 | ___ with medical history of COPD, on home Oxygen 4L, presenting
with acute on chronic shortness of breath.
Active Issues:
--------------
# EMPHYSEMA/COPD: GOLD STAGE 4. COPD exacerbation given
increased SOB, increased cough and sputum production over the
last several days. Trigger for exacerbation unclear, though she
does endorse subjective fevers and chills recently, which may be
suggestive of a URI; of note, her CXR is without evidence of
consolidation. Her D-dimer was negative so imaging for PE was
not pursued. Will plan to treat for other causes of chronic
cough, including GERD and allergic rhinitis. Continued her home
O2 requirement of 4L; she was started on a levofloxacin course
for 7 days, end date ___ in the setting of a COPD
exacerbation. Levofloxacin was chosen because she had
chronically been on azithromycin. She should restart
azithromycin 250mg daily as chronic prophylaxis on ___.
Continued home long-acting inhalers: Dulera and aclidinium and
started standing albuterol and ipratropium nebs. She was also
started on prednisone 40mg x7 days, followed by prolonged taper
30mg x1 week, 20mg x1 week, 10mg x1 week- pulmonologist Dr.
___ was made aware. She was also given a proton pump inhibitor
to treat for GERD and loratidine and fluticasone proprionate
for allergic rhinitis. ___ consult recommended acute ___
rehab vs LTAC.
# Periorbital dermatitis: Improved and resolving. History of
eczema. Most likely in the setting of seasonal allergies vs.
other allergic exposure such as contact. Dermatomyositis felt
unlikely given no proximal muscle weakness or evidence of
myopathy on exam. Improved with supportive management. Recommend
hydrocortisone cream x1 wk if patient is willing
Chronic Issues:
----------------
# HTN: held home meds for now, with plan to restart at time of
discharge
# Anxiety: continued home medications
***TRANSITIONAL ISSUES***
- will need prolonged steroid taper: Prednisone 40mg x1 week,
30mg x1 week, 20mg x1 week, 10mg x1week, and possibly indefinite
steroids.
- treated with Levoquin in setting of COPD exacerbation, end
date ___
- restart azithromycin 250mg daily on ___
- goal O2 sats on 4L NC should be 90-95%
- consider outpatient palliative care given her end stage lung
disease to discuss future goals of care with regards to
hospitalization, potential for repeat tracheostomy, etc. |
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/GI bleed
Major Surgical or Invasive Procedure:
EGD (___)
History of Present Illness:
___ year old gentleman with history of aortic stenosis currently
undergoing TAVR workup, CAD s/p DES to the left main, left
circumflex, LAD, type II DM, who presented to clinic due to
concern for low H/H and guaiac positive stools.
Patient notes having worsening shortness of breath with
exertion as well as dark/tarry stools today. He has felt tired
and fatigued over the past several days but only had dark/tarry
stools for one day. He denied any fevers, chills, night sweats,
diarrhea, chest pain, chest pressure, cough. He does note having
episodes of dry heaving but no vomit or blood noted. Also
acknowledged having lightheadedness over the past two days.
Denies any epigastric pain. Does acknowledge taking "a couple"
ibuprofen for back pain, although he states he has not taken
them everyday.
Given presentation and concern for GI bleed, referred to ___.
In the ED, initial vitals were: 97.1, 128/56, 18, 100% on RA.
Labs were notable for INR 1.3 (not on Coumadin), WBC 11.8, H/H
6.___.5.
LFT's normal except for AST 43. Chemistry panel unremarkable.
Troponin x 1 negative.
Rectal exam notable for melena.
Lactate 1.6
UA 16 RBC, no bacteria.
CXR: no acute cardiopulmonary process. Streaky bibasilar
opacities likely reflect atelectasis.
In the ED, patient received pantoprazole 40 mg IV x 1, 500 cc
normal saline.
Received 1 unit PRBC in the ED.
On the floor, patient continues to feel fatigued. Denies chest
pain, chest pressure, shortness of breath.
Past Medical History:
Actinic Keratosis
Aortic Root Aneurysm
Aortic Stenosis
Basal Cell Carcinoma
Cataract
Diabetes Mellitus Type II
Hypertension
Open-Angle Glaucoma
Osteoarthritis
Seborrheic Keratosis
BPH
Social History:
___
Family History:
Negative for premature atherosclerosis,
aneurysms, or sudden cardiac death. Both his parents died in
their early ___ one from emphysema, one from diabetes.
Physical Exam:
ADMISSION PHYSICAL EXAM
=====================
Vital Signs: 98.1, 138/73, 81, 18, 98% on RA.
General: Alert, oriented, laying comfortably in bed.
HEENT: Sclerae anicteric, by conjunctival pallor, MMM,
oropharynx clear, EOMI, PERRL, neck supple.
CV: Regular rate and rhythm, S1 and S2 present systolic murmur
at right second intercostal space.
Lungs: Clear to auscultation bilaterally.
Abdomen: soft, non-tender, non-distended, no rebound or
guarding.
Ext: Left lower extremity significantly more swollen than right
lower extremity.
Neuro: grossly normal.
DISCHARGE PHYSICAL EXAM
======================
Vital Signs: 98.4, 130s-160/60s-70s, 80s, 18, 92-96% on RA.
General: Alert, oriented, laying comfortably in bed.
HEENT: Sclerae anicteric, by conjunctival pallor, MMM,
oropharynx clear, EOMI, PERRL, neck supple.
CV: Regular rate and rhythm, S1 and S2 present systolic murmur
at right second intercostal space.
Lungs: Clear to auscultation bilaterally.
Abdomen: soft, non-tender, non-distended, no rebound or
guarding.
Ext: Left lower extremity significantly more swollen than right
lower extremity.
Neuro: grossly normal.
Pertinent Results:
====
ADMISSION LABS
=============
___ 05:15PM BLOOD WBC-11.8*# RBC-2.56* Hgb-6.8* Hct-21.5*
MCV-84 MCH-26.6 MCHC-31.6* RDW-17.5* RDWSD-53.2* Plt ___
___ 05:15PM BLOOD Neuts-79.4* Lymphs-11.7* Monos-7.4
Eos-0.8* Baso-0.3 Im ___ AbsNeut-9.33* AbsLymp-1.38
AbsMono-0.87* AbsEos-0.09 AbsBaso-0.03
___ 05:15PM BLOOD ___ PTT-30.1 ___
___ 05:15PM BLOOD Glucose-149* UreaN-39* Creat-0.9 Na-133
K-4.5 Cl-95* HCO3-25 AnGap-18
___ 05:15PM BLOOD ALT-19 AST-43* LD(LDH)-399* AlkPhos-121
TotBili-0.4
___ 05:15PM BLOOD cTropnT-<0.01
___ 02:34AM BLOOD CK-MB-1 cTropnT-<0.01
___ 05:15PM BLOOD Albumin-3.0* Iron-21*
___ 05:15PM BLOOD calTIBC-228* Hapto-364* Ferritn-459*
TRF-175*
___ 08:29PM URINE Color-Yellow Appear-Clear Sp ___
___ 08:29PM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
___ 08:29PM URINE RBC-16* WBC-4 Bacteri-NONE Yeast-NONE
Epi-0
___ 08:29PM URINE CastHy-3*
___ 08:29PM URINE Mucous-RARE
=============
MICROBIOLOGY
=============
___ 5:15 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
=============
PERTINENT IMAGING
================
___ (PA & LAT)
No acute cardiopulmonary process. Streaky bibasilar opacities
likely reflect
atelectasis.
___ (PANOREX FOR DENT
No comparison. Several missing teeth. No evidence of focal
osteolytic
changes.
___ AND TORSO CTA
The TAVR/vascular findings will be reported once the 3D imaging
lab has
performed imaging processing.
Extensive necrotic para-aortic retroperitoneal adenopathy
extending inferiorly
involving the iliac lymph nodes bilateral as well as perirectal
nodes.
Multiple pulmonary nodules as well as mediastinal adenopathy.
These findings are concerning for a metastatic
lymphoproliferative process
such as lymphoma (the necrotic lymph nodes would be atypical).
In the setting
of necrotic lymph nodes tuberculosis should also be considered
in the
differential diagnosis.
Tissue sampling advised.
===============
DISCHARGE LABS
===============
___ 06:35AM BLOOD WBC-9.3 RBC-2.95* Hgb-8.1* Hct-25.1*
MCV-85 MCH-27.5 MCHC-32.3 RDW-17.2* RDWSD-52.7* Plt ___
___ 06:35AM BLOOD ___
___ 06:35AM BLOOD Glucose-92 UreaN-16 Creat-0.8 Na-136
K-3.6 Cl-100 HCO3-23 AnGap-17
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 80 mg PO QPM
2. Aspirin 81 mg PO DAILY
3. Clopidogrel 75 mg PO DAILY
4. GlipiZIDE 5 mg PO DAILY
5. Metoprolol Succinate XL 100 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
8. Ranitidine 150 mg PO BID
9. Tamsulosin 0.4 mg PO QHS
10. Valsartan 80 mg PO DAILY
11. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
Discharge Medications:
1. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth Every 12 hours Disp
#*60 Capsule Refills:*0
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Clopidogrel 75 mg PO DAILY
5. GlipiZIDE 5 mg PO DAILY
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. Metoprolol Succinate XL 100 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
10. Tamsulosin 0.4 mg PO QHS
11. Valsartan 80 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Duodenal ulcer
Melena
GI-Bleed
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: ___ with dyspnea on exertion // ?edema
TECHNIQUE: Chest AP and lateral
COMPARISON: None
FINDINGS:
The cardiomediastinal and hilar contours are within normal limits. The aorta
is tortuous. There is marked thoracic kyphosis. Lungs are hyperinflated.
Streaky bibasilar opacities likely reflect atelectasis. There is a suspected
moderate to large hiatal hernia. No focal consolidation worrisome for
pneumonia, pleural effusion or pneumothorax. No evidence of edema.
IMPRESSION:
No acute cardiopulmonary process. Streaky bibasilar opacities likely reflect
atelectasis.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS
INDICATION: ___ year old man with left lower extremity swelling. // Please
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 and compressibility
are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
There is moderate superficial soft tissue edema within the left lower
extremity.
IMPRESSION:
1. No evidence of deep venous thrombosis in the left lower extremity veins.
2. Moderate superficial soft tissue edema within the left lower extremity.
Radiology Report
EXAMINATION: TEETH (PANOREX FOR DENTAL)
INDICATION: ___ year old man with hx of GI bleed and aortic stenosis getting
TAVR work up // evaluation for TAVR evaluation for TAVR
IMPRESSION:
No comparison. Several missing teeth. No evidence of focal osteolytic
changes.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Weakness, GI bleed
Diagnosed with Gastrointestinal hemorrhage, unspecified
temperature: 97.1
heartrate: 72.0
resprate: 18.0
o2sat: 100.0
sbp: 128.0
dbp: 56.0
level of pain: 0
level of acuity: 2.0 | Key Information for Outpatient ___ year old gentleman
with history of aortic stenosis currently undergoing TAVR
workup, CAD s/p DES to the left main, left circumflex, LAD, type
II DM, who was admitted to ___ with a low H/H and melena.
# Acute blood loss secondary to GI bleed: On admission the
patient was hemodynamically stable. His Hgb was 6.8 from a
baseline of 9. He was given 2 units of PRBCs and responded
appropriately. He was started on Pantoprazole 40mg IV BID, given
fluids. His aspirin and Plavix were continued in the setting of
his recent DES placed in ___. GI evaluated the patient
and performed an EGD on ___. They found multiple duodenal
ulcers and cauterized a visible vessel within one of the ulcers.
He was observed overnight and did not have signs of a rebleed.
His diet was advanced to a regular diet and the patient did
well. His Hgb remained stable at > 8.0. Patient was discharged
home on a PO PPI and with instructions not to take NSAIDs. He
should be on high dose PPI for at least 8 weeks followed by
daily after that. He will need repeat outpatient endoscopy.
# CAD: Patient is s/p catheterizaiton in ___ with DES to
left main, left circumflex, LAD.
- continued aspirin and clopidogrel as above.
- continued atorvastatin 80 mg PO QPM.
- Metoprolol was initially held in the setting of GI bleed.
After he remained stable he was restarted on metoprolol prior to
discharge.
# Left Lower Extremity Swelling: Patient had 2+ pitting edema in
his LLE. ___ was performed and showed no evidence of deep
venous thrombosis.
# Hypertension:
- Initially held valsartan given GI bleed, and re-started upon
stabilization.
- Initially held metoprolol succinate and re-started prior to
d/c.
# Type II DM:
- Held glipizide while in house.
- Started Humalog insulin sliding scale.
# BPH:
- Held tamsulosin initially give GI bleed. Re-started prior to
discharge.
*****TRANSITIONAL ISSUES*****
#CODE: DNR/DNI
#HCP/CONTACT
Next of Kin: ___
Relationship: DAUGHTER
Phone: ___
- NEW MEDICATION: Omeprazole 40mg PO Twice a day for the next 8
weeks followed by daily there after
- FOLLOW-UP: Patient needs a repeat EGD in 8 - 10 weeks.
- INR elevated to 1.4. Not on warfarin. Likely secondary to poor
nutrition status over past month. Please re-draw INR at next
visit and consider vitamin K supplementation.
- continued work up for TAVR
- follow up panorex taken on ___ for TAVR |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Keflex / Keppra / Penicillins
Attending: ___
Chief Complaint:
prolonged seizure with prolonged alteration of consciousness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ man with PMH significant for intractable
epilepsy ___ childhood meningitis who presents after a prolonged
seizure. Per ___ providers, his last seizure was 3 months ago. He
had a seizure this morning and EMS was called. He received 4 mg
Ativan from EMS for continued seizure during transport and
additional 2 mg in ___ for continued seizure, after
which the patient stopped seizing. The patient continued to be
altered. He was transferred to ___ for EEG.
Baseline: verbal, "functional"
Seizure semiologies include: (based on prior notes)
-GTC
-drop attacks followed by generalized tonic-clonic movements
-confused, talk gibberish and have some twitching in his mouth
or hands
-post ictal psychosis with SI
-Post ictal ___ paralysis
Prior AEDs include
Banzel
tegretol
Keppra
depakote
Current AEDs:
Zonisamide 300/500
Phenytoin Extended 200 BID
Oxcarbazepine 600 mg PO BID
ROS is unable to be obtained
Past Medical History:
-Seizures since age ___ years (now ~ 1 per month), following
meningitis as an infant
-OSA
-Mental retardation
-Hyponatremia, baseline serum sodium ranges 127-133
-Pericarditis
-Pericardial effusion
-PAF
-History of C. diff
-Hypothyroidism
-Anemia
-Gingival disease related to Dilantin
Social History:
___
Family History:
No seizure disorder
Physical Exam:
Admission Exam
Vitals:
T= 97.7F, BP= 117/71, HR= 90, RR= 18, SaO2= 94% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, dry MM
Neck: Supple, no nuchal rigidity.
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Neurologic:
-Mental Status: Lethargic, moaning continuously, intermittently
agitated when stimulated. Non-verbal, does not respond to name,
does not answer questions, does not follow commands.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3.5 to 2mm, both directly and consentually; brisk
bilaterally. No clear blink to threat.
III, IV, VI: Unable to assess.
V: Unable to assess
VII: face grossly symmetric
VIII: Unable to assess.
IX, X: Unable to assess.
XI: Unable to assess.
XII: Unable to assess.
-Motor: Normal bulk, paratonia throughout. No adventitious
movements, such as tremor, noted. Moves all extremities
antigravity and symmetrically
-DTRs:
___ Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
- Plantar response was flexor bilaterally.
-Sensory: No deficits to light touch - withdraws all
extremities to mild stimulation.
-Coordination: Unable to assess.
-Gait: Unable to assess.
Discharge Exam
NAD, NCAT, MMM, WWP, no WOB, no CCE.
Awake, alert and interactive, quite talkative with a good sense
of humor. PERRL 3.5 to 2 ___, face symmetric. No drift. Strength
___ in deltoids and IPs.
Pertinent Results:
___ 10:00AM BLOOD WBC-8.7 RBC-3.58* Hgb-11.4* Hct-33.6*
MCV-94 MCH-31.8 MCHC-33.9 RDW-14.0 RDWSD-48.3* Plt ___
___ 11:30AM BLOOD WBC-12.8* RBC-3.53* Hgb-11.2* Hct-32.6*
MCV-92 MCH-31.7 MCHC-34.4 RDW-13.4 RDWSD-45.5 Plt ___
___ 11:30AM BLOOD Neuts-85.4* Lymphs-8.4* Monos-5.2
Eos-0.2* Baso-0.3 Im ___ AbsNeut-10.95* AbsLymp-1.08*
AbsMono-0.67 AbsEos-0.03* AbsBaso-0.04
___ 10:00AM BLOOD Glucose-162* UreaN-13 Creat-0.6 Na-133
K-3.9 Cl-102 HCO3-21* AnGap-14
___ 11:30AM BLOOD Glucose-76 UreaN-10 Creat-0.6 Na-132*
K-3.5 Cl-97 HCO3-20* AnGap-19
___ 11:30AM BLOOD ALT-15 AST-19 AlkPhos-209* TotBili-0.3
___ 10:00AM BLOOD Calcium-8.6 Phos-2.6* Mg-1.8
___ 11:30AM BLOOD Albumin-4.3 Calcium-8.4 Phos-2.9 Mg-1.9
___ 11:39AM BLOOD Lactate-1.5
___ 09:10PM BLOOD ZONISAMIDE(ZONEGRAN)-Test Name
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with AMS // r/o acute process
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
The lateral view it is slight suboptimal due to external artifact projecting
over the posterior chest. There are relatively low lung volumes. No definite
focal consolidation is seen. There is no pleural effusion or pneumothorax.
The cardiac silhouette is top-normal to mildly enlarged. There may be minimal
vascular congestion.
IMPRESSION:
Possible minimal pulmonary vascular congestion. No focal consolidation.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Seizure
Diagnosed with Epilepsy, unsp, not intractable, without status epilepticus
temperature: 97.7
heartrate: 90.0
resprate: 18.0
o2sat: 94.0
sbp: 117.0
dbp: 71.0
level of pain: 0
level of acuity: 2.0 | ___ is a ___ man with PMH significant for intractable
epilepsy ___ childhood meningitis on ZON/PHT who presented after
a prolonged
GTC treated at an OSH with LZP. His mental status was initially
concerning for a a prolonged post-ictal state. His Dilantin
level was in the middle of his baseline range. The precipitant
for prolonged seizure was unknown, but infection (none
identified on UA or CXR) and non-compliance were initially
considered. Initial EEG showed L hemispheric slowing with
occasional sharp and slow-wave discharges, and he had one
subclinical L temporal seizure on morning the morning of ___
on EEG. His work-up, which included LFTs, CXR, lactate, CBC,
chem 10, UA, and urine culture were unremarkable. He was
monitored on telemetry without any events noted.
He was started on clobazam 5mg BID in consultation with his
outpatient epileptologist Dr. ___. His mental status improved
to baseline. Also, we switched his omeprazole to famotidine to
minimize interactions with clobazam. Subsequent EEG over last 24
hours improved significantly as well with only occasional L
temporal
discharges.
Overall, it is possible that a URI may have lowered his seizure
threshold, but there were no other clear triggers. He was
discharged home with resumption of prior home ___ services. He
will follow-up with Dr. ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Confusion, tachycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year-old woman with history of
___ Disease, cognitive impairment, schizoaffective
disorder who presents from nursing home with diaphoresis and
confusion.
HISTORY OF PRESENT ILLNESS:
Ms. ___ is a ___ year-old woman with history of
___ Disease, cognitive impairment, schizoaffective
disorder who presents from nursing home with diaphoresis and
confusion.
As per Neurology consult note: Per discussion with the rehab
staff, patient was in her usual state of health until early this
morning. On morning assessment, staff noted that the patient was
experiencing profuse sweating and was tachypnic. Vitals were
checked and she was saturating at 88% on room air, which is
reduced from her baseline. The nurse believed the patient was at
her baseline neurologically, with severe tremors that were at
baseline and was at her baseline mental status. Due to concern
for hypoxia, she was transferred to ___ for further
evaluation.
The rehab nurse ___ knows the patient well and has followed her
for a while) states that the patient at baseline is awake,
alert,
oriented to self and place but not to time. She typically
answers
questions appropriately but mumbles often. She is able to
normally follow simple commands. She has significant tremors due
to her baseline ___ Disease but is normally able to
ambulate without assistance. She has lived in either a group
home
or a nursing home for the majority of her life due to
psychiatric
comorbidities (bipolar disorder is documented in records). She
has a legal ___, whom was unable to reached
by phone. EMS was contacted and patient was found to be
tachycardic to HR 130s and diaphoretic on arrival.
At ___, vitals were documented as follows: T 98.6F, HR
109, RR 18, BP 122/73, O2 98% (unclear if on room air or NC).
On
exam, she was reportedly alert and oriented to self, hospital
and
month and quite tremulous but denied subjective fever, nausea,
chest pain, abdominal pain, shortness of breath, back pain. Per
RN note, patient frequently called out for help and stated "I'm
sick" but did not elaborate further.
Labs were notable for WBC 17.7, lactate 2.7, Cr 1.44 (previous
Cr
1.15 on ___, trop 0.05, AST 55.
EKG w sinus tachycardia to HR 120s.
UA had 3+ Bacteria with negative ___ and Nit, 1+ epi.
Otherwise, chem 10, coags, digoxin level (0.8) were
unremarkable.
CXR was normal. CT torso was performed, notable for fatty liver
but otherwise unremarkable. She received lorazepam 0.5mg IV,
Keppra 1g x1 IV due to concern for seizures, 1L NS, and her home
Sinemet without significant improvement.
She underwent a noncontrast head CT which revealed a small area
of hyperdensity in the right frontal lobe, which did not appear
to be artifact as it was seen on multiple slices. This was
approximately 10 mm in size, differential to include parenchymal
hematoma versus hyperdense mass. As a result she was transferred
to ___ for further evaluation.
In the ED, initial vitals: T 97.0, HR 110, BP 154/88, RR 22, SO2
97% RA
- Exam notable for: mumbling responses to questions, not clearly
following commands, but is tracking/regarding
- Labs notable for: WBC 13.3, Hb 14.0, AST 50 other LFTs WNL,
MB
Past Medical History:
___ Disease
-Cognitive impairment
-Schizoaffective disorder, Bipolar type
-Anxiety
-Hypothyroidism
-HTN
-Hyperlipidemia
-"hx lung removal"
-Pseudobulbar affect
-CAD
-Dysphagia
Social History:
___
Family History:
FAMILY HISTORY: Unknown
Physical Exam:
=======================
Admission Physical Exam:
=======================
General: awake, no acute distress
HEENT: Sclerae anicteric, dry MM, PERRL, conjunctiva 1+
injection
and tearing, neck supple
CV: Rapid rate, regular rhythm, normal S1 + S2, no murmurs,
rubs,
gallops
Lungs: Limited to cooperation, but appears Clear to auscultation
bilaterally, no wheezes, rales, rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding, +abdominal bruit heard
in LUQ and RUQ
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis,
trace
___ edema. No calf tenderness.
Skin: Warm, skin dry, no rashes or notable lesions. Ecchymosis R
hand, appears tender.
Neuro: Not responding to questions or commands, contracted UEs,
tongue protruding with intermittment lip smacking, CNII-XII
intact, unable to assess strength, appears to have grossly
normal
sensation
=======================
Discharge physical exam
=======================
GENERAL: No acute distress, lying in bed, constant tremor of the
upper extremities.
HEENT: NCAT, EOMI, tongue protruding from mouth
NECK: supple
CV: RRR, S1S2 normal, no MRG,
RESP: lungs CTAB. breathing comfortably
GI: normoactive bowel sounds, soft, NDNT, no suprapubic
tenderness, no organomegaly
EXTREMITIES: no edema
SKIN: No rashes or petechiae
NEURO: AAOx2-3 with prompting, motor and sensory function
grossly
intact
Pertinent Results:
=================
Labs on Admission
=================
___ 12:02PM BLOOD WBC-13.3* RBC-4.39 Hgb-14.0 Hct-45.4*
MCV-103* MCH-31.9 MCHC-30.8* RDW-13.4 RDWSD-51.8* Plt ___
___ 12:02PM BLOOD Neuts-72.8* Lymphs-18.7* Monos-7.1
Eos-0.5* Baso-0.3 Im ___ AbsNeut-9.71* AbsLymp-2.49
AbsMono-0.94* AbsEos-0.06 AbsBaso-0.04
___ 12:02PM BLOOD Glucose-105* UreaN-23* Creat-0.9 Na-144
K-4.2 Cl-106 HCO3-23 AnGap-15
___ 12:02PM BLOOD ALT-6 AST-50* AlkPhos-88 TotBili-0.9
___ 12:02PM BLOOD CK-MB-13* cTropnT-0.04*
___ 01:13AM BLOOD CK-MB-9 MB Indx-0.6 cTropnT-0.02*
___ 10:15AM BLOOD CK-MB-11* MB Indx-0.9 cTropnT-0.02*
___ 06:35AM BLOOD CK-MB-10 MB Indx-1.2
___ 06:45AM BLOOD Calcium-8.6 Phos-2.9 Mg-2.0
___ 02:55PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
===============
Imaging Studies
===============
Chest Xray (___) No acute cardiopulmonary abnormality.
CTA head w/contrast: 1.0 cm round hyperenhancing lesion in the
right frontal lobe, which appeared hyperdense on the
noncontrast exam, with possible evidence of prominent draining
lesion coursing nearby. The finding is nonspecific and may
represent cavernous malformation or other vascular malformation
rather than metastatic disease or primary mass given no
associated edema. Consider MRI for further evaluation plan
clinically amenable.
=============
Microbiology
==============
URINE CULTURE (Final ___: ESCHERICHIA COLI. >100,000
CFU/mL.
Cefazolin interpretative criteria are based on a dosage regimen
of 2g every 8h.
GRAM POSITIVE BACTERIA. >100,000 CFU/mL. Alpha hemolytic
colonies consistent with alpha streptococcus or Lactobacillus
sp.
==================
Labs at Discharge
==================
___ 06:30AM BLOOD WBC-10.0 RBC-4.65 Hgb-14.9 Hct-46.4*
MCV-100* MCH-32.0 MCHC-32.1 RDW-13.2 RDWSD-48.9* Plt ___
___ 06:30AM BLOOD Glucose-139* UreaN-14 Creat-0.9 Na-141
K-4.7 Cl-100 HCO3-28 AnGap-13
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO QPM
2. LORazepam 0.5 mg PO BID
3. Nuedexta (dextromethorphan-quinidine) ___ mg oral BID
4. Carbidopa-Levodopa (___) 1 TAB PO BID
5. Propranolol 10 mg PO BID
6. Fluphenazine 10 mg PO TID
7. Vitamin D ___ UNIT PO QMONTH ON THE ___
8. Levothyroxine Sodium 100 mcg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Digoxin 0.125 mg PO DAILY
11. Cyanocobalamin ___ mcg PO DAILY
12. Amantadine 100 mg PO DAILY
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
2. Propranolol 20 mg PO TID
3. Amantadine 100 mg PO DAILY
4. Atorvastatin 10 mg PO QPM
5. Carbidopa-Levodopa (___) 1 TAB PO BID
6. Cyanocobalamin ___ mcg PO DAILY
7. Digoxin 0.125 mg PO DAILY
8. Fluphenazine 10 mg PO TID
9. Levothyroxine Sodium 100 mcg PO DAILY
10. LORazepam 0.5 mg PO BID
11. Nuedexta (dextromethorphan-quinidine) ___ mg oral BID
12. Vitamin D ___ UNIT PO QMONTH ON THE ___
13. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until you discus it with your Neurologist
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses
==========================
# Urinary Tract Infection
# Right Frontal lobe mass
#Acute encephalopathy likely secondary to UTI induced delirium,
on top of underlying cognitive impairment
Secondary Diagnoses:
___
# Schizoaffective/Bipolar
# Hyperlipidemia
# Anxiety
# Hypothyroidism
# Pseudobulbar affect
Discharge Condition:
Level of Consciousness: Alert and interactive, A0X1-2
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with altered mental status//eval for pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest CT ___, chest radiograph ___ at
05:16: Sixteen
FINDINGS:
Cardiac silhouette size is normal. Mediastinal and hilar contours are
unremarkable apart from aortic knob calcifications. Pulmonary vasculature is
not engorged. No focal consolidation, pleural effusion or pneumothorax is
seen. Multiple remote posterior left-sided rib fractures are present. No
acute osseous abnormalities visualized.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONSQ1213CTHEAD.
INDICATION: History: ___ with hyperdensivity on CT of head// eval for
evidence of ICH and source.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Next, rapid axial imaging was performed through
the brain during the uneventful infusion of 70 mL of Omnipaque350 intravenous
contrast material. Three-dimensional angiographic volume rendered and
segmented images were then generated on a dedicated workstation. This report
is based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
2) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 43.6 mGy (Head) DLP =
21.8 mGy-cm.
3) Spiral Acquisition 2.7 s, 21.2 cm; CTDIvol = 30.1 mGy (Head) DLP = 636.9
mGy-cm.
Total DLP (Head) = 1,562 mGy-cm.
COMPARISON: Outside CT head done ___ at 08:29
FINDINGS:
Motion artifact degrades the quality of the images.
CT head: 10 x 8 mm hyperdense focus within the right frontal lobe is unchanged
compared to CT from earlier in the day, and may represent a hyperdense mass or
a small intraparenchymal hemorrhage. No evidence of interval hemorrhage.
Subacute to chronic infarct in the right basal ganglia (series 2, image 21).
Dilatation of the lateral ventricles is slightly out of proportion to sulcal
size. Periventricular white matter hypo dense changes most likely represent
microangiopathy.
Extracranial partially calcified sebaceous cyst overlying the left frontal
bone. Large mucous retention cyst present in the left maxillary sinus.
Partial opacification of the posterior ethmoid air cells on the right.
Cerumen present in the right external auditory canal.
CTA head: No underlying vascular malformation or inter arterial enhancement of
this hyperdense lesion in the right frontal lobe. Hypoplastic left A1
segment. Moderate atherosclerotic calcifications of the bilateral carotid
siphons, but no significant stenosis. No evidence of large vessel occlusion,
stenosis, or aneurysm. There venous sinuses are patent.
IMPRESSION:
Motion artifact degrades the diagnostic quality of the imaging
10 x 8 mm hyperdense lesion in the right frontal lobe. No underlying vascular
malformation or associated arterial enhancement of this lesion. MRI should be
considered for better characterisation.
No intracranial aneurysms, arterial occlusion or significant stenosis.
Moderate calcific atherosclerotic disease of the carotid siphons bilateral,
but no significant stenosis.
Subacute to chronic infarct in the left basal ganglia. Periventricular
hypodense changes suggesting microvascular disease.
Dilatation of the lateral ventricles which is slightly disproportionate to
sulcal size.
Radiology Report
EXAMINATION: CT HEAD W/ CONTRAST Q1211 CT HEAD
INDICATION: ___ year old woman with ___, schizoaffective who presented
with confusion.// Frontal lobe lesion on previous CT w/out contrast. Unable to
obtain MRI due to agitation. CT with contrast to further characterize lesion
in setting of encephalopathy
TECHNIQUE: Contiguous axial images of the brain were obtained before and
after the intravenous administration of mL of Omnipaque contrast agent.
Thin bone-algorithm reconstructed images and coronal and sagittal reformatted
images were then produced.
DOSE: Total DLP: 749.9
COMPARISON: Head CT from ___.
FINDINGS:
There is no evidence of acute fracture or large territorial infarction. Again
seen is hyper enhancement in the right frontal lobe measuring 10 mm (02:22),
which appeared hyperdense on noncontrast exam from ___. There is
no significant edema surrounding this lesion. On the sagittal and coronal
projection, there is a possible prominent draining vein coursing nearby
(602:35, 601: 28). As previously, there is periventricular and subcortical
white matter hypodensities, which are nonspecific and may represent chronic
small vessel ischemic disease. More discrete focus of hypodensity in the left
basal ganglia is chronic. There is prominence of the ventricles and sulci
suggestive of involutional changes. There is no abnormal enhancement on post
contrast images.
Large polypoid mucous retention cyst is seen in the left maxillary sinus.
Otherwise, the visualized portion of the paranasal sinuses, mastoid air cells,
and middle ear cavities are clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
1.0 cm round hyperenhancing lesion in the right frontal lobe, which appeared
hyperdense on the noncontrast exam, with possible evidence of prominent
draining lesion coursing nearby. The finding is nonspecific and may represent
cavernous malformation or other vascular malformation rather than metastatic
disease or primary mass given no associated edema. Consider MRI for further
evaluation plan clinically amenable.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status, Transfer
Diagnosed with Altered mental status, unspecified, Parkinson's disease
temperature: 97.0
heartrate: 110.0
resprate: 22.0
o2sat: 97.0
sbp: 154.0
dbp: 88.0
level of pain: UA
level of acuity: 2.0 | Patient Summary
Ms. ___ is a ___ year-old woman with history of
___ Disease, cognitive impairment, schizoaffective
disorder who presented from nursing home with tachycardia,
diaphoresis and confusion and was found to have UTI (ucx grew
GAS)treated with 5 day course of ceftriaxone last day ___ and
new frontal lobe lesion on CT Head.
================ |
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, constipation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ yo male w/ h/o diabetes (recently sarted on
glyburide and metformin one week prior to admission), who
presented as a transfer from ___ for
hypertriglyceridemia-induced pancreatitis.
Patient has a family history of "high cholesterol" and ran out
of Fenofibrate on ___ and has not been taking it. Patient
reported that the day prior to admission he experienced severe
dry heaving in the a.m. He also had been experiencing refractory
constipation for 30 hours, which prompted him to take 4 tsp of
Epsom salt as a laxative (did not have a BM following this).
Around 3pm the day of admission the patient felt sick with
slight fever. He called his PCP and sent to ___.
In the OSH ED, his labs were notable for ___ 3927, Cholesterol
448 with LDL 81 HDL 42 ___ ___ (upper limit of normal on
that scale was ~300), WBC 11.2 glucose 320 AST 42.
CT scan at that point showed: mild to moderate acute
pancreatitis without evidence of assoc complication. secondary
inflamm in descending duodenenum. Hepatic steatosis. Colonic
diverticulosis. Mild bilateral inguinal hernias and mild
prostate enlargement. He was transferred to ___ because there
was concern for need for pheresis.
In the ED, initial vitals: 100.2 125 158/71 20 97% RA
- Labs were notable for: WBC 11.5 85%N , h/h 13.6/39.8, lipase
588, Bicarb 17 (AG 14), urine with 1000 glucose, lactate 1.2
- Imaging: No acute cardiopulmonary abnormality on CXR
- Patient was given: Morphine Sulfate 4 mg x 2, Ondansetron 4
mg x 2, 2 L LR + mIVR @350cc/hr, IV Acetaminophen IV 1000 mg
Decision was made to admit to the MICU for persistent
tachycardia and further management.
-VS prior to transfer were: 97.8 123 155/58 22 97% RA
On arrival to the MICU, patient is breathing comfortably on room
air. Reports he is still experiencing discomfort from
constipation. He is able to relay a coherent history.
Review of systems:
Patient notably has a recent h/o of left axillary abscess s/p
I&D with antibiotics completed one day prior to admission.
Reports to chills and slight fever. Normal bowel habits is
1-2/day now is almost 48 hours without BM.
Past Medical History:
Diabetes, recently started metformin and glyburide.
OSA
HTN
Hypertriglyceridemia
Reported history of gallstones (though none visualized on
___ scan).
Social History:
___
Family History:
reports family history of high cholesterol, heart attacks,
diabetes
Physical Exam:
ADMISSION PHYSICAL EXAM
=================
Vitals: 99.3 116/73 113 96% RA
General: obese, no acute distress.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: mild distension. RUQ tenderness to palpation. 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. able to relay coherent history.
DISCHARGE PHYSICAL EXAM
=================
Abdominal pain and tachycardia now resolved. Rest of exam
essentially unchanged.
Pertinent Results:
ADMISSION LABS
==========
___ 08:33PM ___-11.5* RBC-4.54* HGB-13.6* HCT-39.8*
MCV-88 MCH-30.0 MCHC-34.2 RDW-13.2 RDWSD-42.1
___ 08:33PM NEUTS-84.8* LYMPHS-8.9* MONOS-5.2 EOS-0.4*
BASOS-0.3 IM ___ AbsNeut-9.70* AbsLymp-1.02* AbsMono-0.60
AbsEos-0.05 AbsBaso-0.04
___ 08:33PM PLT COUNT-213
___ 08:33PM TRIGLYCER-3013* HDL CHOL-47 CHOL/HDL-12.8
___
___ 08:33PM ALBUMIN-3.5 CALCIUM-8.0* PHOSPHATE-2.4*
MAGNESIUM-1.8 CHOLEST-601*
___ 08:33PM LIPASE-588*
___ 08:33PM ALT(SGPT)-24 AST(SGOT)-12 ALK PHOS-93 TOT
BILI-0.4
___ 08:33PM GLUCOSE-220* UREA N-9 CREAT-0.7 SODIUM-135
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-17* ANION GAP-18
___ 09:04PM ___ PTT-31.8 ___
___ 09:42PM LACTATE-1.2
NOTABLE LABS
=========
___ 08:01AM BLOOD Cortsol-25.4*
___ 08:01AM BLOOD TSH-2.7
___ 11:27AM BLOOD %HbA1c-12.0* eAG-298*
DISCHARGE LABS
==========
___ 06:50AM BLOOD WBC-4.5 RBC-4.75 Hgb-13.3* Hct-41.6
MCV-88 MCH-28.0 MCHC-32.0 RDW-12.8 RDWSD-41.6 Plt ___
___ 06:50AM BLOOD Glucose-139* UreaN-10 Creat-0.7 Na-137
K-3.9 Cl-98 HCO3-26 AnGap-17
___ 03:16AM BLOOD ALT-34 AST-26 AlkPhos-83 TotBili-0.4
___ 06:50AM BLOOD Calcium-8.9 Phos-4.2 Mg-1.8
___ 06:50AM BLOOD Triglyc-546*
MICROBIOLOGY
==========
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
IMAGING/STUDIES
===========
LIVER/GALLBLADDER US ___
1. Echogenic liver consistent with steatosis. Other forms of
liver disease including steatohepatitis, hepatic fibrosis, or
cirrhosis cannot be excluded on the basis of this examination.
2. Splenomegaly.
3. Trace perihepatic ascites.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Cialis (tadalafil) 20 mg oral DAILY:PRN
3. Gemfibrozil 600 mg PO BID
4. GlyBURIDE 5 mg PO BID
5. Losartan Potassium 50 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Medications:
1. Glargine 10 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
RX *insulin glargine [Lantus Solostar] 100 unit/mL (3 mL) AS DIR
10 Units before BKFT; Disp ___ Milliliter Refills:*2
RX *insulin lispro [Humalog KwikPen] 100 unit/mL AS DIR Up to 10
Units QID per sliding scale Disp #*2 Syringe Refills:*2
2. Lovaza (omega-3 acid ethyl esters) 4 grams oral DAILY
RX *omega-3 acid ethyl esters 1 gram 4 capsule(s) by mouth daily
Disp #*160 Capsule Refills:*0
3. amLODIPine 10 mg PO DAILY
4. Cialis (tadalafil) 20 mg oral DAILY:PRN
5. Gemfibrozil 600 mg PO BID
6. Losartan Potassium 50 mg PO DAILY
7. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatitis
Hypertriglyceridemia
Type 2 Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with pancreatitis // effusion?
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Heart size is normal. Minimal atherosclerotic calcifications are demonstrated
at the aortic knob. Mediastinal and hilar contours are otherwise within
normal limits. The pulmonary vasculature is normal. Lungs are clear without
focal consolidation, pleural effusion or pneumothorax. No acute osseous
abnormality is visualized.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with hypertriglyceridemia and history or ruq pain
// r/o gallstone and liver problems
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The liver is diffusely echogenic. The contour of the liver is smooth.
A 0.7 cm cyst is identified in the right lobe of the liver. The main portal
vein is patent with hepatopetal flow. There is trace perihepatic ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 5 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 14.2 cm.
KIDNEYS: Right kidney measures 13.0 cm. Left kidney measures 13.0 cm.
Evaluation of renal cortical echotexture is limited due to poor acoustic
penetration. There is no hydronephrosis. A 1.1 x 1.1 x 1.6 cm parapelvic
cyst is noted in the left kidney.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Echogenic liver consistent with steatosis. Other forms of liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded
on the basis of this examination.
2. Splenomegaly.
3. Trace perihepatic ascites.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Transfer
Diagnosed with Unspecified abdominal pain
temperature: 100.2
heartrate: 125.0
resprate: 20.0
o2sat: 97.0
sbp: 158.0
dbp: 71.0
level of pain: 3
level of acuity: 3.0 | Mr. ___ is a ___ yo M h/o hypertriglyceridemia, HTN, DM, who
presents with acute pancreatitis in the setting of
hypertriglyceridemia, admitted to the ICU for persistent
tachycardia and initiation on insulin gtt for treatment of
hypertriglyceridemia in setting of pancreatitis.
#Acute pancreatitis ___ hypertriglyceridemia: No complicating
features on CT scan with lipase elevated to 588 on admission.
Pain was controlled successfully with morphine and tylenol. A
RUQ ultrasound was performed that showed steatosis and no
gallstones. GI was consulted and recommended initiation of
insulin gtt with D5 containing IV fluids. The patient was kept
NPO, insulin gtt and IVF fluids were initiated. His ___ level
dropped from 3013 on admission ___ to 580s with insulin gtt.
Triglycerides were trended twice daily along with LFT to monitor
for complication of pancreatitis which remained within normal
limits. Gemfibrozil was continued. His diet was started after
triglycerides stabilized in the high 500 range. Insulin lantus
10U given and insulin gtt stopped two hours later. He tolerated
diet and was transferred to the floor. On the floor he
continued to do well with pain resolved on regular diet on day
of discharge. Discharge ___ was stable in the 500's.
#Diabetes mellitus: The patient presented with recently
diagnosed diabetes mellitus, started on metformin and glyburide
less than one week prior to presentation. HbA1C measured at 12%.
He was started on insulin gtt for treatment of
hypertrigylceridemia as above. ___ diabetes consult was
placed. He was given Lantus 10U to overlap with completion of
gtt and placed on humalog sliding scale. He will be discharged
with 10U Lantus, 1:25 ISS for BG>170 and metformin for diabetes
control. He will discuss with his PCP ___ referral to local
endocrinologist.
#Hypertriglyceridemia: As discussed above. Additionally, patient
continued on gemfibrozil and endocrinology recommended starting
Lovaza 4g. He will be discharged with prescription for this
medication.
#OSA: The patient was trialed on CPAP at night.
#Constipation: He was given bowel regimen including senna,
colace, bisacodyl, and miralax.
#Sinus tachycardia: likely in the setting of ongoing
inflammatory response to acute pancreatitis, along with volume
depletion in the setting of pancreatitis as well. He was volume
resuscitated. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
N/V, abdominal pain and body aches
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH Roux-En-Y gastric bypass and metastatic gastric cancer
diagnosed ___ on FOLFOX (___) with multiple recent
admissions in the last month for self-resolving gastric outlet
obstruction, hematochezia ___ presumed anal fissure, abd pain
___
constipation, headache/chills, now returns with Fever,
nausea/vomiting
Patient reported that she has intermittent nausea/vomiting and
diffuse right sided crampy abdominal pain at baseline which she
attributes to her malignancy. She noted that both have been
ongoing and not very responsive to PO dilaudid. She noted that
the pain is worse when she vomits, and is unchanged when she has
a BM. She noted that she is stooling daily, last day of
admission, which was soft/brown. Noted that pain attributed to
anal fissure is gone. She noted that she had 1 episode of NB/NB
emesis this morning after breakfast but did not recur. Stated
that she tolerated dinner in the ED without issue.
Reported that she had a fever last night with chills. She noted
that chills are not unusual for her, but high fever is. Denied
sore throat, productive cough, dysuria, rash, sick contacts.
In the ED, initial VS were: 97.4 95 103/63 18 98% RA. WBC 11.4,
Hgb 10.8, plt 177, LFTs wnl, lipase 34, CHEM wnl, lactate 1.3,
coags wnl. PAtient remained afebrile in the ED.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Per last discharge summary:
- ___ presented to ___ ER with sudden onset
abdominal pain; pelvic ultrasound showed an edematous L ovary
measuring up to 15cm concerning for torsion. R ovary at the time
demonstrated physiologic cysts and measured 5.8 x 6.2 cm. She
underwent laparoscopic ovarian detorsion and left
salpingo-oophrectomy. Pathology from the 15cm ovarian mass
revealed adenocarcinoma, by IHC (positive for CK20 and CDX-2,
CK7 negative) and morphology suggestive of a GI primary. Pelvic
washings revealed rare groups of highly atypical epithelioid
cells, suspicious for malignancy. CA-125, CEA and CA ___ WNL.
Post-op course complicated by code stroke for altered mental
status/unresponsiveness requiring brief ICU admission, workup
was
negative.
- ___ colonoscopy showed ulcer in the descending colon with
normal histology. EGD: superficial anastomotic ulcer, gastritis
and evidence of prior gastric bypass surgery, it did not reach
the remnant stomach. She was readmitted for incisional
cellulitis and subsequently seen in the ED for abdominal pain.
-
CT scans ___, and ___ due to abdominal pain and
cellulitis, then a PET ___ revealed an enlarging right ovary
from 5cm initially to 12cm, mildly FDG avid, without any other
sites of FDG avid disease, however there was some antral
thickening noted in the gastric remnant.
- Established with ___ Heme ___, she was anemic and B12,
iron, vitamin D, vitamin A, and zinc deficient.
- ___ Single balloon push enteroscopy with Dr. ___ an obstructing malignant-appearing mass at the pylorus,
biopsies revealed poorly differentiated carcinoma with signet
ring features, IHC positive for AE1/AE3, CAM 5.2, CK20 and
CDX-2.
She was admitted after the procedure for abdominal pain thought
related to insufflation.
- Case was discussed between Dr. ___ colleagues and
with Dr. ___ at ___. Her pathology from her ovarian
mass was re-reviewed and notable for high grade adenocarcinoma
with signet ring features, consistent with biopsy of her remnant
stomach. Dr. ___ that cytoreductive surgery followed by
HIPEC at this time was unlikely to benefit her given the
aggressive histology. Case discussed her case at ___ tumor board
and with Dr. ___ Dr. ___ the consensus was that
upfront surgery on the pyloric mass and ovarian mass would not
be
likely to be beneficial and the recommendation was for systemic
chemotherapy.
-___ C1D1 palliative mFOLFOX, c/b n/v/d
-Admitted ___
Metastatic gastric cancer, as above
PUD with H. Pylori ___ s/p treatment
PAST SURGICAL HISTORY:
- Laparoscopic gastric bypass Roux-en-Y surgery ___ at ___
___
- ___ Diagnostic laparoscopy, detorsion of the left
adnexa, laparoscopic left salpingo-oophorectomy with
mini-laparotomy
PAST MEDICAL HISTORY:
-Metastatic Gastric Adenocarcinoma as above
-Hx of Roux en Y
-Colonic ulcer seen on Colonoscopy ___ (biopsy unrevealing)
Social History:
___
Family History:
Her mom is ___ no cancer. Her dad passed away age ___ from an MI.
She has one sister, healthy. One son age ___, healthy. Maternal
grandfather with leukemia.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: ___ 2213 Temp: 97.4 PO BP: 99/66 HR: 69 RR: 17 O2
sat: 99% O2 delivery: Ra
GENERAL: Laying in bed, appears tired but comfortable, NAD
EYES: Pupils equally round reactive to light, anicteric sclera
HEENT: Oropharynx clear, moist mucous membranes
NECK: Supple, normal range of motion
LUNGS: Clear to auscultation bilaterally no wheezes rales or
rhonchi, normal respiratory rate
CV: Regular rate and rhythm, no murmurs, distal perfusion intact
ABD: Soft, nondistended, minimally tender to palpation on right
side of abdomen, but not elsewhere, no rebound or guarding,
normoactive BS
GENITOURINARY: No Foley or suprapubic tenderness
EXT: No deformity, normal muscle bulk
SKIN: Warm dry, no rash
NEURO: Alert and oriented x3, fluent speech
ACCESS: Port dressing clean/dry/intact
DISCHARGE PHYSICAL EXAM
=======================
Vitals: T: 98.5 PO BP: 103 / 67 HR: 78 R: 20 SaO2: 98 RA
GENERAL: Laying in bed, NAD
EYES: Pupils equally round reactive to light, anicteric sclera
HEENT: Oropharynx clear, moist mucous membranes
NECK: Supple, normal range of motion
LUNGS: Clear to auscultation bilaterally no wheezes rales or
rhonchi, normal respiratory rate
CV: Regular rate and rhythm, normal S1 and S2 with no murmurs,
distal perfusion intact
ABD: Soft, nondistended, minimally tender to palpation on right
side of abdomen, but not elsewhere, no rebound or guarding,
normoactive BS
GENITOURINARY: No Foley or suprapubic tenderness
EXT: No deformity, normal muscle bulk
SKIN: Warm dry, no rash
NEURO: Alert and oriented x3, fluent speech
ACCESS: Port dressing clean/dry/intact
Pertinent Results:
ADMISSION LABS
==============
___ 01:06PM BLOOD WBC-11.4* RBC-4.05 Hgb-10.8* Hct-35.4
MCV-87 MCH-26.7 MCHC-30.5* RDW-19.9* RDWSD-62.7* Plt ___
___ 01:06PM BLOOD Neuts-61.3 ___ Monos-10.7 Eos-1.1
Baso-1.3* Im ___ AbsNeut-7.01* AbsLymp-2.63 AbsMono-1.22*
AbsEos-0.13 AbsBaso-0.15*
___ 01:06PM BLOOD Glucose-82 UreaN-11 Creat-0.8 Na-142
K-4.1 Cl-108 HCO3-22 AnGap-12
___ 01:06PM BLOOD ALT-20 AST-20 AlkPhos-107* TotBili-0.2
___ 01:06PM BLOOD Albumin-4.1 Calcium-9.0 Phos-3.4 Mg-2.0
___ 01:06PM BLOOD HCG-<5
___ 01:22PM BLOOD ___ pO2-40* pCO2-34* pH-7.32*
calTCO2-18* Base XS--7
___ 01:22PM BLOOD Hgb-8.1* calcHCT-24
MICROBIOLOGY
============
___ 1:06 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 3:15 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 11:53AM URINE Color-Straw Appear-Clear Sp ___
___ 08:06AM URINE Color-Straw Appear-Cloudy* Sp ___
___ 11:53AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 08:06AM URINE Blood-SM* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*
___ 08:06AM URINE RBC-10* WBC-38* Bacteri-NONE Yeast-NONE
Epi-66
___ 08:06AM URINE Mucous-RARE*
IMAGING
=======
CXR, ___:
No acute intrathoracic process.
CT Abdomen, Pelvis, ___:
1. No acute intra-abdominal or intrapelvic process to account
for the
patient's abdominal pain.
2. Persistent gastric antral thickening compatible with known
malignancy
without evidence of obstruction, unchanged from prior study.
3. Large, heterogeneous cystic and solid right adnexal mass,
presumed to be a ___ tumor and unchanged from prior
study.
OTHER PERTINENT STUDIES
=======================
___ 04:31AM BLOOD WBC-10.8* RBC-3.85* Hgb-10.3* Hct-33.9*
MCV-88 MCH-26.8 MCHC-30.4* RDW-19.8* RDWSD-63.3* Plt ___
___ 04:31AM BLOOD Neuts-65.2 ___ Monos-7.6 Eos-2.3
Baso-1.0 Im ___ AbsNeut-7.01* AbsLymp-2.31 AbsMono-0.82*
AbsEos-0.25 AbsBaso-0.11*
DISCHARGE LABS
==============
___ 06:42AM BLOOD WBC-8.4 RBC-3.99 Hgb-10.8* Hct-34.7
MCV-87 MCH-27.1 MCHC-31.1* RDW-18.7* RDWSD-59.3* Plt ___
___ 06:42AM BLOOD Neuts-57.0 ___ Monos-9.2 Eos-2.4
Baso-1.4* Im ___ AbsNeut-4.79 AbsLymp-2.28 AbsMono-0.77
AbsEos-0.20 AbsBaso-0.12*
___ 06:42AM BLOOD Glucose-78 UreaN-8 Creat-0.8 Na-145 K-4.0
Cl-107 HCO3-23 AnGap-15
___ 06:42AM BLOOD ALT-18 AST-18 LD(LDH)-224 CK(CPK)-81
AlkPhos-93 TotBili-0.2
___ 06:42AM BLOOD Albumin-3.8 Calcium-9.1 Phos-4.7* Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Cyanocobalamin 1000 mcg PO DAILY
3. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate
4. Lidocaine-Prilocaine 1 Appl TP PRN R chest port pain
5. Multivitamins 2 TAB PO DAILY
6. OLANZapine (Disintegrating Tablet) 5 mg PO QHS
7. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
8. Pantoprazole 40 mg PO Q12H
9. Polyethylene Glycol 17 g PO Q12H:PRN Constipation - Third
Line
10. Senna 17.2 mg PO BID
11. LOPERamide 2 mg PO QID:PRN diarrhea
12. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
13. Vitamin D ___ UNIT PO 1X/WEEK (___)
14. Cetirizine 10 mg PO DAILY
15. DiphenhydrAMINE ___ mg PO QHS:PRN insomnia, muscle
aches/pains
16. Dexamethasone 1 mg PO ASDIR
Discharge Medications:
1. DICYCLOMine 20 mg PO QID pain
RX *dicyclomine 20 mg 1 tablet(s) by mouth QID as needed Disp
#*30 Tablet Refills:*0
2. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Cetirizine 10 mg PO DAILY
5. Cyanocobalamin 1000 mcg PO DAILY
6. Dexamethasone 1 mg PO ASDIR
7. DiphenhydrAMINE ___ mg PO QHS:PRN insomnia, muscle
aches/pains
8. Lidocaine-Prilocaine 1 Appl TP PRN R chest port pain
9. LOPERamide 2 mg PO QID:PRN diarrhea
10. Multivitamins 2 TAB PO DAILY
11. OLANZapine (Disintegrating Tablet) 5 mg PO QHS
12. Ondansetron ODT 4 mg PO Q8H:PRN Nausea/Vomiting - First
Line
13. Pantoprazole 40 mg PO Q12H
14. Polyethylene Glycol 17 g PO Q12H:PRN Constipation - Third
Line
15. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - First
Line
16. Senna 17.2 mg PO BID
17. Vitamin D ___ UNIT PO 1X/WEEK (___)
18. HELD- HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain -
Moderate This medication was held. Do not restart HYDROmorphone
(Dilaudid) until you speak to a doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS.
abdominal pain secondary to metastatic gastric cancer
SECONDARY DIAGNOSES.
anal fissure
fibromyalgia
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 fever. Please evaluate for pneumonia.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph dated ___
FINDINGS:
A right chest Port-A-Cath is again seen with tip terminating within the
cavoatrial junction. Cardiomediastinal silhouette is within normal limits.
No acute focal consolidation. No pneumothorax or pleural effusion. No
pulmonary edema. Visualized osseous structures are unremarkable.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old woman with history of gastric bypass surgery,
metastatic gastric cancer, who presents with fevers, abdominal pain, and
nausea/vomiting, please evaluate for infectious source, potential gastric
outlet 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) Spiral Acquisition 6.6 s, 52.1 cm; CTDIvol = 13.4 mGy (Body) DLP = 695.0
mGy-cm.
Total DLP (Body) = 695 mGy-cm.
COMPARISON: CT abdomen and pelvis dated ___
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is redemonstration of a subcentimeter hypodense lesion in the upper pole
of the right kidney, compatible with a simple cyst (601:37). Otherwise, there
is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The patient is status post Roux-en-Y gastric bypass with
intact anastomoses. There is redemonstration of marked concentric thickening
of the gastric antrum, which appears similar to prior study from 3 weeks prior
(601:22). There is no upstream gastric dilation to suggest obstruction of the
excluded stomach. Small bowel loops demonstrate normal caliber, wall
thickness, and enhancement throughout. The colon and rectum are within normal
limits.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is a
trace amount of free fluid in the pelvis.
REPRODUCTIVE ORGANS: Intrauterine device is again seen within the uterus in
stable position. There is redemonstration of a large heterogeneous, cystic
and solid mass in the right adnexa measuring 8.3 x 8.1 x 4.0 cm, previously
measuring 7.8 x 9.1 x 4.8 cm.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No acute intra-abdominal or intrapelvic process to account for the
patient's abdominal pain.
2. Persistent gastric antral thickening compatible with known malignancy
without evidence of obstruction, unchanged from prior study.
3. Large, heterogeneous cystic and solid right adnexal mass, presumed to be a
Krukenberg tumor and unchanged from prior study.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: Abd pain, Chills, Vomiting
Diagnosed with Unspecified abdominal pain, Fever, unspecified, Nausea with vomiting, unspecified, Dehydration
temperature: 97.4
heartrate: 95.0
resprate: 18.0
o2sat: 98.0
sbp: 103.0
dbp: 63.0
level of pain: 9
level of acuity: 2.0 | TRANSITIONAL ISSUES
=================
[] Please follow up with palliative care regarding initiation of
duloxetine and further management of pain symptoms
[] Please follow up with oncology, especially in regards to
having missed chemotherapy originally planned for ___
[] Please follow up with oncology regarding stable normocytic
anemia as well as blood cultures drawn on ___ (currently
NGTD)
BRIEF HOSPITAL SUMMARY
=====================
___ PMH Roux-En-Y gastric bypass and metastatic gastric cancer
diagnosed ___ on FOLFOX (___) with multiple recent
admissions in the last month for self-resolving gastric outlet
obstruction, hematochezia ___ presumed anal fissure, as well as
abdominal pain, N/V, body aches believed to be due to neulasta
reaction who presented for this hospitalization with fever at
home up to 102, N/V, and crampy abdominal pain. She was treated
symptomatically with oxycodone, ibuprofen, and dicyclomine for
pain as well as Compazine for nausea with improvement in her
symptoms.
ACUTE ISSUES
===========
#Fever/Chills
Patient presented with 2 day history of chills and reported
temperature measured at home up to 102. Of note, she had a
similar presentation the week prior that was believed to be due
to a reaction to Neulasta that improved with Tylenol,
diphenhydramine, and cetirizine; however, she has not had
Neulasta again between that last admission and this current one.
Patient was afebrile upon admission and remained as such
throughout admission. Her WBC count was 11.4 and trended down to
8.4 during her stay. CXR, CT A/P, and UA were not concerning for
any source of infection. Blood cultures on day 2 showed NGTD. As
she was not neutropenic on admission, she did not receive
antibiotics. She was treated with Tylenol and ibuprofen PRN with
resolution of her chills.
#Abdominal Pain
#Body Aches
Patient presented with R crampy abdominal pain that was
intermittent in nature and not associated with radiation in
symptoms or changes with eating or stooling. She stated she had
been having regular bowel movements prior to admission without
any bright red blood per rectum or black stools. She stated the
pain was partially relieved with dilaudid in the ED. In addition
she also endorsed diffuse body aches that started the same time
as fevers and chills on ___. She denied any recent sick
contacts. LFTs and CK were within normal limits. CT A/P did not
suggest obstruction or other identifiable causes of her
abdominal pain aside from noting stable gastric changes
associated with her known malignancy. She was treated
symptomatically with dicyclomine (a new medication for her),
Tylenol, ibuprofen. Palliative care was consulted and
recommended switching dilaudid to oxycodone, which also helped
her pain. We recommend she follows up with palliative care in
the outpatient setting to consider starting duloxetine to help
both with mood and body aches.
#HA
#Nausea/Vomiting
Patient reported feeling nauseous and experiencing 1 episode of
non-bloody, nonbilious emesis on ___. On admission she denied
further emesis and was able to tolerate PO without issue. Also
reported persistent HA that was worse in morning and associated
with blurry vision and sensitivity to light and sound. Of note,
she endorsed a similar HA on prior admission for which a brain
MRI was done and revealed no metastatic disease or intracranial
pathology. Her nausea was treated with Compazine and her
headaches were treated with the pain medications discussed
above.
#Metastatic Gastric Cancer
On FOLFOX (last ___ with chemotherapy originally planned
for ___. This dose of FOLFOX was missed given her
hospitalization and symptoms described above. Dr. ___
primary oncologist, was the attending on service and aware of
this. Plan to continue chemotherapy when outpatient. Appointment
scheduled for day after discharge.
This patient was prescribed, or continued on, an opioid pain
medication at the time of discharge (please see the attached
medication list for details). As part of our safe opioid
prescribing process, all patients are provided with an opioid
risks and treatment resource education sheet and encouraged to
discuss this therapy with their outpatient providers to
determine if opioid pain medication is still indicated. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Weakness, Hyperventilation
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with Type I diabetes diagnosed ___ years ago, last HbA1c per
his mother ~13%, presented to ___ with acute onset
generalized weakness, shaking, nausea, emesis and
hyperventilation, transferred to ___ for management of
diabetic ketoacidosis.
His symptoms began acutely. ___ endorses recent insulin
noncomplicance because he has "been so busy" lately and forgets
to take his insulin. Per his mother, present at the bedside, he
has had one previous episode of DKA in ___. After
this episode, he had been doing better with taking his insulin
as prescribed and following up with his physician. Recently,
however, he has missed several appointments. Mr. ___ works at
___, where he does eat donuts and other food they have
to offer. He drinks alcohol ~4x/week at least ___ drinks and has
a 9 pack year smoking history. No recent bothersome symptoms
prior to symptom onset including cough, congestion, chest or
abdominal pain, diarrhea, change in urinary habits, or other
pain.
He presented to ___ in the morning of ___ and was
found to have a BG of 314 and anion gap of 22. He received 2L
NS, 10U IV insulin and then was started on an insulin gtt at
7U/hr. K4.1, bicarb of 6. His insulin decreased to 249 a few
hours later and he was switched to D5NS and transferred to
___ for ongoing management. VS upon arrival 97.8 ___ 30 100%. Here in the ED his serum glucose was 221, anion
gap was 24 with bicarb of 5 and K 4.8, Phos 2.1. VBG ___.
Labs further notable for WBC of 16 with 75% neutrophils, H/H
17.3/50.5, Plt 375, lactate 1.5. He was continued on insulin
gtt at 7U/hr and got two more liters of D5NS with ___ MEq
potassium for a total of 4L IVF today. He was admitted to the
___ for ongoing management.
Upon interview in the ___, he is rapidly breathing which he
says is similar to his last episode of DKA. He endorses whole
body weakness, is thirsty, and has been urinating non-stop.
Otherwise, no specific complaints beyond general malaise and an
interest in going home as soon as possible.
Past Medical History:
Type I Diabetes Mellitus
- last reported HbA1c 13%
- diagnosed ___
Social History:
___
Family History:
mother also with Type I diabetes, no complications
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: T: 97.5 BP: 161/99 P: 124 R: 35 O2: 99% RA
General- Alert and oriented, appears very uncomfortable
HEENT- Sclera anicteric, MM dry, chapped lips
Neck- supple, JVP not elevated, no LAD
Lungs- tachypneic with Kussmaul's respirations, clear to
auscultation without adventitious sounds
CV- tachycardic but sounds regular, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing or edema, no
open cuts on bilateral feet
Neuro- motor function grossly normal
DISCHARGE PHYSICAL EXAM
========================
Afebrile, VSS, FSBGs generally in 200s
General- Alert and oriented, appears very uncomfortable
HEENT- Sclera anicteric, MMM
Neck- supple, JVP not elevated, no LAD
Lungs- clear bilaterally
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
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing or edema, no
open cuts on bilateral feet
Neuro- motor function grossly normal
Pertinent Results:
ADMISSION LABS
==============
___ 04:15PM BLOOD WBC-16.0* RBC-5.81 Hgb-17.3 Hct-50.5
MCV-87 MCH-29.8 MCHC-34.3 RDW-11.9 Plt ___
___ 04:15PM BLOOD Neuts-75.1* ___ Monos-5.4 Eos-0.2
Baso-0.4
___ 04:15PM BLOOD ___ PTT-33.6 ___
___ 04:15PM BLOOD Glucose-222* UreaN-10 Creat-0.6 Na-141
K-4.8 Cl-117* HCO3-5* AnGap-24*
___ 04:15PM BLOOD ALT-20 AST-19 AlkPhos-129 TotBili-0.1
___ 04:15PM BLOOD Albumin-4.7 Calcium-8.6 Phos-2.1* Mg-2.3
___ 04:27PM BLOOD ___ pO2-34* pCO2-19* pH-7.07*
calTCO2-6* Base XS--24 Comment-K ADDED ON
___ 04:27PM BLOOD Lactate-1.5 K-4.8
___ 04:27PM BLOOD O2 Sat-71
NOTABLE LABS
============
___ 03:14AM BLOOD WBC-21.0* RBC-5.37 Hgb-16.4 Hct-48.1
MCV-90 MCH-30.5 MCHC-34.1 RDW-12.3 Plt ___
___ 08:30PM BLOOD Glucose-291* UreaN-6 Creat-0.6 Na-140
K-5.0 Cl-125* HCO3-LESS THAN
___ 10:16PM BLOOD Glucose-266* UreaN-7 Creat-0.9 Na-138
K-7.8* Cl-117* HCO3-LESS THAN
___ 03:14AM BLOOD Glucose-145* UreaN-6 Creat-0.7 Na-140
K-4.3 Cl-121* HCO3-LESS THAN
___ 05:23AM BLOOD Glucose-220* UreaN-6 Creat-0.7 Na-135
K-3.7 Cl-117* HCO3-LESS THAN
___ 02:25PM BLOOD Glucose-194* UreaN-6 Creat-0.7 Na-134
K-2.8* Cl-110* HCO3-12* AnGap-15
___ 08:30PM BLOOD Glucose-225* UreaN-6 Creat-0.6 Na-135
K-3.1* Cl-112* HCO3-15* AnGap-11
___ 10:16PM BLOOD Phos-3.1
___ 03:14AM BLOOD Calcium-7.9* Phos-1.6* Mg-1.9
___ 02:25PM BLOOD Calcium-8.6 Phos-1.5* Mg-1.6
___ 05:23AM BLOOD Triglyc-___* HDL-36 CHOL/HD-11.3
LDLmeas-LESS THAN
___ 03:14AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
DISCHARGE LABS
==============
WBCRBCHgbHctMCVMCHMCHCRDWPlt Ct
___
UreaNCreatNaKClHCO3AnGap
___
Triglycerides ___ -> 524
___
___ THAN 3
A1c 14.2
IMMUNOGLOBULIN G SUBCLASS 1 284 L 382-929 mg/dL
IMMUNOGLOBULIN G SUBCLASS 2 162 L 241-700 mg/dL
IMMUNOGLOBULIN G SUBCLASS 3 44 ___ mg/dL
IMMUNOGLOBULIN G SUBCLASS 4 1.2 L 4.0-86.0 mg/dL
IMMUNOGLOBULIN G, SERUM 508 L ___ mg/dL
IMAGING
=======
CXR (___): Very low lung volumes make it difficult to
exclude small areas of subtle pulmonary abnormality, but I see
no regions of the lung abnormal enough to consider pneumonia.
Heart size is normal. No pleural abnormality.
ECG (on admission): Sinus tachycardia. Incomplete right
bundle-branch block pattern. Non-specific
septal ST-T wave changes. No previous tracing available for
comparison.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. HumaLOG Mix ___ KwikPen (insulin lispro protam-lispro) 40
UNITS subcutaneous BID
2. Atorvastatin 20 mg PO DAILY
Discharge Medications:
1. Atorvastatin 20 mg PO DAILY
RX *atorvastatin 20 mg 1 tablet(s) by mouth daily Disp #*90
Tablet Refills:*3
2. HumaLOG Mix ___ KwikPen (insulin lispro protam-lispro) 40
UNITS subcutaneous BID
3. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*3
4. HumaLOG (insulin lispro) 100 unit/mL subcutaneous QACHS
as directed per sliding scale
RX *insulin lispro [Humalog] 100 unit/mL ___ unit SC QACHS Disp
#*1 Unit Refills:*3
Discharge Disposition:
Home
Discharge Diagnosis:
DKA
uncontrolled Type I diabetes
hypertriglyceridemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
AP CHEST, 11:18 A.M., ___
HISTORY: ___ man with DKA and ongoing cough.
IMPRESSION: AP chest reviewed in the absence of prior chest radiographs:
Very low lung volumes make it difficult to exclude small areas of subtle
pulmonary abnormality, but I see no regions of the lung abnormal enough to
consider pneumonia. Heart size is normal. No pleural abnormality.
Radiology Report
HISTORY: Status post PICC placement.
COMPARISON: Chest radiograph from approximately 2 hours prior.
FINDINGS:
A portable frontal chest radiograph demonstrates interval placement of a right
PICC, with the tip in the upper right atrium. The remainder of the exam is
unchanged.
IMPRESSION:
Interval placement of a right PICC, with the tip in the upper right atrium.
The catheter can be pulled back 2 cm to place the tip in the low SVC.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: DIABETIC KETOACIDOSIS
Diagnosed with NIDDM UNCONTROLLED W/KETOACID, LONG-TERM (CURRENT) USE OF INSULIN
temperature: 97.8
heartrate: 108.0
resprate: 30.0
o2sat: 100.0
sbp: 140.0
dbp: 105.0
level of pain: 0
level of acuity: 2.0 | BRIEF SUMMARY STATEMENT: ___ with Type I DM with 1 prior
episode of DKA presenting with weakness and hyperventilation
found to have DKA thought to be secondary to medication
noncompliance and likely dietary indiscretion.
ACTIVE ISSUES
=============
#Diabetic Ketoacidosis: Pt. found to have an anion gap
metabolic acidosis, ketonuria, and hyperglycemia, consistent
with DKA in the setting of insulin noncompliance and high sugar
intake at work. Desite an elevated WBC, pt. without any clear
infectious source on admission. His serum and urine tox
returned negative. Pt. was admitted to the ICU, volume
resuscitated with IVF, and placed on an insulin gtt. His anion
gap gradually closed over the first 24 hours. He began
tolerating POs and was placed on a subcutaneous regimen of
insulin (36 units of Humalog ___ + ISS) per ___ Diabetes
Consult recommendations. Given difficult vascular access, a
PICC line was placed on ___. Pt. remained stable and was
transferred to the floor. ___ was increased to 40 units BID,
and humalog sliding scale increased. A1c 14.2, indicating long
term poor control. Blood sugars improved to 200s for 24 hours
prior to discharge. Patient was offered ___ follow up, but
declined, easier for him to follow with his PCP for the time
being. He has follow up the day after discharge to ensure
adherence and establish close follow up with diabetic nurses for
the next days to weeks. He was started on lisinopril for
proteinuria. He was counseled on and reported good knowledge of
a diabetic diet.
#Hypertriglyceridemia- likely due to diabetes and insulin
deficiency. Improved significantly, started on Lipitor
(previously prescribed by PCP, patient was not taking prior to
admission).
His family visited during this admission and were supportive of
the patient. He agreed to improve adherence and work closely
with his outpatient providers to improve diabetic control.
Full code. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Keflex / Vioxx / Codeine / Iodinated Contrast Media - IV Dye /
ceftriaxone
Attending: ___.
Chief Complaint:
hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ with morbid obesity, chronic
abdominal wounds from prior hernia repairs w/ multiple prior
infections including MRSA & VRE, recurrent infections and sepsis
from chronic foot wounds, HFpEF, CKD (likely ___ DM), IDDM (A1C
9.1 ___, restrictive lung disease, HTN, HLD, prior ETOH
use
disorder, history of PUD, anxiety & depression, chronic pain,
chronic Foley, & recent calcaneal osteomyelitis who presents
after a fall.
The patient was reportedly found down at his nursing home after
a
fall. EMS was called and the patient was found to have a blood
sugar of 35. He was given dextrose and glucagon w/ improvement,
and he was urgently brought to ___. A CXR
obtained at ___ was concerning for LLL PNA and he was started on
vancomycin & levofloxacin. On exam, there was concern for that
his abdominal wound was infected, and imaging of the abdomen was
desired, but the patient was unable to fit in the CT scanner, so
he was transported to ___.
Brief ED Course:
In the emergency department, he was premedicated for CT scan
(given a contrast allergy). He obtained the CT scan of the
abdomen which showed no definitive intra-abdominal or pannus
infection. Incidentally noted was bibasilar atelectasis,
although a superimposed pneumonia could not be excluded. He
desaturated to the upper ___ on room air and required a
non-rebreather, so he was transported to the ICU.
In the ED,
- Initial Vitals:
T 97.7 HR 76 BP 132/80 RR 18 O2 92% 2L NC
- Exam:
"Head NC/AT, appears clinically dry
RRR
Diminished breath sounds due to body habitus
Morbidly obese, large (>6cm) right sided abdominal wound with
purulent drainage noted, surrounding skin is erythematous and
warm to touch but no appreciable fluctuance
Bilateral calcaneal ulcers in various stages of healing"
- Labs:
Na 136
K 3.7
Cl 96
HCO3- 29
BUN 23
Cr 1.1
WBC 10.5
HGB 7.3
platelets 285
- Imaging:
CT Head:
No acute intracranial process. Mild small vessel disease.
CTA Lungs:
1. Extensive soft tissue stranding and edema within the
partially
imaged pannus without evidence of an organized fluid collection.
2. No definite pulmonary embolism or acute aortic injury on this
suboptimal examination.
3. Increased consolidation at the lung bases, right greater than
left is felt to be secondary to atelectasis, however a
superimposed pneumonia or aspiration would be difficult to
exclude.
4. Cholelithiasis.
5. Stable pelvic and inguinal lymphadenopathy.
- Consults: None.
- Interventions:
___ 06:24 IVF NS 100 mL/hr
___ 07:43 PO/NG Citalopram 40 mg
___ 07:43 PO/NG Gabapentin 300 mg
___ 07:43 IV MethylPREDNISolone Sodium Succ 40 mg
___ 08:27 IV Magnesium Sulfate
___ 08:40 SC Insulin
___ 08:41 IV Dextrose 50% 12.5 gm
___ 09:14 IVF D5LR Started 100 mL/hr
___ 09:33 IV Dextrose 50% 12.5 gm
___ 10:23 IV MetroNIDAZOLE
___ 11:00 IV Magnesium Sulfate 4 gm
___ 11:00 IH Ipratropium-Albuterol Neb
___ 11:40 IV Fentanyl Citrate 50 mcg
___ 11:54 IV MetroNIDAZOLE 500 mg
___ 11:58 IV DiphenhydrAMINE 50 mg
___ 12:35 IV MethylPREDNISolone Sodium Succ 40 mg
Past Medical History:
-HFpEF
-Insulin-dependent diabetes mellitus
-Hypertension
-Hyperlipidemia
-Alcohol abuse
-Anxiety/Depression
-Back pain
-Gastroparesis
-Obesity
-PUD
-Rectal fissure
-Restrictive lung disease/COPD
-Vitamin D deficiency
-Abdominal hernia status post multiple repairs
-BPH
-Penile lesion s/p biopsy revealing mild squamous epithelial
hyperplasia ___
-chronic pain
-chronic indwelling Foley
Social History:
___
Family History:
Patient reports his father had diabetes and heart issues.
Per OMR review:
"Father died at ___ years from ___. Mother is alive and well. No
other pertinent FH."
Physical Exam:
ADMISSION EXAM
Vitals reviewed.
GENERAL: Morbidly obese, lying in bed.
HEAD: NC/AT, conjunctiva clear, EOMI, pupils reactive, sclera
anicteric, oral mucosa w/o lesions
NECK: Supple, no LAD.
CARDIAC: Precordium is quiet, PMI non-displaced, RRR, distant
S1S2 w/o m/r/g.
RESPIRATORY: Speaking in full sentences, CTABL.
ABDOMEN: Massive pannus with open intra-abdominal wound with
white-yellow granulation tissue.
EXTREMITIES: Warm, 1+ peripheral edema, open wounds with visible
bone on both heels
NEUROLOGIC: Grossly intact, face symmetric, speech fluent, moves
arms and legs spontaneously.
PSYCHIATRIC: Pleasant and cooperative.
DISCHARGE EXAM
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
MMMs
CV: RRR
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, mild TTP diffusely. Large
midline wound with moist fibrinous center; no obvious acute
inflammation or purulent drainage (wound dressing not fully
taken
down today)
GU: Foley draining yellow urine
SKIN: erythematous, scaly skin of bilateral ___, abdominal wound
as per above, bilateral heel wounds wrapped in kerlix
EXTR: severe bilateral edema
NEURO: Alert, interactive, face symmetric, gaze conjugate with
EOMI, speech fluent, conversing appropriately, motor function
grossly symmetric
PSYCH: patient aggravated early in encounter, then become less
so
upon further discussion
Pertinent Results:
================
IMAGING & STUDIES:
================
___ Transthoracic echocardiogram
CONCLUSION: The left atrium is normal in size. The right atrium
is mildly enlarged. There is mild symmetric left ventricular
hypertrophy with a normal cavity size. There is normal regional
and global left ventricular systolic function. The visually
estimated left ventricular ejection fraction is 55-60%. There is
no resting left ventricular outflow tract gradient. Mildly
dilated right ventricular cavity with normal free wall motion.
There is abnormal interventricular septal motion. The aortic
sinus diameter is normal for gender with normal ascending aorta
diameter for gender. There is a normal descending aorta
diameter. The aortic valve leaflets (3) appear structurally
normal. There is no aortic valve stenosis. There is no aortic
regurgitation. The mitral valve leaflets appear structurally
normal with no mitral valve prolapse. There is trivial mitral
regurgitation. The pulmonic valve leaflets are normal. The
tricuspid valve leaflets appear structurally normal. There is
physiologic tricuspid regurgitation. There is a trivial
pericardial effusion.
IMPRESSION: Poor image quality. Grossly normal biventricular
function. Mildly dilated RV. Mildly dilated aortic sinus. No
significant valvular disease.
Compared with the prior TTE (images not available for review) of
___, there is no obvious change, but the suboptimal image
quality of the studies precludes definitive comparison.
___ X-ray axial and lateral of right heel
IMPRESSION:
Evidence for a soft tissue wound at the plantar aspect of the
heel with
concern for osteomyelitis at the underlying plantar aspect of
the calcaneal
body.
___ CTA chest, CT with contrast abd/pelvisA/P
1. Extensive soft tissue stranding and edema within the
partially imaged
pannus without evidence of an organized fluid collection.
2. Mild right hydronephrosis without evidence of an obstructing
stone or mass.
3. No definite pulmonary embolism or acute aortic injury on this
suboptimal
examination.
4. Increased consolidation at the right lung base is concerning
for pneumonia.
5. Cholelithiasis.
6. Stable pelvic and inguinal lymphadenopathy.
___ CXR
IMPRESSION:
Limited exam given rotation and suboptimal penetration. Mild
edema not
excluded. Right lung base poorly assessed. If needed, a repeat
study with
dedicated PA and lateral views would be helpful to better
assess.
___ CT head without contrast
No acute intracranial process. Mild small vessel disease.
ADMISSION LABS:
==============
___ 05:41AM BLOOD WBC-10.5* RBC-3.27* Hgb-7.3* Hct-25.5*
MCV-78* MCH-22.3* MCHC-28.6* RDW-17.9* RDWSD-50.1* Plt ___
___ 05:41AM BLOOD Neuts-81.9* Lymphs-9.5* Monos-7.5
Eos-0.4* Baso-0.3 Im ___ AbsNeut-8.60* AbsLymp-1.00*
AbsMono-0.79 AbsEos-0.04 AbsBaso-0.03
___ 05:41AM BLOOD ___ PTT-38.9* ___
___ 05:41AM BLOOD Glucose-57* UreaN-23* Creat-1.1 Na-136
K-3.7 Cl-96 HCO3-29 AnGap-11
___ 05:41AM BLOOD Calcium-7.6* Phos-4.4 Mg-1.5*
___ 05:41AM BLOOD CRP-211.1*
___ 09:35AM BLOOD O2 Sat-72
___ 05:48AM BLOOD Lactate-0.7
DISCHARGE LABS:
==============
___ 06:17AM BLOOD WBC-8.2 RBC-3.96* Hgb-8.7* Hct-30.4*
MCV-77* MCH-22.0* MCHC-28.6* RDW-18.3* RDWSD-50.3* Plt ___
___ 07:50AM BLOOD Glucose-191* UreaN-41* Creat-1.1 Na-138
K-4.4 Cl-96 HCO3-33* AnGap-9*
___ 07:30AM BLOOD Calcium-8.2* Phos-4.6* Mg-1.9
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. Atorvastatin 80 mg PO QPM
4. BusPIRone 12.5 mg PO TID
5. Docusate Sodium 100 mg PO BID
6. Gabapentin 300 mg PO TID
7. HydrOXYzine 75 mg PO TID:PRN anxiety
8. Methadone 10 mg PO BID
9. Nicotine Patch 21 mg/day TD DAILY
10. Senna 8.6 mg PO BID:PRN Constipation - First Line
11. Torsemide 40 mg PO QHS
12. TraZODone 50 mg PO QHS:PRN insomnia
13. Vitamin D 1000 UNIT PO DAILY
14. Fluticasone-Salmeterol Diskus (250/50) 2 INH IH BID
15. MetFORMIN (Glucophage) 1000 mg PO BID
16. amLODIPine 10 mg PO DAILY
17. Lisinopril 40 mg PO DAILY
18. MetroNIDAZOLE 500 mg PO Q8H
19. Levofloxacin 750 mg PO Q24H
20. Glargine 40 Units Breakfast
Glargine 40 Units Bedtime
21. Torsemide 100 mg PO QAM
22. Omeprazole 20 mg PO DAILY
23. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
24. Cyanocobalamin 500 mcg PO DAILY
25. Venlafaxine XR 37.5 mg PO DAILY
26. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
27. HumaLOG KwikPen Insulin (insulin lispro) 18 units
subcutaneous BID AC
28. HumaLOG KwikPen Insulin (insulin lispro) 16 units
subcutaneous dinner
29. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze, cough
Discharge Medications:
1. Becaplermin Gel 0.01% 1 Appl TP DAILY
2. Collagenase Ointment 1 Appl TP DAILY
3. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN dypsnea or wheezing
4. Miconazole Powder 2% 1 Appl TP TID:PRN Rash
5. Ramelteon 8 mg PO QHS:PRN insomnia
Should be given 30 minutes before bedtime
6. Glargine 64 Units Breakfast
Glargine 64 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
7. MetFORMIN (Glucophage) 500 mg PO BID
8. Torsemide 120 mg PO DAILY
9. Torsemide 80 mg PO QPM
10. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
11. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze, cough
12. amLODIPine 10 mg PO DAILY
13. Aspirin 81 mg PO DAILY
14. Atorvastatin 80 mg PO QPM
15. BusPIRone 12.5 mg PO TID
16. Cyanocobalamin 500 mcg PO DAILY
17. Docusate Sodium 100 mg PO BID
18. Fluticasone-Salmeterol Diskus (250/50) 2 INH IH BID
19. Gabapentin 300 mg PO TID
20. HydrOXYzine 75 mg PO TID:PRN anxiety
21. LevoFLOXacin 750 mg PO Q24H
22. Lisinopril 40 mg PO DAILY
23. Methadone 10 mg PO BID
Consider prescribing naloxone at discharge
RX *methadone 10 mg 1 tablet(s) by mouth twice a day Disp #*14
Tablet Refills:*0
24. MetroNIDAZOLE 500 mg PO Q8H
25. Nicotine Patch 21 mg/day TD DAILY
26. Omeprazole 20 mg PO DAILY
27. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth up to four times daily
as needed Disp #*20 Tablet Refills:*0
28. Senna 8.6 mg PO BID:PRN Constipation - First Line
29. TraZODone 50 mg PO QHS:PRN insomnia
30. Venlafaxine XR 37.5 mg PO DAILY
31. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hypoglycemia
Uncontrolled type 2 diabetes mellitus
Hypoxic hypercapnic respiratory failure
Obesity hypoventilation syndrome
Suspected sleep apnea
Congestive heart failure with hypervolemia
Chronic foot wounds complicated by calcaneal osteomyelitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with status post fall, ams// Eval for bleeding
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) = 1,495 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute major infarction,hemorrhage,edema,or discrete
mass. Periventricular and subcortical white matter hypodensities are
nonspecific but likely sequelae of chronic small vessel ischemic disease.
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 process. Mild small vessel disease.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with hypoxia// eval for PNA
COMPARISON: Prior study from ___ as well as a radiograph performed
9 hours prior to the current radiograph.
FINDINGS:
AP portable semi upright view of the chest. The patient is rightward rotated
which limits assessment. Patient is known to have a large cardiophrenic fat
pad on the right. The overall cardiomediastinal contour is unchanged. No
definite signs of pneumonia though right lung base suboptimally assessed.
Ground-glass opacity within the lungs may reflect suboptimal penetration
though mild edema not excluded. Bony structures are intact.
IMPRESSION:
Limited exam given rotation and suboptimal penetration. Mild edema not
excluded. Right lung base poorly assessed. If needed, a repeat study with
dedicated PA and lateral views would be helpful to better assess.
Radiology Report
EXAMINATION: CT chest abdomen and pelvis.
INDICATION: ___ Please evaluate for enterocutaneous fistula or abscess.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast in the arterial
phase. Then, imaging was obtained through the abdomen and pelvis in the
portal venous phase. Reformatted coronal and sagittal images through the
chest, abdomen, and pelvis, and oblique maximal intensity projection images of
the chest were submitted to PACS and reviewed.
DOSE: Total DLP (Body) = 2,047 mGy-cm.
COMPARISON: CT chest abdomen pelvis performed ___, CT torso
performed ___.
FINDINGS:
Examination is suboptimal secondary to body habitus. Within this limitation:
CHEST:
HEART AND VASCULATURE: Evaluation of the pulmonary vasculature is limited in
the setting of contrast bolus timing. The visualized pulmonary vasculature
appears well opacified to the segmental level without filling defect to
indicate pulmonary embolus. The main pulmonary artery is dilated up to 3.3
cm. The thoracic aorta appears normal in caliber without evidence of
dissection. Coronary artery calcifications are moderate. Mitral annual
calcifications are mild. Mild cardiomegaly. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary lymphadenopathy. Slightly
prominent right mediastinal lymph node measures up to 1.6 cm and does not
appear appreciably changed compared to ___ (302:69). No hilar
lymphadenopathy. No mediastinal mass.
PLEURAL SPACES: Possible trace right pleural effusion. No left pleural
effusion. No pneumothorax.
LUNGS/AIRWAYS: Increased consolidation at the right lung base may reflect a
developing pneumonia versus aspiration. Left lingular and left lower lobe
atelectasis is also noted. The airways are patent to the level of the
segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder contains gallstones
without wall thickening or surrounding inflammation.
PANCREAS: There is mild fatty atrophy of the pancreas. No focal pancreatic
lesions or pancreatic ductal dilatation is noted. 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 mild right hydronephrosis without evidence of an obstructing stone or
mass. A previously seen right interpolar cyst is not well evaluated on
current examination secondary to overlying beam hardening artifact. No
concerning renal lesions are identified. No hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal (304:79). There is
no free intraperitoneal fluid or free air.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no free
fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are unremarkable.
LYMPH NODES: No pathologically enlarged retroperitoneal or mesenteric lymph
nodes are identified. Mildly enlarged pelvic lymph nodes measure up to 1.6 cm
bilaterally and are not appreciably changed compared to ___
(304:85, 86). Inguinal lymph nodes measure up to 2.0 cm on the left
(304:110).
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions or
acute fracture. Postsurgical changes of ventral hernia repair with mesh
placement are again noted. There is extensive soft tissue stranding and edema
within the partially imaged pannus. No organized fluid collection is
identified. Defect along the midline anterior abdominal wall is unchanged.
IMPRESSION:
1. Extensive soft tissue stranding and edema within the partially imaged
pannus without evidence of an organized fluid collection.
2. Mild right hydronephrosis without evidence of an obstructing stone or mass.
3. No definite pulmonary embolism or acute aortic injury on this suboptimal
examination.
4. Increased consolidation at the right lung base is concerning for pneumonia.
5. Cholelithiasis.
6. Stable pelvic and inguinal lymphadenopathy.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 6:09 pm, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: HEEL (AXIAL AND LATERAL) RIGHT
INDICATION: ___ year old man with bilateral heel pressure ulcers followed by
podiatry, now with rising CRP and worsening pain.// please eval for evidence
of chronic osteo within limits of plain film versus other osseus pathology.
TECHNIQUE: Two views of the right calcaneus.
COMPARISON: None available.
FINDINGS:
No acute fractures or dislocations are seen.Joint spaces are preserved without
significant degenerative changes.There is a soft tissue wound with pocket of
subcutaneous gas at the plantar aspect of the calcaneal tuberosity. There is
evidence for demineralization of the underlying plantar aspect of the
calcaneal body..Scattered mild-to-moderate degenerative changes about the
ankle and midfoot.
IMPRESSION:
Evidence for a soft tissue wound at the plantar aspect of the heel with
concern for osteomyelitis at the underlying plantar aspect of the calcaneal
body.
NOTIFICATION: The impression above was entered by Dr. ___ on ___
at 17:05 into the Department of Radiology critical communications system for
direct communication to the referring provider.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Pneumonia, unspecified organism
temperature: 97.7
heartrate: 76.0
resprate: 18.0
o2sat: 92.0
sbp: 132.0
dbp: 80.0
level of pain: 9
level of acuity: 2.0 | ___ is a ___ year old man with a history of morbid
obesity c/b obesity hypoventilation syndrome, OSA, HFpEF, hernia
repairs c/b chronic abdominal wounds, IDDM, HTN, EtOH use
disorder, anxiety/depression, chronic pain (methadone), chronic
foley, and recent calcanel osteomyelitis (on
levofloxacin/flagyl) who was admitted from rehab with
hypoglycemia and initially required ICU stay for hypercarbic and
hypoxemic respiratory failure and significant diuresis for
volume overload.
# Acute on chronic hypercapneic hypoxic resp failure:
# Acute on chronic diastolic CHF
# Obesity hypoventilation syndrome (OVHS)
# Obstructive sleep apnea (OSA):
Patient arrived at THE hospital lethargic and requiring 6L NC to
15L NRB a rebreather to maintain normal saturations, requiring
admission to the medical ICU. However being more alert, he was
quickly weaned to 2L NC with sats in ___, and safe for transfer
to medicine. Soon he was weaned to RA. However he continued to
desaturate to ___ when sleeping. Assessed by sleep medicine
but adamantly refused BiPAP, CPAP, or a sleep study. Also
refused tracheostomy with ventilator use. Daytime O2 sats
improved modestly with IV diuresis although continued to drop
his O2 when asleep. He used to be on 4L O2 at night but has not
since at least ___ due to insurance issues. Patient likely
has OHVS and OSA. Long smoking history so likely has COPD and
pHTN as well. His (mild) response to diuresis suggests
hypervolemia may play a role although no clear evidence of
pulmonary edema on exam or imaging (both limited due to his
habitus); no evidence of PNA or PE on imaging either. He was
continually diuresed with Lasix 160 IV ___ until ___. He
was then transitioned to oral torsemide. He will be discharged
on 120 mg QAM and 80 mg QPM and will need ongoing monitoring of
labs and volume status. (Unfortunately weights and intake/output
data were inaccurate and/or challenging to interpret).
# IDDM:
Presented with hypoglycemia. The diabetes consult service
followed during this admission and was noted to have extremely
erratic sugars associated with erratic eating habits. Home
metformin held and restarted at a reduced dose on discharge. He
will be discharged on lantus 64 U BID, and a Humalog regimen
incorporating meal-associated insulin and sliding scale together
(see sliding scale for details).
# Enterococcal bactiuria
# Chronic Foley
Ucx ___ sensitive only to linezolid. Likely colonizer given
chronic foley. No fevers, WBC, urinary symptoms, and so not
treated.
# Chronic foot wounds c/b calcaneal osteomyelitis:
Continued metronidazole and levofloxacin (per ID plan for at
least 10 weeks of antibiotics). Continued wound care per
podiatry's instructions. Follow-up in ___ clinic. (See wound care
recommendations below)
# Depression:
Patient endorsed depressed mood and dissatisfaction with poor
quality of life as well as hopelessness. SW consulted this
admission. Patient denied any thoughts of hurting himself.
Continued on buspirone, hydroxyzine PRN, trazodone, and
ramelteon.
# Chronic Abdominal Wound:
# Abdominal pain
Patient with chronic abdominal wound, which remained stable and
did not appear infected during the admission. He experienced
abdominal pain that was stable during the admission, without
evidence of a new acute process. Continued dressing changes. He
has outpatient plastics follow-up next week for pre-op for
surgical intervention in ___.
CHRONIC ISSUES
# HTN: Continued amlodipine and lisinopril
# HLD: Continued Atorvastatin
# Chronic pain: Continued gabapentin, methadone, oxycodone
# Smoker: Continued nicotine patch
# Vitamin D deficiency: Continued cholecalciferol
# GERD: restarted omeprazole at discharge
==================================================
==================================================
POST-DISCHARGE PLANS/RECOMMENDATIONS AND TRANSITIONAL ISSUES |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / NSAIDS (Non-Steroidal Anti-Inflammatory
Drug) / Nortriptyline / vancomycin
Attending: ___.
Chief Complaint:
___ pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w schizoaffective d/o, ? polysubstance abuse, ? RA on
plaquenil, COPD, numerous ___ surgeries with hardware
and resultant hardware and soft tissue infections p/w BLE pain
and erythema. Pt was recently admitted to ___ at end of ___
for BLE cellulitis, seen by ID and started on a 2 week course of
daptomycin (? AIN to vanco). She reports that in the last few
weeks she has had worsening erythema/induration and pain in BLEs
(L worse than R). She has also had fevers, chills, sweats,
nausea and vomiting.
She reports her chronic cough, without chest pain. She reports
dysuria and chronic loose stools. Denies joint pains.
In ED, refceived 1L NS, dapto/cefepime per ID, oxycodone 20mg,
30mg morphine. Labs showed K 7 but hemolyzed, so repeated to
5.4. Lactate wnl.
Past Medical History:
-Schizo-affective disorder
-COPD
-HTN
-Allergic rhinitis
-Hypothyroid
-Hx of Barretts esophagus
-GERD
-Hx of pancreatitis in ___
-Obesity
-Osteoporosis
-Tobacco abuse
-Hyperlipidemia
-Hx of ETOH abuse
-Hx of menorrhagia treated with an ablation procedure several
ears ago at ___; no menses since.
-s/p LLE surgery with L tibial shaft fracture with nonunion---in
chronic pain
-s/p fundoplication for reflux in ___ at ___
-s/p numerous L ankle and leg surgeries
-Pancytopenia [___ biopsy ___ ___ Pancytopenia with moderate
neutropenia. Neutropenia resolved,but she remained
leukocytopenic. Bone marrow biopsy was performed by hematologist
Dr. ___ on ___. Features suspicious for
myelodysplastic syndrome were not seen. Possible etiologies for
the patient's cytopenias include the effects of drugs/toxins
(including alcohol), infection, autoimmune disease or other
inflammatory process. Cytogenetics were normal ___
metaphases). JAK2 mutational analysis was reportedly negative.
Peripheral blood flow cytometry showed no evidence for a
monoclonal B-cell or unusual T-cell population.
- cellulitis admission ___ as above, 2 week course of
daptomycin
Social History:
___
Family History:
Breast cancer
Physical Exam:
97.4 95/65 76 18 99RA
obese, in wheelchair, tangential
NCAT, MMM without lesions
RRR
diffusely ronchorous with expiratory wheezing
s/nt/nd, obese
wwp, 2+ DPPs, numerous well healed surgical scars B LEs, chronic
___ ulcerations, erythema and induration bilaterally up ___ to
___ up LEs without bites/breaks in skin; sensation decreased LLE
per baseline
moving all 4, no droop, interactive
Exam on discharge:
Exam:
Vitals: 98.2 118/54 72 18 99% RA
GEN: NAD, sitting in wheelchair in NAD
HEENT: MMM
CV: RRR, no murmur
RESP: clear to auscultation b.l, no rhonchi, wheeze.
ABD: non tender non distended pos BS
EXT:B/L exemities with chronic skin changes. Left leg with
excoriations. No erythema. ___ edema
NEURO/psych: grossly normal, Pleasant and cooperative
Pertinent Results:
___ 08:21PM BLOOD Lactate-1.4 K-5.4*
___ 08:10PM BLOOD Glucose-86 UreaN-14 Creat-1.3* Na-131*
K-7.6* Cl-95* HCO3-25 AnGap-19
___ 08:10PM BLOOD Plt ___
___ 10:08PM BLOOD ___ PTT-39.7* ___
___ 08:10PM BLOOD WBC-3.7* RBC-3.52* Hgb-9.7* Hct-30.8*
MCV-88 MCH-27.6 MCHC-31.5* RDW-15.1 RDWSD-48.0* Plt ___
___ 08:10PM BLOOD Neuts-57.6 ___ Monos-4.6* Eos-2.7
Baso-0.5 Im ___ AbsNeut-2.13 AbsLymp-1.26 AbsMono-0.17*
AbsEos-0.10 AbsBaso-0.___
IMPRESSION:
1. Bilateral subcutaneous edema most prominent over the distal
lower extremity, left worse than right. No well defined
drainable fluid collection. Findings may represent cellulitis in
the appropriate clinical setting.
2. Chronic osseous changes related to prior trauma, surgery,
and
possibly infection are stable. No evidence of acute
osteomyelitis.
3. No evidence of hardware failure in the right lower
extremity.
4. Mildly impacted fracture at the base of the left first
proximal phalanx.
___ u/s ___
No evidence of deep venous thrombosis in the right or left lower
extremity tveins.
___ cxr
As compared to the previous radiograph, the right PICC line has
been removed.
The lung volumes continue to be low. Moderate cardiomegaly
without pulmonary
edema persists. Old healed right-sided rib fracture. No
pleural
effusions.
No pneumonia
___ xray LEs
1. Findings as above notable for subcutaneous edema within
bilateral lower
legs without soft tissue gas or radiopaque foreign body.
2. Hardware within the right distal tibia and fibula with
perihardware lucency
along the syndesmotic screw raising concern for loosening.
==============================================================
MICRO
___
WOUND CULTURE (Final ___:
ENTEROBACTER CLOACAE COMPLEX. HEAVY GROWTH.
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
CORYNEBACTERIUM SPECIES (DIPHTHEROIDS). HEAVY GROWTH.
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
in this
culture.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 30 mL PO BID
2. Senna 17.2 mg PO BID
3. Hydroxychloroquine Sulfate 200 mg PO BID
4. Docusate Sodium 100 mg PO BID
5. Morphine SR (MS ___ 30 mg PO Q12H
6. Lorazepam 1 mg PO TID
7. Gabapentin 600 mg PO TID
8. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN sore throat
9. Tizanidine 4 mg PO TID:PRN muscle spasm
10. OxycoDONE (Immediate Release) 20 mg PO Q4H:PRN pain
11. Pantoprazole 40 mg PO Q24H
12. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
13. Tiotropium Bromide 1 CAP IH DAILY
14. Furosemide 40 mg PO DAILY
15. Multivitamins W/minerals 1 TAB PO DAILY
16. QUEtiapine Fumarate 25 mg PO QAM
17. Fluticasone Propionate NASAL 2 SPRY NU DAILY
18. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
19. Levothyroxine Sodium 88 mcg PO DAILY
20. Polyethylene Glycol 17 g PO DAILY:PRN constipation
21. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
22. HydrOXYzine 50 mg PO Q8H:PRN itch
23. Systane (peg 400-propylene glycol) 0.4-0.3 % ophthalmic
TID:PRN dry eyes
24. Aluminum-Magnesium Hydrox.-Simethicone 15 mL PO Q4H:PRN GI
upset
25. Guaifenesin-CODEINE Phosphate ___ mL PO Q4H:PRN cough
26. Baclofen 5 mg PO TID
27. melatonin 5 mg oral QHS
28. Zolpidem Tartrate 2.5 mg PO QHS
29. Cetirizine 10 mg PO DAILY
30. Senna 17.2 mg PO DAILY:PRN constipation
31. Pramipexole 1 mg PO BID:PRN restlessleg
32. Acetaminophen 650 mg PO Q6H:PRN pain/fever
33. Lidocaine 5% Patch 2 PTCH TD QAM
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
2. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN sore throat
3. Aluminum-Magnesium Hydrox.-Simethicone 15 mL PO Q4H:PRN GI
upset
4. Docusate Sodium 100 mg PO BID
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
7. Gabapentin 600 mg PO TID
8. Guaifenesin-CODEINE Phosphate ___ mL PO Q4H:PRN cough
9. Hydroxychloroquine Sulfate 200 mg PO BID
10. HydrOXYzine 50 mg PO Q8H:PRN itch
11. Lactulose 30 mL PO BID
12. Levothyroxine Sodium 88 mcg PO DAILY
13. Lorazepam 1 mg PO TID
14. Morphine SR (MS ___ 30 mg PO Q12H
15. Multivitamins W/minerals 1 TAB PO DAILY
16. OxycoDONE (Immediate Release) 20 mg PO Q4H:PRN pain
17. Pantoprazole 40 mg PO Q24H
18. Polyethylene Glycol 17 g PO DAILY:PRN constipation
19. QUEtiapine Fumarate 25 mg PO QAM
20. Senna 17.2 mg PO BID
21. Tiotropium Bromide 1 CAP IH DAILY
22. Tizanidine 4 mg PO TID:PRN muscle spasm
23. Furosemide 40 mg PO DAILY
24. Systane (peg 400-propylene glycol) 0.4-0.3 % ophthalmic
TID:PRN dry eyes
25. Bisacodyl 10 mg PO DAILY:PRN constipation
26. Nicotine Patch 21 mg TD DAILY
27. Baclofen 5 mg PO TID
28. Cetirizine 10 mg PO DAILY
29. Lidocaine 5% Patch 2 PTCH TD QAM
30. Zolpidem Tartrate 2.5 mg PO QHS
31. Acetaminophen 650 mg PO Q6H:PRN pain/fever
32. melatonin 5 mg oral QHS
33. Pramipexole 1 mg PO BID:PRN restlessleg
34. Senna 17.2 mg PO DAILY:PRN constipation
35. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
36. Clindamycin 450 mg PO Q6H Duration: 7 Days
RX *clindamycin HCl 150 mg 3 capsule(s) by mouth Q6hrs Disp #*84
Capsule Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cellulitis
Secondary:
COPD
Chronic pain
Schizoaffective disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with cellulitis and erythema. // SubQ air? Foreign body.
COMPARISON: CT of the right and left lower leg from ___ and ___.
FINDINGS:
Right tibia and fibula: AP and lateral views. Lateral plate and screw
fixation along the distal fibula noted with a single syndesmotic screw. There
is abnormal lucency adjacent to the syndesmotic screw in the distal tibia and
fibula as seen on most recent prior CT exam raising strong concern for
loosening. The other screws extending into the fibula only appear well
seated. Soft tissue edema is noted diffusely without soft tissue gas or
radiopaque foreign body. Limited views of the right knee and right ankle
joint appear to align normally.
Left tibia and fibula: AP and lateral views. There is subcutaneous edema
without soft tissue gas or radiopaque foreign body. Multiple ghost tracks
within the tibia and fibula reflect prior orthopedic hardware. There is
cortical irregularity involving the mid to distal tibia and fibula as on prior
exam reflecting posttraumatic deformity.
Left knee and left ankle align normally. There is partial ankylosis across
the midfoot with metallic screw fragments noted within the talus.
IMPRESSION:
1. Findings as above notable for subcutaneous edema within bilateral lower
legs without soft tissue gas or radiopaque foreign body.
2. Hardware within the right distal tibia and fibula with perihardware lucency
along the syndesmotic screw raising concern for loosening.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with copd p/w cellulitis, sob // r/o pna
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, the right PICC line has been removed.
The lung volumes continue to be low. Moderate cardiomegaly without pulmonary
edema persists. Old healed right-sided rib fracture. No pleural effusions.
No pneumonia.
Radiology Report
EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT)
INDICATION: ___ woman with hardware, bilateral lower extremity
erythema, evaluate for DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the left lower extremity tibial and
peroneal veins. The right lower extremity calf veins are somewhat limited
evaluation due to obscuration from significant overlying soft tissue edema.
Within this limitation, the posterior tibial veins demonstrate wall-to-wall
color flow on longitudinal images, compatible with patency. The peroneal
veins are not seen.
There is normal respiratory variation in the common femoral veins bilaterally.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Radiology Report
EXAMINATION: CT right lower extremity with contrast.
INDICATION: ___ year old woman with recurrent cellulitis and hardware. wanting
to know if pt has osteo or abscess // osteo? abscess?please perform b/l ___ CT
TECHNIQUE: 1mm axial images were obtained of the bilateral lower extremities
from the distal femur through the feet with intravenous contrast. Coronal and
sagittal reformats.
DOSE: Total DLP 1170.40 mGy-cm
COMPARISON: CTs right and left lower extremity ___ and ___
FINDINGS:
Right lower extremity:
No acute fracture or dislocation. There is lateral plate and screw fixation
of the distal fibula with a syndesmotic screw in place. No evidence of
perihardware lucency or hardware fracture. Ossification is seen within the
expected region of the right tibiotalar ligament.
There is a trace suprapatellar joint effusion.
There is mild subcutaneous edema through the imaged lower extremity. More
severe over the distal lower extremity where the edema becomes more confluent.
No well defined, drainable fluid collection or abscess. The edema extends
over the dorsal and lateral aspect of the foot. There is diffuse skin
thickening overlying the distal lower extremity. Mild diffuse muscle atrophy.
The extensor, medial long flexor, and peroneus tendons are grossly intact.
Left lower extremity:
Patient is status post removal of the tibia and fibula hardware. Diffuse
decreased bone mineralization. There is evidence of chronic bony remodeling
of the tibia and fibula consistent with the sequelae of prior trauma, surgery,
and/or infection.
Again seen are two screw fragments are seen in the talus. Stable appearance
of well corticated irregularity of the talonavicular, naviculocuneiform, and
first TMT joints appears chronic. No evidence of periosteal reaction or
osseous erosion.
There is a mildly impacted fracture at the base of the first proximal phalanx.
Significant subcutaneous edema within the lower leg and foot more confluent
distally, but no well defined, drainable fluid collection or abscess. There
is diffuse skin thickening overlying the distal lower extremity. Mild diffuse
muscle atrophy of the of the lower leg is again seen, slightly worse than the
right leg. Apparent removal of a portion of the posterolateral subcutaneous
soft tissues of the calf is again seen and stable.
IMPRESSION:
1. Bilateral subcutaneous edema most prominent over the distal lower
extremity, left worse than right. No well defined drainable fluid collection.
Findings may represent cellulitis in the appropriate clinical setting.
2. Chronic osseous changes related to prior trauma, surgery, and possibly
infection are stable. No evidence of acute osteomyelitis.
3. No evidence of hardware failure in the right lower extremity.
4. Mildly impacted fracture at the base of the left first proximal phalanx.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: n/v/d, B Leg swelling, Leg pain
Diagnosed with CELLULITIS OF LEG, HYPERTENSION NOS
temperature: 98.0
heartrate: 85.0
resprate: 18.0
o2sat: 100.0
sbp: 97.0
dbp: 65.0
level of pain: 10
level of acuity: 3.0 | ___ w schizoaffective d/o, chronic cellulitis and previous
hardware infections in LEs presents with recurrent cellulitis
# BLE cellulitis:
The patient has a history of complicated lower extremity
infections with history of MRSA. Elevated CRP 35. Wound culture
from ___ grew pan-sensitive enterobacte which is likely a
contaminant. The patient had CT of her ___ which was consistent
with cellulitis. There was no drainable fluid collection and no
evidence of osteomyelitis. The patient was seen in consultation
by ID who recommended starting IV daptomycin. The patient's exam
improved and she will be discharged on oral clindamycin to
complete an additional 7 days. She will need to follow up with
ID after discharge. She was seen by orthopedics who felt that
her hardware isn't currently causing a problem, but could be
removed on patient request. The patient should follow up with
Dr. ___ as an outpatient to discuss further. The patient
was also seen by wound care nurses.
# Chronic pain:
The patient is on high doses of narcotics in additon to other
sedaiting medications as an outpatient. She was contiued on her
home regimen of MS contin, oxycodone, tizanidine, baclofen and
gabapentin. She was also continued on bowel regimen. I discussed
the risk of high dose narcotics with the patient and encouraged
her to discuss tapering these medications with her PCP. She
currently follows with PCP at the ___, Dr. ___ will
continue care here at ___ following her discharge from her
___.
#Schizoaffective disorder
The patient was appropriate throughtou her hospitalization and
was continued on seroquel.
# COPD: no acute exacerbation
Continued home inhalers (advair, spiriva)
#?Rheumatoid arthritis
COntinued on Plaquenil |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
clonidine
Attending: ___
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with PMHx HTN, diastolic HF (EF 55%),
tachy-brady syndrome s/p pacemaker, atrial fibrillation on
warfarin, obesity, and chronic pain tapered off of narcotics who
presents with chest pain, DOE and weight gain. He had been
feeling well until a few days prior to presentation to the ___
when he started to have pressure-like chest pain with DOE while
walking around his house. He also noted increased fatigue. His
chest pain was substernal with radiation to the back (not normal
for him) that resolved when sitting down and recurred
intermittently throughout the day. He has had symptoms like this
with prior CHF exacerbations and says "this is not an MI." He
reports moderate compliance with low-salt diet, fluid
restriction, and taking all of his medications. He increased his
PO Lasix from 20mg to 40mg without any improvement in his
symptoms. No recent fevers, chills. He was seen in Dr. ___
office with his concerns and was then referred to the ___. He has
had multiple hospitalizations in the past year for CHF
exacerbations. He was recently admitted ___ for similar
symptoms and received IV diuresis and readjustment of
antihypertensives.
En route to the ___ he received 4 baby asa, 2 nitro in ambulance,
which did nothing to relieve his symptoms.
In the ___, a CXR showed no cardiopulmonary process, trop
negative x2, and a CTA was notable for no aortic dissection or
pulmonary embolism. Cardiology reccommended stress test, but he
was unable to get it on the weekend. Initial plan was for
discharge home with increase in PO lasix and outpt nuclear
stress. While evaluating his ability to ambulate independently,
he triggered for rapid a fib with rates to 140-150. He received
his home medications and his heart rate corrected. He then
ambulated a second time and had repeat Afib with RVR. Cardiology
was consulted and reccommended admission given rising
creatinine, continued chest discomfort with Afib/RVR and need
for IV diuresis.
Labs in the ___ were notable for:
BNP 17,497 (17,280 on ___ during previous admission for CHF
exacerbation)
Cr 2.2
INR 2
lactate 1.3
Negative UA
On review of systems, s/he 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. S/he denies recent fevers, chills or
rigors. S/he denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
(difficult to control)
2. CARDIAC HISTORY:
- CABG:
- PERCUTANEOUS CORONARY INTERVENTIONS:
- PACING/ICD: dual-chamber pacemaker
- Heart failure with preserved EF
- Atrial fibrillation
- Tachybrady syndrome secondary to SSS, s/p dual-chamber
pacemaker
3. OTHER PAST MEDICAL HISTORY:
- Parathyroidadenoma s/p parathyroidectomy ___
- Stage III CKD
- Depression
- Anxiety
- Chronic pain, on narcotics
- GERD
- Gastritis
- Question of sleep apnea
Social History:
___
Family History:
Mother deceased at age ___ h/o Alzheimer's disease and GI
bleeding. Father decease at ___ from lung cancer. Father also had
TB and triple bypass at age ___ family history of early MI,
arrhythmia, cardiomyopathies, or sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.2, 140/103, 87, 20, 97RA
wt: 100.3kg ___ weight 102.7kg; dry weight unclear: per patient
anywhere from 90-100kg)
General: NAD, pleasant male sitting up in bed, speaking in full
sentences
HEENT: NC/AT, PERRL, OP clear, MMM
Neck: supple, no LAD, no carotid bruits, JVP at jawline
CV: irregularly irregular, normal s1/s2, no m/r/g
Lungs: CTAB, diminished in the bases likely ___ body habitus, no
wheeze or rhonchi, no increased WOB
Abdomen: obese, soft, nontender, normoactive bowel sounds
GU: no foley
Ext: warm, well-perfused, trace b/l ___ edema to mid-shin most
prominent in dependent areas; 2+ ___ pulses bilaterally
Neuro: oriented x 3, alert, appropriate affect, moving all 4
exremities, ___ in upper and lower bilateral extremities
Skin: dry, no rash or lesions
DISCHARGE PHYSICAL EXAM:
VS: 97.9, 117-149/69-86, 57-84, 18, 98RA
wt: 102.3 (102.9kg) ___ weight 102.7kg; dry weight unclear: per
patient anywhere from 90-100kg)
General: NAD, pleasant male sitting up in bed, speaking in full
sentences
HEENT: NC/AT, PERRL, OP clear, MMM
Neck: supple, no LAD, no carotid bruits, no JVD
CV: irregularly irregular, normal s1/s2, no m/r/g
Lungs: CTAB, diminished in the bases likely ___ body habitus, no
wheeze or rhonchi, no increased WOB
Abdomen: obese, soft, nontender, normoactive bowel sounds
GU: no foley
Ext: warm, well-perfused, trace b/l ___ edema to mid-shin most
prominent in dependent areas; 2+ ___ pulses bilaterally
Neuro: oriented x 3, alert, appropriate affect, moving all 4
exremities, ___ in upper and lower bilateral extremities
Skin: dry, no rash or lesions
Pertinent Results:
ADMISSION LABS:
___ 11:30AM BLOOD WBC-5.2 RBC-3.64* Hgb-10.8* Hct-33.3*
MCV-92 MCH-29.8 MCHC-32.6 RDW-14.1 Plt ___
___ 11:30AM BLOOD Neuts-80.8* Lymphs-14.6* Monos-3.2
Eos-1.1 Baso-0.2
___ 11:30AM BLOOD ___ PTT-31.7 ___
___ 11:30AM BLOOD Glucose-102* UreaN-22* Creat-1.8* Na-140
K-3.8 Cl-104 HCO3-25 AnGap-15
___ 11:37AM BLOOD Glucose-95 Lactate-1.3 K-4.3
___ 11:37AM BLOOD Hgb-11.0* calcHCT-33
TRENDING LABS:
___ 11:30AM BLOOD ___
___ 11:30AM BLOOD cTropnT-<0.01
___ 05:50PM BLOOD cTropnT-<0.01
DISCHARGE LABS:
___ 06:44AM BLOOD ___ PTT-30.0 ___
___ 12:45PM BLOOD Creat-2.4* Na-142 K-4.1 Cl-103
___ 06:44AM BLOOD Glucose-84 UreaN-36* Creat-2.2* Na-142
K-4.2 Cl-106 HCO3-26 AnGap-14
___ 06:44AM BLOOD Calcium-9.1 Phos-4.3 Mg-2.2
URINE:
___ 11:40AM URINE Color-Straw Appear-Clear Sp ___
___ 11:40AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 11:40AM URINE RBC-2 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
___ 11:40AM URINE Mucous-RARE
IMAGING/STUDIES:
___ CXR: No acute intrapulmonary process
___ CTA Chest
IMPRESSION:
1. No evidence of pulmonary embolism or aortic dissection.
2. Heterogeneous thyroid with a right thyroid nodule which has
been
previously seen on ___ ultrasound.
3. Simple hepatic cyst in segment 5.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Lisinopril 40 mg PO DAILY
3. Lorazepam ___ mg PO Q6H:PRN anxiety
4. Labetalol 300 mg PO TID
5. Diltiazem Extended-Release 240 mg PO DAILY
6. Warfarin 5 mg PO DAILY16
7. HydrALAzine 100 mg PO Q8H
8. Furosemide 20 mg PO DAILY
9. Fluticasone Propionate 110mcg ___ PUFF IH BID
10. Fluoxetine 80 mg PO DAILY
11. Aspirin 81 mg PO DAILY
12. TraZODone 100 mg PO HS:PRN insomnia
13. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
14. Calcitriol 0.25 mcg PO DAILY
15. Calcium Citrate + D (calcium citrate-vitamin D3)
200mg-125Unit tablet oral BID
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN sob
3. Aspirin 81 mg PO DAILY
4. Calcitriol 0.25 mcg PO DAILY
5. Diltiazem Extended-Release 240 mg PO BID
RX *diltiazem HCl 240 mg 1 capsule,extended release 24hr(s) by
mouth twice a day Disp #*30 Capsule Refills:*0
6. Fluoxetine 80 mg PO DAILY
7. Fluticasone Propionate 110mcg ___ PUFF IH BID
8. Furosemide 40 mg PO DAILY
RX *furosemide 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
9. HydrALAzine 100 mg PO Q8H
10. Labetalol 300 mg PO TID
11. Lisinopril 40 mg PO DAILY
12. Lorazepam ___ mg PO Q6H:PRN anxiety
13. TraZODone 100 mg PO HS:PRN insomnia
14. Warfarin 7.5 mg PO DAILY16
RX *warfarin [Coumadin] 7.5 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
15. Calcium Citrate + D (calcium citrate-vitamin D3)
200mg-125Unit tablet oral BID
16. Outpatient Lab Work
please check chem10 and INR on ___ and call in or fax
results to Dr. ___: ___, Fax: ___
and to Dr. ___: ___
Discharge Disposition:
Home
Discharge Diagnosis:
acute on chronic diastolic heart failure 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 with shortness of breath.
TECHNIQUE: Upright AP and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
Left-sided pacemaker device is noted with single lead terminating in the right
ventricle. The heart size is mildly enlarged. The aorta remains tortuous.
The pulmonary vascularity is normal and the lungs are clear. No pleural
effusion or pneumothorax is seen. There are mild to moderate multilevel
degenerative changes noted in the thoracic spine. Partially imaged is a
surgical anchor projecting over the left humeral head.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
HISTORY: Pleuritic chest pain with radiation to the back. Assess for
pulmonary embolism or aortic dissection.
COMPARISON: Chest radiograph ___.
TECHNIQUE: Axial helical MDCT images were obtained from the suprasternal
notch to the upper abdomen with early arterial phase scanning after the
administration of 100 cc of Visipaque. Multiplanar reformatted images in
coronal and sagittal axes were generated. Oblique MIP's were prepared in an
independent workstation.
DLP: 748.73mGy-cm
FINDINGS:
CT Thorax: The airways are patent to the subsegmental level. There is no
mediastinal, hilar, or axillary lymph node enlargement by CT size criteria.
Coronary artery calcifications with dilation of the left atrium is noted.
Pacer wire in seen in the right ventricle. The heart, pericardium, and great
vessels are otherwise unremarkable. No hiatal hernia seen. Lung windows do
not demonstrate any focal opacity. No pleural effusion or pneumothorax seen.
The thyroid is heterogeneous with a 0.8 x 0.8 cm hypoechoic right thyroid
nodule.
CTA Thorax: The aorta and main thoracic vessels are well opacified. The
aorta demonstrates normal caliber throughout the thorax without intramural
hematoma or dissection. The pulmonary arteries are opacified to the segmental
level. No filling defect to suggest pulmonary embolism.
Osseous structures: No blastic or lytic lesions suspicious for malignancy.
Although this study is not designed for assessment of intra-abdominal
structures, there is a 1.5 x 1.1 cm hypoechoic round cystic lesion in segment
5 of the liver. No additional liver lesions seen. The additional visualized
solid organs and stomach are unremarkable.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic dissection.
2. Heterogeneous thyroid with a right thyroid nodule which has been
previously seen on ___ ultrasound.
3. Simple hepatic cyst in segment 5.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CHEST PAIN
Diagnosed with CHEST PAIN NOS, RESPIRATORY ABNORM NEC, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 97.9
heartrate: 106.0
resprate: 16.0
o2sat: 98.0
sbp: 141.0
dbp: 98.0
level of pain: 2
level of acuity: 2.0 | ___ with PMHx HTN, diastolic HF (EF 55%), tachy-brady syndrome
s/p pacemaker, atrial fibrillation CHADS2 of 2 on warfarin,
obesity, and chronic pain recently tapered off of narcotics
presenting with chest pain, DOE and weight gain consistent with
heart failure exacerbation.
# Acute on chronic dCHF exacerbation: Has history of HFPEF, last
echo in ___ with LVEF > 55% and mild symmetric LVH with
normal biventricular cavity size and global systolic function.
He was last hospitalized with exacerbation in ___ and was
discharged with 20mg PO lasix daily. Last seen in ___ clinic on
___ and appeared relatively euvolemic, so no changes to
medications or management were made. He reported complaince with
medications but BP was elevated on admission. He also reported
not "being perfect" with his diet. He had no evidence of
ischemic etiologies for worsening heart failure with negative
trops and normal EKG. The most likely cause for worsening heart
failure could be related to his recent exacerbation of his Afib
with rapid ventricular response despite successful cardioversion
in ___. He briefly had an IV Lasix gtt that was changed to
bolus dosing with moderate repsonse. He appeared euvolemic and
he was continued on Lasix 40mg PO daily. His heart rate was
controlled by increasing his diltiazem to 240 BID with good
response and ventricular rate in the 60-80s. His lisinopril was
held initially given Cr bump, but was restarted prior to
discharge with stable kidney function.
# Hypertension: Patient reported compliance with all mediations,
but BP elevated on admission to floor of 140/103. Goal SBP <
130. His diltiazem was uptitrated and he was continued on
hydralazine, labetalol and lisinopril while also being diuresed.
Patient's blood pressure were more controlled on discharge with
SBP 120-130s.
# AoCRF: Serum creatinine levels have been elevated since ___,
which coincided with his treatment for CHF with diuretics.
Patient with baseline Cr of 1.8. Elevated on admission to 2.2,
likely ___ poor forward flow and renal vasculature congestion
with aggressive diuresis. He was discharged with stable renal
function on lasix 40mg daily and lisinopril 40.
# Atrial Fibrillation: First noted in ___. CHADS2 = 2 for CHF
and age. S/p ablation in ___ that was successful for approx
1 month per patient. Since that time he has noted more frequent
palpitations and worsening heart failure symptoms. He was
continued on warfarin for goal INR ___, which was increased to
coumadin to 7.5 for persistent low INR. His diltiazem was
increased to 240 BID, and continued on labetalol with
ventricular rate <90.
# Tachy/Brady Syndrome: S/P biventricular pacemaker. Not pacing
on recent ECG or tele during admission.
# Chronic Pain: Tapered off of his narcotics as of ___.
Avoided NSAIDs in setting of CKD and hypertension. Tylenol PRN
for pain.
#Depression/Anxiety: Chronic. Stable. Continue home fluoxetine
and lorazepam |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Nausea/vomiting, lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The patient is a ___ F with a complicated past medical history,
including Type I DM c/b ESRD s/p renal transplant ___, CAD s/p
MI ___, antiphospholipid Ab syndrome with remote h/o PE on
coumadin, and scleroderma, who presents with two days of nausea,
vomiting, confusion, and lethargy.
The patient developed nausea during a scheduled dobutamine
stress test on the evening of ___. Her nausea worsened
and she began vomiting on ___, unable to take any POs. She
had many episodes of NBNB emesis. She did not check her blood
glucose during this time but continued to take her standing
insulin (glargine 30U QAM, 40U QHS). On ___, the patient's
nausea and vomiting continued and she became weak and lethargic,
unable to even 'lift her head up'. She had some moderate
substernal burning pain associated with vomiting, which has
since resolved. She urinated normally on ___ but did not
urinate at all on ___ (she catheterizes herself
occasionally for neurogenic bladder. She states her urine looked
dark but denies dysuria or hematuria. She also described some
mild night sweats and subjective fever. She denies any cough,
rhinorrhea, congestion, abdominal pain, diarrhea, or shortness
of breath.
She presented to ___, where labs were notable for
Glucose >600, AG 30, WBC 17.6, Cr 2.0 (baseline 1.0), troponin
0.02. She was started on an insulin gtt, given 3L of NS, and
transferred to ___ for further treatment.
In the ___ ED her anion gap had decreased to 14. She was
quickly converted to SQ insulin with one hour of gtt overlap. By
that time her WBC had decreased to 13.5, BUN/Cr 38/1.8. A UA
revealed 5 WBC, few bacteria and trace leukocyte esterase, also
glucose 1000 and ketones 40. Renal transplant was consulted and
recommended treating bacteriuria with Vancomycin and
ciprofloxacin. She was also restarted on her home tacrolimus and
Cellcept
On the floor, the patient feels much better, denies nausea,
vomiting, confusion, or abdominal pain.
Past Medical History:
- Poorly controlled DM Type 1 complicated by neuropathy,
retinopathy, neurogenic bladder (intermittent straight
catherization) - most recent HgbA1c 12.4 in ___
- End-stage renal disease ___ diabetes s/p L-sided living kidney
transplant in ___
- Scleroderma w/ CREST syndrome
- Antiphospholipid antibody syndrome and remote PE history on
Coumadin ___
- CAD s/p MI in ___ c/ LAD PTCA; s/p PTCA ___: one vessel
disease with LAD 60% apical lesion and 90% ___ diagonal lesion.
___ diagonal branch was treated with ballon angioplasty w/o
stenting. Final angiography demonstrated ___ residual
stenosis and improved flow down the diagonal branch.
- LVH
- Gastroparesis/GERD/Hiatal hernia
- Hypothyroidism
- Gout diagnosed ___ years ago
- Herniated disk
- OSA
- Carpal tunnel s/p release
- H/o multiple UTIs (Enterococcus vanc & amp sensitive,
Klebsiella, E. Coli)
Social History:
___
Family History:
Mother-Multiple myeloma
Sister and ___
Sister-RA
___ disease
Nephewsx2-Alopecia
Daughter ___, celiac disease, MS
Physical Exam:
Physical exam on admission:
VITALS: T 98.3 BP 127/63 HR 97 RR 18 SpO2 97% RA
GENERAL: NAD, appears comfortable
HEENT: dry mucous membranes
NECK: JVP flat
LUNGS: CTAB, no wheezes, rales or rhonchi, transmitted upper
airway sounds
HEART: RRR, normal S1 S2, II/VI systolic murmur at ___
ABDOMEN: quiet bowel sounds, soft, non-distended, no TTP in LLQ
(over donor kidney)
EXTREMITIES: warm and well-perfused, no c/c/e
NEUROLOGIC: A+OX3
Physical exam on discharge:
VS T 97.8 Tm 98.3 145/65 (138-188/65-97) HR ___ RR16 100% RA
I/O: ___ 24hrs ___/4900
FSBG: 9:30am 221->40L 14H -> 12pm 55 - 6pm 221 ->6H->8:30pm 255
->16H->163
Gen: NAD, asleep, comfortable
Cardio: RRR, nl S1 S2, II/VI murmur at ___, unchanged from
previous exam
Pulm: CTAB
Abd: +BS, soft, NT, ND
Ext: wwp, no edema, 2+ DP pulses
Pertinent Results:
Labs on admission:
___ 10:15PM BLOOD Neuts-88.7* Lymphs-5.8* Monos-5.1 Eos-0.2
Baso-0.2
___ 10:15PM BLOOD Glucose-297* UreaN-38* Creat-1.8* Na-137
K-4.5 Cl-104 HCO3-19* AnGap-19
___ 10:15PM BLOOD Calcium-9.0 Phos-3.0 Mg-2.2
___ 10:53PM BLOOD tacroFK-5.3
___ 11:02PM BLOOD Lactate-1.8
___ 10:15PM URINE Color-Straw Appear-Clear Sp ___
___ 10:15PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-1000 Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-TR
___ 10:15PM URINE RBC-0 WBC-5 Bacteri-FEW Yeast-NONE Epi-<1
___ 10:15PM URINE CastHy-4*
___ 08:39AM URINE Hours-RANDOM Creat-56 Na-75 K-23 Cl-81
___ 08:39AM URINE Osmolal-537
Pertinent results:
___ 07:05AM BLOOD ___ PTT-65.5* ___
___ 07:05AM BLOOD ___ PTT-55.6* ___
___ 05:20AM BLOOD ___ PTT-38.8* ___
___ 07:30AM BLOOD ___ PTT-31.8 ___
___ 10:15PM BLOOD cTropnT-0.02*
___ 07:05AM BLOOD CK-MB-5 cTropnT-0.07*
___ 04:10PM BLOOD cTropnT-0.05*
___ 10:53PM BLOOD tacroFK-5.3
___ 07:05AM BLOOD tacroFK-4.1*
___ 07:05AM BLOOD tacroFK-7.8
___ 05:20AM BLOOD tacroFK-5.8
___ 07:30AM BLOOD tacroFK-7.1
___ 11:18PM BLOOD Vanco-25.6*
Labs on discharge:
___ 07:30AM BLOOD WBC-4.4 RBC-3.83* Hgb-11.6* Hct-34.7*
MCV-91 MCH-30.4 MCHC-33.5 RDW-13.5 Plt ___
___ 07:30AM BLOOD ___ PTT-31.8 ___
___ 07:30AM BLOOD Glucose-188* UreaN-19 Creat-1.1 Na-144
K-3.9 Cl-107 HCO3-34* AnGap-7*
___ 07:30AM BLOOD Calcium-9.5 Phos-3.1 Mg-1.8
___ 07:30AM BLOOD tacroFK-7.1
Microbiology:
___ 10:33 pm URINE Site: NOT SPECIFIED ADDED TO
___.
URINE CULTURE (Final ___: ENTEROCOCCUS SP..
>100,000 ORGANISMS/ML.. SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
___ 10:50 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date
___ 11:00 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date
Imaging:
-CXR ___ - No evidence of acute cardiopulmonary process.
-Renal Transplant Ultrasound ___ - The transplant kidney is
imaged in the left hemipelvis and measures 12.7 cm in length.
Echogenicity and renal architecture is normal, and there are no
signs of ___ fluid collection or hydronephrosis.
Color flow and pulsed Doppler assessment demonstrate normal
arterial waveforms in the main renal artery with no delay in
acceleration time and normal peak velocities of 72 cm/sec.
Venous outflow is also normal. Arterial flow is symmetrically
seen throughout the transplant, but the resistive indices are
elevated ranging from 0.79-0.85. The bladder is not evaluated
due to drainage by Foley catheter.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Tacrolimus 1.5 mg PO QAM
2. Tacrolimus 1 mg PO QPM
3. PredniSONE 7.5 mg PO DAILY
4. Mycophenolate Mofetil 500 mg PO BID
5. Atorvastatin 40 mg PO HS
6. Amlodipine 2.5 mg PO DAILY
please hold for sbp<100
7. Allopurinol ___ mg PO DAILY
8. Calcitriol 0.25 mcg PO DAILY
9. cilostazol *NF* 100 mg Oral qod
10. Duloxetine 90 mg PO DAILY
11. Glargine 40 Units Breakfast
Glargine 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
12. Levothyroxine Sodium 137 mcg PO DAILY
13. Metoprolol Succinate XL 12.5 mg PO DAILY
please hold for sbp<100
please hold for hr<60
14. Lorazepam 0.5 mg PO Q8H:PRN anxiety
15. Nitroglycerin SL 0.3 mg SL PRN chest pain
16. Promethazine 25 mg PR Q6H:PRN nausea
17. Promethazine 25 mg PO BID:PRN nausea
18. Ranitidine 150 mg PO HS
19. esomeprazole magnesium *NF* 40 mg Oral bid
20. Gabapentin 800 mg PO BID
21. Hydrocodone-Acetaminophen (5mg-500mg ___ TAB PO Q4H:PRN pain
please hold for rr<12 or increased somnolence
22. Desipramine 50 mg PO DAILY
23. traZODONE 50 mg PO HS:PRN insomnia
24. Valsartan 20 mg PO DAILY
25. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
26. Acetaminophen 1000 mg PO BID:PRN pain
27. Aspirin 81 mg PO DAILY
28. Calcium Carbonate 500 mg PO BID
29. Vitamin D 800 UNIT PO DAILY
30. Warfarin 2.5 mg PO DAILY16
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 2.5 mg PO DAILY
please hold for sbp<100
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO HS
5. Calcitriol 0.25 mcg PO DAILY
6. Calcium Carbonate 500 mg PO BID
7. cilostazol *NF* 100 mg Oral qod
8. Desipramine 50 mg PO DAILY
9. Duloxetine 90 mg PO DAILY
10. Gabapentin 800 mg PO BID
11. Levothyroxine Sodium 137 mcg PO DAILY
12. Lorazepam 0.5 mg PO Q8H:PRN anxiety
13. Metoprolol Succinate XL 12.5 mg PO DAILY
please hold for sbp<100
please hold for hr<60
14. Mycophenolate Mofetil 500 mg PO BID
15. PredniSONE 7.5 mg PO DAILY
16. Promethazine 25 mg PR Q6H:PRN nausea
17. Promethazine 25 mg PO BID:PRN nausea
18. Ranitidine 150 mg PO HS
19. Tacrolimus 1.5 mg PO QAM
20. Tacrolimus 1 mg PO QPM
21. traZODONE 50 mg PO HS:PRN insomnia
22. Valsartan 20 mg PO DAILY
23. Vitamin D 800 UNIT PO DAILY
24. Warfarin 3 mg PO DAILY16
25. Zolpidem Tartrate 10 mg PO HS:PRN insomnia
26. esomeprazole magnesium *NF* 40 mg ORAL BID
27. Hydrocodone-Acetaminophen (5mg-500mg ___ TAB PO Q4H:PRN pain
please hold for rr<12 or increased somnolence
28. Acetaminophen 1000 mg PO BID:PRN pain
29. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
RX *Macrobid ___ mg 1 capsule(s) by mouth every 12 hours Disp
#*12 Tablet Refills:*0
30. Nystatin Oral Suspension 5 mL PO QID:PRN thrush, throat pain
RX *nystatin 100,000 unit/mL 5 mL by mouth four times a day Disp
#*200 Milliliter Refills:*1
31. Outpatient Lab Work
You should have your tacrolimus level checked one week after
discharge from the hospital; on ___.
32. Nitroglycerin SL 0.3 mg SL PRN chest pain
33. Glargine 40 Units Breakfast
Glargine 30 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
-Diabetic ketoacidosis
-Urinary tract infection
-Acute renal insufficiency
Secondary diagnoses:
-Type I diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Nausea and vomiting. Hyperglycemia.
TECHNIQUE: Two views of the chest.
COMPARISON: Multiple prior examinations, most recent dated ___.
FINDINGS: No focal opacity to suggest pneumonia is seen. No pleural
effusion, pulmonary edema, or pneumothorax is present. The heart size is
normal. There is plate-like atelectasis at the right lower hemithorax.
Surgical clips are noted in the right upper quadrant.
IMPRESSION: No evidence of acute cardiopulmonary process.
Radiology Report
RENAL TRANSPLANT ULTRASOUND
CLINICAL INDICATION: ___ female with renal transplant in ___, now
with worsening renal function. Assess for obstruction or signs of rejection.
The transplant kidney is imaged in the left hemipelvis and measures 12.7 cm in
length. Echogenicity and renal architecture is normal, and there are no signs
of ___ fluid collection or hydronephrosis.
Color flow and pulsed Doppler assessment demonstrate normal arterial waveforms
in the main renal artery with no delay in acceleration time and normal peak
velocities of 72 cm/sec. Venous outflow is also normal. Arterial flow is
symmetrically seen throughout the transplant, but the resistive indices are
elevated ranging from 0.79-0.85. The bladder is not evaluated due to drainage
by Foley catheter.
CONCLUSION: Mildly to moderately elevated resistive indices. No evidence of
obstruction.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: NAUSEA/VOMITING
Diagnosed with URIN TRACT INFECTION NOS, END STAGE RENAL DISEASE, VERTIGO/DIZZINESS, KIDNEY TRANSPLANT STATUS
temperature: 98.2
heartrate: 122.0
resprate: 18.0
o2sat: 99.0
sbp: 101.0
dbp: 60.0
level of pain: 0
level of acuity: 2.0 | This is a ___ F with complex past medical history, most notable
for poorly controlled Type I DM c/b ESRD s/p renal transplant
___, CAD s/p MI ___, antiphospholipid Ab syndrome with remote
h/o PE on coumadin, and scleroderma, who presented with DKA,
___, and enterococcal UTI.
Active issues:
#DIABETIC KETOACIDOSIS: The patient initially presented to ___
___ with glucose >600, Anion gap 30. This rapidly improved
with administration of IV fluids and insulin gtt. On transfer to
___ ED, her glucose was 297, and anion gap had almost closed
at 14. She was transition to subcutaneous insulin with one hour
overlap with gtt and maintained on IV fluids until ___, at
which point her creatinine returned to baseline and she was
taking adequate PO fluids. Her nausea and vomiting had resolved
prior to admission to the floor. She was restarted on her home
insulin regimen and her FSBGs remained mostly stable in the
___. The trigger for this episode of DKA was most likely
the patient's UTI, treatment for this was begun immediately upon
admission as below.
#ENTEROCOCCAL URINARY TRACT INFECTION: UA on admission showed
trace leukocytes, 5WBC, few bacteria. The patient has a history
of frequent UTI (likely ___ self-catheterization), although the
patient denied dysuria. She was begun immediately on antibiotic
treatment with vancomycin and ciprofloxacin. Urine culture grew
out >100,000 Enterococcus sensitive to vancomycin, after which
the ciprofloxacin was discontinued and the patient was
maintained on vancomycin until blood cultures from ___ showed
no growth by ___. Prior to discharge, the patient was
transitioned from vancomycin to PO nitrofurantoin, on which she
is discharged and will finish the remainder of a 10-day course
at home. The patient remained afebrile and asymptomatic
throughout her admission.
#ACUTE RENAL INSUFFICIENCY: The patient presented with Crt 2.0
(baseline 1.0), most likely secondary to dehydration, with
possible contribution from post-renal obstruction (patient had
no urine output the day prior to admission). Acute rejection in
the setting of missing 3 doses of immunosuppressants is
possible, but unlikely in this case with rapid response to
intravenous fluid repletion. The patient was maintained on
intravenous fluids until her creatinine returned to near
baseline (1.2) and remained stable, and she was taking adequate
PO fluids. Her creatinine remained at baseline throughout the
remainder of her admission.
#ESRD S/P RENAL TRANSPLANT: The patient missed 3 doses of her
home tacrolimus and Cellcept due to nausea and vomiting. She was
restarted on her immunosuppresant medications upon admission to
the hospital and her tacrolimus levels were trended and followed
by the renal transplant team. Her renal function quickly
returned to baseline with IV fluid repletion. Acute rejection in
the setting of missed immunosuppressants was thought unlikely. A
renal transplant ultrasound on ___ showed no evidence of
obstruction in the graft kidney. The patient's home vitamin D
and calcitriol were continued throughout her admission. She
will need to have her tacrolimus level checked one week after
discharge (___).
#SUPRATHERAPEUTIC INR: On coumadin for antiphospholipid
syndrome. She had an elevated INR of 6.5 (goal 2.5-3.5) on
admission likely due to drug-drug interaction between warfarin
and ciprofloxacin. Her warfarin was held and INR was trended
until it returned to her goal range. It was restarted at 3mg
daily on ___ following an INR of 3.5 the previous day. Her INR
was 1.1 on discharge, and she was instructed to measure her INR
at home daily for the next several days and to communicate the
results to her ___ clinic for further titration of
coumadin. Lovenox bridge was considered, but the patient
reports having been subtherapeutic in the past without any need
for bridge.
#TYPE I DIABETES MELLITUS: The patient was maintained on her
home dose of insulin Glargine (40U QAM and 30U QHS) as well as
her home Humalog sliding scale, with stable daytime FSBGs.
Chronic issues:
#ANTIPHOSPHOLIPID AB SYNDROME with H/O PE: The patient's
warfarin was held due to a supratherapeutic INR as above and
restarted on ___. She will check her INR at home and
communicate results with her ___ clinic as she has
been doing.
#CAD s/p MI: Due to an episode of chest pain during vomiting
before admission, she was ruled out for MI, with EKG only
significant for right axis deviation that was resolving on
follow-up EKG. Her troponin was mildly elevated, peaking at 0.07
in the setting of demand ischemia due to tachycardia on
admission. She remained asymptomatic and was continued on her
home regimen of atorvastatin, metoprolol, and aspirin.
#SCLERODERMA: The patient was maintained on her home dose of
7.5mg prednisone daily with good symptom control.
#HYPERTENSION: The patient remained normotensive to slightly
hypertensive during admission, with systolic blood pressures
ranging 120s - 160, with a one-time asymptomatic SBP of 188,.
She was continued on her home regimen of amlodidpine and
metoprolol. Her home valsartan was held until her Creatinine
returned near baseline and was restarted on ___.
# GOUT: The patient was continued on her home allopurinol.
# PAD: The patient was continued on her home cilostazol 100 mg
every other day.
# DEPRESSION/ANXIETY: The patient was continued on her home
duloxetine and despiramine for depression and Ativan for
anxiety. She was continued on her home trazodone and zolpidem
QHS for sleep.
# HYPOTHYROIDISM: The patient was continued on her home
levothyroxine dose.
# GERD: The patient was continued on her home ranitidine and
Nexium.
Transitional issues:
# FOLLOW-UP:
-Primary care: the patient will be contacted by Dr. ___
office to schedule a follow-up appointment
-Nephrology: the patient will be contacted by Dr. ___
office to schedule a follow-up renal appointment within the next
two weeks
-Endocrinology/diabetes: the patient will follow up with Dr.
___ at the ___ on ___ at 3:30pm
-___: the patient was scheduled to have an appointment
with Dr. ___ the ___ on ___ to plan for a breast biopsy. The patient's admission was
communicated to Dr. ___ the ___ will contact
the patient within a few days of discharge to schedule a new
appointment.
-Blood cultures from admission were pending on 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:
Abd pain, AMS, UTI
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with h/o B cell lymphoma s/p EPOCH and
CHOP in remission, cirrhosis of unknown etiology with multiple
complications, HTN, T2DM, CKD not on HD, seizure d/o, who
presents as transfer from OSH with abd pain, AMS, UTI.
Per history obtained in the ED, patient is altered on arrival,
oriented to person, place and month. He is able to provide
minimal history. He denies chest pain or shortness of breath. He
does note that he has had some dysuria. Per report from ___, he presented with a change in mental status from SNF. He
was noted to have laboratory testing concerning for a UTI as
well
as decreased drainage from peritoneal drain. He was noted to
have
a platelet count of 109, WBC 3.5. H&H of ___. He has a
abdominal
port for ascites drainage, normally draining approximately 1 L
daily with only 75 cc of drainage yesterday. He had Foley placed
at OSH for retention and received Unasyn and ceftriaxone for
UTI.
He was also given lactulose with an ammonia of 97.
For his cirrhosis of unknown etiology, his course has been
complicated by recurrent ascites requiring peritoneal drain
placement, grade 3 varix s/p banding, hepatic hydrothorax, non
occlusive portal vein thrombus, and hepatic encephalopathy. Per
liver team, he was admitted earlier this year for hepatic
hydrothorax requiring chest tube drainage, discovery of a non
occlusive portal vein thrombus. The patient was seen in ___
in clinic. At that time, there was concerned about possible
autoimmune hepatitis (has h/o positive ___ and ___ but liver
biopsy was deferred. In addition, patient's most recent
admissions to ___ was in ___ for ___/SDH after a
mechanical fall. He cannot be anti-coagulated for the PVT due to
this past brain bleed and risk of UGIB from varices. Please see
below for d/c summary
"Mr. ___ is a ___ man with history of high grade B cell
lymphoma s/p abbreviated cycle of DA-EPOCH-R and 4 cycles of
R-CHOP now in complete remission, cirrhosis of unknown etiology
c/b refractory ascites (s/p in situ peritoneal drain), HTN,
T2DM, seizure disorder on phenytoin, and CKD who initially
presented with after fall with head strike c/b L convexity
SAH/SDH with no indication for neurosurgical intervention. He
was found to have new non-occlusive portal vein thrombosis, for
which anticoagulation was deemed too high-risk. He was also
found to have bilateral pleural effusions thought ___ hepatic
hydrothorax, for which a R-sided chest tube was placed and his
ascites was drained weekly. His hospital course was c/b
neutropenia of unclear cause, with bone marrow biopsy
demonstrating reactive hypercellularity but with no obvious
infectious source. He received one dose of filgrastim with
resolution of the neutropenia. He also had an episode of
expressive aphasia with negative CTA head/neck and unchanged
baseline EEG, thought potentially toxic-metabolic in nature;
this resolved without further intervention. He was ultimately
discharged to ___."
In the ED, initial vitals were: T 98.1 HR 79 BP 147/66 RR 18 O2
100% RA
Exam was notable for:
- AOx2 (person, place, month not day), severe asterixis, benign
abdominal exam, no CVA tenderness, PICC line in place, foley in
place from OSH
Labs were notable for: (use specific numbers)
- BUN/CR 85/1.5
- LDH 287
- ALP 172
- Alb 3.4
- INR 1.2
- WBC 3.1
- Hgb 7.6
- Plt 93
Studies were notable for:
- EKG NSR
- UA >182 WBC, +protein, ___, -nitrates -bacteria
- ascites fluid gram stain, culture pending
- BCx2 pending
- UCx pending
Imaging were notable for:
- RUQUS: 1. Nonocclusive thrombosis of the main portal vein,
extending to left portal vein, unchanged from ___.
Right
portal vein was not well visualized. 2. Cirrhotic liver with
evidence of portal hypertension. Moderate volume ascites.
- CXR: Questionable infiltrate.
- CT head: No large vessel territorial infarct, acute
intracranial hemorrhage, or space-occupying lesion. Small
hyperattenuating focus in the left super orbital soft tissues
possibly reflecting retained debris versus soft tissue
calcification.
The patient was given:
- vancomycin 1000mg
- Lactulose, rifaximin, acyclovir, docusate
Consults:
- Hepatology/Liver
On arrival to the floor, patient is stable and states pain but
not able to pinpoint where. Continues to deny any fever, chills,
CP, SOB.
Past Medical History:
DLBCL s/p EPOCH and CHOP in remission
Cirrhosis c/b ascites (pleurX drain), varices, hydrothorax, HE
Hypertension
T2DM
CKD
Seizures
Social History:
___
Family History:
Not pertinent to this admission
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VITALS: ___ Temp: 98.3 PO BP: 151/72 R Lying HR: 80
RR:
18 O2 sat: 99% O2 delivery: Ra FSBG: 240
GENERAL: Elderly male lying in bed with protuberant abdomen.
Sleeping but arousable. In no acute distress.
HEENT: NCAT, PERRL, EOMI. Scleral icterus
CARDIAC: RRR, S1 S2, systolic ejection murmur best heard at the
LUSB
LUNGS: CTAB. No wheezes, rhonchi or rales. No increased work of
breathing.
BACK: No CVA tenderness.
ABDOMEN: +BS, soft, very distended, PleurX catheter in RUQ,
dressing c/d/i
GU: foley in place
EXTREMITIES: 1+ pitting edema b/l to ankles. PICC in LUE.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: AOx2 (person, place, knows month not date). severe
asterixis
LINES: PICC in LUE dressing c/d/i.
DISCHARGE PHYSICAL EXAM:
========================
VITALS: T: 98.2 PO BP: 154/66R Sitting Hr: 67bpm RR: 18
02:99 Ra
GENERAL: Elderly male chronically ill appearing in no acute
distress. Sitting at edge of bed, eating his breakfast.
HEENT: NCAT, PERRL, EOMI. Scleral icterus
CARDIAC: RRR, no m/r/g
LUNGS: CTAB on anterior auscultation. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: +BS, distended but soft, PleurX catheter in RUQ
dressing
c/d/I. Nontender to palpation, without guarding or rebound.
EXTREMITIES: no ___. PICC in LUE.
SKIN: Warm. Cap refill <2s. No rashes.
NEUROLOGIC: alert, appropriate, +asterixis
LINES: PICC in LUE dressing c/d/i.
Pertinent Results:
ADMISSION LABS:
===============
___ 12:00PM BLOOD WBC-3.1* RBC-2.28* Hgb-7.6* Hct-24.8*
MCV-109* MCH-33.3* MCHC-30.6* RDW-17.2* RDWSD-67.8* Plt Ct-93*
___ 12:00PM BLOOD Neuts-71.0 Lymphs-10.1* Monos-15.7*
Eos-1.6 Baso-0.3 Im ___ AbsNeut-2.17 AbsLymp-0.31*
AbsMono-0.48 AbsEos-0.05 AbsBaso-0.01
___ 12:00PM BLOOD ___ PTT-31.2 ___
___ 12:00PM BLOOD Glucose-102* UreaN-85* Creat-1.5* Na-145
K-4.2 Cl-106 HCO3-22 AnGap-17
___ 12:00PM BLOOD ALT-25 AST-31 LD(LDH)-287* AlkPhos-172*
TotBili-0.2
___ 12:00PM BLOOD Albumin-3.4*
___ 12:41PM BLOOD Lactate-0.9
RELEVANT LABS:
===============
___ 12:00PM URINE Color-Straw Appear-Hazy* Sp ___
___ 12:00PM URINE Blood-TR* Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*
___ 07:36PM ASCITES TNC-136* RBC-576* Polys-3* Lymphs-63*
Monos-2* Mesothe-2* Macroph-30*
___ 07:36PM ASCITES TotPro-1.6 Glucose-122
___ 05:00PM ASCITES TNC-91* RBC-427* Polys-2* Lymphs-53*
Monos-40* Atyps-3* Other-2*
___ 05:00PM ASCITES TotPro-1.4 Glucose-155
DISCHARGE LABS:
===============
___ 10:08AM BLOOD WBC-3.7* RBC-2.44* Hgb-8.2* Hct-25.0*
MCV-103* MCH-33.6* MCHC-32.8 RDW-18.4* RDWSD-69.0* Plt Ct-93*
___ 10:08AM BLOOD Neuts-72.1* Lymphs-10.0* Monos-14.4*
Eos-2.7 Baso-0.0 Im ___ AbsNeut-2.66 AbsLymp-0.37*
AbsMono-0.53 AbsEos-0.10 AbsBaso-0.00*
___ 10:08AM BLOOD ___ PTT-27.8 ___
___ 10:08AM BLOOD Glucose-184* UreaN-67* Creat-1.6* Na-135
K-4.4 Cl-98 HCO3-23 AnGap-14
___ 10:08AM BLOOD ALT-42* AST-42* AlkPhos-222* TotBili-0.3
___ 10:08AM BLOOD Calcium-8.7 Phos-4.1 Mg-1.7
MICROBIOLOGY:
=============
-___ 12:00 pm URINE CATHETER.
URINE CULTURE (Final ___:
YEAST. ~7000 CFU/mL.
-___ 4:38 pm PERITONEAL FLUID PERITONEAL FLUID.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count, if
applicable.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
STUDIES:
=========
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___
1. Nonocclusive thrombosis of the main portal vein, extending to
left portal vein, unchanged from ___. Right portal
vein was not well visualized.
2. Cirrhotic liver with evidence of portal hypertension.
Moderate volume
ascites.
CHEST (PORTABLE AP) Study Date of ___ Compared to chest
radiographs ___ through ___. Atelectasis at the
right lung base is mild. Right pleural effusions small if any,
both
unchanged. Upper lungs clear. Heart size normal.
Left PIC line ends in the low SVC.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. amLODIPine 10 mg PO DAILY
3. Atovaquone Suspension 1500 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Furosemide 80 mg PO DAILY
6. Phenytoin Sodium Extended 200 mg PO TID
7. rifAXIMin 550 mg PO BID
8. Spironolactone 200 mg PO DAILY
9. Thiamine 100 mg PO DAILY
10. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
11. Multivitamins W/minerals 1 TAB PO DAILY
12. Triamcinolone Acetonide 0.1% Cream 1 Appl TP DAILY
13. Glargine 4 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
14. Ascorbic Acid ___ mg PO DAILY
15. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO DAILY
2. Lactulose 30 mL PO TID
3. Acyclovir 400 mg PO Q12H
4. amLODIPine 10 mg PO DAILY
5. Ascorbic Acid ___ mg PO DAILY
6. Atovaquone Suspension 1500 mg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. Furosemide 80 mg PO DAILY
10. Glargine 4 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
11. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Phenytoin Sodium Extended 200 mg PO TID
14. rifAXIMin 550 mg PO BID
15. Spironolactone 200 mg PO DAILY
16. Thiamine 100 mg PO DAILY
17. Triamcinolone Acetonide 0.1% Cream 1 Appl TP DAILY
Discharge Disposition:
Extended Care
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Hepatic encephalopathy
SECONDARY DIAGNOSIS:
Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT
INDICATION: ___ with history of lymphoma, abdominal ascites with drain in
place. Altered mental status and reduced abdominal port drainage.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Ultrasound of the liver gall bladder dated ___
FINDINGS:
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.
There is a nonocclusive thrombus in the main portal vein extending into the
left portal vein, similar in appearance from ___. The main portal
vein has hepatopetal flow. Right portal vein was not well visualized. There
is moderate amount of ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 3 mm
GALLBLADDER: There is no evidence of stones. Gallbladder wall thickening is
likely related to cirrhosis.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity with unchanged severe splenomegaly.
Spleen length: 16.6 cm
RETROPERITONEUM: The visualized portions of the IVC are within normal limits.
IMPRESSION:
1. Nonocclusive thrombosis of the main portal vein, extending to left portal
vein, unchanged from ___. Right portal vein was not well visualized.
2. Cirrhotic liver with evidence of portal hypertension. Moderate volume
ascites.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: ___ with h/o B cell lymphoma s/p EPOCH and CHOP in remission,
cirrhosis of unknown etiology with multiple complications, HTN, T2DM, CKD not
on HD, seizure d/o, who presents as transfer from OSH with abd pain, AMS, UTI.
Came to hospital with PICC// L PICC placement L PICC placement
IMPRESSION:
Compared to chest radiographs ___ through ___. Atelectasis at the
right lung base is mild. Right pleural effusions small if any, both
unchanged. Upper lungs clear. Heart size normal.
Left PIC line ends in the low SVC.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Altered mental status, UTI, Transfer
Diagnosed with Unspecified abdominal pain
temperature: 98.1
heartrate: 79.0
resprate: 18.0
o2sat: 100.0
sbp: 147.0
dbp: 66.0
level of pain: 7
level of acuity: 2.0 | ___ with h/o B cell lymphoma s/p EPOCH and CHOP in remission,
cirrhosis of unknown etiology c/b ascites s/p peritoneal drain,
SBP, esophageal varices, hepatic hydrothorax, non occlusive
portal vein thrombus, HTN, T2DM, CKD not on HD, seizure d/o, who
presented as transfer from OSH with abdominal pain and AMS. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
R face and arm weakness
Major Surgical or Invasive Procedure:
TPA at OSH.
History of Present Illness:
Mr. ___ is a ___ year old right handed male with past medical
history notable for thyroid cancer s/p resection, Tourette
syndrome and macular degeneration who presented with acute onset
of right upper extremity weakness.
Patient reports he was in his usual state of health until 7:15PM
when he reported right facial droop and right upper extremity
weakness after leaving a restaurant. He was eating dinner with
his friend and feeling well. He walked into his car from the
parking lot. He noticed that when he tried to turn on the
ignition in the car, he had difficulty elevating the right arm
against gravity. He still was able to lift his arm up enough to
drive, and actually drove to the Emergency Department. His
weakness was most prominent in the right hand and had difficulty
performing fine motor functions, such as opening and closing the
car door. He also reported parasthesias over the entire right
hand. He baseline has intermittent parasthesias of the left hand
which he attributes to neuropathy, but the right hand
parasthesias were new. He was with his friend at the time who
reported his behavior was normal. Denies difficulties producing
or comprehending speech. Denied visual changes, dizziness and
vertigo.
Patient then presented to ___, where his NIHSS was 4,
scoring 2+ for RUE strength, 1+ for facial droop, 1+ for sensory
defects. He had NCHCT that per report was negative for acute
hemorrhage, notable only for age related involuted changes.
Vitals were notable for hypertension to 200s-220s/120s for which
nicardipine drip was started. After SBP<185, he was given tPA at
8:40 ___ (1 hour and 35 minutes after onset), with significant
improvement in right sided strength. Patient was transferred to
___ for post-tPA care.
By the time of arrival to ___, patient reports his right upper
extremity strength has significantly improved. He can now
sustain
the right upper extremity against gravity. He reports mild
"clumsiness" of the right hand but no focal weakness.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies focal
weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
Thyroid cancer s/p resection ___
Macular degeneration
Tourette syndrome
s/p appendectomy ___
Social History:
___
Family History:
Family Hx: Mother died of MI at age ___. Father had ___
Disease, died at age ___ of unknown heart issue.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
Physical Exam:
Vitals: T: 97.3F P: 58-60 R: 18 BP: 175-178/93-102 SaO2: 96%
RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted
Abdomen: soft, NT/ND, normoactive bowel sounds, no masses or
organomegaly noted.
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Attentive, able to name ___ backward without
difficulty. Language is fluent with intact repetition and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Could
name all objects on stroke card. Able to read without
difficulty. Speech was not dysarthric. Able to follow both
midline and appendicular commands. Pt was able to register 3
objects and recall ___ at 5 minutes. The pt had good knowledge
of
current events. There was no evidence of neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to finger wiggling and
counting
in all quadrants.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: Right lower facial droop with delayed activation. Symmetric
forehead wrinkle and orbicularis occuli strength bilaterally.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___- ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
DISCHARGE PHYSICAL EXAMINATION:
Largely unchanged with improvement in Wrist and finger extensor
strength.
Pertinent Results:
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD Plt
Ct
___ 05:00AM 8.1 3.95* 11.3* 35.0* 89 28.6 32.3 13.4
43.5 210 Import Result
___ 06:15AM 13.9* 4.24* 12.4* 36.8* 87 29.2 33.7 13.5
42.6 246 Import Result
___ 09:55AM 12.5* 4.41* 12.7* 37.9* 86 28.8 33.5 13.2
41.6 245 Import Result
___ 04:33AM 11.5* 4.34* 12.3* 37.8* 87 28.3 32.5 13.2
42.5 248 Import Result
___ 10:58PM 10.2* 4.57* 13.2* 40.0 88 28.9 33.0 13.2
42.4 262 Import Result
DIFFERENTIAL Neuts Bands Lymphs Monos Eos Baso Atyps Metas Im
___ AbsLymp AbsMono AbsEos AbsBaso
___ 04:33AM 73.9* 18.1* 7.0 0.3* 0.3 0.4 8.50*
2.08 0.81* 0.04 0.03 Import Result
___ 10:58PM 66.4 24.8 6.8 0.6* 0.4 1.0 6.80*
2.54 0.70 0.06 0.04 Import Result
BASIC COAGULATION ___, PTT, PLT, INR) ___ PTT Plt Ct ___
___ 05:00AM 210 Import Result
___ 06:15AM 246 Import Result
___ 09:55AM 245 Import Result
___ 04:33AM 248 Import Result
___ 04:33AM 10.8 28.6 1.0 Import Result
___ 10:58PM 262 Import Result
___ 10:58PM 10.8 28.4 1.0 Import Result
Chemistry
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 05:00AM 87 14 0.9 132* 3.8 96 26 14 Import Result
___ 06:15AM 96 13 1.0 131* 3.7 95* 23 17 Import
Result
___ 04:33AM 109* 18 1.1 129* 3.7 92* 26 15 Import
Result
___ 10:58PM 114* 17 1.1 130* 4.2 92* 25 17 Import
Result
ESTIMATED GFR (MDRD CALCULATION) estGFR
___ 10:58PM Using this Import Result
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
___ 04:33AM 23 23 173 264 67 0.3 Import Result
OTHER ENZYMES & BILIRUBINS GGT
___ 04:33AM 17 Import Result
CPK ISOENZYMES CK-MB MB Indx cTropnT
___ 04:33AM 10 3.8 <0.01 Import Result
CHEMISTRY TotProt Albumin Globuln Calcium Phos Mg UricAcd Iron
Cholest
___ 06:15AM 8.4 Import Result
___ 04:33AM 6.3* 3.8 2.5 146 Import Result
DIABETES MONITORING %HbA1c eAG
___ 04:33AM 5.4 108 Import Result
LIPID/CHOLESTEROL Triglyc HDL CHOL/HD LDLcalc
___ 04:33AM 117 50 2.9 73 Import Result
PITUITARY TSH
___ 04:33AM 6.4* Import Result
THYROID T4 T3
___ 06:15AM 5.6 62* Import Result
IMAGING:
HEAD CT NON CONTRAST with CTA H and N (___):
1. No evidence acute intracranial abnormalities.
2. Approximately ___ stenosis of the proximal to mid left
internal carotid artery by NASCET criteria. Mild right proximal
internal carotid artery atherosclerosis without stenosis by
NASCET criteria.
3. The left vertebral artery arises directly from the aortic
arch, a normal variant.
4. Small caliber of the P1 segment of the right posterior
communicating artery is most likely related to fetal type
configuration with greater supply from the right posterior
communicating artery, but its irregular appearance is suggestive
of superimposed atherosclerosis. No evidence for flow-limiting
stenosis elsewhere in the major intracranial arteries.
5. Status post thyroidectomy with unchanged abnormal appearance
of the right laryngeal cartilages.
MR HEAD WITHOUT CONTRAST (___): Punctate foci of acute
infarct in the left parietal cortical and subcortical regions.
No MRI signs of hemorrhage
ECHOCARDIOGRAM (___): The left atrial volume index is
normal. No atrial septal defect is seen by 2D or color Doppler.
Left ventricular wall thickness, cavity size, and global
systolic function are normal (LVEF = 65%). Right ventricular
chamber size and free wall motion are normal. 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. Trivial mitral regurgitation is seen. The left
ventricular inflow pattern suggests impaired relaxation. The
estimated pulmonary artery systolic pressure is normal. There is
no pericardial effusion.
EEG (___):
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 40 mg PO QPM
2. Tamsulosin 0.4 mg PO QHS
3. Finasteride 5 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Sertraline 200 mg PO DAILY
6. Levothyroxine Sodium 137 mcg PO DAILY
7. TraZODone 300 mg PO QHS
8. pimozide 6 mg oral BID
9. melatonin 10 mg oral QHS
Discharge Medications:
1. Apixaban 5 mg PO BID
2. Ciprofloxacin HCl 500 mg PO Q12H Duration: 4 Days
3. LevETIRAcetam 750 mg PO BID
4. Atorvastatin 40 mg PO QPM
5. Finasteride 5 mg PO DAILY
6. Levothyroxine Sodium 137 mcg PO DAILY
7. melatonin 10 mg oral QHS
8. pimozide 6 mg oral BID
9. Sertraline 200 mg PO DAILY
10. Tamsulosin 0.4 mg PO QHS
11. TraZODone 300 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
L MCA territory Stroke likely Cardioembolic in nature
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ year old man with acute onset of right facial droop and right
upper extremity weakness, s/p tPA. concern for L MCA stroke // eval for L MCA
stroke
TECHNIQUE: MRI of the brain is performed and includes the following
sequences: sagittal T1-weighted, axial fast spin echo T2-weighted,axial flair,
axial diffusion weighted and axial gradient echo images .
COMPARISON: CT angiography of ___.
FINDINGS:
Punctate foci of acute infarcts are seen in the left parietal cortical and
subcortical region. There is no evidence of hemorrhage. There is no mass
effect midline shift hydrocephalus. Vascular flow voids are maintained. 8 mm
well-defined hyperintensity in the junction of the deep and superficial lobe
of left parotid gland repeat due to cyst or other benign lesion and is
incompletely evaluated.
IMPRESSION:
Punctate foci of acute infarct in the left parietal cortical and subcortical
regions. No MRI signs of hemorrhage
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with stroke, please eval for aspiration // eval
for aspiration PNA
COMPARISON: ___
FINDINGS:
Heart is normal in size. The aorta is diffusely tortuous without change.
Lungs are clear except for linear foci of scarring or atelectasis within the
lung bases. No pleural effusion or pneumothorax. A healed left rib fracture
incidentally noted, without change.
IMPRESSION:
Bibasilar focal linear atelectasis or scar with otherwise clear lungs.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ year old man with right weakness, evaluate for stroke,
evaluate vessels. Review of prior imaging studies indicates that the patient
has history of thyroidectomy in ___ for cancer.
TECHNIQUE: A noncontrast CT of the head was first performed. Rapid axial
imaging was subsequently performed from the aortic arch through the head
during infusion of 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated. This report is based on interpretation of all
of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 6.0 s, 6.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
301.0 mGy-cm.
3) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 59.9 mGy (Head) DLP =
30.0 mGy-cm.
4) Spiral Acquisition 5.2 s, 40.9 cm; CTDIvol = 31.0 mGy (Head) DLP =
1,267.3 mGy-cm.
Total DLP (Head) = 2,401 mGy-cm.
COMPARISON: ___ CT neck and ___ soft tissue neck MRI are
available for correlation.
FINDINGS:
HEAD CT:
Some of the images were repeated due to motion artifact. There is no evidence
of acute intracranial hemorrhage, mass effect or large vascular territorial
infarction. Ventricles and sulci are normal in size for the patient's age.
The basilar cisterns are not compressed.
There is mild mucosal thickening in the ethmoid air cells and along the floor
of the right maxillary sinus. There are multiple bilateral maxillary and
mandibular periapical lucencies. Mastoid air cells and middle ear cavities
are well aerated. The orbits appear unremarkable.
CTA NECK:
The left vertebral artery arises directly from the aortic arch, a normal
variant. Great vessel origins are widely patent. There is minimal calcified
plaque in the proximal left subclavian artery without stenosis.
There is mild mixed plaque in the proximal right internal carotid artery
without stenosis by NASCET criteria. There is mild calcified plaque in the
proximal to mid left internal carotid artery with ___ stenosis by NASCET
criteria (images 553:1, 553:43).
The right vertebral artery appears widely patent. There is mild calcified
plaque in the left vertebral artery at C6 without significant associated
stenosis.
CTA HEAD:
Small caliber of the P1 segment of the right posterior communicating artery is
most likely related to fetal type configuration with greater supply from the
right posterior communicating artery, but its irregular appearance is
suggestive of superimposed atherosclerosis. Otherwise, there is no evidence
for flow-limiting stenosis in the anterior or posterior circulation. There is
no evidence for an aneurysm.
OTHER:
There is a coarse calcification in the nasopharynx just to the left of
midline, image 3:218, decreased compared to the ___ soft tissue neck
CT. There are no pathologically enlarged cervical lymph nodes. Evidence of
thyroidectomy and right laryngeal cartilage deformities are again noted, with
apparent fusion of the right thyroid and cricoid cartilages. There is mild
atelectasis in the included upper lungs. There are extensive degenerative
changes in the cervical spine.
IMPRESSION:
1. No evidence acute intracranial abnormalities.
2. Approximately ___ stenosis of the proximal to mid left internal carotid
artery by NASCET criteria. Mild right proximal internal carotid artery
atherosclerosis without stenosis by NASCET criteria.
3. The left vertebral artery arises directly from the aortic arch, a normal
variant.
4. Small caliber of the P1 segment of the right posterior communicating artery
is most likely related to fetal type configuration with greater supply from
the right posterior communicating artery, but its irregular appearance is
suggestive of superimposed atherosclerosis. No evidence for flow-limiting
stenosis elsewhere in the major intracranial arteries.
5. Status post thyroidectomy with unchanged abnormal appearance of the right
laryngeal cartilages.
RECOMMENDATION(S): MRI would be more sensitive for an acute infarction, if
clinically warranted.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CVA, Transfer
Diagnosed with Cerebral infarction, unspecified, S/p admn tPA in diff fac w/n last 24 hr bef adm to crnt fac
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | Mr. ___ is a ___ man with a PMH of HLD, thyroid
cancer s/p resection, Tourette syndrome and macular
degeneration, who initially presented to an outside hospital
with the acute onset of RUE weakness and facial droop. On
initial assessment at OSH, exam notable for SBP 200s-220s, NIHSS
4 with right facial and upper extremity weakness. Was given tPA
approximately 1:45 hrs from onset with improvement in proximal
right upper extremity strength by the time of transfer to ___
for post-tPA care.
Pt has risk factors given hyperlipidemia and prior history of
malignancy. No known hx of HTN, although presented with SBP>200.
No hx of atrial#Fo fibrillation in the past. The patient was
admitted to the Neurology Stroke Service for post-TPA management
and further care.
The following issues were managed:
#Neuro: Multiple punctate foci of ischemia
-Given the abrupt onset and multiple areas of ischemia in the
left cortex, the patient was started on eliquis.
-Telemetry monitoring did not show atrial fibrillation, however
likely the patient could have paroxysmal afib and will require
further long-term monitoring.
-Other stroke risk factors were also assessed, LDL was within
normal limits . HbA1C was also 5.4. No significant
atherosclerosis was noted, however patient was found to have a
left fetal PCA on imaging.
-Patient recovered well s/p TPA and was cleared by ___ to return
home with outpatient ___ services.
#Neuro: Focal Motor Status Epilepticus
-During the patient's hospitalization, the patient was noted to
have developed sudden onset right facial and arm twitching that
lasted 12 minutes consistent with focal motor status epilepticus
likely due to cortical irritation in the area where patient had
ischemic injury.
-The patient was loaded with IV keppra and put on a maintenance
dose of this medication of PO 750mg BID. Since this episode, the
patient did not have any further events.
-The patient also had a routine EEG obtained to have for
baseline purposes s/p his ischemic injury.
#Pulmonary:
-Patient noted to at times desaturated overnight during deep
sleep with spontaneous recovery. The patient could also have an
underlying sleep apnea or sleep disorder which can be evaluated
in the outpatient with a sleep study.
#ID: Urinary Tract Infection:
-On Urinalysis testing, patient noted to have leukocyturia and
hematuria. He was placed on IV Ceftriaxone with a goal of
treatment for UTI with antibiotics for 7 days total (until
___.
-The patient remained aefebrile during the hospitalization.
1. Dysphagia screening before any PO intake? (X) Yes, confirmed
done - () Not confirmed () No
2. DVT Prophylaxis administered? (X) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
() Yes - () No
4. LDL documented? (X) Yes (LDL = 73) - () 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 - (X)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 (verbally or
written)? (X) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(X) Yes - () No
9. Discharged on statin therapy? () Yes - (X) No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (X Yes [Type: ()
Antiplatelet - (X Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (X Yes - () No - () N/A
Transitions of Care Issues:
1. Stroke follow-up appointment is scheduled for this patient.
2. In addition, patient will be sent home with ___
monitor to look for evidence of afib.
3. Patient was started on eliquis
4. Patient's TSH was measured to be high and the T3 was noted to
be low. Patient should have repeat testing to elucidate the
interpretation of thyroid function tests. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
seasonal / Lipitor / Ambien
Attending: ___.
Chief Complaint:
Intermittent unsteadiness
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ female with history of breast cancer s/p right mastectomy
(___), hypothyroidism on Synthroid, osteoporosis and Vit B12
deficiency who presents with intermittent unsteadiness x5d. As
per the patient, she awoke on ___ morning (___) and
when she went to get out of bed she felt unsteady on her feet,
so she spoke with her family who thought that she may be
dehydrated and encouraged her to drink water. By lunchtime she
was feeling much better and did not experience any further
dizziness or strange sensations for the next two days. On
___, she awoke and again felt dizzy, however
this time she rehydrated, but the dizziness did not resolve
until ___. Finally on ___, she awoke in the
morning, experienced the dizziness, but this time it was
persistent and was not abating, thus she called her PMD who was
out of town, so she was referred to ___ Urgent
Care.
Past Medical History:
Osteoporosis
Depression
Insomnia
Hiatal hernia
Hypothyroidism
B12 deficiency
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
Vitals: T: 97.3 HR:68 BP:175/74 RR:21 SaO2:97% on RA
General: NAD
HEENT: NCAT, neck supple
___: RRR, nml S1/S2, no murmur
Pulmonary: CTA b/l, no crackles or wheezes
Abdomen: Soft, NT, ND,
Extremities: Warm, no edema
Neurologic Examination:
MS: Awake, alert, oriented x 3. Able to relate history without
difficulty. Attentive, able to name ___ backward without
difficulty. Speech is fluent with full sentences, intact
repetition, and intact verbal comprehension. No paraphasias. No
dysarthria. Normal prosody. No apraxia. No evidence of
hemineglect. No left-right confusion. Able to follow both
midline and appendicular commands.
Cranial Nerves - PERRL 3->2 brisk. VF full to number counting.
EOMI, no nystagmus. V1-V3 without deficits to light touch
bilaterally. No facial movement asymmetry. Hearing intact to
finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
Motor - Normal bulk and tone. No drift. No tremor or asterixis.
[Delt] [Bic] [Tri] [ECR] [IP] [Quad] [Ham] [TA] [Gas]
[C5] [C5] [C7] [C6] [L2] [L3] [L5] [L4] [S1]
L 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5
Sensory - No deficits to light touch or proprioception
bilaterally.
DTRs:
[Bic] [___] [Quad]
L 2+ 2+ 2+
R 2+ 2+ 2+
Plantar response flexor bilaterally.
Coordination - No dysmetria with finger to nose testing
bilaterally. Good speed and intact cadence with rapid
alternating movements.
Gait - Normal initiation. wide base with decreased stride length
and limited arm swing. mild sway, +sway Romberg.
DISCHARGE PHYSICAL EXAMINATION:
MS: Alert, oriented, follows commands, no dysarthria
CN: EOM full, no nystagmus, face symmetric
Motor: normal tone/bulk; ___ strength UE and ___
Sensory: Intact to light touch throughout
Pertinent Results:
___ 06:39AM BLOOD WBC-6.6 RBC-4.34 Hgb-11.8 Hct-37.1 MCV-86
MCH-27.2 MCHC-31.8* RDW-15.4 RDWSD-47.8* Plt ___
___ 11:25PM BLOOD WBC-6.6 RBC-4.53 Hgb-12.1 Hct-38.7 MCV-85
MCH-26.7 MCHC-31.3* RDW-15.2 RDWSD-47.3* Plt ___
___ 11:25PM BLOOD Neuts-70.6 Lymphs-17.1* Monos-8.6 Eos-2.6
Baso-0.8 Im ___ AbsNeut-4.66 AbsLymp-1.13* AbsMono-0.57
AbsEos-0.17 AbsBaso-0.05
___ 11:25PM BLOOD ___ PTT-32.3 ___
___ 06:39AM BLOOD Glucose-83 UreaN-17 Creat-1.1 Na-139
K-4.0 Cl-104 HCO3-25 AnGap-14
___ 11:25PM BLOOD Glucose-93 UreaN-15 Creat-0.9 Na-139
K-4.2 Cl-102 HCO3-26 AnGap-15
___ 11:25PM BLOOD ALT-16 AST-21 AlkPhos-143* TotBili-1.2
___ 06:39AM BLOOD Calcium-8.8 Phos-3.4 Mg-2.0
___ 11:25PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:32AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
CT Head
1. No evidence of infarct or hemorrhage.
2. 1.6 x 2.0 x 1.9 cm hyperdense medial left frontal lobe mass.
Recommend
contrast brain MRI for further evaluation.
3. Paranasal sinus disease, concerning for chronic sinus
disease or
polyposis, as described.
MRI/MRA
1.5 cm left medial occipital meningioma without surrounding
brain edema. No other enhancing brain lesions. Small vessel
disease and brain atrophy. No significant abnormalities are
seen on MRA of the head and neck.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 75 mcg PO DAILY
2. Vitamin D ___ UNIT PO 1X/WEEK (___) ___
3. B12 (cyanocobalamin-cobamamide) 5,000-100 mcg sublingual
DAILY
Discharge Medications:
1. wheelchair miscellaneous ONCE
RX *wheelchair Use as needed Disp #*1 Each Refills:*0
2. B12 (cyanocobalamin-cobamamide) 5,000-100 mcg sublingual
DAILY
3. Levothyroxine Sodium 75 mcg PO DAILY
4. Vitamin D ___ UNIT PO 1X/WEEK (___) ___
5.Walker
Dispense 1 Rolling Walker
ICD9 386.10
Duration: Ongoing
Attending: Dr. ___, ___
6.Outpatient Physical Therapy
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Benign Paroxysmal Positional Vertigo
Meningioma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK
INDICATION: ___ year old woman with left frontal mass concerning for
meningioma presenting with ataxia // ?menigioma
TECHNIQUE: T1 sagittal and axial and FLAIR, T2, susceptibility and diffusion
axial images of the brain were acquired. Following gadolinium administration,
T1 axial and MPRAGE sagittal images were acquired with axial and coronal
reformats. 3D time-of-flight MRA of the circle of ___ was obtained.
Gadolinium enhanced MRA of the neck was acquired.
COMPARISON: Head CT ___.
FINDINGS:
There is no evidence of acute infarct. There is no evidence of midline shift
or hydrocephalus. Mild to moderate brain atrophy and small vessel disease are
seen. There is a 1.5 cm mass in the medial left occipital region with
demonstrate homogeneous enhancement indicating of a meningioma. There is no
surrounding edema seen. There are no other enhancing lesions seen.
Specifically no intraparenchymal enhancement is identified.
There is opacification of the left frontal sinus anterior ethmoid air cells
and maxillary sinus indicative of obstructive sinusitis.
MRA of the head shows normal signal in the arteries of the anterior and
posterior circulation. No evidence of vascular occlusion stenosis or an
aneurysm greater than 3 mm in size seen. No abnormal vascular structures are
seen surrounding the left medial occipital mass.
MRA of the neck shows normal flow in the carotid and vertebral arteries. No
evidence of stenosis or occlusion or dissection seen.
IMPRESSION:
1.5 cm left medial occipital meningioma without surrounding brain edema. No
other enhancing brain lesions. Small vessel disease and brain atrophy. No
significant abnormalities are seen on MRA of the head and neck.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dizziness
Diagnosed with Dizziness and giddiness
temperature: 98.3
heartrate: 82.0
resprate: 14.0
o2sat: 98.0
sbp: 143.0
dbp: 82.0
level of pain: 0
level of acuity: 2.0 | ___ right handed female with h/o breast cancer s/p right
mastectomy (___), hypothyroidism, with incidental mass on CT
who presents with intermittent unsteadiness x5d. CT mass
suspicious for meningioma given that it is well circumscribed
and there is no visible edema on CT. MRI was ordered which
confirm this as well as no evidence of infarct. After admission
to the neurology service, ___ Hall Pike Maneuver was performed
and was positive to the right consistent with a diagnosis of
benign paroxysmal positional vertigo. Physical therapy was
consulted and performed vestibular physical therapy with relief
some of her symptoms. They recommended discharge home with home
physical therapy services. She was instructed to call her PCP to
schedule ___ follow up appointment in ___ weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine / Codeine / Keflex / Iodine-Iodine Containing /
Tetracycline / Lipitor / Ace Inhibitors / Glyburide / Metformin
/ Clonidine / Percocet / Benadryl / Flovent Diskus / Spiriva
with HandiHaler / hydralazine / chlorthalidone
Attending: ___
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with PMH of HFpEF, CAD s/p
PCI ×3 with multiple stents placed, peripheral vascular disease,
DMII, COPD, HTN, h/o CVA, and HLD who presents with left sided
substernal chest pain radiating to the left arm and back x1 day.
The patient was seen by Dr. ___ in clinic on ___ and
shortly after returning home, she developed left sided
substernal
burning that progressed into a shooting pain that radiated into
her left arm and back. Had associated nausea, diaphoresis and
SOB. She took NTG x3 with resolution of her symptoms and
presented to ___ ED for further management.
Of note, the patient had a dobutamine stress echo from ___
which did not show any evidence of inducible ischemia. She has
had multiple discussions with Dr. ___ coronary
angiography, but the patient and her family have been hesitant
given pain with the procedure (she does not tolerate
sedation/pain medication ___ allergies) as well as her
underlying
renal disease.
Past Medical History:
-CAD: s/p D1 (___), OM1 (___), and proximal RCA (___) stents.
-PAD status post multiple peripheral vascular interventions in
the right superficial femoral artery. ___ peripheral
angiogram in her LLE, with subsequent two stents to L SFA. s/p R
-CIA stent w/ R EIA ___ stenosis. Aorta has diffuse
atherosclerosis.
-Moderate non proliferative diabetic retinopathy bilaterally
-Interstitial lung disease, suspected fibrotic NSIP versus
chronic HP
-Atrial fibrillation on warfarin c/b tachy-brady syndrome s/p
PPM
-dCHF (EF 70% ___
-DMII
-HTN
-Hypothyroidism
-Allergic rhinitis
-Hyperlipidemia
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: 97.6PO 169/55 61 16 96% RA
GENERAL: Sitting comfortably in bed, NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, MMM
NECK: supple, JVD approximately 10cm at 45 degree angle
HEART: RR, ___ systolic murmur heard throughout the precordium.
No rubs or gallops
LUNGS: Inspiratory crackles at the lung bases with L>R. No
rhonchi or wheezes
ABDOMEN: Soft, ND, NTTP, +BS
EXTREMITIES: WWP, trace pedal edema
NEURO: A&Ox3, moving all 4 extremities with purpose
DISCHARGE PHYSICAL EXAM:
========================
VS: 24 HR Data (last updated ___ @ 519)
Temp: 98.5 (Tm 98.5), BP: 156/63 (143-163/49-72), HR: 60
(59-63), RR: 18 (___), O2 sat: 96% (95-98), O2 delivery: Ra
I/Os: -520mL
DRY WEIGHT: 174 LBS
GENERAL: sitting comfortably on edge of the bed, NAD
HEENT: AT/NC, MMM
HEART: regular, ___ systolic murmur
LUNGS: soft bibasilar crackles
ABDOMEN: soft, non-tender, non-distended
EXTREMITIES: 1+ nonpitting edema in compression stockings
NEURO: alert, responding to questions appropriately, moving all
4
extremities with purpose
Pertinent Results:
ADMISSION LABS
================
___ 10:28PM BLOOD WBC-8.9 RBC-3.53* Hgb-10.9* Hct-33.1*
MCV-94 MCH-30.9 MCHC-32.9 RDW-13.4 RDWSD-45.7 Plt ___
___ 10:28PM BLOOD Neuts-70.2 Lymphs-12.9* Monos-10.4
Eos-5.7 Baso-0.6 Im ___ AbsNeut-6.28* AbsLymp-1.15*
AbsMono-0.93* AbsEos-0.51 AbsBaso-0.05
___ 10:28PM BLOOD Plt ___
___ 11:54PM BLOOD ___ PTT-32.0 ___
___ 10:28PM BLOOD Glucose-173* UreaN-51* Creat-1.6* Na-144
K-4.9 Cl-107 HCO3-20* AnGap-17
___ 10:28PM BLOOD cTropnT-0.02*
___ 04:00AM BLOOD CK-MB-2 cTropnT-0.02* proBNP-2852*
___ 10:28PM BLOOD Calcium-9.0 Phos-3.8 Mg-2.2
IMAGING
================
___ CXR
IMPRESSION:
No evidence of pneumonia.
Stable chronic interstitial abnormality most likely represents
age related
fibrosis.
Left-sided pacemaker.
DISCHARGE LABS
=================
___ 07:50AM BLOOD WBC-6.6 RBC-3.58* Hgb-11.0* Hct-33.8*
MCV-94 MCH-30.7 MCHC-32.5 RDW-12.9 RDWSD-45.0 Plt ___
___ 07:50AM BLOOD ___ PTT-32.8 ___
___ 07:50AM BLOOD Glucose-139* UreaN-44* Creat-1.7* Na-142
K-4.2 Cl-103 HCO3-24 AnGap-15
___ 07:50AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Apixaban 2.5 mg PO BID
2. Carvedilol 18.75 mg PO BID
3. Levothyroxine Sodium 100 mcg PO DAILY
4. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25 mcg/actuation
inhalation DAILY
5. Ranexa (ranolazine) 500 mg oral BID
6. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral DAILY
7. Ranitidine 150 mg PO DAILY
8. amLODIPine 10 mg PO DAILY
9. Aspirin 81 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Losartan Potassium 50 mg PO DAILY
13. Pravastatin 80 mg PO QPM
14. Gabapentin 100 mg PO QHS
15. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
Discharge Medications:
1. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Carvedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
3. Losartan Potassium 50 mg PO BID
RX *losartan 50 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
4. amLODIPine 10 mg PO DAILY
5. Anoro Ellipta (umeclidinium-vilanterol) 62.5-25
mcg/actuation inhalation DAILY
6. Apixaban 2.5 mg PO BID
7. Aspirin 81 mg PO DAILY
8. Gabapentin 100 mg PO QHS
9. Levothyroxine Sodium 100 mcg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
12. Pravastatin 80 mg PO QPM
13. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral DAILY
14. Ranexa (ranolazine) 500 mg oral BID
15. Ranitidine 150 mg PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS: Unstable angina, acute on chronic heart
failure with preserved ejection fraction
SECONDARY DIAGNOSES: Hypertension, Atrial fibrillation, Chronic
kidney disease, Peripheral vascular disease, history of CVA,
Hyperlipidemia, Type 2 diabetes mellitus, Chronic obstructive
pulmonary disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with shortness of breath getting diuresed//
?interval change ?interval change
IMPRESSION:
Compared to chest radiographs since ___ most recently ___.
Moderate to severe cardiomegaly is chronic. Pleural effusions small if any.
No pneumothorax. No pulmonary edema. No pneumonia or is substantial
atelectasis.
Vascular pattern in the lungs suggests chronic lung disease, perhaps emphysema
though conceivably interstitial fibrosis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Chest pain, unspecified
temperature: 98.8
heartrate: 82.0
resprate: 16.0
o2sat: 97.0
sbp: 193.0
dbp: 65.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ year old female with history of CAD s/p
multiple stents, HFpEF, PVD, CKD, DMII, HTN, and HLD who
presents with substernal chest pressure found to have mild
troponin elevation without EKG changes iso CKD concerning for
unstable angina vs. NSTEMI. Patient remained chest pain free
while in house. She was diuresed due to volume overload and had
uptitration of coreg and losartan due to hypertension. She was
discharged on a diuretic regimen of furosemide 40mg daily.
ACUTE ISSUES:
==============
# ?Unstable Angina
# Known Coronary Artery Disease
# Chest pain
Patient presents with substernal chest pressure radiating to her
left arm and back that occurred while ambulating to her house.
Pain resolved after 3 doses of NG with symptoms concerning for
angina. Troponin on admission mildly elevated to 0.02 in the
setting of CKD, but EKG reassuringly without STE or depressions
and patient was without chest pain on arrival to ER. She has a
known history of significant coronary artery disease with
multiple stents.
Recent dobutamine stress in ___ without evidence of
inducible ischemia. Suspect pain was secondary to volume
overload and hypertension. Per patient, she would not like to
undergo cath due to risk of kidney injury in the setting of
contrast. She was monitored on telemetry and continued on home
Aspirin 81mg daily and pravastatin 80mg daily. Her carvedilol
was increased to 25mg BID for antianginal effects and blood
pressure control. Her home losartan was increased to 50mg BID
for blood pressure control. She also continued on her home
ranexa.
#HFpEF:
#LVOT obstruction
LVEF >55% on last TTE. Appeareded volume overloaded with
elevated JVP and 2+ pedal edema to knees on admission. Not on
daily diurectics at home due to worsening renal function. Due to
an inducible LVOT gradient on her ___ stress test, careful
diuresis was done to avoid detrimental preload reduction. She
was diuresed with lasix 20mg IV daily or BID. When euvolemic,
she was switched to 40mg daily. She was continued on home
losartan. Her coreg was increased as above. Her losartan was
also increased.
#HTN:
Patient continued to have elevated SBPs while in house with SBP
values of 150-180s. Her coreg was increased and her home
losartan was increased. Her home amlodipine 10mg was continued.
#Normocytic Anemia: Likely anemia of chronic disease. No current
signs or symptoms of bleeding. Will require further follow-up
with out-patient provider |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Gold Sodium Thiomalate
Attending: ___
Chief Complaint:
Palpitations and lightheadedness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with hypertension, diabetes mellitus,
rheumatoid arthritis, remote H/O atrial fibrillation in ___,
presenting with palpitations and lightheadedness.
On the morning of admission, he felt palpitations while getting
out of bed. This lasted throughout the day. Later in the day, he
felt lightheaded while walking and decided to come into the ED.
He has no chest pain, shortness of breath, diaphoresis, nausea,
vomiting, paroxysmal nocturnal dyspnea, or lower extremity
swelling. The last time he felt palpitations was ___ years ago.
Per brief review of records, the last documentation of atrial
fibrillation was in ___.
He reports having laryngitis for the past month, for which he
has called his PCP, but has not been able to follow up. He notes
some diarrhea the night before, but otherwise negative
infectious review of symptoms (no fevers, chills, diarrhea,
nausea, vomiting, cough, rhinorrhea, headache, dysuria, urinary
urgency or frequency). He does report an 8 lb weight loss in the
past 5 months and decreased appetite.
Of note, the patient was recently seen in the ED for syncopal
episode on ___. This was felt to be vasovagal and he was
discharged after hydration with IV fluids.
In the ED initial vitals were: T 98.1 HR 170 BP 130/76 RR 18
Sp02 100% on RA. Labs/studies notable for no leukocytosis,
Hgb/Hct 12.8/39.6 (appears to be near baseline). Chem panel
unremarkable, K 3.6, Cr. 0.8. CXR was normal. Patient was given
NS, Diltiazem 10 mg IV X 3 and 30 mg po X 2. Vitals on transfer
HR 93 BP 112/95 RR 16 Sp02 98% on RA.
After arrival to the cardiology ward, he was in NSR and reported
feeling well, no longer having palpitations or lightheadedness.
Past Medical History:
1. Hypertension
2. Insomnia
3. Mononeuritis multiplex
4. Type 2 diabetes mellitus
5. Paroxysmal atrial fibrillation - has been on warfarin in the
past but developed GI bleeding.
6. Rheumatoid arthritis
7. H/O prosthetic knee joint infection, on chronic suppressive
antibiotics; E. coli septic arthritis
8. Recent admit for syncope attributed to orthostatic
hypotension from diarrhea
9. Cl. difficile colitis
10. Hyperlipidemia
11. Bilateral knee replacements
12. GERD
13. Right hip replacement
14. BPH
Social History:
___
Family History:
No family history of syncope, sudden cardiac death, or cardiac
disease. Brother w/ h/o "throat cancer". No other family history
of gastrointestinal diseases.
Physical Exam:
On admission
GENERAL: Elderly man, appearing well, resting comfortably in
bed.
VS: T 98.2 BP 132/78 HR 83 RR 18 SaO2 98% on RA
HEENT: NCAT. Sclera anicteric. No scleral pallor. Abrasion on
chin.
NECK: No JVD.
CARDIAC: RRR; no murmurs, rubs or gallops
LUNGS: Hoarse voice. CTAB--no wheezes or crackles.
ABDOMEN: Soft, ___, not distended.
EXTREMITIES: No edema. Warm and well perfused.
SKIN: No stasis dermatitis, no rashes.
NEURO: No gross motor or coordination abnormalities.
Pertinent Results:
___ 11:24AM BLOOD ___
___ Plt ___
___ 11:24AM BLOOD ___
___ Im ___
___
___ 11:24AM BLOOD ___
___
___ 11:24AM BLOOD ___
___ 11:24AM BLOOD ___
___ 07:17AM BLOOD ___
___ 11:24AM BLOOD ___
___ 11:52 am STOOL CONSISTENCY: NOT APPLICABLE
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
___ 8:55 am STOOL CONSISTENCY: NOT APPLICABLE
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
ECG ___ 11:22:36 AM
Atrial fibrillation with a rapid ventricular response (150 bpm).
Compared to the previous tracing the rhythm is now atrial
fibrillation.
ECG ___ 7:46:26 ___
Sinus rhythm. Very low voltage in lead aVL, suggestive of poor
contact on the lead. Compared to the previous tracing of
___, atrial fibrillation is no longer present. Clinical
correlation is suggested.
CXR ___
Cardiac size is normal. The lungs are clear. There is no
pneumothorax or pleural effusion. Hyperinflation of the lungs is
again noted.
IMPRESSION: No acute cardiopulmonary abnormality
Echocardiogram ___
The left atrial volume index is normal. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). No atrial septal defect is seen by 2D or
color Doppler. The estimated right atrial pressure is ___ mmHg.
Normal left ventricular wall thickness, cavity size, and
regional/global systolic function (biplane LVEF = 57 %). The
aortic root is mildly dilated at the sinus level. 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. Mild (1+) mitral regurgitation is seen. The
estimated pulmonary artery systolic pressure is high normal.
There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. Mild mitral
regurgitation with normal valve morphology. Mildly dilated
ascending aorta.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Loratadine 10 mg PO DAILY
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
3. ammonium lactate 12 % topical DAILY
4. Aspirin 81 mg PO DAILY
5. Cyanocobalamin 100 mcg PO DAILY
6. Doxazosin 4 mg PO HS
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. FoLIC Acid 1 mg PO DAILY
9. leflunomide 20 mg oral DAILY
10. Lisinopril 10 mg PO DAILY
11. Simvastatin 20 mg PO QPM
Discharge Medications:
1. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*1
2. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
4. ammonium lactate 12 % topical DAILY
5. Aspirin 81 mg PO DAILY
6. Cyanocobalamin 100 mcg PO DAILY
7. Doxazosin 4 mg PO HS
8. Fluticasone Propionate NASAL 2 SPRY NU DAILY
9. FoLIC Acid 1 mg PO DAILY
10. leflunomide 20 mg oral DAILY
11. Loratadine 10 mg PO DAILY
12. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
-Atrial fibrillation with rapid ventricular response
-Prior gastrointestinal bleeding
-Diarrhea
-Hypertension
-Hyperlipidemia
-Type 2 diabetes mellitus
-Rheumatoid arthritis
-Gastroesophageal reflux disease
-Vocal hoarseness
-Weight loss
-Anorexia
-Benign prostatic hypertrophy
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 palpiations, A fib w/ rvr // pulm edema
TECHNIQUE: Single frontal view of the chest
COMPARISON: Chest radiographs from ___.
FINDINGS:
Cardiac size is normal. The lungs are clear. There is no pneumothorax or
pleural effusion. Hyperinflation of the lungs is again noted.
IMPRESSION:
No acute cardiopulmonary abnormality
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Tachycardia
Diagnosed with Unspecified atrial fibrillation, Diarrhea, unspecified
temperature: 98.1
heartrate: 170.0
resprate: 18.0
o2sat: 100.0
sbp: 130.0
dbp: 76.0
level of pain: 0
level of acuity: 1.0 | Mr. ___ is a ___ with hypertension, diabetes mellitus,
rheumatoid arthritis, remote H/O documented atrial fibrillation
in ___, presented with palpitations and was found to be in
atrial fibrillation with a rapid ventricular rate that converted
after initial attempts at rate control with diltiazem.
# Atrial fibrillation: Per ED report, ventricular rate to 170s
on presentation. He received diltiazem 10 mg IV x3 and diltiazem
30 mg po x 2 and 3 L IVF in ED. Upon transfer to floor, he was
in NSR at ___ with stable BP and no longer feeling palpitations.
TSH normal. Possible triggers included hypovolemia and
electrolyte shifts from diarrhea, decreased appetite and PO
intake (discussed below). ___ seemed unlikely (afebrile,
no leukocytosis). CHADS2 = 2. CHADS2VASC = 3. Patient has
history of GI bleed as well as H/O syncope/falls and
subarachnoid hemorrhage. ___ = 3. Given this,
anticoagulation was deferred. He was started on metoprolol 25 mg
q6 hours and transitioned to metoprolol succinate. Lisinopril
was decreased (after initial discontinuation) to allow for BP
toleration of metoprolol. TTE revealed normal EF.
# Diarrhea: Possibly causing hypovolemia and electrolyte shifts,
triggering his episode of atrial fibrillation. Stool O+P and
stool culture were negative.
# Weight loss and decreased appetite: Given smoking history, his
recent voice change, 8 lb weight loss in the past few months,
decreased appetite and PO intake were concerning for malignancy.
CXR without any nodules. Patient has declined colonoscopy
several times due to not having a ride. This could be
contributing to hypovolemia and AF discussed above.
# Hypertension: Hypotensive in setting of metoprolol and
lisinopril. Discontinued home lisinopril initially and resumed
at lower dose as above.
# Type 2 Diabetes mellitus: Last HbA1c in ___ was 5.8%. Not
currently on any agents per patient. He did not require insulin
during this admission.
# RA: Continued Leflunomide 20 mg and acetaminophen prn.
# BPH: Continued home Doxazosin 4 mg QHS
TRANSITIONAL ISSUES:
[ ] New medication: Metoprolol 50 mg extended release daily.
[ ] Continue to encourage colonoscopy.
[ ] Consider further workup as outpatient, e.g., lung CT.
[ ] Consider ENT referral as outpatient.
[ ] Patient reports that he would like to be DNR/DNI, however
has not discussed this in the past with any providers.
Exploration of patient's values/goals should be continued with
___ provider as outpatient, especially if malignancy
workup is pursued.
[ ] Monitor for diarrheal symptoms.
[ ] Will require BP check and assessment of renal function and
electrolytes at ___ Episodic Visit given that lisinopril was
started at half of home dose (5 mg instead of 10 mg). Will also
require PCP follow up for similar issues in ___ weeks.
# CODE: Do not resuscitate (DNR/DNI). Patient says he would not
want measures to "bring him back." This includes intubation and
resuscitation, even if felt to be temporary.
# CONTACT/HCP: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
indomethacin / oxycodone / Topamax / magnesium sulfate
Attending: ___
Chief Complaint:
Fevers, headache, diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with hx acute liver failure ___
acetaminophen overdose s/p DDLT (___) c/b delayed abdominal
closure, sigmoid ulceration, renal failure requiring RRT,
recently admitted for GI bleed, who presents with fever and
headache.
She notes 4 days of diarrhea, 2 days of fevers to 100.9 and
chills with nausea and worsening severe HA. She denied any
cough/respiratory symptoms, dysuria/urinary symptoms. Also
denied
vision changes, numbness, tingling, weakness. No rashes. She
reported minimal abdominal tenderness other than RUQ pain which
she states is chronic. She states she has been taking her
medications as prescribed. She has been feeling depressed
lately.
She denied any sick contacts.
With regard to her liver transplant, she initially presented in
___ after a Tylenol overdose (suicide attempt). She developed
fulminant liver failure and underwent DDLT on ___. The
procedure was notable for a difficult arterial anastomosis
requiring supra-celiac aortic conduit. Furthermore she had
significant abdominal edema requiring delayed closure with
multiple abdominal washouts. Her post-operative course was
complicated by ___ requiring RRT and sigmoid ulceration. Her
subsequent course was further complicated by re-admissions for
___ in ___ and GI bleeding/partial obstruction in
___,
most recently discharged on ___.
In the ED initial vitals: T 102.4, HR 85. BP 119/73, RR 18, SaO2
100% RA
-Exam notable for: lethargic and uncomfortable appearing, normal
neuro exam, RUQ tenderness, slow cap refill
-Labs notable for:
CBC: WBC 2.6, Hb 9.7 (baseline), plt 266
Chem7: Cr 2.5
LFTs: wnl
Coags: INR 1.8, PTT 36
-Imaging notable for:
RUQ U/S: patent hepatic vasculature, stable fluid collections
in
region of ligamentum teres and main portal vein, small R pleural
effusion
CXR: Interval decrease in now small to moderate right pleural
effusion.
-Consults:
--Liver: sepsis workup, abx coverage taking into consideration
prior blood cultures, CMV VL, consider LP if no source, admit to
ET
-Patient was given:
Acetaminophen 1000mg
1L LR
vancomycin 1000mg
Zosyn 2.25g
Prochlorperazine 10mg
Diphenhydramine 25mg
Ceftriaxone 2g
Vitals on transfer: T 99.7, HR 90, BP 134/81, RR 18, O2 sat 97%
on RA
On the floor, the patient endorses the above history. She states
that she began having nonbloody diarrhea about 4 days ago, with
her last BM being diarrhea the night prior to admission. She
developed a fever yesterday as well as a severe headache. The
headache is currently ___ in severity, without any photophobia
or phonophobia. She denies nuchal rigidity. She also denies
emesis but has had some nausea. She has stable chronic RUQ
abdominal pain that has been present for months and has not
changed in the past few days. She denies any cough, but notes
that she feels some tightness in her chest that is relieved by
taking a deep breath. She denies dysuria, hematuria, urinary
urgency or frequency.
Patient also reporting a remote history of dysphagia that began
several months ago and resolved, but that has recently started
again a few weeks ago. She feels that food is getting caught
entering her stomach. She denies any odynophagia. She also has
stable right foot pain that is currently being worked up, she
reports having had an EMG yesterday. The pain began after her
liver transplant surgery and is somewhat relieved by gabapentin.
Patient denies any sick contacts. She reports she is taking all
of her medications as prescribed.
REVIEW OF SYSTEMS: Positive per HPI, remaining 10 point ROS
reviewed and negative.
Past Medical History:
- Acute liver failure ___ acetaminophen toxicity s/p DDLT in
___
- HTN
- PE x2 on apixaban
- MDD/Anxiety with multiple suicide attempts
Social History:
==============
SOCIAL HISTORY
==============
- ___
- Family: Has two children, ages ___ and ___-- patient left her
husband and children ___ years ago in setting of death of her
mother and suicide attempt requiring hospitalization
- Relationship status: Currently has supportive relationship
with
boyfriend.
- Primary supports: sister, 2 brothers, 2 children, stepfather,
boyfriend
- ___: living alone in an apartment prior to suicide attempt
- Education: High school
- Employment/income: unemployed and on SSDI, with reported
financial stressors, unable to pay her recent
- Spiritual: Denies
- Access to weapons: Denies
Family History:
==========================
FAMILY PSYCHIATRIC HISTORY
==========================
- Psychiatric Diagnoses: Mother with reported depression. Aunt
with depression
- ___ Use Disorders: Father with heavy alcohol use. Mom
also had alcohol use problems.
- Suicide Attempts/Completed Suicides: maternal aunt attempted
suicide.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: ___ Temp: 99.6 PO BP: 144/89 L Sitting HR: 83 RR:
18 O2 sat: 98% O2 delivery: Ra
GENERAL: NAD
HEENT: NC/AT, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: +BS. Soft abdomen, nondistended, tender to palpation in
RUQ, nontender in other quadrants. No rebound or guarding.
EXTREMITIES: no cyanosis, clubbing, or edema. R foot tender to
palpation diffusely but without erythema, warmth or induration.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3. No focal neurologic deficits. Moving all 4
extremities with purpose with ___ strength in all extremities.
CN
II-XII tested and intact. SILT in all extremities. No asterixis.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAMINATION:
24 HR Data (last updated ___ @ 749)
Temp: 98.2 (Tm 98.4), BP: 160/89 (127-160/79-89), HR: 74
(73-78), RR: 18 (___), O2 sat: 91% (91-97), O2 delivery: RA
GENERAL: NAD
HEENT: EOMI, PERRL, anicteric sclera, pink conjunctiva, MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: decr breath sounds right lower lung fields, no wheezes,
rales, rhonchi, breathing comfortably without use of accessory
muscles
ABDOMEN: normoactive bowel sounds. Soft abdomen, mildly
distended, tender to minimal palpation in RUQ, nontender in
other
quadrants. No rebound or guarding.
BACK: No tenderness to palpation of posterior ribs. No CVAT.
EXTREMITIES: no cyanosis, clubbing, or edema.
NEURO: A&Ox3. No focal neurologic deficits. Moving all 4
extremities with purpose. No asterixis.
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes.
Pertinent Results:
ADMISSION LABS:
================
___ 01:10PM BLOOD WBC-2.6* RBC-3.26* Hgb-9.7* Hct-30.3*
MCV-93 MCH-29.8 MCHC-32.0 RDW-13.8 RDWSD-47.1* Plt ___
___ 01:10PM BLOOD Neuts-40 ___ Monos-17* Eos-7
Baso-4* AbsNeut-1.04* AbsLymp-0.83* AbsMono-0.44 AbsEos-0.18
AbsBaso-0.10*
___:10PM BLOOD ___ PTT-36.3 ___
___ 01:10PM BLOOD Glucose-113* UreaN-40* Creat-2.5* Na-139
K-4.7 Cl-110* HCO3-16* AnGap-13
___ 01:10PM BLOOD ALT-23 AST-16 AlkPhos-105 TotBili-0.2
___ 07:01AM BLOOD Albumin-4.3 Calcium-9.5 Phos-4.1 Mg-1.1*
___ 03:15PM BLOOD CMV VL-NOT DETECT
DISCHARGE LABS:
===============
___ 06:13AM BLOOD WBC-3.1* RBC-2.75* Hgb-8.1* Hct-25.2*
MCV-92 MCH-29.5 MCHC-32.1 RDW-15.2 RDWSD-50.7* Plt ___
___ 07:00AM BLOOD Neuts-47 ___ Monos-11 Eos-9*
Baso-3* Myelos-2* AbsNeut-1.69 AbsLymp-1.01* AbsMono-0.40
AbsEos-0.32 AbsBaso-0.11*
___ 07:00AM BLOOD Poiklo-1+* Ovalocy-1+* Acantho-1+* RBC
Mor-SLIDE REVI
___ 06:13AM BLOOD ___ PTT-33.3 ___
___ 06:13AM BLOOD Glucose-104* UreaN-23* Creat-1.5* Na-146
K-4.2 Cl-112* HCO3-23 AnGap-11
___ 06:13AM BLOOD ALT-23 AST-22 AlkPhos-155* TotBili-<0.2
___ 06:13AM BLOOD Albumin-3.7 Calcium-8.7 Phos-3.8 Mg-2.1
___ 06:13AM BLOOD tacroFK-9.7
INTERVAL LABS:
================
___ 07:00AM BLOOD CRP-167.6*
___ 06:00AM BLOOD CRP-30.4*
___ 07:01AM BLOOD tacroFK-7.3
___ 06:19AM BLOOD tacroFK-9.4
___ 07:00AM BLOOD tacroFK-10.6
___ 07:20AM BLOOD tacroFK-9.3
___ 06:12AM BLOOD tacroFK-11.1
___ 05:50AM BLOOD tacroFK-11.6
___ 06:00AM BLOOD tacroFK-9.1
IMAGING AND STUDIES:
=====================
___ Imaging CTA ABD W&W/O C & RECON
IMPRESSION:
1. There is a small 5 mm pseudoaneurysm of the right hepatic
artery branch
with significant narrowing proximal to the pseudoaneurysm which
may account for the previously seen elevated velocity on the
ultrasound examination. The left hepatic artery arises directly
from the aorta and is patent.
2. Stable left hepatic lobe pneumobilia and mild periportal
edema.
3. Slight interval increase in the right-sided pleural effusion.
___ Imaging DUPLEX DOPP ABD/PEL
IMPRESSION:
1. Elevated velocity in the proximal main hepatic artery up to
275 cm/sec
which is concerning for possible stenosis. CT angiogram of the
abdomen is
recommended for further evaluation of the hepatic artery. The
transplant
hepatic vasculature is otherwise patent.
2. Trace fluid again seen adjacent to the ligamentum teres,
unchanged from
prior imaging.
3. Stable right pleural effusion.
MICROBIOLOGY:
==============
___ 1:10 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH
___ 12:33 am STOOL CONSISTENCY: LOOSE Source:
Stool.
**FINAL REPORT ___
C. difficile PCR (Final ___:
Reported to and read back by ___ ON ___ AT
2:50PM.
POSITIVE. (Reference Range-Negative).
The C. difficile PCR is highly sensitive for toxigenic
strains of
C. difficile and detects both C. difficile infection
(CDI) and
asymptomatic carriage. Therefore, positive C. diff PCR
tests
trigger reflex C. difficile toxin testing, which is
highly
specific for CDI.
C. difficile Toxin antigen assay (Final ___:
POSITIVE. (Reference Range-Negative).
PERFORMED BY ___.
This result indicates a high likelihood of C. difficile
infection
(CDI).
___ 12:33 am STOOL CONSISTENCY: LOOSE Source:
Stool.
MICROSPORIDIA STAIN (Pending):
CYCLOSPORA STAIN (Pending):
FECAL CULTURE (Final ___:
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
RARE POLYMORPHONUCLEAR LEUKOCYTES.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
No E. coli O157:H7 found.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with shortness of breath, fever// Pneumonia present?
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
FINDINGS:
Small to moderate right pleural effusion has decreased in the interval. There
is slight blunting of the left costophrenic angle, but no large pleural
effusion. No definite focal consolidation is seen. The cardiac silhouette
size is mildly enlarged. Mediastinal contours are unremarkable. No pulmonary
edema seen.
IMPRESSION:
Interval decrease in now small to moderate right pleural effusion.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: Signs of rejection, other liver abnormalities, hepatic or portal
vein thrombosis present?
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: Liver/gallbladder ultrasound ___.
FINDINGS:
Liver: The hepatic parenchyma is within normal limits. No focal liver
lesions are identified. Small fluid collection is again seen in the region of
the ligamentum teres measuring approximately 3.8 cm, similar to prior. An
additional fluid collection is again seen in the region of the portal vein
which measures approximately 2 cm, similar to prior. There is no ascites.
Bile ducts: There is no intrahepatic biliary ductal dilation. The common
hepatic duct measures 5 mm.
Gallbladder: The gallbladder appears within normal limits, without stones,
abnormal wall thickening, or edema.
Pancreas: The imaged portion of the pancreas appears within normal limits,
with portions of the pancreatic tail obscured by overlying bowel gas.
Spleen: The spleen demonstrates normal echotexture, and measures 9.9 cm.
Kidneys: The right kidney measures 9.4 cm. The left kidney measures 12.1 cm.
No stones, masses, or hydronephrosis are identified in either kidney.
Other: There is an unchanged small right pleural effusion.
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate direction.
Main portal vein velocity is 54.2 cm/sec.
Right and left portal veins are patent, with antegrade flow.
The main hepatic artery is patent, with appropriate waveform.
Right, middle and left hepatic veins are patent, with appropriate waveforms.
IMPRESSION:
1. Patent hepatic vasculature.
2. Stable fluid collections in the region of the ligamentum teres and main
portal vein.
3. Small right pleural effusion.
Radiology Report
EXAMINATION: CT abdomen pelvis without intravenous contrast.
INDICATION: ___ year old woman with neutropenic fever s/p liver transplant
with RUQ, RLQ abdominal pain and diarrhea.// Please evaluate for cholangitis,
abdominal abscess, perforation, appendicitis or other infectious etiology.
Please use PO contrast, but no IV contrast ___ ___.
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.2 s, 55.2 cm; CTDIvol = 8.7 mGy (Body) DLP = 479.4
mGy-cm.
Total DLP (Body) = 479 mGy-cm.
COMPARISON: CT abdomen and pelvis dated compared to ___ and
most recent dated ___.
FINDINGS:
LOWER CHEST: Cardiac size is within normal limits. No evidence of calcified
atherosclerosis of the coronary arteries. No pericardial effusion. Bilateral
pleural effusions, trace left and minimal interval increase of small right.
ABDOMEN:
HEPATOBILIARY: The patient is status post liver transplant with no change in a
small volume left hepatic pneumobilia when compared to most recent prior dated
___. A small stent is again noted extending from the right
anterior biliary ductal system with the common bile duct and into the
duodenum. Cholangitis cannot be evaluated given lack of contrast. On prior
scan there was extensive periportal edema and fluid tracking along the
falciform ligament which is not well visualized on current evaluation due to
lack of contrast. The portal vein and hepatic venous anastomosis cannot be
well assessed on current study to the left of intravenous contrast. 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 surgically absent.
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 left kidney is larger when compared to the right. In the
interpolar region of the left kidney is a well-circumscribed renal cyst that
measures up to 36 mm. There is no hydronephrosis. There are punctate
calcific densities in the left kidney which are likely within the wall of the
renal cyst. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Redemonstrated is a
diverticulum in the third portion of the duodenum, (series 2, image 46). The
other small bowel loops demonstrate normal caliber and wall thickness
throughout. There is continued wall thickening of the cecum, ascending and
proximal transverse colon with adjacent fat stranding that may represent
colitis of infectious or inflammatory etiology. There is no evidence of
intraperitoneal free air or drainable fluid collection. The appendix is
normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal
limits.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted in the arteries.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Again demonstrated is a containing hernia into the canal Nuck.
IMPRESSION:
1. Acute colitis of the cecum, ascending and proximal transverse colon which
is likely due to infectious or inflammatory etiology.
2. Status post liver transplant with no interval change evident, however,
given the lack of intravenous contrast the portal vein and hepatic venous
anastomosis cannot be well assessed on current examination.
3. No evidence of appendicitis or fluid collections in the abdomen and pelvis.
Radiology Report
INDICATION: ___ year old woman with c diff c/f perf// c/f perf
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
There are no abnormally dilated loops of large or small bowel. There is no
free intraperitoneal air, although evaluation is limited by portable supine
technique. There are multiple surgical clips in the upper abdomen related to
liver transplant. A biliary stent projects over the right upper quadrant of
the abdomen. There are no acute osseous abnormalities.
IMPRESSION:
No radiographic evidence of free intraperitoneal air, although evaluation is
limited by portable supine technique.
Radiology Report
EXAMINATION: CT of the abdomen/pelvis without contrast
INDICATION: ___ year old woman with c diff// c/f possible perf
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP: 506 mGY-cm.
COMPARISON: CT abdomen and pelvis performed today, on ___, at
13:18.
FINDINGS:
LOWER CHEST: There is a moderate right pleural effusion, unchanged compared to
CT of the abdomen/pelvis from earlier the same day. No left pleural effusion.
Bibasilar atelectatic changes have increased.
ABDOMEN:
HEPATOBILIARY: The patient is status post liver transplant. Again seen is
pneumobilia in the left lobe. There is a small stent extending from the right
anterior intrahepatic duct to the second portion of the duodenum. As
mentioned on previous exam, cholangitis cannot be evaluated given lack of
intravenous contrast. The previously noted extensive periportal edema and
fluid tracking along the falciform ligament appears unchanged. Transplant
vessels and anastomoses are unable to be assessed in the absence of
intravenous contrast. There is no evidence of focal liver lesions within the
limitation of this unenhanced scan. There is no evidence of intrahepatic or
extrahepatic biliary dilation. The gallbladder is surgically absent.
PANCREAS: The pancreas is homogeneous in attenuation, without main ductal
dilatation.
SPLEEN: The spleen is normal in size and homogeneous in attenuation.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The left kidney is larger than the right. In the interpolar region
of the left kidney is a 3.6 cm renal cyst, demonstrating mural calcification
posteriorly versus layering calcific debris. There is no hydronephrosis.
There is a 4 mm nonobstructing stone in the upper pole of the left kidney
(series 3, image 32). There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. There is a duodenal
diverticulum involving at the junction of the second and third segments.
Small bowel loops are normal in caliber. There is diffuse wall thickening of
the colon, from the cecum to the rectum. Wall thickening of the ascending and
transverse colon appears improved compared to the earlier CT. Wall thickening
of the descending colon and rectum is better appreciated on the current study
secondary to interval progression of oral contrast to the rectum, and is
likely unchanged compared to earlier CT. There is pericolonic fat stranding,
most pronounced in the right upper quadrant and paracolic gutter. The
appendix is normal and is opacified with oral contrast. There is no
pneumatosis or pneumoperitoneum. There is no organized fluid collection.
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. There is no significant
atherosclerotic disease.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: There are incisional changes along the midline anterior
abdominal wall.
IMPRESSION:
1. Persistent pancolitis. Wall thickening of the ascending and transverse
colon appears improved compared to the earlier CT. Wall thickening of the
descending colon and rectum is better appreciated on the current study
secondary to interval progression of oral contrast to the rectum, and is
likely unchanged compared to earlier CT. No pneumatosis or pneumoperitoneum.
2. No interval change in the appearance of the liver transplant.
Radiology Report
INDICATION: ___ year old woman s/p liver transplant with c. diff colitis and
abdominal pain// Please evaluate for stool burden, air fluid levels, evidence
of perforation or obstruction.
TECHNIQUE: Upright abdominal radiographs were obtained.
COMPARISON: Abdominal radiograph ___. CT abdomen and pelvis ___.
FINDINGS:
There are surgical clips in the upper abdomen from liver transplant surgery.
A biliary stent is noted. There are several air-filled loops of colon, which
are nondilated. There are no dilated loops of small bowel. There is no
significant stool burden. There is no evidence of free intraperitoneal air.
No acute osseous abnormalities are identified.
IMPRESSION:
1. No evidence of bowel obstruction or free intraperitoneal air.
2. No significant stool burden.
Radiology Report
INDICATION: ___ year old woman with c. diff colitis, abdominal pain.//
Evidence of ileus? Interval change from prior?
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: Abdominal radiograph ___
FINDINGS:
Again seen surgical clips in the upper abdomen from prior liver transplant
surgery. A biliary stent is noted. There are several air filled loops of
colon, which are nondilated. There are no dilated loops of small bowel.
There is no significant stool burden. There is no evidence of free
intraperitoneal air. No acute osseous abnormalities are identified. There is
atelectasis of the right lower lung.
IMPRESSION:
1. Several air-filled loops of colon, grossly unchanged from prior film with
no evidence of bowel obstruction.
2. No significant stool burden.
Radiology Report
INDICATION: ___ year old woman with R sided posterior chest wall pain// Please
evaluate for rib fracture or bony pathology
COMPARISON: ___ and ___
FINDINGS:
Frontal chest radiograph as well as 8 views of the bilateral rib cage. A
right pleural effusion is again noted, small to moderate in size. There is
likely compressive lower lung atelectasis on the right. Minimal subsegmental
atelectasis is noted in the left lung base. The heart appears mildly
enlarged. No pneumothorax. No definite signs of pneumonia. Mediastinal
contour is normal. Imaged bony structures are intact. Dedicated views of the
ribs show no evidence of fracture. BBs marked the site of pain. Prominent
costochondral junction calcification. Multiple surgical clips are noted in
the upper abdomen in this patient with history of prior liver transplant.
IMPRESSION:
1. No displaced rib fracture.
2. Moderate sized right-sided pleural effusion with compressive atelectasis in
the right lower lung.
3. Mild cardiomegaly.
4. Minimal atelectasis in the left lower lung.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: ___ year old woman s/p DDLT recently admitted for GI bleed, who
presents with neutropenic fever and C diff infection// RUQ pain, previously
with abdominal fluid collection near portal vein- please look at vasculature
and biliary system
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Abdomen CT ___, Doppler ultrasound ___
FINDINGS:
LIVER: The transplant hepatic parenchyma appears within normal limits. The
contour of the liver is smooth. There is no focal liver mass. Trace fluid is
again seen adjacent to the ligamentum teres unchanged from prior imaging.
There is no ascites. A right pleural effusion is stable from prior imaging.
BILE DUCTS: There is no intrahepatic biliary dilation. A stent is again
visualized in the common bile duct.
GALLBLADDER: The patient is status post cholecystectomy.
PANCREAS: The pancreas is not visualized due to overlying bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 10.2 cm
KIDNEYS: No hydronephrosis is seen on limited views the kidneys. A simple
cortical cyst is again noted in the left kidney.
DOPPLER EXAMINATION: The main, right and left portal veins are patent with
hepatopetal flow. High velocity flow measuring up to 275 cm/sec is seen
within the proximal main hepatic artery. This is a change from prior imaging.
Resistive indices of the intrahepatic arteries measure 0.63 in the left
hepatic artery and 0.49 in the right hepatic artery. The hepatic veins are
patent.
IMPRESSION:
1. Elevated velocity in the proximal main hepatic artery up to 275 cm/sec
which is concerning for possible stenosis. CT angiogram of the abdomen is
recommended for further evaluation of the hepatic artery. The transplant
hepatic vasculature is otherwise patent.
2. Trace fluid again seen adjacent to the ligamentum teres, unchanged from
prior imaging.
3. Stable right pleural effusion.
RECOMMENDATION(S): CT angiogram recommended look for hepatic artery stenosis.
NOTIFICATION: The findings were discussed via telephone by ___
with ___ on ___ at 2:15 pm, 20 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: Abdominal CTA
INDICATION: ___ year old woman with RUQ abdominal pain, RUQUS with elevated
velocity in the proximal main hepatic artery up to 275 cm/sec concerning for
possible stenosis.// CTA recommended to further evaluate high velocity flow in
the main hepatic artery
TECHNIQUE: CTU: Multidetector CT of the abdomen and pelvis were acquired
prior to and after intravenous contrast administration with the patient in
prone position. The non-contrast scan was done with low radiation dose
technique. The contrast scan was performed with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.1 s, 33.2 cm; CTDIvol = 2.3 mGy (Body) DLP = 76.8
mGy-cm.
2) Spiral Acquisition 2.3 s, 30.7 cm; CTDIvol = 8.6 mGy (Body) DLP = 262.6
mGy-cm.
3) Spiral Acquisition 2.3 s, 30.9 cm; CTDIvol = 8.6 mGy (Body) DLP = 265.4
mGy-cm.
4) Spiral Acquisition 2.0 s, 26.2 cm; CTDIvol = 9.0 mGy (Body) DLP = 236.3
mGy-cm.
5) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 2.7 mGy (Body) DLP = 1.3
mGy-cm.
6) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 2.7 mGy (Body) DLP = 1.3
mGy-cm.
7) Stationary Acquisition 3.6 s, 0.5 cm; CTDIvol = 16.0 mGy (Body) DLP =
8.0 mGy-cm.
Total DLP (Body) = 852 mGy-cm.
COMPARISON: Multiple prior abdominal CTs, most recently ___.
Doppler ultrasound ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. Moderate right
pleural effusion, slightly larger than in prior study.
ABDOMEN:
HEPATOBILIARY: Status post liver transplantation. Mildly heterogeneous
attenuation of the liver and mild periportal edema. Again seen is pneumobilia
in the left lobe. Small stent extending from the right anterior intrahepatic
duct of the second portion of the duodenum, unchanged. The gallbladder is
surgically absent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: Imaged portions of the kidneys are of normal and symmetric size with
normal nephrogram. There is no nephrolithiasis or ureterolithiasis. There is
no hydronephrosis. Large left renal cyst to the left with a small parietal
calcification measures approximately 2.6 cm (303:75). There is no perinephric
abnormalities. There is no evidence of urothelial lesions. The distal
ureters and bladder are unremarkable.
GASTROINTESTINAL: The stomach is unremarkable. A duodenum diverticulum is
again redemonstrated. The imaged portions of the small bowel loops in:
Demonstrate normal caliber, wall thickness, and enhancement throughout.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy.
VASCULAR: The left hepatic artery branch originates directly from the aorta.
The right hepatic artery demonstrates a 5 mm pseudoaneurysm. There is
significant narrowing proximal to the pseudoaneurysm. (Series 601, image 53)
and (series 601, image 51) and (series 301, image 58). There are 2 left-sided
renal arteries. No significant atherosclerosis of the abdominal aorta.
Abdominal aorta is normal in caliber. The hepatic and portal vein branches
appear patent.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal wall is within normal limits.
IMPRESSION:
1. There is a small 5 mm pseudoaneurysm of the right hepatic artery branch
with significant narrowing proximal to the pseudoaneurysm which may account
for the previously seen elevated velocity on the ultrasound examination. The
left hepatic artery arises directly from the aorta and is patent.
2. Stable left hepatic lobe pneumobilia and mild periportal edema.
3. Slight interval increase in the right-sided pleural effusion.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 6:00 pm.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with Fever, unspecified
temperature: 102.4
heartrate: 85.0
resprate: 18.0
o2sat: 100.0
sbp: 119.0
dbp: 73.0
level of pain: 7
level of acuity: 2.0 | PATIENT SUMMARY
==============
Ms. ___ is a ___ woman with hx acute liver failure ___
acetaminophen overdose s/p DDLT (___) c/b delayed abdominal
closure, sigmoid ulceration, renal failure requiring RRT,
recently admitted for GI bleed, who presented with fever,
headache, diarrhea, neutropenia, and metabolic acidosis and was
found to have C diff colitis. She is s/p 10 days of inpatient
treatment, with improvement of symptoms. Immunosuppressive meds
were also adjusted during her stay.
ACUTE ISSUES:
=============
# Neutropenic fever
# Diarrhea
# C. difficile colitis
C. diff PCR and toxin assay positive on admission. CT showed
pancolitis. Absolute neutrophil count ~1000. Course also
complicated by BRBPR which likely reflected irritation of known
sigmoid ulcer in setting of c. diff colitis and known
hemorrhoids. CRP elevated 167, which downtrended to 30 after
treatment with IV Flagyl and PO/PR Vancomycin. Blood and urine
cultures, UA without growth.
#RUQ vs. Right chest wall pain
Patient with ongoing pain ill-described of R chest wall/ RUQ.
Elevated alk phos but otherwise LFTs wnl. Hx of PE and on
apixiban. Sometimes described reproducible pain with palpation
of chest wall. CXR without evidence fracture. RUQUS without PVT.
Initially concerning for hepatic artery stenosis, but CTA
abdomen was not concerning. Increased hepatic artery velocities
likely ___ R hepatic pseudoaneurysm vs aberrant L hepatic
anatomy, but thought to be clinically insignificant per
radiology. Suspect diaphragmatic irritation secondary to
colitis, improved with treatment of c diff.
#Non-anion gap metabolic acidosis
Most likely secondary to bicarbonate losses in the setting of
severe diarrhea from C. difficile colitis. Improved with
treatment of c. diff.
___ on CKD
Post transplant course c/b ___, renal failure with brief HD
requirement. Cr 2.5 on admission, up from 1.9 on recent
discharge now down to 1.8. Most likely pre-renal in setting of
diarrhea/decreased PO intake and now improving.
#R foot pain
Currently being worked up as outpatient, had EMG ___.
Decreased gabapentin dosing for renal function.
CHRONIC ISSUES:
===============
#H/o fulminant liver failure ___ APAP OD s/p DDLT ___
CMV negative donor/recipient. Course c/b sigmoid ulceration and
renal failure. Azathioprine was recently discontinued during
last
admission due to leukopenia. Decreased tacrolimus to 4 mg Q12H,
then to 3.5 mg Q12H on discharge. Continue Bactrim SS daily,
valganciclovir 450 q48h.
#Hx of PE: Continued apixaban 5mg BID.
#HTN: Stopped home carvedilol while infected, then restarted at
a lower dose.
#GERD: Continued home pantoprazole.
#MDD/Anxiety
s/p multiple suicide attempts, most recently ___. Continued
home mirtazapine, hydroxyzine, venlafaxine. Decreased gabapentin
per renal dosing.
TRANSITIONAL ISSUES:
====================
#Immunosuppresion
#S/p DDLT ___
[] Monitor tacro level (decreased to 3.5 at discharge)
[] Monitor neutropenia with weekly CBC.
[] Increased valgancyclovir to 450mg daily per creatinine
clearance.
#C difficile colitis
[] Consider probiotics to prevent recurrence
#Known sigmoid ulcer
[] Plan for repeat colonoscopy after stable resolution of c.
diff colitis
#Stable right pleural effusion:
[] Noted on imaging since ___. TTE with normal cardiac
function. Did not pursue thoracentesis this admission as
effusion stable, patient was asymptomatic and would require
stopping anticoagulation with apixaban.
#HTN:
[] Restarted carvedilol at a lower dose s/p resolution of
infection. Uptitrate prn.
# CODE: FULL confirmed
# CONTACT: ___ son ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim
Attending: ___
Chief Complaint:
Malaise fatigue
Major Surgical or Invasive Procedure:
Paracentesis
History of Present Illness:
___ hx of etoh cirrhosis, roux-en-y bypass Ulcer at the GJ
anastomosis here c/o fevers and chills since day prior. Pt
reports feeling generalized malaise yesterday and subsequently
developed fevers to 101, arthrlagias/myalgias as well. Denies
abd pain, n/v/d, HA, cough, sore throat, rhinorrhea, blood in
stool, dysuria, flank pain, sob, chest pain.
In the ED, initial vitals were T101.6 116 113/64 18 100% RA.
Labs notable for WBC 8.9, HCT 26.3, ALT 34 AST 53 AP 125 Tbili
2.2, lactate 2.9. UA clean, CXR was unremarkable. She was given
vanc and cefepime and transferred to the floor.
Past Medical History:
- EtOH cirrhosis
- alcohol-induced hepatitis
- Narcolepsy
- Hypothyroidism
- GERD
- Asthma: of childhood, no longer active nor treated
- Past history of panic attacks, anxiety, and depression
- Claustrophobia
- Roux-en-Y gastric bypass ___: persistent iron deficiency
following bypass, anastamotic ulcer noted in last
hospitalization ___
- Hx of seizure: during last hospitalization, attributed to
electrolyte disarray
- Lap cholecystectomy ___
- Cesarean section x 2 in ___ and ___
- Sinus surgery ___
- Tonsillectomy and adenoidectomy ___
Social History:
___
Family History:
Grandfather and mother with lung cancer.
Physical Exam:
Vitals: 98.1/99.6 105/66 106 18 99%
General: Pleasant, no acute distress, no asterixis, speech
fluent
HEENT: No scleral icterus. PERRL. MMM.
Lymph: No cervical, supraclavicular or submandibular LAD
appreciated.
CV: ___ holosystolic murmur best appreciated over LUSB.
Lungs: CTAB. No wheezes/rales/rhonchi
Abdomen: Distended. Normoactive BS in all quadrants. TTP in RUQ,
+fluid wave.
Ext: 2+ DP/radial pulses, equal bilaterally. No lower extremity
edema. Legs were equal in size.
Skin: No spider angiomas appreciated. No jaundice appreciated.
LABORATORY DATA: Reviewed, see below.
Discharge:
General: no acute distress, no asterixis, speech fluent
HEENT: No scleral icterus. PERRL. MMM.
Lymph: No LAD appreciated.
CV: ___ holosystolic murmur best appreciated over LUSB.
Lungs: CTAB. No wheezes/rales/rhonchi
Abdomen: Slightly Distended. Normoactive BS in all quadrants.
TTP in RUQ, +fluid wave.
Ext: 2+ DP/radial pulses, equal bilaterally. No lower extremity
edema. Legs were equal in size.
Skin: No spider angiomas appreciated. No jaundice appreciated.
LABORATORY DATA: Reviewed, see below.
Pertinent Results:
___ 10:13PM ___ PTT-33.5 ___
___ 08:15PM GLUCOSE-157* UREA N-14 CREAT-0.6 SODIUM-137
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-25 ANION GAP-13
___ 08:15PM ALT(SGPT)-34 AST(SGOT)-53* ALK PHOS-125* TOT
BILI-2.2*
___ 08:15PM LIPASE-34
___ 08:15PM ALBUMIN-3.1*
___ 08:15PM LACTATE-2.9*
___ 08:15PM WBC-8.7# RBC-3.22* HGB-8.0* HCT-26.3* MCV-82
MCH-25.0* MCHC-30.6* RDW-19.4*
___ 08:15PM NEUTS-87.2* LYMPHS-5.5* MONOS-6.4 EOS-0.6
BASOS-0.3
___ 08:15PM PLT COUNT-205
___ 08:05PM URINE HOURS-RANDOM
___ 08:05PM URINE UHOLD-HOLD
___ 08:05PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 08:05PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-TR BILIRUBIN-NEG UROBILNGN-4* PH-6.5 LEUK-NEG
___ 08:05PM URINE RBC-2 WBC-4 BACTERIA-FEW YEAST-NONE
EPI-2 TRANS EPI-<1
___ 08:05PM URINE HYALINE-1*
___ 08:05PM URINE MUCOUS-RARE
___ 02:29PM ALT(SGPT)-33 AST(SGOT)-63* ALK PHOS-116* TOT
BILI-2.5*
Final Report
INDICATION: ___ year old woman with EtOH cirrhosis, abdominal
pain and fever,
recently tapped ___ // rule out SBP
TECHNIQUE: Ultrasound guided diagnostic paracentesis
COMPARISON: Paracentesis dated ___
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated
a small
amount ofascites. 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 20 gauge spinal needle was advanced into the largest fluid
pocket in the
right lower quadrant under direct ultrasound visualization and
15 mL of clear,
straw-colored fluid was removed. The fluid was sent to the lab
as requested.
The patient tolerated the procedure well without immediate
complication.
Estimated blood loss was minimal.
Dr. ___ attending radiologist, was present throughout the
critical
portions of the procedure.
IMPRESSION:
Successful uncomplicated ultrasound guided diagnostic
paracentesis yielding 15
mL of clear yellow fluid from right lower quadrant. The fluid
was sent to the
lab as requested.
The study and the report were reviewed by the staff radiologist.
___. ___
___. ___
___ ___ 7:37 ___
Final Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with etoh cirhosis // please
eval for PVT;
please perform with doppler.
TECHNIQUE: Grey scale and color Doppler ultrasound images of
the abdomen were
obtained.
COMPARISON: ___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The
contour of the
liver is smooth. There is no focal liver mass. Main portal vein
is patent with
hepatopetal flow. There is a small amount of ascites, as well as
a small right
effusion.
DOPPLER: Color flow and pulse Doppler analysis were shows a
patent portal vein
without evidence of thrombosis. The main portal vein velocity is
42
centimeters/second. Right middle and left hepatic veins and
inferior vena cava
are patent. Hepatic arterial waveforms are normal. .
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD
measures 5 mm.
GALLBLADDER: Status post cholecystectomy. .
SPLEEN: Normal echogenicity, measuring 14.8 cm cm.
KIDNEYS: The right kidney measures 11.5 cm. The left kidney
measures 11.3 cm.
Normal cortical echogenicity and corticomedullary
differentiation is seen
bilaterally. There is no evidence of masses, stones or
hydronephrosis in the
kidneys.
RETROPERITONEUM: Visualized portions of aorta and IVC are within
normal
limits.
IMPRESSION:
No focal liver abnormality and normal liver Doppler. Small right
effusion and
ascites again noted as well as splenomegaly. .
___. ___
___ ___ 4:42 ___
Imaging Lab
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN Wheezing
2. Cyanocobalamin 50 mcg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Lactulose 30 mL PO BID
5. LaMOTrigine 50 mg PO BID
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 40 mg PO BID
9. Ondansetron 4 mg PO BID:PRN nausea
10. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
11. Rifaximin 550 mg PO BID
12. Simethicone 40-80 mg PO QID:PRN gas/abdominal pain
13. Spironolactone 150 mg PO DAILY
14. Thiamine 100 mg PO DAILY
15. Ursodiol 750 mg PO QHS
16. Vitamin D 50,000 UNIT PO EVERY 2 WEEKS
17. Furosemide 60 mg PO DAILY
18. Triamcinolone Acetonide 0.025% Cream 1 Appl TP DAILY
19. Sucralfate 1 gm PO QID
20. TraZODone 50 mg PO HS:PRN insomnia
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN Wheezing
2. Cyanocobalamin 50 mcg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Lactulose 30 mL PO BID
5. LaMOTrigine 50 mg PO BID
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 40 mg PO BID
9. Ondansetron 4 mg PO BID:PRN nausea
10. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
11. Rifaximin 550 mg PO BID
12. Simethicone 40-80 mg PO QID:PRN gas/abdominal pain
13. Spironolactone 150 mg PO DAILY
14. Sucralfate 1 gm PO QID
15. Thiamine 100 mg PO DAILY
16. TraZODone 50 mg PO HS:PRN insomnia
17. Triamcinolone Acetonide 0.025% Cream 1 Appl TP DAILY
18. Ursodiol 750 mg PO QHS
19. Furosemide 60 mg PO DAILY
20. Vitamin D 50,000 UNIT PO EVERY 2 WEEKS
21. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth Twice
Daily Disp #*3 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
1. Viral Syndrome
2. Clogged feeding tube
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 fevers, sob // pna
COMPARISON: ___.
FINDINGS:
PA and lateral views of the chest provided. There is a feeding tube in place
with its tip at the GE junction. Advancement is recommended to ensure tip
positioned in the stomach. Lungs are clear. There is no focal consolidation,
large 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. Dobbhoff tube tip in the GE junction.
Advancement recommended.
Radiology Report
INDICATION: ___ year old woman with EtOH cirrhosis, abdominal pain and fever,
recently tapped ___ // rule out SBP
TECHNIQUE: Ultrasound guided diagnostic paracentesis
COMPARISON: Paracentesis dated ___
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a small
amount ofascites. 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 20 gauge spinal needle was advanced into the largest fluid pocket in the
right lower quadrant under direct ultrasound visualization and 15 mL of clear,
straw-colored fluid was removed. The fluid was sent to the lab as requested.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ attending radiologist, was present throughout the critical
portions of the procedure.
IMPRESSION:
Successful uncomplicated ultrasound guided diagnostic paracentesis yielding 15
mL of clear yellow fluid from right lower quadrant. The fluid was sent to the
lab as requested.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with etoh cirhosis // please eval for PVT;
please perform with doppler.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: ___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. Main portal vein is patent with
hepatopetal flow. There is a small amount of ascites, as well as a small right
effusion.
DOPPLER: Color flow and pulse Doppler analysis were shows a patent portal vein
without evidence of thrombosis. The main portal vein velocity is 42
centimeters/second. Right middle and left hepatic veins and inferior vena cava
are patent. Hepatic arterial waveforms are normal. .
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 5 mm.
GALLBLADDER: Status post cholecystectomy. .
SPLEEN: Normal echogenicity, measuring 14.8 cm cm.
KIDNEYS: The right kidney measures 11.5 cm. The left kidney measures 11.3 cm.
Normal cortical echogenicity and corticomedullary differentiation is seen
bilaterally. There is no evidence of masses, stones or hydronephrosis in the
kidneys.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
No focal liver abnormality and normal liver Doppler. Small right effusion and
ascites again noted as well as splenomegaly. .
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with FEVER, UNSPECIFIED
temperature: 101.6
heartrate: 116.0
resprate: 18.0
o2sat: 100.0
sbp: 113.0
dbp: 64.0
level of pain: 7
level of acuity: 3.0 | ASSESSMENT AND PLAN
___ yo F w/PMH significant for alcoholic cirrhosis and previous
Roux-en-Y gastric bypass presents with fever.
# Fever: Most likely infectious source is upper respiratory
tract infection vs. SBP secondary to paracentesis. Received
vanc/cef in ED, narrowed to ceftriaxone overnight on night of
admission.
Viral panel was negative. We started ceftriaxone at 2g daily. ___
guided diagnostic para on ___ showed 525 WBC, 9 Polys, at which
point we decided to treat for SBP for 5 days with oral
Ciprofloxacin.
Her dobbhoff became clogged. We were unsuccessful at unclogging.
Pt needs placed under MAC. Pt made follow up for replacement. |
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, lethargy
Major Surgical or Invasive Procedure:
Intubation and mechanical sedation
History of Present Illness:
___ w/PMH HTN p/w sob + weakness x 4d, found to be
hypotensive/tachycardic and admitted to ___ for c/f occult
infection/septic picture. Pt states that he recently returned
from ___, had a mild cough x 4d. Reports mild dyspnea, worse
on exertion. Patient reports that he did not get up at all
during the plane flight. Denies hemoptysis. Patient reports no
fever/chills/nausea/vomiting/diarrhea/dysuria. He did present to
his PCP yesterday morning and was tested with rapid strep
screen, results pending.
.
In the ED,
initial vitals: 97.2 74 105/50 16 96% 2L Nasal Cannula
Labs significant for:
WBC 6.6, Hct 35.6 Plts 192. PMN 82%
BUN 45, Cr 1.1, Gluc 258, P 0.9, ALT 41, AST 22, AP 28, u/a
+ketones 40, proBNP 171
Ca: 8.1 Mg: 1.6 P: 0.9
.
EKG: 1mm st depressions in anterior septal leads. tachycardia to
120s.
CTPA: showed no PE or aortic pathology. Bedside ultrasound did
not demonstrate any significant effusion or major wall
.
After CT the patient became tachycardic once again to the mid
___. Received 2L NS. At this time he was febrile to 102
received Tylenol, vancomycin, levofloxacin and metronidazole.
Admitted for c/f occult infection
.
On arrival to the ICU, the pt was tachycardic to 130s-140. He
had an episode almost immediately of what was thought to be
seizure-like activity; He flailed himself across the bed with
jerking extremity movements. After this he appeared to be very
confused. Was given 1mg IV ativan. He was noted to have melena
and vomited coffee-ground appearing material. NG lavage was
performed, which showed coffee-grounds and did not clear even
after 400 ccs. GI was consulted. HCT was rechecked on arrival to
the unit and was now at 22 from 35 earlier. ABG performed which
did confirm this lab result. 3u pRBCs were ordered with plan to
give all. Also ABG showed that he had a primary respiratory
alkalosis. Pt was hypomagnesemic, hypophosphatemic, and
electrolytes were repleted.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, or wheezing. Denies chest pain, chest
pressure, palpitations, or weakness. Denies nausea, vomiting,
diarrhea, constipation, abdominal pain, or changes in bowel
habits. Denies dysuria. Denies arthralgias or myalgias. Denies
rashes or skin changes.
Past Medical History:
HTN
HLD
possible alcohol abuse
possible smoking
sleep apnea
Social History:
___
Family History:
Both parents with diabetes
Physical Exam:
ADMISSION EXAM:
Vitals: T:99.3 BP:121/97 P:132 R:21 O2: 99% 3L NC
General: Alert, oriented, appears to have shallow breathing
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: thick, but supple, JVP not elevated, no LAD
Lungs: mild crackles at the bases. no wheezing
CV: tachycardic, III/VI systolic murmur that radiates to the
axilla
Abdomen: distended, protuberant, but soft without pain on
palpation or guarding. no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Pertinent Results:
ADMISSION LABS:
___ 03:10AM BLOOD WBC-6.6 RBC-3.75* Hgb-11.6* Hct-35.6*
MCV-95 MCH-31.0 MCHC-32.6 RDW-13.4 Plt ___
___ 03:10AM BLOOD Neuts-82.0* Lymphs-12.7* Monos-4.6
Eos-0.2 Baso-0.5
___ 03:10AM BLOOD ___ PTT-26.3 ___
___ 03:10AM BLOOD Glucose-258* UreaN-45* Creat-1.1 Na-135
K-4.8 Cl-100 HCO3-26 AnGap-14
___ 03:10AM BLOOD ALT-41* AST-22 AlkPhos-28* TotBili-0.2
___ 03:10AM BLOOD proBNP-171*
___ 03:10AM BLOOD cTropnT-<0.01
___ 03:10AM BLOOD Albumin-3.7 Calcium-8.1* Phos-0.9* Mg-1.6
___ 03:10AM BLOOD D-Dimer-<150
___ 03:10AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 03:33AM BLOOD Lactate-1.8
___ 10:59AM BLOOD WBC-4.7 RBC-2.37*# Hgb-7.4*# Hct-22.2*#
MCV-93 MCH-31.3 MCHC-33.5 RDW-13.8 Plt ___
___ 03:28AM URINE Color-Yellow Appear-Clear Sp ___
___ 03:28AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-150 Ketone-40 Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 07:07AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
___ 10:59AM BLOOD Ethanol-NEG
___ 10:59AM BLOOD CK-MB-2 cTropnT-<0.01
___ 10:59AM BLOOD CK(CPK)-96
MICROBIOLOGY:
Blood cultures ___: pending
Medications on Admission:
Hydrochlorothiazide 25 mg Oral Tablet Take 1 tablet daily
Fluticasone 50 mcg/Actuation Nasal Spray, Suspension
Discharge Disposition:
Home
Discharge Diagnosis:
GI bleed
gastric ulcer
acute blood loss anemia
duodenitis
Probable Aspiration Pneumonia
Mechanical Ventillation for respiratory distress
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with weakness and cough.
STUDY: AP upright and lateral chest radiograph.
COMPARISON: None.
FINDINGS: Lordotic positioning. The cardiomediastinal and hilar contours are
unremarkable. Possible minimal altectasis in the left lower lobe. No focal
infiltrate identified. There is no pleural effusion or pneumothorax.
IMPRESSION: Minimal atelectasis. No focal infiltrate identified.
Radiology Report
HISTORY: ___ male with shortness of breath after a long flight as
well as tachycardia and hypertension.
STUDY: Chest CTA; MDCT images were generated through the chest without IV
contrast. Subsequent MDCT images were generated through the chest after the
uneventful IV administration of 100 cc of Optiray intravenous contrast.
Coronal, sagittal and right and left oblique reformatted images were also
generated.
COMPARISON: None.
FINDINGS: The visualized portion of the thyroid appears unremarkable. There
is no axillary or hilar. Scattered mediastinal lymph nodes measure at the
upper limits of normal (most prominent in the subacarinal station measuring 22
x 11 mm - 3;27). The aorta is of a normal caliber along its course without
evidence of dissection or intramural hematoma. The pulmonary arterial trunk
is within normal limits and there are no filling defects of the pulmonary
arterial tree down to the subsegmental level. The tracheobronchial tree is
also patent to the subsegmental level. There is no pleural or pericardial
effusion. Incidental note is made of a common origin of the brachiocephalic
and left common carotid arteries, a normal variant. The lungs are clear.
The imaged portion of the upper abdomen shows a fatty liver.
The visualized skeleton shows no aggressive-appearing lytic or sclerotic
lesion with only minimal degenerative change.
IMPRESSION:
1. No PE or acute aortic syndrome.
2. Enlarged subcarinal lymph node.
3. Fatty liver.
Radiology Report
HISTORY: Upper GI bleed electively intubated for EGD.
CHEST, SINGLE AP PORTABLE SUPINE VIEW.
There are low inspiratory volumes. An ET tube is present. The tip lies
approximately 5.2 cm above the carina. There is patchy infrahilar opacity,
left greater than right, of uncertain etiology or significance, particularly
in light of low lung volumes. The possibility of a focal infiltrate or focus
of aspiration cannot be excluded. Remainder of both lungs is grossly clear.
No effusion or CHF.
IMPRESSION: Patchy infrahilar opacities, particularly about the left hilum,
which are new compared with ___. They were not apparent on a ___ CT
scan, so, in the absence of intervening pathology, may very well represent
atelectasis related to low lung volumes. In the appropriate clinical setting,
the ddx would include aspiration or infectious infiltrate.
Radiology Report
REASON FOR EXAMINATION: Fever, gastrointestinal bleeding, intubated.
Portable AP chest radiograph was reviewed in comparison to ___.
Meanwhile, the patient was extubated. Heart size and mediastinal silhouettes
are stable. Left lower lobe opacity appears to be increased in the interim
and might reflect atelectasis, although aspiration or progression of pneumonia
cannot be excluded in this location. No appreciable pleural effusion is seen.
No pneumothorax is demonstrated.
Radiology Report
CLINICAL HISTORY: ___ man with shortness of breath and cough.
COMPARISON: ___.
FINDINGS: Heart size is normal. Persistent bilateral infrahilar opacities
are likely atelectasis most commonly due to hypoventilation or aspiration.
Large azygous vein argues for increased central venous pressures. No
appreciable pleural effusions. No pneumothorax.
Radiology Report
HISTORY: Hypertension status post intubation access or worsening pneumonia.
FINDINGS: In comparison with the study of ___, the patient has taken a
substantially better inspiration. Cardiac size is within normal limits. No
vascular congestion or pleural effusion. The areas of opacification in the
infrahilar regions, especially on the left, are not appreciated, most likely
reflecting the better inspiration.
There is still some prominence in the azygos region, though no definite
engorgement of pulmonary vessels in the central or peripheral areas.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: DYSPNEA, LETHARGY
Diagnosed with TACHYCARDIA NOS, HYPOTENSION NOS
temperature: 97.2
heartrate: 74.0
resprate: 16.0
o2sat: 96.0
sbp: 105.0
dbp: 50.0
level of pain: 0
level of acuity: 3.0 | ___ y/o M history of HTN, HLD presents with hypotension and
shortness of breath, with initial concern for PE given recent
travel. However d-dimer and CTA were negative. Patient
ultimately found to have anemia and UGI bleed and transferred to
___.
.
# GIB: Pt presented with tachycardia, lethargy, found to have
melena on rectal exam and coffee grounds on NG lavage (not
clearing with 400cc). Denies n/v/epigastric pain. Denies
significant NSAID use or hx of ulcers, gastritis. Endorses some
EtOH use s/p trip to ___ but no h/o ETOH abuse. HCT 35 on
admission, down from ___ HCT of 49.5. Repeat HCT was 22.2. got
5uprbc. No known cirrhosis or varices. Imaging here documented
fatty liver but no cirrhosis. [patient was electively intubated
for egd due to episodes of apnea. intubated ___, extubated ___
w/o events] Patient undewent EGD on endoscopy showed dried blood
mixed with food in stomach, couldn't visualize well. on ___
underwent repeat EGD which showed stomach ulcer with "cherry red
spot" that was clipped x2, likely source of bleeding, also had
some smaller erosions. Patient will need f/u with GI as well as
repeat EGD in ___ weeks.
Patient HCT were trended and remained stable. On day of transfer
out of ICU HCT was 31. Patient's diet was advanced to clears on
___ and tolerated well. His H pylori serology was POSITIVE.
Since is currently on levofloxacin for possible pneumonia, he
can start a course of triple therapy for H. Pylori once he is
done with a course of levofloxacin. He remained on a protonix
drip for 72h to end on ___ and then transition to high dose
oral BID PPI. It will be important to document a treatment cure
for h. pylori during his future endoscopy because of the
presence of significant PUD.
He will be discharged on a prevpac
(lansoprazole/clarithromycin/amoxicillin) to take for 14d and
then take a BID PPI after completion.
# FEVER/Respiratory Distress requiring intubation and mechanical
ventillation after first EGD
Patient with fever to 102.9 on day of admission with
non-specific respiratory symptoms. His initial CXR not
suggestive of PNA. Patient at the time was hypotensive with
concern for sepsis so he was started on vanc/levoflox/flagyl.
Antibiotics were then narrowed to levofloxacin for ?CAP.
Following procedure patient developed productive cough and nasal
congestion with cxr note of bibasilar opacities suggesive of
?aspiration event given recent intubation. Upon arriving to the
medical floor he had a lower grade fever to 100.2, but no signs
of ongoing sepsis. The GI team reported copious purulent nasal
secretions at the time of his second endoscopy raising the
possibility of sinusitis. His fever curve continued to decline.
He will be discharged on clarithromycin/amoxicillin to treat
his H.Pylori and these antibiotics also have good coverage for
community acquired pneumonia organisms.
# Hyperglycemia: Patient was hyperglycemic on presentation,
possibly due to stress response. A1C of 6.2
# Seizure/Loss of Consciousness - on arrival to FICU pt
experienced a short episode of seizure activity, followed by
confusion. Denies history of seizure disorder. Received 1mg
ativan. No further episodes since. ___ have been related to
metabolic disturbances. Unlikely withdrawal seizure, as patient
has not been scoring on CIWA. No further seizure activity.
# ?Alcohol Abuse: Pt endorses ___ glasses of wine a night,
though this value changes with different encounters with various
medical providers. Recent trip to ___ but denies drinking
to excess at that time. Pt with documented hx of alcohol use on
Atrius records but no clear documentation of abuse.
# ___: Cr 1.1 at presentation (baseline 0.8). Improved to
baseline with fluid resuscitation.
.
# Fatty liver - seen on CT. c/f diabetes or could be ___ alcohol
use vs metabolic syndrome given A1c 6.2. Does not appear to have
progressed to cirrhosis. ALT mildly elevated, AST wnl. Alk phos
mildly elevated. No RUQ symptoms, no vomiting or pain. No
abdominal pain or tenderness. Recommend outpatient followup.
Plan At discharge
--clarithromycin/amoxicillin for possible pneumonia
--nasal saline rinse
--clarithromycin/amoxicillin/omeprazole x2 weeks for h. pylori
--arrange outpatient GI followup for repeat endoscopy |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Doxycycline / fluconazole
Attending: ___.
Chief Complaint:
Bradycardia and Hypotension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with a history of metastatic lung cancer s/p cycle
4 premetrexed/carboplatin who is admitted with bradycardia and
hypotension. The patient states she has been feeling very tired
and weak and has had dizziness and lightneadedness when she
walks. She has fallen twice recently. She has found by a home
health nurse to have a heart rate as low as the ___ and a blood
pressure as low as the ___ systolic. She went to her local ED
and recieved a dose of atropine and antibiotics and was
transferred to the ED here. The patient states that about a week
ago she started having some dysuria. In the last couple of days
she has had urinary frequency as well. She reports having a UTI
a month ago and her symptoms did get better before these started
again last week. She denies any fevers, cough, shortness of
breath, nausea, or change in ostomy output.
REVIEW OF SYSTEMS:
- All reviewed and otherwise negative.
Past Medical History:
PAST ONCOLOGIC HISTORY (per OMR):
1. Presented to office of Primary Care Physician in ___
with two weeks of new headaches, dizziness, abnormal gait,
visual
changes, and loss of appetite. She was subsequently evaluated
in
an outside Emergency Department with imaging that revealed
multiple intracranial lesions.
2. Patient was transferred to ___ on ___. She was
started
on Keppra and dexamethasone. A MRI of the head revealed
multiple
ring-enhancing lesions in bilateral cerebral and cerebellar
hemispheres with associated FLAIR signal abnormality, and
restricted diffusion.
3. A CT scan of the chest on ___ revealed a likely primary
lung neoplasm obliterating the left upper lobe bronchus with
secondary left upper lobe. There was a small to moderate simple
left layering pleural effusion with adjacent subsegmental
atelectasis. A CT scan of the abdomen/pelvis on the same day
revealed an enlarged rounded left iliac chain lymph node
measuring 1.4 x 1.1 x 1.3 cm. There were multiple bilateral
renal hypodense lesions.
4. Patient underwent left thoracentesis on ___. Pathology
was consistent with lung adenocarcinoma. For purposes of
molecular testing, patient underwent EBUS with biopsy of level 4
and level 7 lymph nodes. Molecular testing returned positive
for
KRAS mutation. EGFR mutation was not detected. Rearrangements
in ALK and ROS1 were not detected.
5. Patient initiated whole brain external beam radiation while
hospitalized. She completed three out of five planned
fractions.
Patient was discharged home on ___.
6. Patient completed whole brain radiation therapy on ___.
Total dose ___ cGY.
7. Patient was re-admitted at ___ on ___ with symptoms of
headache, nausea, emesis, and gait instability in the setting of
steroid taper. CT scan of the head on admission showed stable
to
slightly improved vasogenic edema.
8. A bone scan on ___ showed left frontal bone, left
posterior parietal bone, and right sacroiliac joint increased
uptake, consistent with metastatic disease. Patient received
B12
injection sometime between ___ and ___. Folate was
also initiated during hospitalization. She was discharged home
with open-access hospice services and increased dose of
dexamethasone on ___.
9. Cycle 1 of palliative carboplatin/pemetrexed administered on
___. Dexamethasone tapered off between cycles 1 and 2.
Cycle 2 administered on ___. PET imaging revealed stable
disease. Cycle 2 was complicated by anorexia and excessive
fatigue. Dexamethasone resumed at dose of 4 mg daily on ___
with improvement in symptoms. Cycle 3 administered on ___.
Cycle 4 ___.
PAST MEDICAL HISTORY:
Metastatic lung adenocarcinoma as above
Ulcerative colitis
Gastroesophageal reflux disease
Thyroid nodule
Migraines
Breast cyst
Plantar fasciitis
Abdominal colectomy and ileorectal anastomosis
Thyroidectomy
Tubal ligation
Social History:
___
Family History:
Mother: ___ degeneration.
Father: ___ bowel disease, CVA.
Maternal grandfather: CVA.
Brother: ___ bowel disease.
Sister: DM.
Physical Exam:
PHYSICAL EXAM:
General: NAD
VITAL SIGNS: T 97.2 HR 42 BP 95/55 O2 100%RA
HEENT: MMM
CV: Bradycardia
PULM: CTAB
ABD: Soft, NTND, no masses or hepatosplenomegaly, ostomy
present
with brown stool output.
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: Superficial abrasion to left arm.
NEURO: Alert and oriented, no focal deficits.
Pertinent Results:
___ 06:35AM GLUCOSE-88 UREA N-13 CREAT-0.7 SODIUM-133
POTASSIUM-3.8 CHLORIDE-98 TOTAL CO2-26 ANION GAP-13
___ 06:35AM ALT(SGPT)-22 AST(SGOT)-27 ALK PHOS-41 TOT
BILI-0.3
___ 06:35AM cTropnT-<0.01
___ 06:35AM CALCIUM-8.9 PHOSPHATE-2.9 MAGNESIUM-1.7
___ 06:35AM WBC-6.2 RBC-2.98* HGB-8.8* HCT-27.3* MCV-92
MCH-29.5 MCHC-32.2 RDW-23.1* RDWSD-76.7*
___ 07:34PM LACTATE-2.0
Portable Chest X-ray ___:
IMPRESSION:
Persistent left upper lobe collapse without evidence of
pneumonia. Decreasing mass, left hilus and left upper lobe.
Possible pulmonary metastasis, right lower lobe.
This examination neither suggests nor excludes the diagnosis of
pulmonary embolism.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LeVETiracetam 500 mg PO BID
2. Multivitamins 1 TAB PO DAILY
3. Omeprazole 40 mg PO DAILY
4. Vitamin D ___ UNIT PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. B Complete (vitamin B complex) 0 ORAL DAILY
7. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150
mg-unit-mg-mg oral DAILY
8. Lorazepam 0.5 mg PO QHS:PRN Insomnia, Nausea
9. OxyCODONE SR (OxyconTIN) 10 mg PO QHS
10. Prochlorperazine 10 mg PO Q6H:PRN Nausea
11. TraZODone 50 mg PO QHS:PRN Insomnia
12. Clotrimazole 1 TROC PO QID
13. Atovaquone Suspension 1500 mg PO DAILY
14. Dexamethasone 4 mg PO DAILY
15. Dronabinol 2.5 mg PO BID
16. TraMADOL (Ultram) 50 mg PO Q4H:PRN Pain
Discharge Medications:
1. Atovaquone Suspension 1500 mg PO DAILY
2. Clotrimazole 1 TROC PO QID
3. Dexamethasone 4 mg PO DAILY
4. Dronabinol 2.5 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
6. LeVETiracetam 500 mg PO BID
7. Lorazepam 0.5 mg PO QHS:PRN Insomnia, Nausea
8. Omeprazole 40 mg PO DAILY
9. OxyCODONE SR (OxyconTIN) 10 mg PO QHS
10. Prochlorperazine 10 mg PO Q6H:PRN Nausea
11. TraMADOL (Ultram) 50 mg PO Q4H:PRN Pain
12. TraZODone 50 mg PO QHS:PRN Insomnia
13. Vitamin D ___ UNIT PO DAILY
14. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth every six (6) hours
Disp #*48 Capsule Refills:*0
15. B Complete (vitamin B complex) 1 tablet ORAL DAILY
16. Multivitamins 1 TAB PO DAILY
17. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-5-150
mg-unit-mg-mg oral DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
C. difficile infection
Adrenal insufficiency
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with metastatic lung cancer and hypotension.
// Evaluate for pneumonia.
TECHNIQUE: CHEST (PORTABLE AP)
COMPARISON: CT chest from 1 day prior, PA and lateral views of the chest
dated ___, portable view of the chest dated ___
FINDINGS:
There is persistent elevation of the left hemidiaphragm with opacity of the
left hemithorax and elevation of the left mainstem bronchus and a stable
Luftsichel sign, consistent with continued left upper lobe collapse although
the volume of the collapsed lobe and the large central mass have mass have
both decreased since ___. Right basilar atelectasis is noted and
there could be a small metastatic nodule. There is no radiographic evidence
of pneumonia, though evaluation on recent CT is more specific. The cardiac
silhouette and pulmonary vasculature are unremarkable and unchanged since the
prior examinations. No definite pleural effusion or pneumothorax identified.
IMPRESSION:
Persistent left upper lobe collapse without evidence of pneumonia. Decreasing
mass, left hilus and left upper lobe. Possible pulmonary metastasis, right
lower lobe.
This examination neither suggests nor excludes the diagnosis of pulmonary
embolism.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hypotension, Transfer
Diagnosed with Urinary tract infection, site not specified
temperature: 97.9
heartrate: 64.0
resprate: 16.0
o2sat: 98.0
sbp: 148.0
dbp: nan
level of pain: 0
level of acuity: 2.0 | ___ yo female with a history of metastatic lung cancer s/p cycle
4 premetrexed/carboplatin who is admitted with bradycardia and
hypotension.
Concern for UTI: U/A at ___ concerning for UTI with
___ WBC, ___ RBC, 0 Epis, 2 + bacteria, moderate ___, -
nitrites but culture growing mixed bacteria consistent with
contamination. U/a and culture here negative. She was initially
put on ceftriaxone which was discontinued.
C. Diff: C. diff positive with some increased watery ostomy
output. Started on PO vancomycin for 14 day course.
Hypotension: possibly due to infection, adrenal insufficiency or
dehydration. Her baseline systolic blood pressures in clinic
appears to be 100-120. She did not appear significantly
hypovolemic on examination and infection overall did not appear
severe enough to be causing this degree of hypotension. She was
placed on stress dose steroids with hydrocortisone with
improvement in her blood pressure. She was transitioned back to
her home dose of decadron prior to discharge. BP's on day of
discharge 120's systolic.
Bradycardia: she has chronic sinus bradycardia for years, no
changes on ECG, no evidence of conduction disease on telemetry
or ECG. She does report increased falls and ? syncopal episode
at home. Her bradycardia may be contributing but she is not
interested in an intervention such as a pacemaker. TSH normal.
Chest pressure: Atypical chest pressure since she fell, likely
musculoskeletal (reproducible on exam), no ischemic ECG changes,
troponin negative and resolved. Could also be due to lung mets.
Thrush
Continued home clotrimazole.
Metastatic Lung Cancer
S/p cycle 4 premetrexed/carboplatin ___. She is finished
with carboplatin, per oncology plan to continue with maintenance
premetrexed. Continued home atovaquone, dronabinol, folic acid,
keppra, ativan, omeprazole, pampazine, and trazadone.
FEN:
Regular diet
PAIN: Continued home oxycontin at night and PRN ultram. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Sulfa (Sulfonamide Antibiotics) / Opioids-Morphine
& Related
Attending: ___.
Chief Complaint:
Shortness of Breath
Major Surgical or Invasive Procedure:
RHC ___
History of Present Illness:
Ms. ___ is a ___ female with history of CAD
s/p MI and s/p CABG ___ years ago, HTN, HLD, DM, and CHF
presenting with shortness of breath waking her up from sleep at
0300 this morning. She also reports five pound weight gain over
the past 2 days from dry weight 160-161 lbs to 167 lbs. She
notes that she ate a lot of salty food at a family party 2 days
ago. Otherwise denies any recent symptoms of illness prior to
this episode. Only recent stressor is that brother in law passed
away unexpectedly 1 month ago. Patient has had multiple
admissions for similar presentations including here in ___
and ___ in ___. En route she was given SLNG x3
and Lasix 20 mg IV.
- In the ED initial vitals were: 98.6 64 182/50 16 99% BiPAP.
- On arrival in ED, was placed on BiPAP for tachypnea and
respiratory distress, weaned down to NRB then to NC.
- Exam with inspiratory crackles and 2+ lower extremity pitting
edema.
- Labs/studies notable for: WBC 18.4 (87% PMNs, 5.6% lymphs),
H/H 10.5/32.8 (at baseline), Plt 194, Na 142, K 4.0, BUN/Cr
64/1.8 (baseline Cr 1.7-2.0), trop < 0.01, CK-MB 2, BNP 1610,
lactate 1.1. UA with large leuks, negative nitrite, 52 WBCs.
- Patient was given: Lasix 40mg IV x 2 and started on a
nitroglycerin gtt at 0.8 mcg/kg/min.
- CXR with mild pulmonary edema and cardiomegaly.
- Vitals on transfer: 98.7 71 149/58 29 96% 4L NC. I/Os: Voided
500 cc's as of 5 AM.
On the floor, patient denies chest pain or current SOB,
continues to endorse SOB but is feeling improved.
Past Medical History:
PAST MEDICAL HISTORY:
- CAD s/p MI and s/p CABG
- ___ persantine stress showed no large WMAs
- CHF (borderline LVEF, mod diastolic dysfxn) with multiple
exacerbations
- Diabetes c/b retinopathy, nephropathy, and neuropathy
- Hyperlipidemia
- Hypertension
- ?CKD ___ DM
- Legally blind
- COPD
- Gout
- PVD
- Severe OA
- Depression
-h/o pancreatitis
- Hemorrhoids
- Glaucoma
- Legally blind
- h/o tubular villous adenoma on ___ ___
- s/p hip replacement
Social History:
___
Family History:
Family history of HTN and DM (mother).No family history of early
MI, arrhythmia, cardiomyopathies, or sudden cardiac death;
otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 159/73 72 22 94%/4L
Weight: 76.7 kg (dry weight 77 kg in ___ but reports recently
161 lbs/73.2 kg)
GENERAL: Pleasant woman in no acute distress. Mood, affect
appropriate.
HEENT: NCAT. PERRL, EOMI. MM slightly dry.
NECK: Supple with JVP of 12 cm.
CARDIAC: RRR, II/VI systolic murmur loudest LUSB.
LUNGS: No accessory muscle use, appears slightly dyspneic,
speaking in full sentences. Crackles and poor air movement
midway up bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: 2+ pitting edema to knees bilaterally.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
DISCHARGE PHYSICAL EXAM:
VS: 98.5 ___ 18 92-95%RA
I/O: 400/950 (24h)
Weight: 74.1 / 74.1 kg yesterday (dry weight 77 kg in ___ but
reports recently 161 lbs/73.2 kg)
GENERAL: Pleasant woman in no acute distress. Mood, affect
appropriate. Legally blind.
HEENT: NCAT. PERRL, EOMI. MMM
NECK: Supple, JVP 9
CARDIAC: RRR, II/VI systolic murmur loudest LUSB.
LUNGS: No accessory muscle use, speaking in full sentences.
Trace bibasilar crackles.
ABDOMEN: Soft, NTND, normoactive bowel sounds.
EXTREMITIES: ___ pitting edema to shins bilaterally
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
ADMISSION LABS:
___ 03:30AM BLOOD WBC-18.4*# RBC-3.95 Hgb-10.5* Hct-32.8*
MCV-83# MCH-26.6 MCHC-32.0 RDW-14.3 RDWSD-42.6 Plt ___
___ 03:30AM BLOOD Neuts-86.9* Lymphs-5.6* Monos-4.7*
Eos-1.6 Baso-0.4 Im ___ AbsNeut-15.98* AbsLymp-1.03*
AbsMono-0.86* AbsEos-0.30 AbsBaso-0.08
___ 03:30AM BLOOD Plt ___
___ 03:30AM BLOOD Glucose-261* UreaN-64* Creat-1.8* Na-142
K-4.0 Cl-108 HCO3-22 AnGap-16
___ 03:30AM BLOOD cTropnT-<0.01
___ 03:30AM BLOOD CK-MB-2 proBNP-1610*
___ 03:30AM BLOOD Calcium-8.7 Phos-4.1 Mg-2.0
___ 03:37AM BLOOD Lactate-1.1
DISCHARGE LABS:
___ 04:30AM BLOOD WBC-9.0 RBC-3.35* Hgb-9.0* Hct-28.6*
MCV-85 MCH-26.9 MCHC-31.5* RDW-14.6 RDWSD-44.3 Plt ___
___ 07:10AM BLOOD Glucose-125* UreaN-87* Creat-1.7* Na-141
K-4.0 Cl-102 HCO3-27 AnGap-16
___ 07:10AM BLOOD Calcium-9.3 Phos-4.4 Mg-2.3
STUDIES:
CXR ___
1. Mild pulmonary edema.
2. Cardiomegaly.
ECG ___
Sinus rhythm. Left ventricular hypertrophy with secondary
repolarization
changes. Possible old anterior myocardial infarction. Compared
to the
previous tracing of ___ no change.
Right heart cath ___
Mildly elevated R and L sided filling pressures with moderate
pulmonary hypertension and preserved cardiac output.
MICROBIOLOGY:
Urine culture ___: E. coli and Klebsilla pneumonia, pan
sensitive.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Carvedilol 25 mg PO BID
5. Citalopram 10 mg PO DAILY
6. Docusate Sodium 100 mg PO DAILY:PRN constipation
7. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
8. Omeprazole 40 mg PO DAILY
9. Vitamin D 500 UNIT PO DAILY
10. Glargine 26 Units Bedtime
11. Simvastatin 40 mg PO QPM
12. Torsemide 20 mg PO BID
13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
14. Dorzolamide 2%/Timolol 0.5% Ophth. 2 DROP BOTH EYES QHS
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Carvedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg Take 1 tablet by mouth twice a day. Disp
#*60 Tablet Refills:*1
5. Omeprazole 40 mg PO DAILY
6. Vitamin D 500 UNIT PO DAILY
7. Atorvastatin 20 mg PO QPM
RX *atorvastatin 20 mg Take 1 tablet by mouth daily. Disp #*30
Tablet Refills:*1
8. Citalopram 10 mg PO DAILY
9. Docusate Sodium 100 mg PO DAILY:PRN constipation
10. Dorzolamide 2%/Timolol 0.5% Ophth. 2 DROP BOTH EYES QHS
11. Glargine 26 Units Bedtime
12. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
13. HydrALAzine 75 mg PO Q8H
RX *hydralazine 50 mg Take 1 tablet by mouth three times a day.
Disp #*90 Tablet Refills:*1
RX *hydralazine 25 mg Take 1 tablet by mouth three times a day.
Disp #*90 Tablet Refills:*1
14. Isosorbide Mononitrate (Extended Release) 90 mg PO DAILY
RX *isosorbide mononitrate 60 mg Take 1 tablet by mouth daily.
Disp #*30 Tablet Refills:*1
RX *isosorbide mononitrate 30 mg Take 1 tablet by mouth daily.
Disp #*30 Tablet Refills:*1
15. Torsemide 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Acute on Chronic Diastolic Heart Failure
- Complicated UTI
Secondary Diagnosis:
- Hypertension
- Hyperlipidemia
- CAD s/p MI and CABG
- Diabetes Mellitus
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: ___ with CHF // eval for pulmonary edema
TECHNIQUE: Portable AP view of the chest was obtained
COMPARISON: ___
FINDINGS:
The cardiac silhouette is significantly enlarged, similar to prior
examinations. Again noted are surgical clips in the mediastinum. No midline
sternal wires are identified. Hazy, bilateral opacities are noted, which are
diffuse. The pulmonary vasculature is mildly indistinct. A small right
pleural effusion may be present. There is no pneumothorax. Bibasilar
atelectasis is noted.
IMPRESSION:
1. Mild pulmonary edema.
2. Cardiomegaly.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with heart failure. // Please evaluate for
vascular congestion, pleural effusions, acute process. Please evaluate
for vascular congestion, pleural effusions, acute process.
COMPARISON: Chest radiographs since ___ most recently ___.
IMPRESSION:
Previous mild pulmonary edema has resolved. Pulmonary vasculature is still
engorged. Severe cardiomegaly is chronic. No pleural abnormality. Vascular
clips denote prior coronary bypass grafting.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Heart failure, unspecified
temperature: 98.6
heartrate: 64.0
resprate: 16.0
o2sat: 99.0
sbp: 182.0
dbp: 50.0
level of pain: 0
level of acuity: 1.0 | ___ y/o F w/hx CAD s/p MI and s/p CABG ___ ago, HTN, HLD, DM,
and CHF with preserved EF presenting with CHF exacerbation in
setting of hypertension and diet indiscretion.
# Acute on Chronic Diastolic Heart Failure: Previous TTE in
___ with EF > 75%. proBNP elevated to 1610 on admission.
Potential triggers include patient's reported dietary
indiscretion, hypertension to 180s on arrival, and UTI (see
below). No known history of CAD and CMs negative. She was
diuresed with Lasix drip and boluses. When euvolemic she
underwent R heart cath which showed moderate pulmonary
hypertension and mildly elevated right/left sided filling
pressures with preserved cardiac output. She was continued on
imdur and amlodipine as below. Carvedilol was decreased to 12.5
mg bid.
# Hypertension: Continued home imdur and amlodipine. Carvedilol
was decreased to 12.5 mg bid from 25 mg bid given heart failure.
As patient remained hypertensive in house hydralazine was added
and dose uptitrated.
# Complicated urinary tract infection: Urine culture on
admission grew E. coli and Klebsiella. She denied symptoms.
Given DM2 she was treated for complicated UTI with ceftriaxone
and transitioned to ciprofloxacin to complete ___AD s/p MI and CABG: Patient had ___ persantine stress which
showed no large WMAs. Patient has had no recent chest pain and
troponins negative. She was continued on home ASA, imdur, and
carvedilol. Simvastatin was changed to atorvastatin given that
simvastatin is contraindicated with amlodipine.
# CKD: Cr 1.8 on admission (baseline Cr 1.7-2.0). No further
action was required.
# Diabetes Type II: Contineud on glargine and Humalog sliding
scale. Doses adjusted as needed.
# Hyperlipidemia: Home simvastatin was changed to atorvastatin
given concern for contraindication of simvastatin with
amlodipine.
# Gout: Continued home allopurinol
#GERD: Continued home omeprazole 40mg
# Glaucoma: Continued home eye drops
# CODE: Full Code
# CONTACT: ___ (brother) ___ (home),
___ (cell) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
tachypnea
Major Surgical or Invasive Procedure:
___ - Thoracentesis
___ - TIPS
___ - EGD with banding of bleeding esophageal varices
___- thoracentesis
___- paracentesis
___ - TIPS upsize
History of Present Illness:
___ year old woman with history of ETOH cirrhosis who presented
to the hospital on ___ for weight loss and failure to thrive
over the past several weeks. She has had ___ weight loss and
decrease appetite. Also had a waxing and waning cough with
sputum production.
On the medical floor the patient was found to have some ascites
but no large pocket. She was found to have an acute drop in her
hemoglobin and received a blood transfusion. She underwent an
EGD records of grade 2 varices and evidence of portal
hypertensive gastropathy. Urine culture came back positive for
a E. coli UTI and she was treated with ceftriaxone from
___.
The patient was having dyspnea for approximately 1 week prior to
admission. There was concern previously this was secondary to
chronic bronchitis and occasional asthma symptoms. Initially
her chest x-ray showed no acute process. 2 days later she was
found to have a hepatic hydrothorax and new oxygen requirement.
Chest x-ray showed evidence right-sided pleural effusion. The
patient underwent thoracentesis and 8 ___ tube placement for
slow therapeutic drainage by interventional pulmonology. The
pigtail was removed on ___.
The patient has been having persistent wheezing and was getting
standing up for this.
For her dyspnea she also further workup which included a CTA
that was negative for PE. She had a TTE with no evidence of
intrapulmonary shunting. She was being diuresed on the floor
with Lasix and spironolactone.
The patient started spiking fevers on ___ to 100.5 with unclear
etiology. Her pleural fluid had no evidence of infection.
Chest x-ray with question infiltrate given that the patient was
having only pulmonary symptoms decision was made to start her on
treatment with levofloxacin for community-acquired pneumonia.
Given that she was also having diarrhea C. difficile test was
sent. She had bilateral lower extremity ultrasounds that were
negative for DVT.
On the evening of ___ patient triggered on the medical floor
for tachypnea with rates to 36. The patient was in distress and
unable to speak full sentences. She was also notably
uncomfortable.
VS prior to transfer were notable for 98.2 115 / 65 88 36 91 RA.
The patient was given 60 mg of IV Lasix as well as. On
evaluation she reports the albuterol nebulizer helped somewhat
with her breathing. And she felt feels less short of breath.
However she still appears tachypneic. Per the nursing and
medical team this is an acute change from how she felt prior.
Chest x-ray had been obtained and was reviewed which is
concerning for a right sided large reaccumulation of her pleural
fluid.
Past Medical History:
1. History of seasonal asthma for which she takes Xopenex
p.r.n.
2. Chronic bronchitis. She attributes it to secondhand smoke
exposure from both parents.
3. History of familial tremor (father and daughter).
4. History of cirrhosis ___ as above.
5. History of GI bleed thought to be secondary to portal
hypertension ___ as above.
6. History of hepatic encephalopathy treated successfully with
rifaximin and lactulose, now just on lactulose.
7. History of pansensitive E. coli UTI in ___.
8 Anxiety and Depression
Social History:
___
Family History:
Father living, hypercholesterolemia, hard of hearing.
Mother died at age ___ in ___ of the colon infarct, on a
blood thinner, history of pacemaker, history of breast cancer,
which she attributes to estrogen use. Brother living, healthy.
Three children, a daughter who lives in the ___ with her
fiance, another daughter who lives in ___, ___ son
who attends ___ as a freshman and lives with her
during vacations. She has no grandchildren. Family history is
positive for diabetes mellitus in her paternal grandmother, type
2.
Physical Exam:
ADMISSION
=========
VITALS: Afebrile, HR 87, BP 131/76 RR 30 SPO2 94%
GENERAL: Jaundiced, tachypneic, lying in bed
HEENT: Sclera icteric, dry MM,
LUNGS: Tachypneic, using accessory muscles, ability completing
full sentences, decreased breath sounds at right axilla and
right base. She is expiratory wheezing noted
CV: Tachycardic with no murmurs noted
ABD: Soft, nontender, distended, no rebound or guarding
EXT: Warm, well perfused, no edema
SKIN: Jaundiced
NEURO: AAO x3, moving upper and lower extremities to command.
DISCHARGE:
===============
VS: 98.5 108 / 65 97 18 93 Ra
General: lying in bed, NAD
HEENT: dry MM, dobhoff tube in place, jaundice
Lung: Decreased breath sounds bibasilarly.
Card: regular, no murmurs
Abd: soft, distended, non-tender
Ext: no edema
Neuro: no asterixis, flat affect, A+O x3
Pertinent Results:
ADMISSION
=========
___ 01:33PM BLOOD WBC-7.2 RBC-2.41* Hgb-8.8* Hct-24.3*
MCV-101* MCH-36.5* MCHC-36.2 RDW-13.8 RDWSD-51.1* Plt Ct-56*
___ 01:33PM BLOOD Neuts-79.9* Lymphs-7.2* Monos-11.7
Eos-0.3* Baso-0.6 Im ___ AbsNeut-5.77 AbsLymp-0.52*
AbsMono-0.84* AbsEos-0.02* AbsBaso-0.04
___ 03:30PM BLOOD ___ PTT-34.4 ___
___ 01:33PM BLOOD Glucose-119* UreaN-11 Creat-0.6 Na-122*
K-3.1* Cl-68* HCO3-29 AnGap-28*
___ 01:33PM BLOOD ALT-26 AST-130* AlkPhos-197* TotBili-7.8*
___ 01:33PM BLOOD Lipase-95*
___ 01:33PM BLOOD Albumin-3.3* Calcium-7.1* Phos-2.8
Mg-0.9*
___ 04:20AM BLOOD Hapto-180
___ 01:33PM BLOOD Acetone-SMALL
___ 01:33PM BLOOD CRP-132.8*
___ 11:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:42PM BLOOD Lactate-4.6* K-2.5*
___ 11:50AM URINE Color-DkAmb Appear-Hazy Sp ___
___ 11:50AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-MOD Urobiln->12 pH-6.0 Leuks-LG
___ 11:50AM URINE RBC-1 WBC-48* Bacteri-MANY Yeast-NONE
Epi-1 TransE-1
___ 11:50AM URINE CastHy-4*
___ 10:23PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 07:00AM PLEURAL TNC-69* RBC-756* Polys-9* Lymphs-33*
___ Meso-5* Macro-53*
___ 07:00AM PLEURAL TotProt-1.2 Glucose-139 LD(LDH)-94
Albumin-0.8 Cholest-13 ___ Misc-PRO-BNP =
INTERIM LABS:
=============
___ 06:43AM BLOOD Ret Aut-6.2* Abs Ret-0.15*
___ 04:20AM BLOOD Ret Aut-0.9 Abs Ret-0.02
___ 03:52PM BLOOD ___ 03:42AM BLOOD Lipase-158*
___ 01:33PM BLOOD Lipase-95*
___ 03:52PM BLOOD Hapto-94
___ 05:22AM BLOOD VitB12-1048*
___ 04:57AM BLOOD Hapto-79
___ 06:43AM BLOOD Hapto-122
___ 04:06AM BLOOD Triglyc-141
___ 06:50AM BLOOD Cortsol-11.8
___ 01:33PM BLOOD CRP-132.8*
___ 05:37AM BLOOD Vanco-4.9*
MICRO:
======
blood culture: consistently negative
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 6:50 am PLEURAL FLUID PLEURAL FLUID.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ENTEROCOCCUS SP.. >100,000 CFU/mL.
ENTEROCOCCUS SP.. SECOND MORPHOLOGY. 10,000-100,000
CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ =>32 R <=2 S
LINEZOLID------------- 2 S
NITROFURANTOIN-------- 64 I <=16 S
TETRACYCLINE---------- <=1 S =>16 R
VANCOMYCIN------------ =>32 R 1 S
___ 8:21 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
3+ ___ per 1000X FIELD): BUDDING YEAST.
RESPIRATORY CULTURE (Final ___:
Commensal Respiratory Flora Absent.
YEAST. MODERATE GROWTH.
___ 3:51 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
Source: Line-arterial.
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
___ 4:47 pm BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
Source: Line-cvl.
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
___ 10:32 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
YEAST. 10,000-100,000 CFU/mL.
___ 5:38 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
STUDIES:
========
___ Imaging CHEST (PA & LAT)
No acute intrathoracic process.
___ Imaging LIVER OR GALLBLADDER US
1. Patent portal vein with hepatofugal flow, new since ___.
2. Cirrhotic liver with macronodular contour as recently
characterized on MRI ___.
___ Imaging CTA CHEST
Motion limited examination demonstrates:
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Large right and small left effusions, worse when compared to
prior MR.
3. Advanced cirrhosis with splenomegaly and gastroesophageal
varices,
consistent with portal hypertension.
4. Collapse of the right lower lobe due to compressive
atelectasis from the large right pleural effusion.
5. Atelectasis or early airspace disease left lung base.
___ Cytology PLEURAL FLUID
NEGATIVE FOR MALIGNANT CELLS.
- Mesothelial cells, lymphocytes, and histiocytes in a
background of red blood cells
___ Cardiovascular ECHO
The left atrial volume index is mildly increased. No late
contrast is seen in the left heart (suggesting absence of
significant intrapulmonary shunting). Mild symmetric left
ventricular hypertrophy with normal cavity size, and
regional/global systolic function (biplane LVEF = 61 %). The
estimated cardiac index is high (>4.0L/min/m2). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. Mild to moderate (___) mitral regurgitation is seen.
There is mild pulmonary artery systolic hypertension. There is
no pericardial effusion. A left pleural effusion is present.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with preserved regional and global
biventricular systolic function. Mild-moderate mitral
regurgitation with normal valve morphology. Mild pulmonary
artery systolic hypertension. No definite intrapulmonary shunt
identified.
___ Imaging BILAT LOWER EXT VEINS
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
___ Imaging PORTABLE ABDOMEN
There is moderate to severe distention of the stomach despite
the presence of an enteric tube that appears to end in the
proximal jejunum. Mottled gas within the stomach is presumably
due to ingested contents. No dilated loops of small intestine
are seen. There is gas throughout the nondistended colon,
suggestive of mild ileus. No definite free air on supine.
Partially seen pleural effusions.
IMPRESSION:
Findings of gastric obstruction despite the presence of an
enteric tube.
___ Imaging TIPS
1. Pre-TIPS right atrial pressure of 29 and portal pressure
measurement of 55
resulting in portosystemic gradient of 26 mmHg.
3. Contrast enhanced portal venogram showing esophageal varices
arising from
the coronary vein with very little flow into the portal vein.
4. Post-TIPS and embolization portal venogram showing lack of
flow into the
embolized esophageal varices with good flow into the hepatic
parenchyma and
through the underdilated TIPS.
5. Post-TIPS right atrial pressure of 37 and portal pressure of
56 resulting
in portosystemic gradient of 19 mmHg.
6. NG tube placement. Thoracentesis with 1.5 L of yellowish
fluid removed.
IMPRESSION:
Successful right internal jugular access with transjugular
intrahepatic
portosystemic shunt placement with decrease in porto-systemic
pressure
gradient.
RECOMMENDATION(S):
1. Given the patient's acute hepatic decompensation, the TIPS
was under
dilated to 6 mm in order to maximize hepatic parenchymal
perfusion while still decreasing the portosystemic gradient
enough to decrease variceal bleeding. However, the patient
continues to be at high risk for rebleed if she does not return
for full dilation of the TIPS. We will continue to monitor the
patient's LFTs, and when they began to decrease/normalize and
her acute hepatic decompensation begins to resolve, we can
discuss timing to bring the patient back for TIPS stent
dilation.
2. Suggest continued NG tube decompression, given patient's
abdominal
distention.
___ Imaging CHEST (PORTABLE AP)
In comparison with the earlier study of this date, there is
little overall
change. Again there are low lung volumes with large right
pleural effusion and underlying compressive atelectasis.
Multiple mild atelectatic changes and small effusion on the
left.
The monitoring and support devices appear stable.
___ Imaging LIVER OR GALLBLADDER US
1. Patent TIPS.
2. Right pleural effusion. Small ascites.
3. Nondistended gallbladder containing sludge with thickened
wall in keeping with underlying liver disease.
___ Imaging CHEST (PORTABLE AP)
Comparison to ___. The tip of the endotracheal tube
projects
approximately 25 mm above the carina. There is now complete
opacification of the right hemithorax. Stable left retrocardiac
atelectasis, stable appearance of the left heart border.
___ Imaging CHEST (PORTABLE AP)
Compared to chest radiographs ___ through ___.
Very large right pleural effusion has not improved, collapses
the entire right lung, responsible for over circulation in the
left lung and shifting the mediastinum to the left. No
pneumothorax.
Right PIC line ends close to the superior cavoatrial junction.
Nasogastric feeding tube passes into the stomach and out of
view.
___ Imaging US THORACENTESIS NEEDLE
Successful ultrasound-guided diagnostic and therapeutic right
thoracentesis.
___ Imaging DUPLEX DOPP ABD/PEL
1. Patent TIPS with expected reduction in peak systolic velocity
after TIPS dilation on ___.
2. No focal liver lesions.
3. Stable splenomegaly. No ascites.
4. A right pleural effusion is noted.
___ Imaging CHEST (PORTABLE AP)
IMPRESSION:
Increased consolidation in the right lower lobe may represent
atelectasis,
though pneumonia is not excluded in the proper clinical setting.
Slight
interval decrease in right pleural effusion.
DISCHARGE LABS:
================
___ 05:48AM BLOOD WBC-9.9 RBC-2.29* Hgb-7.6* Hct-22.9*
MCV-100* MCH-33.2* MCHC-33.2 RDW-UNABLE TO RDWSD-UNABLE TO Plt
Ct-58*
___ 05:48AM BLOOD Plt Ct-58*
___ 05:48AM BLOOD ___ PTT-49.7* ___
___ 03:52PM BLOOD ___ 05:48AM BLOOD Glucose-111* UreaN-34* Creat-0.6 Na-130*
K-4.1 Cl-92* HCO3-28 AnGap-14
___ 06:43AM BLOOD Ret Aut-6.2* Abs Ret-0.15*
___ 05:48AM BLOOD ALT-21 AST-63* AlkPhos-93 TotBili-4.0*
___ 05:48AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.7
___ 03:52PM BLOOD Hapto-94
___ 05:22AM BLOOD VitB12-1048*
___ 04:06AM BLOOD Triglyc-141
___ 01:33PM BLOOD CRP-132.8*
___ 09:05AM URINE Color-Yellow Appear-Hazy Sp ___
___ 09:05AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-MOD
___ 09:05AM URINE RBC-13* WBC-24* Bacteri-FEW Yeast-NONE
Epi-0
___ 05:21PM URINE Hours-RANDOM UreaN-400 Creat-61 Na-27
Cl-<20 HCO3-LESS THAN
___ 10:23PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. clonazePAM 1 mg oral QHS:PRN
2. Rifaximin 550 mg PO BID
3. FoLIC Acid 1 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Ferrous Sulfate 325 mg PO Frequency is Unknown
6. Multivitamins 1 TAB PO DAILY
7. Mirtazapine 15 mg PO QHS
8. Nadolol 20 mg PO BID
9. Omeprazole 20 mg PO BID
10. Spironolactone 50 mg PO DAILY
Discharge Medications:
1. CefTAZidime 1 g IV Q12H
last day ___. Fluconazole 200 mg PO Q24H
continue while foley in place
3. Fluticasone Propionate 110mcg 3 PUFF IH BID
4. Lactulose 30 mL PO BID
5. Lidocaine 5% Patch 1 PTCH TD QAM
6. Linezolid ___ mg PO Q12H
___ will contact to narrow
7. Midodrine 15 mg PO TID
8. Pantoprazole 40 mg PO Q24H
9. Simethicone 40-80 mg PO QID:PRN gas pain
10. clonazePAM 1 mg oral QHS:PRN
11. FoLIC Acid 1 mg PO DAILY
12. Furosemide 20 mg PO DAILY
13. Mirtazapine 15 mg PO QHS
14. Multivitamins 1 TAB PO DAILY
15. Rifaximin 550 mg PO BID
16. Spironolactone 50 mg PO DAILY
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Primary Diagnosis
==================
Septic shock
Alcoholic cirrhosis
Hepatic hydrothorax
Urinary tract infection
Respiratory failure
Renal failure
Secondary Diagnosis
================
Hyponatremia
Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP upright AND LAT)
INDICATION: ___ with sob and cough// r/o PNA r/o fluid overload
COMPARISON: None
FINDINGS:
AP upright and lateral views of the chest provided.
There is no focal consolidation, effusion, or pneumothorax. Mild basal
dependent atelectasis noted. The cardiomediastinal silhouette is normal.
Imaged osseous structures are intact. Chronic appearing right upper posterior
rib deformities are noted. No free air below the right hemidiaphragm is seen.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with known cirrhosis with new decompensation// PVT?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Liver MRI from ___. Abdominal ultrasound from ___.
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture. The contour of the
liver is nodular, consistent with cirrhosis. Macro nodular appearance of the
liver likely reflects regenerative nodules in the setting of cirrhosis. The
main portal vein is patent with hepatofugal flow. Flow had been hepatopetal
in ___. There is no 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 head and body of the pancreas are within normal limits. The tail
of the pancreas is not visualized due to the presence of gas.
SPLEEN: Normal echogenicity, measuring 13 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. Patent portal vein with hepatofugal flow, new since ___.
2. Cirrhotic liver with macronodular contour as recently characterized on MRI
___.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with fever, cough, hypoxia// Eval for
consolidation/pneumonia Eval for consolidation/pneumonia
IMPRESSION:
Interval increase in right pleural effusion is substantial the fusion is
currently large. There is small left pleural effusion. There are bibasal
opacities highly concerning for developing infection. There is vascular
congestion but no overt pulmonary edema. No pneumothorax.
Old rib fractures on the right.
Radiology Report
EXAMINATION: CT ANGIOGRAM OF THE CHEST
INDICATION: ___ year old woman with alcoholic cirrhosis/hepatitis with new O2
requirement and tachycardia.// Evaluate for pulmonary embolism, edema,
effusion, infiltrate.
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 4.1 s, 32.6 cm; CTDIvol = 11.6 mGy (Body) DLP = 377.7
mGy-cm.
Total DLP (Body) = 380 mGy-cm.
COMPARISON: MR abdomen ___
FINDINGS:
Examination limited due to motion.
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is
independent origin of the left vertebral artery from the aorta. There is no
evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental
pulmonary arteries. The main and right pulmonary arteries are normal in
caliber, and there is no evidence of right heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
The thyroid gland appears unremarkable.
There is no evidence of pericardial effusion. Large right and small left
effusion noted with overlying atelectasis. There is near complete collapse of
the right lower lobe due to compressive atelectasis from the large right
pleural effusion.
No evidence for pulmonary vascular congestion or pneumothorax. Bronchial wall
thickening compatible with mild to moderate bronchitis is noted. There is
linear scarring and atelectasis within the right middle lobe and pleural
thickening with mild loculation of pleural fluid at the anteromedial right
upper lobe.
Limited images of the upper abdomen are notable for a nodular, cirrhotic
liver, splenomegaly and extensive gastroesophageal varices. Enteric tube
courses into the stomach, its tip not visualized-view. The heterogeneity
within the liver with nodular configuration is compatible with advanced
cirrhosis.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
Multiple old healed rib fractures are seen within the right hemithorax. Large
periesophageal varices are noted. Multilevel degenerative disc disease is
noted throughout the thoracic spine with mild multilevel disc narrowing.
There is severe disc narrowing within the lower cervical spine with mild
retrolisthesis of C6 on C7.
IMPRESSION:
Motion limited examination demonstrates:
1. No evidence of pulmonary embolism or acute aortic abnormality.
2. Large right and small left effusions, worse when compared to prior MR.
3. Advanced cirrhosis with splenomegaly and gastroesophageal varices,
consistent with portal hypertension.
4. Collapse of the right lower lobe due to compressive atelectasis from the
large right pleural effusion.
5. Atelectasis or early airspace disease left lung base.
Radiology Report
INDICATION: ___ year old woman with Rt chest tube placement// PTX? Residual
fluid? Contact name: ___: ___
TECHNIQUE: AP portable view of the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
Right-sided pigtail catheter seen with portions of the curled component
projecting overlying and external to the thoracic cavity. No pneumothorax
identified. There are persistent bilateral pleural effusions and given
differences in projection, potentially slightly smaller on the right though
difficult to assess accurately. Cardiac silhouette is enlarged, unchanged.
Enteric tube extends off the inferior field of view.
IMPRESSION:
Right pigtail catheter with a portions of the curled component both overlying
and external to the thoracic cavity. No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with right chest tube for likely hepatic
hydrothorax// Please evaluate for size of pleural effusion or PTX
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
IMPRESSION:
Small right pleural effusion has decreased. Right pleural catheter is in
place. There are low lung volumes. Cardiomegaly is stable. Mild vascular
congestion has improved. Bibasilar opacities have improved. There is
probably small left effusion. There is no evident pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with alc hep/cirrhosis with fever and SOB.
Recent chest tube placement for R pleural effusion likely d/t hepatic
hydrothorax. CT removed previously.// Please eval for effusion, edema,
infiltrate.
IMPRESSION:
In comparison with the study of ___, there is increased haziness at the
right base with poor definition of the hemidiaphragm, consistent with
reaccumulation of layering pleural effusion. Some of this could merely
represent a more upright position of the patient.
The cardiomediastinal silhouette is stable. Mild indistinctness of pulmonary
vessels is consistent with mild elevation of pulmonary venous pressure.
Radiology Report
INDICATION: ___ year old woman with decompensated cirrhosis with hepatic
hydrothorax.// Please evaluate for worsening effusion, edema, or infiltrate.
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___ from earlier in the day
FINDINGS:
Low bilateral lung volumes with a persisting right pleural effusion and
subjacent atelectasis. Minimal left basal atelectasis is also present. No
pneumothorax. The size of the cardiac silhouette is enlarged but unchanged.
An enteric tube courses below the level the diaphragms but beyond the field of
view of this radiograph.
IMPRESSION:
No significant interval change since the prior chest radiograph.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with low grade fevers of unclear etiology//
please evaluate for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Radiology Report
INDICATION: ___ year old woman with recent R pleural effusion drainage, more
tachypneic,? re-accumulation/PNA.// ___ year old woman with recent R pleural
effusion drainage, more tachypneic,? re-accumulation/PNA.
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of the enteric tube courses below the level the diaphragms but beyond
the field of view of this radiograph.
There is a large right pleural effusion with overlying
atelectasis/consolidation. No pneumothorax is identified. The left lung
demonstrates bibasilar atelectasis. The size of the cardiac silhouette is
unchanged.
IMPRESSION:
Increasing right pleural effusion with underlying atelectasis/consolidation.
Radiology Report
EXAMINATION: Chest Radiograph
INDICATION: ___ year old woman with decompensated cirrhosis and large right
pleural effusion with ongoing tachypnea, please evaluate for worsening in
pleural effusion, edema, or pneumonia.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Large right pleural effusion and associated atelectasis is grossly unchanged.
Mild cardiomegaly is stable. The left lung is clear. There is no
pneumothorax. Nasoenteric tube courses in the stomach with the tip not
visualized.
IMPRESSION:
Grossly unchanged large right pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with cirrhosis and hypoxia and increasing
leukocytosis// Please evaluate for pneumonia or interval change of pleural
effusion Please evaluate for pneumonia or interval change of pleural
effusion
IMPRESSION:
Comparison to ___. Mild increase in extent of the pre-existing right
pleural effusion and of the resulting atelectasis of the right lower lungs.
Stable appearance of the heart and of the left lung. Stable course of the
feeding tube.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with cirrhosis, acute resp failure and
hypotension on the floor. Now s/p RIJ CVL and intubation// eval RIJ CVL
placement and ETT placement Contact name: ___: ___ eval
RIJ CVL placement and ETT placement
IMPRESSION:
Comparison to ___. The patient has been intubated. The tip of the
endotracheal tube projects 1 cm above the carinal. The device should be
pulled back by approximately 1-2 cm, to avoid intubation of the right main
bronchus. The patient has also received a right internal jugular vein
catheter. The course of the catheter is unremarkable, the tip projects over
the cavoatrial junction. No complications, notably no pneumothorax. The
previously placed feeding tube is in stable correct position. Increasing
extent of the pre-existing right pleural effusion, with compressive
atelectasis of the right lung basis. The left lung and the left heart border
appear stable.
Radiology Report
INDICATION: ___ year old woman with cirrhosis and abdominal distension now
septic// evaluate for abdominal distension
TECHNIQUE: Supine frontal abdomen
COMPARISON: MRI ___ in upper abdomen on CT chest ___.
FINDINGS:
There is moderate to severe distention of the stomach despite the presence of
an enteric tube that appears to end in the proximal jejunum. Mottled gas
within the stomach is presumably due to ingested contents. No dilated loops
of small intestine are seen. There is gas throughout the nondistended colon,
suggestive of mild ileus. No definite free air on supine.
Partially seen pleural effusions.
IMPRESSION:
Findings of gastric obstruction despite the presence of an enteric tube.
Radiology Report
EXAMINATION: US ABD LIMIT, SINGLE ORGAN PORT
INDICATION: ___ year old woman with hx of cirrhosis now with rising WBC count
and abdominal distension// evaluate for ascites and new abdominal distension
TECHNIQUE: Limited imaging of the abdomen for ascites.
COMPARISON: ___
FINDINGS:
Limited 4 quadrant ultrasound to assess for ascites. There is a small amount
of ascites, mostly in the right lower quadrant. A right pleural effusion is
partially imaged. The partially imaged liver appears heterogeneous.
IMPRESSION:
Small amount of ascites, mostly seen in the right lower quadrant.
Right pleural effusion.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 4 EXAMS
INDICATION: ___ year old woman with hepatic encephalopathy, sepsis, esophageal
bleeding// dobhoff placement
TECHNIQUE: Chest single view
COMPARISON: ___
FINDINGS:
Feeding tube tip is in the distal stomach on the last, fourth radiograph.
Cardiopulmonary findings are stable compared with earlier today. No
pneumothorax. Gastric distension come multiple dilated loops of bowel,
partially seen.
IMPRESSION:
Feeding tube tip is in the distal stomach.
Distended stomach, multiple bowel loops in the upper abdomen.
Radiology Report
INDICATION: ___ year old woman with EtOH cirrhosis now with variceal bleed on
massive transfusion protocol// TIPS/variceal embo
COMPARISON: Abdominal ultrasound from ___. Chest radiograph from ___.
TECHNIQUE: OPERATORS: Dr. ___, Radiology resident and Dr. ___
___, attending 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: General anesthesia was administered by the anesthesiology
department. Please refer to anesthesiology notes for details.
CONTRAST: 205 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 36 min, 463 mGy
PROCEDURE:
1. Right thoracentesis.
2. Right internal jugular venous access using ultrasound.
3. Contrast enhanced portal venogram.
4. Pre TIPS right atrial and portal venous pressure measurements.
5. Placement of a 10 mm x 4 mm x 2 ___ covered stent.
6. Post stenting balloon angioplasty of the TIPS shunt with a 6 mm balloon.
7. Post stenting splenic venogram.
8. Sclerosis/coil embolization of esophageal varices arising from the coronary
vein.
9. Post embolization venogram.
10. Balloon angioplasty of the distal TIPS shunt with a 10 mm balloon.
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. The neck/abdomen/chest was prepped and draped in the usual
sterile fashion.
A large amount of right pleural fluid was noted. Using ultrasound guidance, a
5 ___ ___ catheter was advanced into the fluid pocket, yielding pleural
fluid which was attached to negative pressure bottles.
Under continuous ultrasound guidance, the patent right internal jugular vein
was compressible and accessed using a micropuncture needle. Images of
ultrasound access were stored on PACS. Subsequently a Nitinol wire was passed
into the right atrium using fluoroscopic guidance. A small incision was made
at the needle entry site. The needle was exchanged for a micropuncture sheath.
The Nitinol wire was removed and a ___ wire was advanced distally into
the IVC.
The micropuncture sheath was then removed and a 10 ___ sheath was advanced
over the wire into the inferior vena cava. Using a modified C2 Cobra catheter
and ___ wire, access was obtained in the right hepatic vein. Appropriate
position was confirmed with contrast injection and fluoroscopy in AP and
lateral views.
The dilator was advanced through the sheath. Once the sheath was placed in an
appropriate position, the cannula device was inserted over the ___ wire and
the wire was exchanged for ___ needle. The angled sheath was turned
anteriorly. The needle was then advanced through liver parenchyma and the
needle was withdrawn over its sheath. The sheath was withdrawn while gentle
suction was applied. Upon blood return, a Glidewire was introduced into the
catheter to pass into the portal vein. A straight flush catheter was advanced
over the wire and a contrast enhanced portal venogram was performed. Next
right atrial and portal venous pressure measurements were obtained.
An Amplatz wire was advanced through the straight flush catheter into the
splenic vein. The catheter was removed and a 10 mm x 6 cm x 2 ___
covered covered stent was advanced into appropriate position and deployed.
Following stent deployment, the stent was dilated using a 6 mm balloon.
The straight flush catheter was advanced over the wire and the wire was
removed. A splenic venogram was performed, demonstrating esophageal varices
arising from the coronary vein. The coronary vein was accessed and an
occlusion balloon inflated at the origin. 20 cc of a ___ mixture of
Sotradecol 3%, lipiodol, and air were injected. Subsequently, the occlusion
balloon was deflated and several ___ coils deployed. Post embolization
portal venogram demonstrated cessation of flow through the esophageal varices,
hepatic parenchymal flow, and a small amount of flow through the underdilated
TIPS. A 10 mm balloon was used to dilate the distal stent. Post TIPS
pressures were obtained at the proximal splenic vein, in the portal vein, and
right atrium.
The sheath was then removed from the right internal jugular vein site and
pressure held for 10 minutes to achieve hemostasis. The thoracentesis
catheter was removed. Sterile dressings were applied. Given the patient's
abdominal distention and blood seen within the bowel on preprocedure
ultrasound, a nasogastric tube was placed yielding dark blood and clots.
The patient tolerated the procedure well. There were no immediate
post-procedure complications. The patient was transferred to the ICU in stable
condition.
FINDINGS:
1. Pre-TIPS right atrial pressure of 29 and portal pressure measurement of 55
resulting in portosystemic gradient of 26 mmHg.
3. Contrast enhanced portal venogram showing esophageal varices arising from
the coronary vein with very little flow into the portal vein.
4. Post-TIPS and embolization portal venogram showing lack of flow into the
embolized esophageal varices with good flow into the hepatic parenchyma and
through the underdilated TIPS.
5. Post-TIPS right atrial pressure of 37 and portal pressure of 56 resulting
in portosystemic gradient of 19 mmHg.
6. NG tube placement. Thoracentesis with 1.5 L of yellowish fluid removed.
IMPRESSION:
Successful right internal jugular access with transjugular intrahepatic
portosystemic shunt placement with decrease in porto-systemic pressure
gradient.
RECOMMENDATION(S):
1. Given the patient's acute hepatic decompensation, the TIPS was under
dilated to 6 mm in order to maximize hepatic parenchymal perfusion while still
decreasing the portosystemic gradient enough to decrease variceal bleeding.
However, the patient continues to be at high risk for rebleed if she does not
return for full dilation of the TIPS. We will continue to monitor the
patient's LFTs, and when they began to decrease/normalize and her acute
hepatic decompensation begins to resolve, we can discuss timing to bring the
patient back for TIPS stent dilation.
2. Suggest continued NG tube decompression, given patient's abdominal
distention.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with cirrhosis, now s/p TIPS// ?interval change
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
IMPRESSION:
Large right pleural effusion with adjacent atelectasis is likely unchanged
allowing the difference in positioning of the patient. Small left effusion
with adjacent atelectasis is stable. Right IJ catheter tip is at the
cavoatrial junction. NG tube tip is out of view below the diaphragm. ET tube
is slightly low the tip only 1 cm from the carina, could be retracted 1-2 cm
for more standard position. There is no evident pneumothorax. Cardiac size
cannot be evaluated.
Radiology Report
INDICATION: ___ year old woman with abdominal distension// Evaluate for ileus
vs obstruction
TECHNIQUE: Portable supine and left lateral decubitus abdominal radiograph
was obtained.
COMPARISON: Portable radiograph ___. MR abdomen ___.
FINDINGS:
There are ___ abnormally dilated loops of large or small bowel. Gaseous
distention of large bowel loops with redundant large bowel loops as seen on
prior MR. ___ radiographic evidence of small-bowel obstruction.
There is ___ free intraperitoneal air on left lateral decubitus radiograph.
Osseous structures are unremarkable.
Enteric tube appears coiled in the stomach. Coil pack for soft tissue varices
projects over the left upper abdomen. TIPS stent is noted in the right upper
quadrant. There are ___ unexplained soft tissue calcifications or radiopaque
foreign bodies.
IMPRESSION:
___ radiographic evidence of small-bowel obstruction.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with hepatic hydrothorax// Evaluate for
interval change
IMPRESSION:
In comparison with the study of ___, the tip of the endotracheal tube now
measures approximately 2.3 cm above the carina. The other monitoring and
support devices appear stable. Increased haziness at the right base could
reflect either some increase in right pleural effusion or a more supine
position of the patient. The left effusion is much smaller and there are
bilateral atelectatic changes at the bases.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman intubated// any change in ETT position or
pulmonary infiltrates?
IMPRESSION:
In comparison with the study of ___, the tip of the endotracheal tube lies
approximately 2.2 again there are bilateral layering pleural effusions, more
prominent on the right with underlying compressive atelectasis. Although the
pulmonary vessels are not well seen, they do appear to be indistinct and
engorged, consistent with some elevation of pulmonary venous pressure.
In view of the extensive pulmonary changes, it would be extremely difficult to
exclude superimposed pneumonia in the appropriate clinical setting, especially
in the absence of a lateral view. Cm above the carina. Other monitoring and
support devices are stable.
Radiology Report
INDICATION: ___ year old woman with cirrhosis, GIB, shock without BM eval for
obstruction// eval for obstruction
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: Abdominal radiograph ___.
FINDINGS:
There are no abnormally dilated loops of small bowel. There is continued
dilation of the cecum but decreased gaseous distention of other large bowel
loops. No radiographic evidence of small bowel obstruction.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are unremarkable.
Enteric tube is coiled in the stomach. Coil pack is seen in the left upper
quadrant. TIPS stent is seen in the right upper quadrant. There are no
unexplained soft tissue calcifications or radiopaque foreign bodies.
IMPRESSION:
Continued dilation of the cecum, with decreased gaseous distention of the
other large bowel loops.
Radiology Report
INDICATION: ___ year old woman with abdominal distention// Evaluate for
gastric distention
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: Abdominal radiograph ___
FINDINGS:
Continued dilation of the cecum, measuring 11.6 cm, minimally decreased
compared with 12.6 cm on ___. Previously seen dilated loops in the
pelvis have improved. No other areas of bowel dilatation. Interval decrease
in gastric prominence. Pelvic phleboliths. Degenerative changes lower lumbar
spine stomach is filled with food particles.
Enteric tube is coiled in the stomach, tip is near gastroduodenal junction..
Coil pack in the left upper quadrant is noted. TIPS stent again noted in the
right upper quadrant. Bilateral pleural effusions, basilar consolidations are
better seen on chest radiograph from today.
IMPRESSION:
No gastric distension.
Dilatation of the cecum has minimally improved. Improved previously seen
distended bowel loops in the pelvis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with right effusion// Evaluate for interval
change
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
IMPRESSION:
Allowing the difference in positioning of the patient large right pleural
effusion with adjacent atelectasis is unchanged. There are lower lung
volumes. Vascular congestion in the left lung has improved. Cardiac size
cannot be evaluated. Left lower lobe opacities are stable. Lines and tubes
in unchanged standard position. No other interval change from prior study.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with known right effusion// Evaluate for
interval change Evaluate for interval change
IMPRESSION:
Comparison to ___. Increase in extent of the right pleural effusion.
Stable monitoring and support devices. Mild increase in retrocardiac
atelectasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with worsening desats, known pleurla effusion,
intubated// any e/o mucus plugging/lobar collapse?
IMPRESSION:
In comparison with the earlier study of this date, there is little overall
change. Again there are low lung volumes with large right pleural effusion
and underlying compressive atelectasis. Multiple mild atelectatic changes and
small effusion on the left.
The monitoring and support devices appear stable.
Radiology Report
EXAMINATION:
CT of the chest abdomen and pelvis.
INDICATION: ___ year old woman with distended colon, abdominal distention,
fever refractory to broad abx// any intrabdominal process to account for fever
and hypotension
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast in the arterial
phase. Then, imaging was obtained through the abdomen and pelvis in the
portal venous phase. Reformatted coronal and sagittal images through the
chest, abdomen, and pelvis, and oblique maximal intensity projection images of
the chest were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 1.8 s, 28.4 cm; CTDIvol = 11.6 mGy (Body) DLP = 328.6
mGy-cm.
2) Spiral Acquisition 3.3 s, 52.2 cm; CTDIvol = 19.1 mGy (Body) DLP = 997.3
mGy-cm.
3) Sequenced Acquisition 0.5 s, 0.5 cm; CTDIvol = 1.7 mGy (Body) DLP = 0.9
mGy-cm.
4) Sequenced Acquisition 0.5 s, 0.5 cm; CTDIvol = 1.7 mGy (Body) DLP = 0.9
mGy-cm.
5) Stationary Acquisition 4.1 s, 0.5 cm; CTDIvol = 13.8 mGy (Body) DLP =
6.9 mGy-cm.
Total DLP (Body) = 1,334 mGy-cm.
COMPARISON: CT of the chest from ___ MRI of the abdomen from ___.
FINDINGS:
CHEST:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus.
There is some motion artifact at the bases, mildly limiting evaluation of the
peripheral vessels. Mildly prominent main pulmonary artery, suggest pulmonary
artery hypertension. 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: Endotracheal tube is in unchanged position.
Right-sided PICC line has its tip terminating in the cavoatrial junction. No
axillary, mediastinal, or hilar lymphadenopathy is present. No mediastinal
mass.
PLEURAL SPACES: There has been interval increase in size in a large
right-sided pleural effusion with a similar small left-sided pleural effusion.
LUNGS/AIRWAYS: There is mucous plugging noted in bilateral lower lobes. There
is complete collapse of bilateral lower lobes, and moderate atelectasis of the
posterior right upper lobe. Mild atelectasis of the medial right middle lobe
mild lingular atelectasis. Findings have worsened since prior. This areas of
mosaic attenuation, with mild interlobular septal thickening best seen at the
apex, likely from edema. There is more prominent shift of mediastinal
structures to the left secondary to volume loss and right pleural effusion.
Streak artifacts from coil within the abdomen degrades the images and limits
the evaluation.
ABDOMEN:
HEPATOBILIARY: Again noted is nodular contour of the liver with hypertrophy of
the lateral segments of its left lobe in keeping with cirrhosis. A TIPS
appears patent. There is heterogeneous enhancement of the liver, however
given the absence of arterial phase, evaluation for HCC is limited. There is
no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder has mild wall thickening, similar compared with ___,
likely reactive, or from underlying chronic hepatic disease.
There is small volume ascites.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: There is a new hypodense area in the periphery of the spleen,
suggestive of an infarct, involving ___ of the spleen, predominantly along
the periphery..
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: Two enteric tubes are noted, one of which terminates in the
GE junction which is likely a temperature probe, clinically correlate, and the
other order within the gastric body. Note is made of fluid-filled ascending
and descending colon, associated with bowel wall edema. There is no free
intraperitoneal fluid or free air.
PELVIS: There is small amount of pelvic free fluid. The bladder is
decompressed containing a Foley catheter within it.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: The patient is status post esophageal varices embolization.
Periesophageal and perigastric varices are noted, along with a new outpouching
seen (2b: 114) with surrounding hyperdense material measuring approximately
2.7 x 2.0 cm concerning for a hematoma. There is no abdominal aortic
aneurysm.
BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions or
acute fracture. The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Status post esophageal varices embolization with a new outpouching seen
about one of the varices medial to the gastric cardia, with focus of an
extraluminal contrast measuring 2 cm, and, and surrounding 2.7 x 2.0 cm
hyperdensity concerning for a hematoma. These findings are concerning for a
variceal bleed.
2. New splenic infarct.
3. Fluid-filled ascending and descending colon, associated with bowel wall
edema, may be reactive or from colitis. Please correlate clinically.
4. Cirrhotic liver with patent TIPS, with small volume ascites.
5. Interval increase in size in a large right-sided pleural effusion with a
similar small left-sided pleural effusion. Extensive atelectasis and volume
loss in the lower lungs, complete atelectasis of bilateral lower lobes, and
secretions within bronchial tree of lower lobes.
6. No evidence of pulmonary embolism.
7. Mild gallbladder wall thickening, similar to ___, likely
reactive or from underlying chronic hepatic disease. Clinically correlate to
exclude cholecystitis.
RECOMMENDATION(S): An ___ consultation is recommended.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 6:40 pm, 5
minutes after discovery of the findings.
Radiology Report
INDICATION: ___ year old woman with tube in place, right effusion// Evaluate
for interval change
TECHNIQUE: Single portable view of the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
ET tube is 3.4 cm from the carina. Right IJ central venous catheter tip
projects over the mid SVC. Increased opacity in the right hemithorax is
compatible with pleural effusion with secondary mass effect including leftward
mediastinal shift are unchanged. Retrocardiac opacity silhouetting the
hemidiaphragm is unchanged.
IMPRESSION:
No significant interval change.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman intubated not following commands// any e/o
bleed?
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 10.0 s, 17.0 cm; CTDIvol = 48.8 mGy (Head) DLP =
829.0 mGy-cm.
Total DLP (Head) = 842 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of hemorrhage, edema, shift of normally midline
structures, or evidence infarction. Mild prominence of the ventricles and
sulci suggest involutional changes. Moderate mucosal thickening and fluid
with aerosolized secretions in the bilateral sphenoid sinuses is noted. The
remaining imaged paranasal sinuses are clear. The middle ear cavities are
well aerated. There is partial opacification of the mastoid air cells
bilaterally the bony calvarium is intact.
IMPRESSION:
Atrophy. No evidence of mass, hemorrhage or infarction
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with abdominal distention// assess for
obstruction
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
IMPRESSION:
Allowing the difference in positioning of the patient there is no interval
change in large right pleural effusion, small left pleural effusion with
adjacent atelectasis. There is minimal vascular congestion. Lines and tubes
in standard position
Radiology Report
INDICATION: Assess for obstruction
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: Abdominal radiograph ___.
FINDINGS:
Abdominal radiograph limited by motion.
Significant interval improvement in dilation of cecum. No abnormally dilated
small or large bowel loops.
Assessment for free intraperitoneal air is limited on supine radiographs. If
there is clinical concern for pneumoperitoneum, advise upright or left lateral
decubitus radiograph, or cross-sectional imaging.
Osseous structures are notable for mild degenerative changes of the lumbar
spine.
Pelvic phleboliths are again noted. Coil pack is seen in the left upper
quadrant. Enteric tube is coiled in the stomach with tip near the antrum.
TIPS stent is again noted in the right upper quadrant. There are no
unexplained soft tissue calcifications or radiopaque foreign bodies. Large
right pleural effusion is better assessed on chest radiograph performed are
earlier on the same day.
IMPRESSION:
Significant improvement in cecal dilation and no radiographic evidence of
obstruction.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with cirrhosis// Evaluate for liver/biliary
pathology + ascites
TECHNIQUE: Grey scale, color, and spectral Doppler ultrasound images of the
abdomen were obtained.
COMPARISON: CT of the abdomen pelvis from ___
Abdominal ultrasound from ___
FINDINGS:
The liver appears diffusely coarsened and nodular consistent with known
cirrhosis. No focal liver lesions are identified. There is small ascites.
The spleen measures 13.1 cm. There is no intrahepatic biliary dilation. The
common hepatic duct measures 6 mm. The nondistended gallbladder contains
sludge and demonstrates wall thickening, consistent with underlying liver
disease.
The main portal vein is patent with hepatopetal flow (images labeled MPV
likely truly represents the right portal vein).
The TIPS is patent and demonstrates wall-to-wall flow.
Portal vein and intra-TIPS velocities are as follows:
Main portal vein: 33 cm/sec.
Proximal TIPS: 91 cm/sec.
Mid TIPS: 174 cm/sec.
Distal TIPS: 104 cm/sec.
Flow within the left portal vein is towards the TIPS shunt. Flow within the
right anterior portal vein is towards the TIPS. Appropriate flow is seen in
the hepatic veins and IVC.
A patent umbilical vein is re-demonstrated.
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.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
A right pleural effusion is noted.
IMPRESSION:
1. Patent TIPS.
2. Right pleural effusion. Small ascites.
3. Nondistended gallbladder containing sludge with thickened wall in keeping
with underlying liver disease.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with resp failure// eval for interval change
IMPRESSION:
In comparison with the study of ___, there is even further opacification
involving almost the entire right hemithorax, consistent with pleural effusion
and some significant volume loss in the right lung. Small left effusion with
atelectatic changes at the base.
Monitoring and support devices are stable.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with intubated// assess tube position and
pulmonary edema assess tube position and pulmonary edema
IMPRESSION:
Comparison to ___. The tip of the endotracheal tube projects
approximately 25 mm above the carina. There is now complete opacification of
the right hemithorax. Stable left retrocardiac atelectasis, stable appearance
of the left heart border.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS
INDICATION: ___ year old woman with alcoholic cirrhosis here w/ GIB, hypoxic
respiratory failure and persistent fevers/leukocytosis without a clear
source// asymmetric swelling, please assess for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the right common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the tibial and peroneal veins.
Mild subcutaneous edema noted.
There is normal respiratory variation in the common femoral veins bilaterally.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower extremity veins.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with intubated// please eval ETT placement and
for edema or consolidations please eval ETT placement and for edema or
consolidations
IMPRESSION:
Compared to chest radiographs ___ through ___. Very large right pleural
effusion completely collapsing right lung and severely shifting mediastinum
leftward is unchanged since ___, worsened since ___. Progressive
heterogeneous opacification in the left lung could be due to edema from
redirected blood flow, but raises concern for widespread aspiration or
multifocal pneumonia.
Heart size is indeterminate, probably at least mildly enlarged.
Indwelling esophageal drainage tube passes a probe ending just above the
diaphragm, and is looped in the stomach passing out of view. ET tube in
standard placement. Right jugular line ends in the low SVC.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with alcoholic cirrhosis, here w/ GIB c/b
hypoxic respiratory failure, recently extubated// interval change?
IMPRESSION:
In comparison with the study of ___, the endotracheal tube is been removed.
An there again is essentially complete opacification of the right hemithorax
with some volume loss in the ipsilateral lung, but with shift of the
mediastinal contents to the left.
Otherwise little change. Again
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with hepatohydrothorax s/p right chest tube
placement// PTX? Residual fluid? Contact name: ___: ___
IMPRESSION:
In comparison with the earlier study of this date, placement of a chest tube
at the right base has has no appreciable affects on the continued complete
opacification of the right hemithorax. Monitoring support devices unchanged.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with chest tube// interval change interval
change
IMPRESSION:
NG tube tip in the stomach. Right internal jugular line tip is at the level
of lower SVC. Right PICC line tip is at the level of mid to lower SVC.
Heart size and mediastinum are stable
There is substantial interval decrease in right pleural effusion which is
currently small to moderate, the position of the right pigtail catheter is
unchanged.
Apical pneumothorax cannot be excluded, minimal.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with new picc// R picc 43cm Contact name:
sal, ___: ___
IMPRESSION:
In comparison with the study of earlier in this date, there is an placement
right subclavian PICC line that extends to the mid to lower portion of the
SVC. Otherwise, little change.
Radiology Report
INDICATION: ___ year old woman with cirrhosis and pleural effusion s/p chest
tube placement clamped for several hours// eval pleural effusion
COMPARISON: ___
IMPRESSION:
Support lines and tubes are unchanged in position. Cardiomediastinal
silhouette is within normal limits. There is a large right-sided pleural
effusion and increased density at the right lung, worse since previous.
Several old right upper posterior rib fractures are again seen. Left lung is
relatively clear.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US
INDICATION: ___ year old woman with alcoholic cirrhosis and gib c/b
respiratory failure and recurrent fevers// ? DVT in setting of new PICC
placement
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 right subclavian vein.
The right internal jugular and axillary veins are patent, show normal color
flow and compressibility. A PICC line is visualized within the left basilic
vein. The right brachial and basilic veins are patent, compressible and show
normal color flow and augmentation. The right cephalic vein is not
visualized.
IMPRESSION:
1. Nonvisualization of the right cephalic vein. Otherwise, no evidence of
deep vein thrombosis in the right upper extremity.
2. PICC line within the right basilic vein.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with cirrhosis, hepatic hydrothorax// eval for
pulm edema, interval change in pleural effusion eval for pulm edema,
interval change in pleural effusion
IMPRESSION:
Comparison to ___. There is now complete opacification of the right
hemithorax. The right pleural drain is no longer visible. The right internal
jugular vein catheter has been removed. The other monitoring and support
devices are in unchanged position. Mediastinal shift to the left, with a
decrease in volume of the left hemithorax. Mild retrocardiac atelectasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with lung collapse// progression
progression
IMPRESSION:
Compared to chest radiographs ___ through ___.
Since ___, large right pleural effusion has recurred, responsible for
persistent leftward mediastinal shift, with no appreciable change since ___. Subsegmental atelectasis at the left base is mild to moderate. Heart
size is indeterminate since the right heart border is obscured. No
pneumothorax.
Right PIC line ends in the right atrium. Nasogastric drainage tube passes
into the stomach and out of view.
Radiology Report
INDICATION: ___ year old woman with alcoholic cirrhosis here w/ GIB,
respiratory failure, hepatic hydrothorax. s/p TIPS placement but was not
upsized.// please upsize tips
COMPARISON: TIPS placement from ___
TECHNIQUE: OPERATORS: Dr. ___ resident and Dr. ___, ___
radiologist performed the procedure. Dr. ___ supervised the
trainee during the key components of the procedure and has reviewed and agrees
with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
75 mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service
time of 40 mins during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: As above plus Zofran
CONTRAST: 45 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 12 min, 317 mGy
PROCEDURE: 1. Right internal jugular venous access using ultrasound.
2. Pre-procedure right atrial and portal vein pressure measurements.
3. Contrast enhanced portal venogram.
4. Balloon angioplasty of the existing stent with 10 and 12 mm balloon
5. Post angioplasty right atrial and portal vein pressure measurements.
6. Post angioplasty portal venogram
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The neck/abdomen/chest was prepped and draped in the usual sterile
fashion.
Thoracentesis/Paracentesis
Under continuous ultrasound guidance, the patent right internal jugular vein
was compressible and accessed using a micropuncture needle. Images of
ultrasound access were stored on PACS. Subsequently a Nitinol wire was passed
into the right atrium using fluoroscopic guidance. A small incision was made
at the needle entry site. The needle was exchanged for a micropuncture sheath.
The Nitinol wire was removed and a ___ wire was advanced distally into
the IVC.
The micropuncture sheath was then removed and a 10 ___ sheath was advanced
over the wire into the inferior vena cava. Using a MPA and a glidewire
access was obtained into the TIPS stent. Appropriate position was confirmed
with contrast injection and fluoroscopy in AP and lateral views. Then,
pressure measurements were taken in the RA and portal. Then, over ___
wire the stent was dilated with a 10 mm balloon. Repeat pressure measurements
were taken. Repeat angioplasty was performed with a 12 mm balloon and repeat
pressure measurements taken. A run was performed again.
The sheath was then removed from the right internal jugular vein site and
pressure held for 10 minutes to achieve hemostasis. Steri-strips and sterile
dressings were applied.
The patient tolerated the procedure well. There were no immediate
post-procedure complications. The patient was transferred to the PACU in
stable condition.
FINDINGS:
1. Pre dilation porto-systemic gradient of 21 mmHg
2. Pre dilation venogram demonstrating IMV varix as well as coronary vein
varix filling esophageal varices
3. Post dilation (10 mm) porto-systemic gradient of 17 mmHg
4. Post dilation (12 mm) portosystemic gradient of 14 mmHg
5. Post dilation venogram demonstrating resolution of flow through varices
with all flow through TIPS
IMPRESSION:
Successful dilation of existing TIPS stent up to 12 mm with reduction of
pressure gradient from 21 mmHg to 14 mmHg
RECOMMENDATION(S): Monitor hepatic hydrothorax; the patient may benefit from
a parallel TIPS if the ascites/hepatic hydrothorax is not improved.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with pulmonary problesm// Progression of
pulmonary disease Progression of pulmonary disease
IMPRESSION:
Compared to chest radiographs ___ through ___ one.
Very large right pleural effusion has not improved, collapses the entire right
lung, responsible for over circulation in the left lung and shifting the
mediastinum to the left. No pneumothorax.
Right PIC line ends close to the superior cavoatrial junction. Nasogastric
feeding tube passes into the stomach and out of view.
Radiology Report
INDICATION: ___ year old woman with EtOH cirrhosis/alc hep and complicated
hospital course with MICU stay and respiratory failure from large hepatic
hydrothorax, now with increased O2 requirement and hypotension// ? interval
change
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of right PICC line projects over the cavoatrial junction. An enteric
tube projects over the left upper quadrant.
Re-demonstrated is a complete whiteout of the right hemithorax with no
significant shift of mediastinal structures. Atelectasis and mild vascular
congestion is present within the left lung.
IMPRESSION:
No significant interval change since the prior chest radiograph.
Radiology Report
INDICATION: ___ year old woman with hydrothorax// please tap fluid
TECHNIQUE: Ultrasound guided diagnostic and therapeutic thoracentesis
COMPARISON: None
FINDINGS:
Limited grayscale ultrasound imaging of the right hemithorax demonstrated a
large amount of pleural fluid. A suitable target in the deepest pocket in the
right posterior mid scapular line was selected for thoracentesis.
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 buffered with
sodium bicarbonate was instilled for local anesthesia.
A 5 ___ catheter was advanced into the largest fluid pocket in the right
posterior mid scapular line and 0.4 L of serosanguinous fluid was removed.
Fluid samples were submitted to the laboratory for cell count, differential,
culture, and cytology.
The patient tolerated the procedure well without immediate complications.
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:
Successful ultrasound-guided diagnostic and therapeutic right thoracentesis.
Radiology Report
INDICATION: ___ year old woman with hepatic hydrothorax s/p ___ cc removal of
fluid thoracentesis// eval for pneumothorax or new pulmonary edema
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
There is again noted a near complete whiteout of the right hemithorax with
shift of the mediastinal structures towards the right. The tip of a right
PICC line projects over the right atrium. The left lung demonstrates mild
atelectasis. No pneumothorax or large pleural effusion on the left. The
enteric tube projects over the left upper quadrant.
IMPRESSION:
No significant interval change since the prior radiograph. Near complete
whiteout of the right lung and mediastinal shift towards the right, likely
reflecting an increased atelectatic component and decreased pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with history of varices, cirrhosis, needs
feeding tube// eval NG tube placement eval NG tube placement
IMPRESSION:
Right PICC line tip is at the level of cavoatrial junction. The up of tube
tip is in the stomach. Heart size and mediastinum are stable. There is
interval substantial decrease in right pleural effusion, potentially after
thoracocentesis. There is no definitive pneumothorax demonstrated.
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: ___ year old woman with s/p TIPS// TIPS eval
TECHNIQUE: Grey scale, color, and spectral Doppler ultrasound images of the
abdomen were obtained.
COMPARISON: Abdominal ultrasound ___
FINDINGS:
The liver appears diffusely coarsened and nodular consistent with known
cirrhosis. No focal liver lesions are identified. There is no ascites. There
is stable splenomegaly, with the spleen measuring 14.7 cm. There is no
intrahepatic biliary dilation. The CHD measures 3 mm. There is no evidence of
stones or gallbladder wall thickening. Gallbladder sludge is noted. A right
pleural effusion is also noted.
Note is made that there was a TIPS redo on ___.
The main portal vein is patent with hepatopetal flow.
The TIPS is patent and demonstrates wall-to-wall flow.
Portal vein and intra-TIPS velocities are as follows:
Main portal vein: 25 cm/sec (previously 33 cm/sec)
Proximal TIPS: 76 cm/sec (previously 91 cm/sec)
Mid TIPS: 83 cm/sec (previously 174 cm/sec)
Distal TIPS: 74 cm/sec (previously 104 cm/sec)
Flow within the left portal vein is towards the TIPS shunt. Flow within the
right anterior portal vein is towards the TIPS. Appropriate flow is seen in
the hepatic veins and IVC.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
KIDNEYS: Limited views of the kidneys demonstrate no hydronephrosis.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Patent TIPS with expected reduction in peak systolic velocity after TIPS
dilation on ___.
2. No focal liver lesions.
3. Stable splenomegaly. No ascites.
4. A right pleural effusion is noted.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with SOB// interval change
COMPARISON: Chest x-ray is ___ through ___
FINDINGS:
Portable AP upright view of the chest is provided.
Right PICC line terminates at the cavoatrial junction. NG tube terminates in
the stomach. Lung volumes are low. There is pulmonary vascular congestion.
There is slight interval decrease in right pleural effusion. There is
increased consolidation of the right lower lobe. There is no pneumothorax..
Cardiomediastinal silhouette stable. Aneurysm coils are noted in the mid
abdomen.
IMPRESSION:
Increased consolidation in the right lower lobe may represent atelectasis,
though pneumonia is not excluded in the proper clinical setting. Slight
interval decrease in right pleural effusion.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Weakness
Diagnosed with Weakness
temperature: 98.2
heartrate: 89.0
resprate: 14.0
o2sat: 96.0
sbp: 106.0
dbp: 67.0
level of pain: 0
level of acuity: 3.0 | ___ woman with decompensated EtOH cirrhosis who
initially presented to ___ on ___ with fatigue, and was found
to have new ascites/hydrothorax and a UTI. Patient has had a
long complicated hospital course, has been transferred twice to
the ICU for hypoxemic respiratory failure, most recently on
___ when she then developed hypotension in the setting of
bleeding esophageal varices. She underwent TIPS w/banding on
___, without further episodes of GI bleeding. During this MICU
stay, she also developed an enterococcus UTI which was treated
with linezolid. She continued to be febrile and hypotensive even
after a full treatment course, and in this setting received
further broad spectrum antibiotics and antifungals. A family
meeting was held, and the decision was made to focus on comfort
measures only. Antibiotics were therefore stopped, and when this
happened her fevers also stopped and her mental status improved.
Infectious work-up, including pleural fluid and ascitic fluid,
remains negative. She continued to have ongoing large hepatic
hydrothorax, requiring frequent thoracentesis and at one point a
chest tube was placed. However given the large volume output and
subsequent fluid/hemodynamic shifts as well as the rapid
reaccumulation of fluid, the chest tube was removed and she was
aggressively diuresed with Lasix gtt, spironolactone,
torsemide/metolazone with improvement. Given ongoing hypoxemia,
repeat chest xray was done which showed improvement of
hydrothorax but also revealed a consolidation consistent with
HAP. Patient was treated with HAP coverage with resolution of
oxygen requirement. After a palliative consult, patient made it
clear she wanted everything to be done so she could go home
healthy and see her family/new grandson. Patient was discharged
to an LTAC.
#CAP: presented with CAP on CXR, treated with CTX, azithro until
___.
#Fever: Patient had temperature of 100.8 on ___. Urine thought
to be most likely source given weakly positive UA and patient
was empirically covered with linezolid given h/o VRE; when urine
culture returns her LTAC will be contacted to narrow her
antibiotics.
#HAP
#Respiratory Distress/Tachypnea/R Pleural Effusion/Pneumonia
Patient initially transferred to the MICU for tachypnea and
hypoxemia. Found to have an acute increase in R sided pleural
effusion concerning for recurrent hepatic hydrothorax with
evidence of acute pulmonary edema. She had negative CTA, and TTE
was without intrapulmonary shunting. She was diuresed
aggressively with and started on duonebs and albuterol along
with levofloxacin with improvement in her oxygenation. On ___
- TIPS upsize was performed by ___ with further diuresis w/ Lasix
and metolazone with further improvement in her respiratory
status. She was subsequently transferred out of the ICU to the
floor, where she continued to be hypoxemic. CXR showed worsening
right hydrothorax so patient had several thoracentesis done to
help alleviate this. Once improved, patient continued to be
hypexoemic. Repeat CXR showed forming consolication consistent
with HAP. Patient was treated with vanc and ceftax for 8 days.
Oxygen requirement resolved.
# E. Coli UTI: UCx grew E. Coli sensitive to CTX. She was
treated with CTX from ___ to ___.
#Alcoholic cirrhosis/hepatitis w/ grade 2 varices and
encephalopathy:
Continued home FoLIC Acid, rifaxamin, lactulose, spironolactone;
held nadolol briefly while in the ICU.
# Hyponatremia: Patient had an acute decrease in sodium with a
nadir of 126. This was thought to be a combination of diuretic
effect and SIADH in the setting of her lung disease. She was
placed on a fluid restriction with some improvement in her
sodium. She was discharged on a 1.2L fluid restriction with a
sodium of 130.
#Weight loss/poor nutrition/Refeeding: Started on tubefeeds with
nutrition following.
#Anemia Hb slightly down from baseline on admission, drop in H/H
with hematemesis on ___ with multiple transfusions of PRBC, on
endoscopy bleeding esophageal varices s/p TIPS and banding on
___. No further bleeding. Discharge H/H: 7.6/22.9
___: Renal consulted, attributed to over diuresis. Patient was
kept even and ___ resolved. On discharge, Cr: 0.7
CHRONIC:
# History of alcohol abuse: Although patient denying alcohol
use, family is concerned about her alcohol use. Her current
presentation was consistent with alcohol use. She was counseled
extensively about the importance of stopping alcohol use and
enrolling in relapse prevention as outpatient.
#Electrolyte abnormalities
#Refeeding sydnrome: Hyponatremia, hypomagnesaemia,
hypocalcemia, hypophosphatemia, and hypokalemia likely
nutritional given poor PO intake. Consistent with starvation
ketosis on admission, which is now improved although developed
refeeding syndrome after starting tube feeds which required
aggressive electrolyte repletion.
#Anxiety/depression. The patient is followed by Dr. ___
___. She was continued on home remeron and clonazepam. She also
received lorazepam PRN.
#History of asthma, chronic bronchitis: She received duoneb and
albuterol treatments. She was also placed on advair for
controller medication. |
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 s/p MVA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of HTN & Afib (s/p PPM placed in ___ with
chest pain and negative ACS workup, negative radiologic trauma
workup i/s/o a motor vehicle crash, being evaluated for ?syncope
and pain.
Briefly, early in the morning of ___, Mr. ___ was driving
~35 mph along a straight road to go ___ with his wife, when,
per his report, he heard a noise under the car, the car suddenly
stopped, airbags deployed, and the car rolled three times. There
was no LOC. ___ noted two sources of chest pain after the
accident. The first, on the lateral R aspect of his ribcage, he
attributed to striking the armrest of his car. The second was a
substernal "squeezing" sensation, ___ severity, no radiation to
his arm, no pleuritic component, not worse with movement. He
experienced this pain several months ago for a 2 minute episode,
and was advised by his physician that this was likely of msk
etiology. Prior stress test was negative.
In the ED, exam notable for BP 186/85, flank pain reproducible
on palpation. trops<0.01x2 ___ trop negative overnight). INR
1.9. Negative FAST, CT head and CT torso negative for acute
trauma. TTE showed mild AS, AR, mild RA dilation with mild
global free wall hypokinesis. EKG was V-paced wih negative
Sgarbossa criteria. Cardiology and trauma were consulted.
Patient received Nitro GGT, atenolol 25 mg, milk of magnesia.
Symptoms improved and he was tapered from nitro. He was admitted
to medicine for syncope evaluation, though patient denied LOC.
He may have a hx of syncope years ago secondary to afib.
Please see nightfloat admission note for home medications,
allergies, FH, and SH, which I have confirmed with the patient.
This morning, the patient described improvement in his
substernal chest pain (down to ___, and his flank pain (___).
The substernal pain has been constant since the accident. No
radiation to arm or diaphoresis. No palpitations, sob, pleuritic
cp. No nausea, vomiting, diarrhea, constipation, weakness, or
confusion. No lightheadedness upon standing. Endorses mild
abdominal pain that he has had for several days.
Past Medical History:
HTN
HLD
Afib (s/p PPM placed in ___
BPH
Macular degeneration
Thyroid Cancer
Hypothyroidism
CKD
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION:
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, 2 cm erythematous erosion on hard
R side of hard palate, behind border of dentures. EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, ___ systolic murmur heard
throughout precordium.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding. BS+.
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema.
Echymosis over L elbow and bilateral shins. Full ROM without TTP
on L elbow
Neuro: ___. ___ strength upper/lower extremities, grossly
normal sensation. No focal deficits.
DISCHARGE:
VITALS: Tm 99.7 Tc 98.0 P 70-76, BP 153-164/67-88, R 18 spo2
98%
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, 2 cm erythematous erosion on hard
R side of hard palate, behind border of dentures. EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, ___ systolic murmur heard
throughout precordium.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding. BS+.
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema.
Echymosis over L elbow and bilateral shins. Full ROM without TTP
on L elbow
Neuro: ___. ___ strength upper/lower extremities, grossly
normal sensation. No focal deficits.
Pertinent Results:
ADMISSION:
___ 05:41AM BLOOD WBC-8.2 RBC-4.33* Hgb-13.4* Hct-40.9
MCV-95 MCH-30.9 MCHC-32.8 RDW-14.3 RDWSD-49.3* Plt ___
___ 05:41AM BLOOD ___ PTT-31.9 ___
___ 05:41AM BLOOD Glucose-154* UreaN-27* Creat-1.3* Na-140
K-4.0 Cl-103 HCO3-25 AnGap-16
___ 05:51AM BLOOD Calcium-8.6 Phos-2.8 Mg-2.4
___ 05:41AM BLOOD cTropnT-<0.01
___ 10:34AM BLOOD cTropnT-<0.01
___ 05:51AM BLOOD CK-MB-3 cTropnT-<0.01
DISCHARGE:
___ 05:51AM BLOOD WBC-8.0 RBC-4.00* Hgb-12.3* Hct-37.9*
MCV-95 MCH-30.8 MCHC-32.5 RDW-14.4 RDWSD-50.0* Plt ___
___ 05:51AM BLOOD ___ PTT-33.5 ___
___ 05:51AM BLOOD Glucose-113* UreaN-21* Creat-1.1 Na-142
K-3.9 Cl-105 HCO3-27 AnGap-14
___ CT TORSO:
1. No active bleeding or solid organ injuries.
2. No hemothorax, hemoperitoneum, or pneumoperitoneum.
3. Pulmonary edema and cardiomegaly.
4. Mediastinal lymphadenopathy may be reactive.
5. No displaced fractures identified.
6. Prostatomegaly.
7. Mid left kidney likely hemorraghic or proteinaceous cyst.
Nonurgent renal ultrasound is recommended.
___ CT HEAD: No acute process
___ CT C-SPINE: No fracture
CT Head/CSpine:
No acute fracture or traumatic malalignment.
ECG: V-paced, Sgarbossa negative.
TTE: Mild aortic stenosis and regurgitation. Moderate left
ventricular hypertrophy with normal left ventricular
regional/global systolic function. Mild RV dilation and mild
global RV systolic hypokinesis. Trivial pericardial effusion. No
clear evidence of cardiac trauma.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. dutasteride 0.5 mg oral daily
2. Terazosin 5 mg PO QHS
3. Lisinopril 20 mg PO BID
4. Atenolol 25 mg PO BID
5. magnesium hydroxide 2 tablespoons oral qOD:PRN
6. Warfarin 5 mg PO DAILY16
7. Simvastatin 40 mg PO QPM
8. Hydrochlorothiazide 25 mg PO DAILY
9. Levothyroxine Sodium 100 mcg PO 6X/WEEK (___)
10. Vitamin D ___ UNIT PO DAILY
11. Artificial Tears ___ DROP BOTH EYES QID
12. Fluticasone Propionate NASAL 2 SPRY NU PRN allergies
Discharge Medications:
1. Artificial Tears ___ DROP BOTH EYES QID
2. Atenolol 25 mg PO BID
3. Hydrochlorothiazide 25 mg PO DAILY
4. Levothyroxine Sodium 100 mcg PO 6X/WEEK (___)
5. Lisinopril 20 mg PO BID
6. Simvastatin 40 mg PO QPM
7. Terazosin 5 mg PO QHS
8. Vitamin D ___ UNIT PO DAILY
9. Chloraseptic Throat Spray 1 SPRY PO Q4H:PRN sore throat
RX *phenol [Chloraseptic] 0.5 % 1 Spray q4h:prn Disp #*1 Bottle
Refills:*0
10. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % 1 Patch Daily:prn Disp #*30 Patch Refills:*0
11. dutasteride 0.5 mg oral daily
12. Fluticasone Propionate NASAL 2 SPRY NU PRN allergies
13. magnesium hydroxide 2 tablespoons ORAL QOD:PRN constipation
do not take within 4 hours of levothyroxine
14. Warfarin 5 mg PO DAILY16
15. Acetaminophen 1000 mg PO Q8H:PRN pain
Take 1000mg every 8 hours as needed for pain
RX *acetaminophen 500 mg 2 tablet(s) by mouth q8h:prn Disp #*60
Tablet Refills:*0
16. Outpatient Lab Work
ICD-10 I48.1 Atrial Fibrillation
Please draw INR on ___ and send results to
Dr. ___: ___: ___, ___
Phone: ___
Fax: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
S/p motor vehicle accident
Musculoskeletal pain
Atrial Fibrillation
Discharge Condition:
Discharge Condition: Stable
Mental Status: AOx3
Ambulatory Status: Independent
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with mvc // eval for ich, c spine fracture, intra
abd injury
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 17.7 cm; CTDIvol = 45.5 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None available.
FINDINGS:
There is no evidence of acute territorial infarction, hemorrhage, edema, or
large mass. Periventricular and subcortical white matter hypodensities are
nonspecific, but likely represent chronic small vessel ischemic disease.
Prominence of the ventricles and sulci is suggestive of involutional changes.
Evaluation for fracture at the skullbase is mildly limited by motion. No
acute fracture seen. There is moderate mucosal thickening in the ethmoid air
cells. The visualized portion of the paranasal sinuses, mastoid air cells,
and middle ear cavities are otherwise clear. The orbits are unremarkable.
There is moderate carotid siphon and vertebral artery calcification.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: History: ___ with mvc // eval for ich, c spine fracture, intra
abd injury
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.4 s, 25.1 cm; CTDIvol = 37.3 mGy (Body) DLP = 935.9
mGy-cm.
Total DLP (Body) = 936 mGy-cm.
COMPARISON: None available.
FINDINGS:
Alignment is normal. No fractures are identified. There is no critical spinal
canal stenosis. There is no prevertebral soft tissue swelling. Moderate to
severe degenerative change is worst at C5-6, where there is disc space
narrowing, endplate sclerosis, and osteophytosis.
IMPRESSION:
No acute fracture or traumatic malalignment.
Radiology Report
INDICATION: History: ___ with motor vehicle collision, crushing chest pain
TECHNIQUE: Supine AP view of the chest
COMPARISON: None. Patient is currently listed as EU critical.
FINDINGS:
A pacer device is noted with leads terminating in the right atrium and right
ventricle. Moderate cardiomegaly is noted. The aorta demonstrates
atherosclerotic calcifications. Enlargement of the right pulmonary artery
remains suggests underlying pulmonary arterial hypertension. There is mild
pulmonary edema with possible trace bilateral pleural effusions. No
pneumothorax is detected on this supine view. Retrocardiac opacity may
reflect atelectasis. No displaced rib fractures are demonstrated.
IMPRESSION:
Moderate cardiomegaly, mild pulmonary edema and possible trace pleural
effusions. Probable retrocardiac atelectasis.
Radiology Report
INDICATION: History: ___ with MVC w/ crushing Chest pain*** WARNING ***
Multiple patients with same last name! // acute aortic injury vs chest wall
trauma
TECHNIQUE: MDCT axial images were acquired through the chest, abdomen and
pelvis following intravenous contrast administration with split bolus
technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence: 1) Stationary Acquisition 7.0 s, 0.5 cm; CTDIvol
= 33.7 mGy (Body) DLP = 16.9 mGy-cm. 2) Spiral Acquisition 9.4 s, 74.1 cm;
CTDIvol = 18.4 mGy (Body) DLP = 1,360.8 mGy-cm. Total DLP (Body) = 1,378
mGy-cm.
COMPARISON: None available.
FINDINGS:
CHEST: HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury. Pacer wire tips are seen in the right atrium and
right ventricle. Coronary calcifications are extensive. Cardiomegaly is
moderate. The heart, pericardium, and great vessels are otherwise within
normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: Prevascular and pretracheal lymph nodes
measure up to 9 mm in short axis. No axillary or hilar lymphadenopathy is
present. No mediastinal mass or hematoma.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There is consolidation in the posterior right upper lobe.
Interlobular septal thickening and patchy areas of ground glass opacity and
dependent atelectasis in bilateral lower lobes and right middle lobe are
compatible with mild pulmonary edema and mild atelectasis. There is
peribronchial thickening in the lower lobes bilaterally. The airways are
patent to the level of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. There
is no evidence of focal lesion or laceration. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder is within
normal limits.
PANCREAS: Mild fatty atrophy, but has normal attenuation throughout, without
evidence of focal lesions or pancreatic ductal dilatation. There is no
peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesion or laceration.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no hydronephrosis. There is no perinephric abnormality. Multiple
cortical cysts. No solid enhancing masses. 8 mm hyperdense cyst in left renal
interpolar region.
GASTROINTESTINAL: Hiatal hernia is small. Small bowel loops demonstrate normal
caliber, wall thickness, and enhancement throughout. Moderate amount of stool
throughout the colon. The colon and rectum are otherwise within normal
limits. There is no evidence of mesenteric injury.
There is no free fluid or free air in the abdomen.
PELVIS: There is a 11 mm left posterior bladder diverticulum. The distal
ureters are unremarkable. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is enlarged.
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.
Extensive atherosclerotic disease is noted throughout abdominal aorta.
BONES: There is no acute fracture. No focal suspicious osseous abnormality.
There is moderate degenerative change and degenerative disc disease throughout
the thoracolumbar spine.
SOFT TISSUES: Bilateral inguinal hernias containing fat are noted.
IMPRESSION:
1. No active bleeding or solid organ injuries.
2. No hemothorax, hemoperitoneum, or pneumoperitoneum.
3. Pulmonary edema and cardiomegaly.
4. Mediastinal lymphadenopathy may be reactive.
5. No displaced fractures identified.
6. Prostatomegaly.
7. Mid left renal likely hemorraghic or proteinaceous cyst.
RECOMMENDATION(S): Nonurgent renal ultrasound is recommended.
Gender: M
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: MVC
Diagnosed with Chest pain, unspecified, Car driver injured in collision w car in traf, init
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 1
level of acuity: nan | ___ PMH of Afib (s/p PPM placed in ___, on coumadin), HTN, who
presented s/p motor vehicle accident of unclear circumstances,
had a negative trauma workup, but was admitted for observation
and evaluation of chest pain, which was thought to be mostly
musculoskeletal who was discharged with appropriate follow up
#Motor Vehicle Accident
Circumstances are unclear as patient is unable to provide
clarity as to what led his car to flip over causing airbags to
deploy. Denies mechanical dysfunction of car or hitting an
object. Patient denied LOC and noted that he recalls entire
incident. Patient was seen by trauma surgery in ED, and had CT
C-Spine, Head, Torso which was negative for acute injury.
However, had chest pain and was admitted to medicine service.
Patient ambulated with nurse the night after the incident, and
strength/balance was found to be normal. Pain on right chest
wall was felt to be musculoskeletal.
#Chest Pain
Presented with two sources of mild chest pain: substernal and on
lateral aspect of R ribcage. ACS workup negative as troponin
were negative x3. EKG was difficult to interpret as was paced,
and interrogation of pacer showed no abnormalities. TTE
performed which showed mild AS/AR, moderate LVH, normal LV
regional/global systolic function, mild RV dilation, mild global
RV systolic hypokinesis, trivial pericardial effusion, no clear
evidence of cardiac trauma. Fortunately, sub-sternal chest pain
resolved with time, however, patient warrants consideration of
outpatient stress test or repeat TTE to trend findings, as he
noted that he had similar pain 2 months ago. As for right sided
chest pain, it was reproducible with palpation, felt to be ___
airbag trauma, and was given a lidocaine patch for it.
#HTN
During hospitalization patient was noted to have HTN to 190 most
likely ___ withholding medications in setting of trauma.
Patient's BP improved with restarting home regimen.
#AFib
Coumadin was continued at home dose of 5mg daily during
hospitalization. INR 1.9 on discharge, and patient needs repeat
INR checked on ___ by ___
#Oral lesion
Patient was found to have ~1.5 cm raised purple lesion on hard
palate which he noticed after the accident. Was felt to be
possibly ___ trauma from dentures being forced backward by
airbag. Speech and swallow performed bedside exam and patient
was able to swallow normally. He was rec'd to follow up with ENT
in 2 weeks to ensure that it has resolved, or for further
evaluation if it persists. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Lipitor / liothyronine
Attending: ___
Chief Complaint:
Lower extremity weakness
Major Surgical or Invasive Procedure:
___ guided biopsy of T7 vertebral lesion (___)
Spinal angiogram for embolization of bilateral T7 feeders
(___)
Bilateral T6, T7, T8 laminectomy with medial facetectomy
and foraminotomy with excision of extradural mass/epidural mass
at ___
History of Present Illness:
___ male history of intellectual disability, diabetes
mellitus, urothelial cell cancer of the upper urinary tract
status post partial nephrectomy (___),
urothelial/transitional cell cancer of the bladder s/p
trans-urethral bladder mass resection (___), ESRD on HD MWF
who p/w ___ weeks of worsening back pain and difficulty
ambulating with "buckling" of right leg and difficulty
urinating. Patient denies any fevers. No recent trauma. Denies
any numbness or weakness of the upper extremities and only
endorses numbness of the left knee.
As an outpatient, MRI at ___ on ___ notable
for:
MRI thoracic spine without contrast: Impression there is a mixed
signal extra medullary extradural mass centered at the T7 level
resulting in displacement cord compression. This could represent
a meningioma. This finding could further evaluate the
contrast-enhanced study. There are surgical consult suggested.
Possibly 5.8 x 0.9 cm in the craniocaudal and AP dimension. MRI
cervical spine without contrast. Impression: Small central
herniation at the C3-C4 level narrowing the AP diameter of the
canal with focal myelomalacia. Left lateral herniation at C4
through C5 level comprising the the neural foraminal recess.
Small central herniation at the C6 through C7 level. Mild
diffuse
thinning of the lower cervical upper thoracic cord.
Past Medical History:
History of upper tract TCC s/p right nephroureterectomy
Bladder cancer
CKD, dialysis dependent
HTN
Seizure d/o
DM
Anemia
Arthritis
Chronic Constipation
GERD
HLD
Vitamin D deficiency
BPAD
Intermittent Explosive Disorder
PAST SURGICAL HISTORY:
R UE BRACHIOCEPHALIC AV FISTULA ___
right nephroureterectomy
Social History:
___
Family History:
No Family History currently on file.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 98.8, BP 114/62, HR 79, RR 18, SpO2 96% RA
General: alert and interactive, responds to questions with ___
words, developmental delay, NAD, foley in place
Eyes: Sclera anicteric
HEENT: wearing corrective glasses, PERRL, MMM,
Resp: CTAB, unlabored respirations, no wheezes, crackles, or
rhonchi
CV: RRR, systolic ejection murmur, 2+ radial and DP pulses, RUE
AVF
GI: soft, non-distended, no tenderness to palpation, +BS, no
rebound or guarding
MSK: warm, well-perfused, no lower extremity edema
Neuro: Alert and oriented to person and place, ___ left ankle dorsi- and
plantar flexion, ___ right ankle dorsi- and plantar flexion,
intact sensation bilaterally
DISCHARGE PHYSICAL EXAM:
Vitals: Temp: 98.2 PO BP: 138/66 L Lying HR: 74 RR: 18 O2 sat:
100% O2 delivery: 3LNC
General: alert, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Lungs: clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops
Abdomen: soft, tenderness to palpation in RUQ, non-distended,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly.
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 grossly intact. Proximal right and left ___ 3+ to
___, able to extend right and left ___ (3+/5), can
wiggle toes. do not appreciate any clonus. SILT bilaterally.
Skin: Reports tenderness on back near surgical site.
Pertinent Results:
LABS
-----
INITIAL LABS:
___ 09:04PM ___ PTT-25.8 ___
___ 09:04PM NEUTS-59.5 ___ MONOS-10.8 EOS-4.3
BASOS-0.9 IM ___ AbsNeut-4.02 AbsLymp-1.63 AbsMono-0.73
AbsEos-0.29 AbsBaso-0.06
___ 09:04PM WBC-6.8 RBC-3.18* HGB-9.9* HCT-32.0*
MCV-101*# MCH-31.1 MCHC-30.9* RDW-16.7* RDWSD-61.3*
___ 09:04PM PLT COUNT-311
___ 09:04PM ALBUMIN-3.7 CALCIUM-10.1 PHOSPHATE-2.9
MAGNESIUM-2.6
___ 09:04PM ALT(SGPT)-22 AST(SGOT)-22 LD(LDH)-168 ALK
PHOS-101 TOT BILI-0.2
___ 09:04PM GLUCOSE-79 UREA N-17 CREAT-4.3* SODIUM-141
POTASSIUM-4.4 CHLORIDE-99 TOTAL CO2-32 ANION GAP-10
Discharge Labs
___ 07:10AM BLOOD WBC-8.3 RBC-2.56* Hgb-7.8* Hct-24.5*
MCV-96 MCH-30.5 MCHC-31.8* RDW-14.5 RDWSD-50.5* Plt ___
___ 07:10AM BLOOD Glucose-85 UreaN-83* Creat-5.8*# Na-135
K-4.9 Cl-87* HCO3-27 AnGap-21*
___ 07:10AM BLOOD ALT-20 AST-23 AlkPhos-104 TotBili-<0.2
DirBili-<0.2
___ 07:10AM BLOOD Calcium-11.7* Phos-7.9* Mg-3.5*
IMAGING
--------
MRI T-SPINE (___)
1. Expansile osseous lesion in the posterior aspect of T7
vertebral body with erosion of the posterior cortex, partially
seen on the ___
abdominal/pelvic CT. Associated epidural mass centered in the
right lateral
spinal canal from mid T6 through mid T8 levels, with spinal cord
compression at T7 and associated spinal cord edema from T6
through T8. This was previously seen on the ___
thoracic spine MRI without contrast.
2. No evidence for osseous, epidural, or leptomeningeal
metastatic disease in the cervical or lumbar spine.
3. Multilevel cervical degenerative disease on with
mild-to-moderate spinal
canal narrowing and partial spinal cord compression at C3-C4,
associated with focal myelomalacia, as seen on the ___ cervical spine MRI without contrast.
4. Several disc herniations without spinal cord compression are
again seen in the thoracic spine.
5. Congenital lumbar spinal stenosis with superimposed
degenerative changes, as described in detail in the preceding ___ noncontrast lumbar spine MRI report.
6. The partially visualized left kidney again demonstrates
hydronephrosis,
mild cortical thinning, and multiple cystic lesions which are
not
characterized on this exam.
7. Multi circumscribed T2 hyperintense, nonenhancing
subcentimeter right
posterior subpleural lesions along the right posterior sixth,
seventh, eighth ribs, and a similar circumscribed oval 18 mm
left posterior subpleural lesion along the left posterior eighth
rib, are suggestive of paraspinal ganglia; there is no evidence
for a mass or rib erosion on the ___. Circumscribed oval T2 hyperintense, peripherally enhancing
structure medial to the left internal carotid artery at the
level of C6, 10 x 11 x 20 mm, may represent a lymphatic
structure, a ganglion, a nerve sheath tumor, or a necrotic lymph
node.
MRI L-SPINE (___)
IMPRESSION:
1. No evidence of a lumbar spine mass.
2. Extensive edema involving the right greater than left lumbar
paraspinal
musculature is nonspecific with the differential including
reactive edema from trauma and degenerative change as well as
infection/inflammation. Neoplastic involvement is less likely
but cannot be excluded given history of TCC/bladder cancer and
thoracic mass.
3. Edema within the lower back subcutaneous at may represent
extension from
the above described paraspinal process, although may also
represent normally found dependent changes.
4. Multilevel degenerative changes of the lumbar spine most
significant at
L4-L5 and L5-S1 where there is mild-to-moderate spinal canal
narrowing.
5. Mild amount of nonspecific presacral edema likely correlates
with the
patient's recently described bladder cancer.
6. Findings compatible with renal osteodystrophy correlating
with the
patient's history of end-stage renal disease.
CT CHEST W/O CONTRAST (___)
FINDINGS:
Diffuse enlargement of the thyroid gland is demonstrated. Aorta
and pulmonary arteries are stable in appearance, with main
pulmonary artery being 3 cm in diameter, unremarkable. Heart
size is normal. There is no pericardial or pleural effusion. No
mediastinal, hilar or axillary lymphadenopathy is demonstrated.
Pre-vascular minimal soft tissue interspersed with fat is most
likely consistent with thymic residual. No definitive
lymphadenopathy is seen. Airways are patent to the subsegmental
level bilaterally. Lungs are clear. T7 lytic lesion with soft
tissue component is re-demonstrated, better appreciated on
previous MRI. Assessment of the upper abdomen demonstrate
multiple gallstones are no
evidence of cholecystitis
IMPRESSION:
No definitive evidence of intrathoracic metastatic disease.
Other than the known T7 metastatic focus.
CT ABD & PELVIS WITH CONTRAST (___)
FINDINGS:
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout.
There is no evidence of focal lesions. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The
gallbladder contains gallstones without wall thickening or
surrounding inflammation.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of focal lesions or pancreatic ductal
dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout,
without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size
and shape.
URINARY: Patient is status post a right total nephrectomy.
Partially
exophytic hypodensities in the left kidney are unchanged and
likely renal
cysts. This study is not optimized for assessment of the left
upper urinary tract. Previously seen left hydronephrosis has
resolved. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel
loops demonstrate normal caliber, wall thickness, and
enhancement throughout. The colon and rectum are within normal
limits. The appendix is normal.
PELVIS: The bladder is suboptimally assessed due to streak
artifact from
bilateral hip prostheses. It appears collapsed around a Foley
catheter.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Inadequate assessment of the reproductive
organs due to streak artifact in the pelvis.
LYMPH NODES: There is no or mesenteric lymphadenopathy.
Thereis 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 inthe lumbar spine or pelvis.
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
No evidence of metastatic disease in the abdomen and pelvis
MR HEAD W & W/O CONTRAST (___)
IMPRESSION:
1. Study is mildly degraded by motion.
2. No acute intracranial abnormality.
3. 7 mm left occipital dural based enhancing mass with minimal
mass effect on adjacent occipital lobe. While finding may
represent a meningioma, metastatic disease is not excluded on
the basis of this examination. Recommendation attention on
follow-up imaging.
4. Paranasal sinus disease , as described.
SPINAL SEL A-GRAM (___)
IMPRESSION:
Tumor blush appreciated on injection of both right and left T7
radicular
arteries. Successful embolization of right and left T7
radicular arteries.
T-SPINE (___)
FINDINGS:
Vertebral body and disc heights are preserved. No fracture,
subluxation, or degenerative change is detected. The no
suspicious lytic or sclerotic lesions are seen. Suture material
projects over the T7, T8 levels. Visualize cardiomediastinal
structures and lungs are within normal limits.
IMPRESSION:
Postoperative changes of the thoracic spine with no acute
abnormality
identified.
MICRO
-------
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION
PATH
-------
Thoracic Spine Biopsy (___) (___):
Unremarkable cartilage and fragments of bone.
Trilineage hematopoietic bone marrow.
No malignancy identified in this biopsy, multiple levels are
examined.
Surgical Resection of Mass (___) NOT FINALIZED.
Initial pathology read did not find evidence of malignancy.
Reported as papillary hemangioma. Final report pending at
discharge.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcitriol 0.25 mcg PO DAILY
2. Calmoseptine (menthol-zinc oxide) 0.44-20.6 % topical other
3. Nephrocaps 1 CAP PO DAILY
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
5. amLODIPine 5 mg PO DAILY
6. Amoxicillin ___ mg PO PREOP dental procedures
7. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
8. Aspirin 81 mg PO DAILY
9. CarBAMazepine 300 mg PO TID
10. Cinacalcet 90 mg PO DAILY
11. Docusate Sodium 100 mg PO BID
12. Ezetimibe 10 mg PO DAILY
13. Famotidine 20 mg PO DAILY
14. Fluticasone Propionate NASAL 2 SPRY NU DAILY
15. Gold Bond Medicated Foot (menthol) 1 % topical DAILY:PRN
16. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
17. Lactulose 30 mL PO TID constipation
18. LORazepam 0.5 mg PO BID:PRN anxiety
19. Lotrisone (clotrimazole-betamethasone) ___ % topical
BID:PRN
20. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08
gram-1.8 kcal/mL oral QPM
21. RisperiDONE 3 mg PO QHS
22. RisperiDONE 1 mg PO DAILY
23. Rosuvastatin Calcium 40 mg PO QPM
24. Senna 8.6 mg PO BID:PRN constipation
25. sevelamer CARBONATE 800 mg PO TID W/MEALS
26. Tamsulosin 0.4 mg PO QHS
27. linaGLIPtin 5 mg oral DAILY
28. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Bisacodyl ___AILY constipation
2. Lidocaine 5% Patch 1 PTCH TD QAM
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*18
Tablet Refills:*0
4. Sarna Lotion 1 Appl TP DAILY
5. Acetaminophen 1000 mg PO TID
6. sevelamer CARBONATE 1600 mg PO TID W/MEALS
7. amLODIPine 5 mg PO DAILY
8. Amoxicillin ___ mg PO PREOP dental procedures
9. Artificial Tears ___ DROP BOTH EYES PRN dry eyes
10. Aspirin 81 mg PO DAILY
11. Calmoseptine (menthol-zinc oxide) 0.44-20.6 % topical other
12. CarBAMazepine 300 mg PO TID
13. Cinacalcet 90 mg PO DAILY
14. Docusate Sodium 100 mg PO BID
15. Ezetimibe 10 mg PO DAILY
16. Famotidine 20 mg PO DAILY
17. Fluticasone Propionate NASAL 2 SPRY NU DAILY
18. Gold Bond Medicated Foot (menthol) 1 % topical DAILY:PRN
19. Guaifenesin-Dextromethorphan 5 mL PO Q6H:PRN cough
20. Lactulose 30 mL PO TID constipation
21. linaGLIPtin 5 mg oral DAILY
22. LORazepam 0.5 mg PO BID:PRN anxiety
23. Lotrisone (clotrimazole-betamethasone) ___ % topical
BID:PRN
24. Nephrocaps 1 CAP PO DAILY
25. Nepro Carb Steady (nut.tx.imp.renal fxn,lac-reduc) 0.08
gram-1.8 kcal/mL oral QPM
26. RisperiDONE 3 mg PO QHS
27. RisperiDONE 1 mg PO DAILY
28. Rosuvastatin Calcium 40 mg PO QPM
29. Senna 8.6 mg PO BID:PRN constipation
30. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Cord compression
Spinal mass
Secondary diagnoses:
End stage renal disease
Anemia
Seizure disorder
Developmental delay
Urothelial renal cancer
Urothelial bladder cancer
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: MR ___ SPINE W/O CONTRAST ___ MR SPINE
INDICATION: History: ___ with thoracic spine massIV contrast to be given at
radiologist discretion as clinically needed// ? eval for spinal masses
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
For the purposes of numbering, the lowest rib bearing vertebral body was
designated the T12 level.
Vertebral body alignment is preserved. Vertebral body heights are preserved.
Mild multilevel endplate irregularity most significantly at L4 and L5 may
correlate with renal osteodystrophy given the patient's history of end-stage
renal disease.
The visualized portion of the spinal cord is preserved in signal and caliber.
The conus medullaris terminates at the level of L1-L2.
Reduced T2 signal within the L3-L4 intervertebral disc is likely on a
degenerative basis.
There is extensive edema involving the right greater than left lumbar
paraspinal musculature. There is also a mild amount of nonspecific presacral
edema. No organized fluid collection is identified. Dependent edema is
present within the lower back subcutaneous fat.
There are congenitally shortened pedicles resulting in diffuse narrowing of
the spinal canal.
At T12-L1 there are congenitally shortened pedicles, slight disc bulging,
ligamentum flavum thickening and facet osteophytes resulting in mild spinal
canal narrowing and mild bilateral neural foraminal narrowing.
At L1-L2 there are congenitally shortened pedicles, slight disc bulging,
ligamentum flavum thickening and facet osteophytes resulting in mild spinal
canal narrowing mild bilateral neural foraminal narrowing.
At L2-L3 there are congenitally short pedicles, slight disc bulging,
ligamentum flavum thickening and facet osteophytes with mild spinal canal
narrowing, moderate right and mild left neural foraminal narrowing.
At L3-L4 there are congenitally shortened pedicles, mild symmetric disc
bulging, ligamentum flavum thickening and facet osteophytes resulting mild
spinal canal narrowing and mild-to-moderate bilateral neural foraminal
narrowing.
At L4-L5 there are congenitally shortened pedicles, symmetric disc bulging,
ligamentum flavum thickening and facet osteophytes resulting in
mild-to-moderate spinal canal narrowing and severe bilateral neural foraminal
narrowing.
At L5-S1 there are congenital short pedicles, symmetric disc bulging,
ligamentum flavum thickening and facet osteophytes resulting in mild to
moderate spinal canal narrowing and severe bilateral neural foraminal
narrowing.
Other:
The left kidney is slightly atrophic and there are a few left renal T2
hyperintensities compatible with cysts.
IMPRESSION:
1. No evidence of a lumbar spine mass.
2. Extensive edema involving the right greater than left lumbar paraspinal
musculature is nonspecific with the differential including reactive edema from
trauma and degenerative change as well as infection/inflammation. Neoplastic
involvement is less likely but cannot be excluded given history of TCC/bladder
cancer and thoracic mass.
3. Edema within the lower back subcutaneous at may represent extension from
the above described paraspinal process, although may also represent normally
found dependent changes.
4. Multilevel degenerative changes of the lumbar spine most significant at
L4-L5 and L5-S1 where there is mild-to-moderate spinal canal narrowing.
5. Mild amount of nonspecific presacral edema likely correlates with the
patient's recently described bladder cancer.
6. Findings compatible with renal osteodystrophy correlating with the
patient's history of end-stage renal disease.
Radiology Report
EXAMINATION: MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE
INDICATION: ___ with developmental delay, diabetes, renal carcinoma s/p
nephrectomy, end-stage renal disease on dialysis, bladder tumor s/p resection,
now presenting with back pain, difficulty ambulating, urine retention.
Outside noncontrast MRI spine showing thoracic mass with cord compression.
Contrast enhanced imaging of the entire spine is requested for surgical
planning.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 imaging was performed. Axial GRE images of the cervical spine were
performed. After the uneventful administration of 20 mL of ProHance contrast
agent, additional axial and sagittal T1 images were obtained.
COMPARISON: ___ lumbar spine MRI without contrast at 01:04
___ cervical and thoracic spine MRIs
___ CT abdomen/pelvis
___ CT chest
FINDINGS:
There are 7 cervical vertebrae, 12 rib-bearing vertebrae, 4 lumbar-type
vertebrae, and a partially sacralized L5, as seen on prior imaging studies.
The localizer sequence also demonstrates S-shaped thoracolumbar curvature.
Biconcave shape of multiple vertebral bodies may be secondary to loss of bone
mineralization and/or renal osteodystrophy.
Motion artifact limits evaluation, mildly on most images.
CERVICAL:
No evidence for suspicious bone marrow lesions. No evidence for an epidural
or intrathecal mass. The cerebellar tonsils are normally positioned.
Visualized posterior fossa appears unremarkable. There is multilevel
degenerative disease as recently seen on the ___ cervical spine
MRI.
C2-C3: Small central disc protrusion mildly indents the ventral thecal sac.
Moderate to severe bilateral neural foraminal narrowing by uncovertebral and
facet osteophytes.
C3-C4: Central disc protrusion causes moderate to severe spinal canal stenosis
with partial spinal cord compression. High T2 signal in the cord at this
level is consistent with myelomalacia. Severe bilateral neural foraminal
narrowing by uncovertebral and facet osteophytes.
C4-C5: Left paracentral disc protrusion plus/minus endplate osteophytes cause
mild left ventral cord remodeling without cord compression and mild spinal
canal narrowing. Moderate to severe right and severe left neural foraminal
narrowing by uncovertebral and facet osteophytes.
C5-C6: Broad-based central disc protrusion plus/minus endplate osteophytes
minimally indent the ventral thecal sac without mass effect on the spinal
cord. Moderate to severe bilateral neural foraminal narrowing by
uncovertebral and facet osteophytes.
C6-C7: Central disc protrusion approaches the ventral spinal cord with mild
spinal canal narrowing. No definite cord deformity is seen. Mild to moderate
left neural foraminal narrowing by uncovertebral and facet osteophytes.
C7-T1: No spinal canal narrowing. Mild bilateral neural foraminal narrowing
by facet osteophytes.
THORACIC:
There is a 1.6 x 1.6 x 1.7 cm expansile mass in the posterior aspect of T7
vertebral body, with erosion of the posterior cortex which was partially seen
on the ___ abdominal/pelvic CT. There is an associated epidural
mass centered in the right lateral spinal canal from mid T6 through mid T8
levels, which at the level of T7 displaces the thecal sac anteriorly and to
the left, resulting in effacement of CSF around the cord and cord compression.
This was previously seen on the recent ___ thoracic spine MRI
without contrast. Faint T2 hyperintensity in the spinal cord from mid C6
through lower T8 levels is better seen on the prior MRI due to motion artifact
on the present study.
T2-T3: Left paracentral disc protrusion indents the ventral thecal sac without
spinal cord contact or significant spinal canal narrowing.
T5-T6: Left paracentral disc protrusion abuts the left ventral spinal cord.
However, the cord is surrounded by plentiful CSF laterally and posteriorly,
and there is no significant spinal canal stenosis.
LUMBAR:
No evidence for suspicious osseous lesion. No evidence for an epidural or
intrathecal mass. The conus medullaris appears unremarkable, terminating at
L1-L2. Edema within right greater than left posterior paravertebral muscles
and overlying subcutaneous fat edema is again noted. Congenital lumbar spinal
canal narrowing and superimposed degenerative changes are described in detail
in the same day report for the preceding noncontrast lumbar spine MRI.
OTHER:
There is a circumscribed oval T2 hyperintense, peripherally enhancing
structure medial to the left internal carotid artery at the level of C6, 10 x
11 x 20 mm on images 14:26 and 8:18 (AP, transverse, craniocaudad), which may
represent a lymphatic structure, a ganglion, a nerve sheath tumor, or a
necrotic lymph node.
There are multiple circumscribed T2 hyperintense, nonenhancing subcentimeter
right posterior subpleural lesions along the right posterior sixth, seventh,
eighth ribs, and a similar circumscribed oval 18 mm left posterior subpleural
lesion along the left posterior eighth rib, suggestive of paraspinal ganglia.
No corresponding mass or rib erosion is seen on the ___ CT.
Partially visualized left kidney demonstrates hydronephrosis with mild
cortical thinning, as well as multiple cystic lesions which are not
characterized on this exam, as seen on the ___ abdominal/pelvic CT.
IMPRESSION:
1. Expansile osseous lesion in the posterior aspect of T7 vertebral body with
erosion of the posterior cortex, partially seen on the ___
abdominal/pelvic CT. Associated epidural mass centered in the right lateral
spinal canal from mid T6 through mid T8 levels, with spinal cord compression
at T7 and associated spinal cord edema from T6 through T8. This was
previously seen on the ___ thoracic spine MRI without contrast.
2. No evidence for osseous, epidural, or leptomeningeal metastatic disease in
the cervical or lumbar spine.
3. Multilevel cervical degenerative disease on with mild-to-moderate spinal
canal narrowing and partial spinal cord compression at C3-C4, associated with
focal myelomalacia, as seen on the ___ cervical spine MRI without
contrast.
4. Several disc herniations without spinal cord compression are again seen in
the thoracic spine.
5. Congenital lumbar spinal stenosis with superimposed degenerative changes,
as described in detail in the preceding ___ noncontrast lumbar
spine MRI report.
6. The partially visualized left kidney again demonstrates hydronephrosis,
mild cortical thinning, and multiple cystic lesions which are not
characterized on this exam.
7. Multi circumscribed T2 hyperintense, nonenhancing subcentimeter right
posterior subpleural lesions along the right posterior sixth, seventh, eighth
ribs, and a similar circumscribed oval 18 mm left posterior subpleural lesion
along the left posterior eighth rib, are suggestive of paraspinal ganglia;
there is no evidence for a mass or rib erosion on the ___ abdominal
CT.
8. Circumscribed oval T2 hyperintense, peripherally enhancing structure medial
to the left internal carotid artery at the level of C6, 10 x 11 x 20 mm, may
represent a lymphatic structure, a ganglion, a nerve sheath tumor, or a
necrotic lymph node.
NOTIFICATION: Electronic wet reading to the emergency department was provided
when this report was signed at 14:19 on ___. The emergency
department and the consulting spine service were already aware of the thoracic
spine mass compressing the spinal cord and degenerative disease compressing
the cervical spinal cord from prior noncontrast MRIs.
Radiology Report
EXAMINATION: CT-guided spine biopsy
INDICATION: ___ year old man with ___ male history of mental
retardation, diabetes mellitus, renal carcinoma status post partial
nephrectomy, ESRD last dialysis today, who presents with days 4 weeks of
worsening back pain and difficulty ambulation found to have cord compression
(T6-T8 extradural mass) on MRI.// 5x1cm extradural mass at level of
T6-T8...tissue diagnosis?
COMPARISON: MRI of the thoracic spine dated ___. CT scan of the
abdomen and pelvis dated ___.
PROCEDURE: CT-guided spine biopsy.
OPERATORS: Dr. ___ fellow and Dr. ___ radiologist.
Dr. ___ supervised the trainee during the key components of the
procedure and reviewed and agrees with the trainee's findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a prone position on the CT scan table. Limited
preprocedure CTscan of the intended biopsy area was performed. Based on the
CT findings an appropriate position for the biopsy was chosen. The site was
marked.
The site was prepped and draped in the usual sterile fashion. 1% lidocaine
were administered to the subcutaneous and deep tissues for local anesthetic
effect. Under CT guidance, a 11 gauge coaxial needle was introduced into the
lesion. An 13 gauge core biopsy device with a 30 mm throw was used to obtain
1 core biopsy specimen, which were sent for pathology.
The procedure was tolerated well and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.1 s, 15.6 cm; CTDIvol = 17.8 mGy (Body) DLP = 254.2
mGy-cm.
2) Stationary Acquisition 8.3 s, 1.4 cm; CTDIvol = 86.6 mGy (Body) DLP =
124.6 mGy-cm.
Total DLP (Body) = 397 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of
150 mcg fentanyl throughout the total intra-service time of 35 minutes during
which patient's hemodynamic parameters were continuously monitored by an
independent trained radiology nurse.
FINDINGS:
Lytic lesion along the posterior aspect of the T7 vertebral body with
sclerotic borders, which was targeted for biopsy.
IMPRESSION:
Technically successful biopsy of T7 vertebral body lesion. A single 13 gauge
30 mm core was submitted for pathology. No immediate postprocedure
complication.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ male history of intellectual disability, diabetes
mellitus, papillary urothelial renal cancer status post partial nephrectomy,
ESRD on ___, status post transitional cell carcinoma s/p
resection of bladder tumor, who presents with days 2 weeks of worsening back
pain and difficulty ambulation found to have cord compression/mass. Concerning
for mets from historical primary vs new tumor.// ?metastatic disease
TECHNIQUE: MDCT of the chest was obtained from thoracic inlet to upper
abdomen. Axial images were reviewed in conjunction with coronal and sagittal
reformats
COMPARISON: ___
FINDINGS:
Diffuse enlargement of the thyroid gland is demonstrated. Aorta and pulmonary
arteries are stable in appearance, with main pulmonary artery being 3 cm in
diameter, unremarkable. Heart size is normal. There is no pericardial or
pleural effusion.
No mediastinal, hilar or axillary lymphadenopathy is demonstrated.
Pre-vascular minimal soft tissue interspersed with fat is most likely
consistent with thymic residual. No definitive lymphadenopathy is seen.
Airways are patent to the subsegmental level bilaterally. Lungs are clear.
T7 lytic lesion with soft tissue component is re-demonstrated, better
appreciated on previous MRI.
Assessment of the upper abdomen demonstrate multiple gallstones are no
evidence of cholecystitis
IMPRESSION:
No definitive evidence of intrathoracic metastatic disease. Other than the
known T7 metastatic focus.
Radiology Report
EXAMINATION: CT abdomen and pelvis
INDICATION: ___ male history of intellectual disability, diabetes
mellitus, papillary urothelial renal cancer status post partial nephrectomy,
ESRD on ___, status post transitional cell carcinoma s/p
resection of bladder tumor, who presents with days 2 weeks of worsening back
pain and difficulty ambulation found to have cord compression/mass. Concerning
for mets from historical primary vs new tumor.// ? metastatic disease?
TECHNIQUE: Oncology 2 phase: Multidetector CT of the abdomen and pelvis was
done as part of CT torso with IV contrast. A single bolus of IV contrast was
injected and the abdomen and pelvis were scanned in the portal venous phase,
followed by scan of the abdomen in equilibrium (3-min delay) phase.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.0 s, 66.6 cm; CTDIvol = 21.5 mGy (Body) DLP =
1,431.9 mGy-cm.
2) Spiral Acquisition 2.5 s, 33.7 cm; CTDIvol = 20.1 mGy (Body) DLP = 675.1
mGy-cm.
3) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.4 mGy (Body) DLP = 1.7
mGy-cm.
4) Stationary Acquisition 8.4 s, 0.5 cm; CTDIvol = 46.9 mGy (Body) DLP =
23.5 mGy-cm.
Total DLP (Body) = 2,132 mGy-cm.
COMPARISON: CT dated ___ and MRI dated ___
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
___ for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder contains gallstones
without wall thickening or surrounding inflammation.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: Patient is status post a right total nephrectomy. Partially
exophytic hypodensities in the left kidney are unchanged and likely renal
cysts. This study is not optimized for assessment of the left upper urinary
tract. Previously seen left hydronephrosis has resolved. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The bladder is suboptimally assessed due to streak artifact from
bilateral hip prostheses. It appears collapsed around a Foley catheter.
There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: Inadequate assessment of the reproductive organs due to
streak artifact in the pelvis.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture in
the lumbar spine or pelvis.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
No evidence of metastatic disease in the abdomen and pelvis
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ male history of intellectual disability, diabetes
mellitus, papillary urothelial renal cancer status post partial nephrectomy,
ESRD on ___, status post transitional cell carcinoma s/p
resection of bladder tumor, who presents with days 2 weeks of worsening back
pain and difficulty ambulation found to have cord compression/mass. Concerning
for mets from historical primaries vs new tumor. mellitus, papillary
urothelial renal cancer status post partial nephrectomy, ESRD on ___
___, status post transitional cell carcinoma s/p resection of
bladder tumor, who
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: None.
FINDINGS:
Study is mildly degraded by motion.
There is an approximately 6 (AP) x 4 (TV) x 7 (SI) mm left occipital dural
based enhancing lesion with minimal adjacent mass effect and no definite edema
is noted (see 12,11,13:13; 101:134; 14:103; 100:63).
Probable arachnoid granulation overlying the right posterior frontal vertex is
noted (see 2:14; 14:117; 9,13:24).
Multiple foci of falcine probable fat are noted (see 2:12; 14:102).
No definite additional masses are identified. No definite additional
abnormality enhancement is noted.
There is no evidence of hemorrhage, midline shift or infarction. The
ventricles and sulci are preserved in caliber and configuration.
IMPRESSION:
1. Study is mildly degraded by motion.
2. No acute intracranial abnormality.
3. 7 mm left occipital dural based enhancing mass with minimal mass effect on
adjacent occipital lobe. While finding may represent a meningioma, metastatic
disease is not excluded on the basis of this examination. Recommendation
attention on follow-up imaging.
4. Paranasal sinus disease , as described.
RECOMMENDATION(S): 7 mm left occipital dural based enhancing mass with
minimal mass effect on adjacent occipital lobe. While finding may represent a
meningioma, metastatic disease is not excluded on the basis of this
examination. Recommendation attention on follow-up imaging.
Radiology Report
EXAMINATION: T7 through T9 spinal angiogram and embolization of bilateral T7
radicular arteries feeding bony tumor
During the procedure the following vessels were selectively catheterized
angiograms were performed:
Left T9 radicular artery
Right T9 radicular artery
Right T8 radicular artery
Right T7 radicular artery
Left T8 radicular artery
Left T7 radicular artery
Right common femoral artery
INDICATION: Is a ___ gentleman with a known history of kidney cancer.
He had difficulty with ambulation was found to have a T7 through T9 intradural
extramedullary mass. Orthopedic spine surgery has plans for decompression and
possible resection. Neurosurgery was consulted for embolization of any
vascularity in the setting of bony likely kidney cancer metastasis.
TECHNIQUE: Anesthesia: The patient was maintained under general anesthesia
during the entirety of the procedure by a trained an independent certified
anesthesia provider. Please see separately dictated anesthesia documentation.
The patient's hemodynamic and respiratory parameters were monitored
continuously throughout the duration of the case by a trained and independent
observer.
The patient was identified and brought to the neuro radiology suite. He was
transferred to the fluoroscopic table supine. Moderate sedation was
administered. Bilateral groins were prepped and draped in standard sterile
fashion. A time-out was performed. The right common femoral artery was
identified using anatomic and radiographic landmarks. The right common
femoral artery was accessed using standard micropuncture technique after
infiltration of local anesthetic. A short 5 ___ sheath was introduced,
connected to continuous heparinized saline flush, and secured.
Next a 5 ___ RDC catheter was introduced. The catheter was connected to a
syringe of 50% contrast/saline. The catheter was used to obtain angiograms
of the left T9, right T9, right T8 and right T7 radicular arteries. There was
tumor blush identified on the right T7 injection. A duo microcatheter was
introduced along with a synchro 2 standard wire and positioned distal to the
position of the blush. 2 coils were placed more distal to prevent on X from
embolizing to the more distal location. Hand injection was performed which
showed that there was still filling of the distal territory of the T7
radicular artery but it was slowed. The micro wire was removed. The catheter
was prepared with 5 1 cc injections of saline. It was then flushed with 0.4
cc of DMSO. Onyx was then injected until the radicular artery had been
embolized. On X was injected during continuous fluoroscopic guidance. The
microcatheter and diagnostic catheter were both removed and discarded.
Next a Cobra diagnostic catheter was introduced. It was connected to a
syringe of saline. It was used to access the left T8 and then left T7
radicular arteries. Tumor blush was identified at the left T7 radicular
artery. The Cobra catheter was treated out for a 4 ___ RDC which had
better positioning within the radicular artery. A fresh duo microcatheter was
introduced over a synchro 2 standard wire. It was advanced distal into the
microcatheter. The micro wire was removed. A micro injection was performed
in order to confirm positioning of the microcatheter. The microcatheter was
flushed with 4 cc of saline. It was flushed with 0.4 cc of DMSO. Onyx was
injected until the left T7 radicular artery was embolized. The microcatheter
in diagnostic catheters were removed. The embolic material was injected
during continuous fluoroscopic guidance.
Right common femoral angiogram was performed via hand injection through the
sheath. The sheath was removed and the arteriotomy was closed using a 6
___ Perclose. The patient was removed from the fluoroscopy and transferred
intubated to the operating room. He was not awakened between procedures.
Additional 20 minutes of manual compression was applied to the groin sided
operating room prior to flipping the patient prone.
OPERATORS: Dr. ___ Dr. ___ physician performed the
procedure. Dr. ___ supervised the trainee during the key
components of the procedure and has reviewed and agrees with the trainee's
findings.
COMPARISON: None
FINDINGS:
Left T9 radicular artery: Normal segmental artery. No evidence of tumor
blush.
Right T9 radicular artery: Normal segmental artery. No evidence of tumor
blush.
Right T8 radicular artery: Normal segmental artery. No evidence of tumor
blush.
Right T7 radicular artery: Significant tumor blush identified.
Left T8 radicular artery: Normal segmental artery. No evidence of tumor blush.
Left T7 radicular artery: Significant tumor blush identified.
Right common femoral artery: Arteriotomy is above the bifurcation. There is
good distal runoff. There is no evidence of dissection. Vessel caliber
appropriate for closure device.
IMPRESSION:
Tumor blush appreciated on injection of both right and left T7 radicular
arteries. Successful embolization of right and left T7 radicular arteries.
RECOMMENDATION(S): Plan per orthopedic
Radiology Report
EXAMINATION: THORACIC SINGLE VIEW IN OR
INDICATION: Intraoperative radiographs during T6-T8 laminectomy infusion
TECHNIQUE: Four cross-table lateral radiographs of the spine are provided
COMPARISON: ___ spine MRI
FINDINGS:
Assessment is severely limited by underpenetration and overlying artifact.
The thoracic vertebral levels are difficult to delineate. The two surgical
markers on the last radiograph (number 4) project at approximately the T2-3
and T6 levels. The lowest needle-like marker seen on radiograph 3 projects
approximately at the thoracolumbar junction. Vertebral body is grossly
maintained. Please refer to operative report for details.
IMPRESSION:
Assessment is severely limited by underpenetration and overlying artifact the
thoracic vertebral bodies and their levels cannot be well delineated.
Alignment is grossly maintained. Please refer to operative note for details.
Radiology Report
EXAMINATION: T-SPINE
INDICATION: ___ year old man who presented with symptoms c/f spinal cord
compression, now s/p T6-T8 laminectomy and tumor resection.// post-op
evaluation s/p T6-T8 laminectomy and tumorresection. post-op evaluation
s/p T6-T8 laminectomy and tumorresection.
TECHNIQUE: Frontal and lateral view radiographs of the thoracic spine.
COMPARISON: Intraoperative images dated ___
FINDINGS:
Vertebral body and disc heights are preserved. No fracture, subluxation, or
degenerative change is detected. The no suspicious lytic or sclerotic lesions
are seen. Suture material projects over the T7, T8 levels. Visualize
cardiomediastinal structures and lungs are within normal limits.
IMPRESSION:
Postoperative changes of the thoracic spine with no acute abnormality
identified.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abnormal MRI, Buttock pain
Diagnosed with Other specified diseases of spinal cord
temperature: 98.7
heartrate: 88.0
resprate: 18.0
o2sat: 99.0
sbp: 135.0
dbp: 76.0
level of pain: 10
level of acuity: 2.0 | SUMMARY STATEMENT
=================
___ male history of intellectual disability, diabetes
mellitus, papillary urothelial renal cancer status post partial
nephrectomy, transitional cell carcinoma s/p resection of
bladder tumor, ESRD on ___ who presented with days ___ weeks
of worsening back pain and difficulty w/ambulation found to have
osseous lesion in the posterior aspect of the T7 vertebral body
with associated epidural mass from mid T6 through mid T8 levels,
with spinal cord compression
at T7 and associated spinal cord edema from T6 through T8.
Underwent ___ guided biopsy on ___ which was non-revealing.
He underwent embolization of the mass followed by T6-T8
laminectomy w/ tumor resection on ___.
Pathology of the mass returned shortly before discharge as
papillary hemangioma. The final report is still pending.
ACUTE ISSUES
============
#T7 vertebral body mass
#Spinal cord compression
Patient presented with symptoms of cord compression with nearly
1 month of lower extremity weakness (R>L) and urinary retention
with evidence T7 bony lesion and new extra medullary extradural
mass extending from T6-T8 on MRI w/ evidence of cord
compression. Given the patient's history of malignancy, we were
concerned that this mass may represent metastatic transitional
cell carcinoma. Ortho spine and radiation oncology were
consulted. Before treatment, it was decided that pt have biopsy
to determine etiology. He underwent ___ biopsy on ___ w/o
evidence of tumor on path (nondiagnostic). Patient underwent
embolization of the mass prior to resection with neurosurgery.
He then underwent T6-T8 laminectomy w/ tumor resection on ___
(ortho spine). Tumor was noted to be very vascular. Imaging
studies conducted included (1) CT chest/abd/pelvis w/o evidence
of metastatic disease, (2) MRI brain w/ 7mm dural based L
occipital mass, c/f meningioma but cannot r/o metastatic
disease. After surgical resection of the mass, pt had improved
___ weakness on exam ___ bilaterally on exam). He
received dexamethasone while waiting surgical resection and
several days days post-op (___). No evidence of urinary
retention after surgery. ___ post op plain films were without
acute change. Neuro oncology/neurology was also consulted given
MRI findings and have recommended follow up as an outpatient
with repeat imaging. Radiation oncology is planning for
potential radiation therapy ___ weeks after surgery. Weakness
significantly improved at discharge.
Pathology of the mass returned shortly before discharge as
papillary hemangioma. The final report is still pending.
#Post op pain
Pt had back pain in the setting of known vertebral lesion and
and T6-T8 laminectomy ___. Pain is worse when dependent on
incision site. Incision site looks c/d/i, though he is quite
tender under dressing on exam. He has been receiving Tylenol 1g
TID with good effect. Post-op he has been receiving OxyCODONE
5mg PO PRN (asking for ___ doses per day). He also has a
lidocaine 5% Patch.
#Sacral wound
Was being followed outpatient in group home. Has two stage 3
pressure ulcers. Wound care team has been following patient
with recommendations of:
-Commercial wound cleanser or normal saline to cleanse
wounds.
-Pat the tissue dry with dry gauze.
-Apply protective barrier wipe to periwound tissue and air
dry.
-Apply Duoderm gel to yellow wound bed
-Apply Sacral Mepilex to cover both sites
-Change dressing q 3 days
CHRONIC ISSUES
=================
#ESRD
HD MWF. HD MWF. Patient initially underwent extra sessions of
dialysis given need for MRI with contrast. Access: RUE AVF. His
sevelamer was increased from 800 mg TID to ___ mg TID w/meals
given persistently elevated phos. Due to hypercalcemia, his
vitamin D and calcitriol were held. He was continued on
cinacalcet and nephrocaps. Diet was renal. EPO was held as we
were concerned for malignancy.
#Hypercalcemia
Elevated PTH, calcium and phos consistent with tertiary
hyperparathyroidism given ESRD. VItamin D supplementation and
calcitriol were stopped during this hospitalization.
#Anemia: Likely secondary to ESRD. Hgb very slowly
down-trending. We held EPO given concern for malignancy. ___ be
able to resume EPO pending final path. Received mircera 150 mcg
on ___.
#Urothelial cell (transitional cell) carcinoma of the bladder
s/p TURBT
#Urothelial cell (transitional cell) carcinoma s/p R
nephroureterectomy:
Followed by urology as outpatient with recent hospitalization in
___ for urinary retention and failed voiding trials.
Continued on tamsulosin.
#Developmental delay
#Intermittent explosive disorder
Continued risperidone 3 mg QPM and 1mg daily
Lorazepamd 0.5 mg PO BID:PRN anxiety
#Seizure disorder
Continued CarBAMazepine 300 mg PO TID
#HTN:
Continued amlodipine 5 mg daily
#HLD
Continued rosuvastatin 40 mg qpm
Continued ezetimibe 10 mg daily
Continued aspirin 81 mg daily
#DM
Held home linaGLIPtin 5 mg oral DAILY in house and pt was on
ISS. He required very little insulin.
#BPH:
Continued home tamsulosin
#GERD:
Continued famotidine 20 daily
#Rhinitis
Continued fluticasone propionate nasal 2 spray daily
**TRANSITIONAL ISSUES** |
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, vomiting, elevated LFTs.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
PCP: ___
.
CC: fever, vomiting, elevated LFTs.
.
HPI/EVENTS: ___ h/o HTN/HLD, CKD Stage II, s/p L hip fx ___
admitted for elevated LFTs. Mr. ___ is at baseline usually
quite independent, able to ambulate with a walker - but with an
unstable gait requiring assistance at all times (fall risk).
Mentally intact however occasional episodes of sundowning, with
good appetite. Has 24 hr assistance at home. He was in his
USOH until 1d PTA when developed decreased appetite. No abd
pain. Last night at 2AM vomiting and noted to be mildly
rhonchorous thereafter. Assessed by daughter (former ICU RN
found pt to be febrile 100.4, vitals however stable).
Presented to ___. There vitals stable. Labs notable
for WBC 4, ALT/AST 417/669, t bili 2.8, alp 208. Found to have
RLL PNA on CXR. Abd CT, RUQ prelim c/w acute cholecystitis. No
CBD dilation. Also w/ 7 cm AAA. Given ctx/azithro and zosyn.
Surgery consult there recommended ERCP and thus, pt transferred
to ___.
In ED here, vitals 99.1 60 104/46 22 94% 4L nc. EKG: NSR,
normal intervals, no STE elevation or depression. Admitted for
further eval. ERCP aware. .
ROS: per HPI, denies chills, night sweats, headache, vision
changes, rhinorrhea, congestion, sore throat, chest pain,
abdominal pain, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria. A 10 pt review of sxs was
otherwise negative.
Past Medical History:
# HTN/hyperchol
- TTE ___: EF 55-60%, mild AS (1.5 cm2, peak grad 28),
Septal E' 0.05, E/A 0.64, E wave decel 311 - c/w Grade I
diastolic dysfunction
# CKD Stage II (b/l Cr 1.3-1.5) # L hip fracture s/p LHR ___
- course c/b RLL PNA
# BPH
# Vit B12 def, pernicious anemia?
# ___
# glaucoma
Social History:
___
Family History:
___: NC
Physical Exam:
Vital Signs: 100.4 120/70 80 20 94% on 4L NC O2
glucose:
.
GEN: NAD, well-appearing, very hard of hearing, but pleasant and
interactive, responds to simple commands
EYES: PERRL, EOMI, conjunctiva clear, anicteric
ENT: moist mucous membranes, no exudates
NECK: supple
CV: RRR s1s2 nl, no m/r/g
PULM: R base crackles up to ___ up, no r/r/w
GI: normal BS, NT/ND, no HSM, ___ sign negative
EXT: warm, no c/c/e
SKIN: no rashes
NEURO: alert, oriented x 2, answers ? appropriately, follows
commands, non focal
PSYCH: appropriate
ACCESS: PIV
FOLEY: present
Pertinent Results:
# OSH Labs (___): WBC 4.0, H/H 12.1/37.0, BUN/Cr ___, lipase
76, AST/ALT 669/417, AP 208, TBili 2.86, alb 3.8, lactate 2.4
# Blood cx (___):
Anaerobic bottle: CITROBACTER KOSERI
AMOX/CLAV S 8
CEFAZOLIN S <=4
CEFTAZIDIME S <=1
CEFTRIAXONE S <=1
CIPROFLOXACIN S <=0.25
ERTAPENEM S <=0.5
GENTAMICIN S <=1
IMIPENEM S <=0.25
LEVOFLOXACIN S <=0.12
PIP/TAZ S <=4
TOBRAMYCIN S <=1
TRIM/SULFA S <=20
OTHER DATA:
# OSH abd/pelvic CT (___): Right lower lobe pneumonia. Very
large infra renal abdominal aortic aneurysm. Gallstones and
pericholecystic fluid although the appearances are in a way more
suggestive of third spacing than acute cholecystitis, ultrasound
correlation given the abnormal LFTs is suggested. Hiatal hernia,
bilateral pleural effusions, bilateral inguinal hernias, which
should be correlated clinically.
# OSH RUQ U/S (___): GB is dilated and contains several small
gallstones. GB wall is thickened up to 5-7 mm and there is
edema in the gallbladder wall and also slight pericholecystic
fluid suggestive of acute cholecystitis but the patient does not
experience any pain during palpation. CBD measures only 3 mm in
diameter.
1.5 cm large cyst in the left lobe of the liver with clear
sonolucent interior. The liver has otherwise normal appearance.
In the distal lumbar aorta there is a large aneurysmal
formation with a thick thrombus. The aneurysm has a sagittal
diameter of 7 cm. In the right kidney there is a small cyst
with a diameter of 1 cm. The kidneys have otherwise normal
appearance as has the head of the pancreas. The main body and
the tail could not be visualized because of gas.
# OSH CXR (___): There is an ill-defined parenchymal infiltrate
spread over a large portion of the right lung base of
bronchopneumonic appearance. The left lung is clear as is the
right lung apex. There is no definite pleural effusion and
there is no evidence of acute congestive failure. The cardiac
size is within normal limits.
# MRCP (___): Cholelithiasis with extensive gallbladder wall
edema reflecting undelrying cholecystitis, though chronicity is
less certain in the absence of adjacent stranding and hepatic
parenchymal abnormalities. No choledocholithiasis. 7.6 cm
infrarenal abdominal aortic aneurysm for which surgical
consultation is recommended. Right upper and lower lobe
pneumonia.
# CXR (___): Opacities in the right lung are improving. Left
basilar opacity is improving. Right pleural effusion is not
significantly changed. Left pleural effusion is likely smaller.
There is no pneumothorax. There is no evidence of pulmonary
edema. Heart size is normal
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Zebeta (bisoprolol fumarate) 5 mg oral Daily
2. Amlodipine 5 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE Q12H
6. Travatan Z (travoprost) 0.004 % ophthalmic Daily
Discharge Medications:
1. Amlodipine 5 mg PO DAILY
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP RIGHT EYE Q12H
3. Zebeta (bisoprolol fumarate) 5 mg oral Daily
4. Levofloxacin 750 mg PO Q48H
RX *levofloxacin 750 mg 1 tablet(s) by mouth Q48H Disp #*5
Tablet Refills:*0
5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every
eight (8) hours Disp #*30 Tablet Refills:*0
6. Aspirin 81 mg PO DAILY
7. Simvastatin 20 mg PO DAILY
8. Travatan Z (travoprost) 0.004 % ophthalmic Daily
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cholangitis/cholecystitis
RLL pneumonia
Delirium
Abdominal aortic aneurysm
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old man with h/o COPD, htn, hld p/w cough, vomiting,
found to have PNA and transaminitis and likely acute cholecystitis // eval
CBD, ? cholecystitis
TECHNIQUE: Limited noncontrast imaging with multiplanar T1 and T2 weighted
sequences performed at 1.5 Tesla. This study was prematurely terminated at
the request of the patient.
COMPARISON: Abdominal ultrasound from ___ and abdominal CT from ___.
FINDINGS:
Correlating to the findings on the ___ CT are posterior right lower
and upper lobe pulmonary consolidations. No pleural effusion is identified.
Portions of the mediastinum are included in the field of view on the coronal
sequences and are notable for dilated caliber of the main pulmonary artery and
main-branch pulmonary arteries. The proximal maximum diameter of the pulmonary
arteries measures 3.7 cm.
The liver parenchyma is in normal in signal intensity. There is a single
hepatic lesion within segment III with a maximum diameter of 1.6 cm, appearing
T2 hyperintense, T1 hypointense, with a well-circumscribed border, compatible
with a simple hepatic cyst.
There is no intra or extrahepatic bile duct dilation. The CBD measures 8 mm.
There is no choledocholithiasis.
There is cholelithiasis within the dependent portions of the gallbladder
fundus. The gallbladder is elongated, with a length of 10 cm, but without
convexity of the contour. The gallbladder mucosa appears intact. The
gallbladder wall is thickened and there is T2-hyperintense signal in the wall
consistent with edema. There is a tiny amount of pericholecystic fluid. There
is no surrounding stranding within the adjacent fat and the abutting hepatic
parenchyma does not demonstrate any grossly abnormal signal intensity.
The kidneys demonstrate multiple small peripelvic cysts. A 1.4 cm lesion
arising from the interpolar aspect of the right kidney is T1 hyperintense and
T2 hypointense, arising at the junction of the renal sinus fat and the
adjacent parenchyma, possibly a hemorrhagic cyst, but incompletely
characterized on this
noncontrast examination.
The adrenal glands, spleen and pancreas are unremarkable.
There is minimal free pelvic fluid, within physiologic limits. No
lymphadenopathy is seen.
Note is made of the urinary bladder being decompressed with a Foley catheter.
A left hip prosthesis is present. Visualized osseous structures are otherwise
unremarkable.
There is an eccentric infrarenal abdominal aortic aneurysm measuring up to 7.6
x 6.8 cm axially (series 6, image 37), and extending approximately 7.3 cm
cranio caudally (series 3, image 19) with a large thrombosed component, better
characterized on the contrast enhanced CT examination performed on the same
day.
IMPRESSION:
Very limited MRI due to patient's inability to cooperate.
Cholelithiasis with extensive gallbladder wall edema, with an appearance more
classic for third-spacing than acute cholecystitis. No choledocholithiasis.
7.6 cm infrarenal abdominal aortic aneurysm for which surgical consultation is
recommended.
Right upper and lower lobe pneumonia.
NOTIFICATION: The findings and recommendations were communicated by Dr
___ to Dr ___ at 930AM on ___ by phone, approximately 45 minutes after
initial interpretation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)CHEST (PORTABLE AP)i
INDICATION: ___ year old man with acute cholecystitis, AS and hypoxia. //
Please evaluate for cause of hypoxia
COMPARISON: Chest radiographs since ___ most recently ___.
IMPRESSION:
Extensive consolidation has worsened in most of the right lung and base of the
left lung. The sparing of the mid and upper regions of the left lung makes it
less likely that this is pulmonary edema. Instead pulmonary hemorrhage or
widespread aspiration pneumonia should be considered. Heart size is normal.
Pleural effusions are presumed, but not substantial. No pneumothorax. Thoracic
aorta is generally large and tortuous
Radiology Report
HISTORY: ___ man with hypoxia and fever.
FINDINGS: Comparison is made to the prior radiograph from ___ at
6:28 a.m.
FINSINGS: The opacities within the right lung have improved. There is also
improvement of the left basilar opacity. There are bilateral pleural
effusions. There are no pneumothoraces.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Fever
Diagnosed with RESPIRATORY ABNORM NEC
temperature: 99.1
heartrate: 60.0
resprate: 22.0
o2sat: 94.0
sbp: 104.0
dbp: 46.0
level of pain: nan
level of acuity: 2.0 | ASSESSMENT & PLAN: ___ h/o HTN/HLD, CKD Stage II, s/p L hip fx
___ admitted for elevated LFTs.
# GI: Mr. ___ was admitted from ___ with elevated LFTs
and RUQ U/S, abd CT w/ signs of acute cholecystitis which
included GB distention, perichole fluid, wall thickening, and GB
stones. There was however no CBD dilation. He also presented
with elevated LFT which were concerning for cholangitis. He,
however, did not have any leukocytosis or ___ sign on
presentation or throughout the hospitalization. He was initially
placed on unasyn IV and then later levo/flagyl which was
transitioned to oral form on HD3.
He was evaluated by ERCP who recommended MRCP. The MRCP did
not reveal any new findings (cholecystitis, no CBD) and was
largely limited by motion artifact (as he was delirious during
the study). Ultimately, his LFTs downtrended and the OSH blood
cxs returned positive for Citrobacter (pansens). These were
consistent with cholangitis/transitioned bacteremia with passage
of a stone.
Mr. ___ was able to tolerate a regular diet and had no N/V,
abd pain on the day of discharge. He will complete a 2 week
course of abx for presumed cholecystitis and cholangitis. He
still has GB stones, but is not a likely candidate for elective
cholecystectomy given his age.
# RLL PNA: Mr. ___ also was noted to be hypoxic requiring
initially 4L NC O2. CXR showed RLL infiltrate and was likely
___ aspiration in setting of N/V. It is likely that the
cholangitis/cholecystitis led to N/V and then to the aspiration
PNA. He was able to wean off the oxygen and the levoflox was
continued to help cover the aspiration pneumonia too.
# Delirium: Mr. ___ had episodes of sundowning. He was
initially delirious, but became increasingly cognitively intact
as the cholangitis/cholecystitis and pneumonia was treated. He
is exceptionally hard of hearing and had a hearing aid in place.
We aimed to optimize his nutrition, hydration, sleep. His
daughter ___ also came daily to help provide frequent
reorientation.
# AAA - Mr ___ was found to have an incidental infrarenal 7 cm
AAA on U/S and Abd CT. There was some evidence of intramural
thrombus. This was treated conservatively given his age. His
daughter (HCP) was made aware of this diagnosis and agreed with
conservative approach.
# HTN/HLD: on zebeta, norvasc. On statin, ASA.
# Glaucoma: on latanoprost and alphagan gtt
# OTHER ISSUES AS OUTLINED.
#FEN: [X] IVF [X] Oral [] NPO [] Tube Feeds []
Parenteral
#DVT PROPHYLAXIS: [X]heparin sc []SCDs
#LINES/DRAINS: [X] Peripheral [] PICC [] CVL [X] Foley
#PRECAUTIONS: [X] Fall [] Aspiration []
MRSA/VRE/CDiff/ESBL/Droplet /Neutropenic
#COMMUNICATION: daughter ___ (HCP) at ___
#CONSULTS: ERCP, ___
#CODE STATUS: DNR/DNI. Confirmed w/ daughter ___ (HCP) after
extensive discussions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
ACE Inhibitors / Beta-Blockers (Beta-Adrenergic Blocking Agts) /
cephalexin / Cephalosporins / hydrochlorothiazide / iodine /
metoprolol / morphine / Penicillins / Sulfa (Sulfonamide
Antibiotics) / yellow dye
Attending: ___.
Chief Complaint:
Thigh pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ hx HTN, COPD, OSA on CPAP, h/o PE ___ years ago on
warfarin, s/p Spine surgery (L1 kyphoplasty d/t L1 compression)
___ (d/c'd to rehab day prior to arrival) who now presents
from rehab d/t right thigh pain. Morning on day of arrival
patient noted new right anterior thigh pain that occurred during
an abrupt hip flexion. Pain started distally close to patella
and radiated proximally to inguinal area. Pain was tingling and
burning, worse with movement of leg and better without movement.
No associated swelling or redness of skin. Not associated with
chest discomfort, no change in his breathing, no new dyspnea.
Pain improved with oxycodone, which he takes for post surgical
pain. Denies trauma to that area. At rehab SaO2 noted to be 87%
(baseline 85-93% per patient d/t COPD) and so transferred to
___ ED for further eval.
In the ED initial vitals were: 98.0 hr 90 123/55 16 93% 3l
- Labs were significant for INR 1.1, Hct 28.7 (d/c was 28.4), E
5.1, Cr 1.7 (baseline 1.4-1.7) TnT <.01, BNP 112
-- CT Abd/Pelvis w/out contrast with no evid of RP bleed
-- Right Leg doppler without evid of DVT
-- CXR without focal findings
-- EKG without evid of right heart strain
-- ED had clinical suspicion of PE and was started on Heparin
gtt, no CTA done
Vitals prior to transfer were: 98.0 88 128/66 16 90% RA
On the floor, patient denies right thigh pain. Endorses mild low
back post surgical pain which is not new. Denies bladder
retention, bowel incontinence, saddle anesthesia. Denies
weakness in Right or Left leg. Does not endorse pleuritic chest
pain, does not endorse any new dyspnea and has baseline
"shortness of breath" due to COPD. Denies any new skin changes,
denies any new swelling of any leg.
Re COPD - patient notes SaO2 reading on home O2 monitor when
sleeping anywhere between 86-93%. Notes b/l lower legs with
chronic edema that is not acutely worse.
Of note, at last admission INR was reversed with VitaminK pre op
and on discharge INR was 1.1, was restarted on PO Warfarin
5mg/day with plan for close INR checks and to increase dose as
needed. He was not bridged.
Past Medical History:
Gout
Depression
Hypertension
COPD
BPH
Hyperlipidemia
DVT/PE - on coumadin
OSA on CPAP
TIA/CVA
Left carotid stenosis
Hypertension
Asthma
PAD
Upper back surgery x2
Lumbar spine surgery x2
Right rotator cuff surgery
Left knee surgery
Bilateral greater saphenous radiofrequency ablation
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission Physical Exam:
========================
Vitals - T:98.3 BP:133/63 HR: 88 02 sat: 92%RA
GENERAL: NAD, comfortable at rest, low back pain with leaning
forward, AAOx3, able to talk on cell phone and find photos of
his dog on cellphone
HEENT: NC in place, pink conjunctiva, moist mucosa
CARDIAC: Distant heart sounds without any obvious murmur,
+S1/S2,
LUNG: CTAB, trace crackles L>R at bases. No wheezing. No
accessory muscle use.
ABDOMEN: Obese, non tender, +BS.
EXTREMITIES: B/L lower leg with chronic venous stasis changes
and moderate firm pitting edema to mid shin
-- Right thigh with evid of prior skin graft, non tender on firm
palpation, no pain with bending at hip/knee, no erythema, no
cords
-- both legs and thighs are equal in size
-- No inguinal pain on the right and no pain with coughing
BACK: no vertebral body pain, surgical scars well healed,
Miliaria of upper back
PULSES: 2+ DP pulses bilaterally
NEURO: CN ___ intact, strength of RLE = LLE at knee and ankle,
sensaiton intact symmetrically,
-- no saddle anesthesia
Discharge Physical Exam:
========================
Vitals - T:98.3 BP:135/58 HR: 81 02 sat: 92%RA (90%RA with
ambulation)
GENERAL: NAD
HEENT: NCAT, pink conjunctiva, moist mucosa
CARDIAC: Distant heart sounds without any obvious murmur,
+S1/S2,
LUNG: CTAB, minimal crackles L>R at bases. No wheezing. No
accessory muscle use.
ABDOMEN: Obese, non tender, +BS.
EXTREMITIES: B/L lower leg with chronic venous stasis changes
and moderate firm pitting edema to mid shin
-- Right thigh with evid of prior skin graft, non tender on firm
palpation, no pain with bending at hip/knee, no erythema, no
cords
-- both legs and thighs are equal in size
-- No inguinal pain on the right and no pain with coughing
BACK: no vertebral body pain, surgical sites well healed without
erythema or drainage, Miliaria of upper back
PULSES: 2+ DP pulses bilaterally
NEURO: CN ___ intact, strength of RLE = LLE at knee and ankle,
sensation intact symmetrically, +leg raise test on right side,
ambulatory with TLSO brace
-- no saddle anesthesia
Pertinent Results:
Admission Labs:
===============
___ 07:20PM BLOOD WBC-4.4 RBC-3.34* Hgb-9.1* Hct-28.7*
MCV-86 MCH-27.4 MCHC-31.8 RDW-17.7* Plt ___
___ 07:20PM BLOOD Neuts-66.7 ___ Monos-7.7 Eos-5.1*
Baso-0.3
___ 07:20PM BLOOD Glucose-98 UreaN-24* Creat-1.7* Na-137
K-3.8 Cl-101 HCO3-26 AnGap-14
___ 07:20PM BLOOD CK-MB-2 cTropnT-<0.01 proBNP-112
___ 07:21PM BLOOD Lactate-0.7
Discharge Labs:
===============
___ 07:00AM BLOOD ___
___ 10:10AM BLOOD PTT-52.1*
___ 07:00AM BLOOD Glucose-100 UreaN-21* Creat-1.7* Na-135
K-4.0 Cl-102 HCO3-25 AnGap-12
___ 07:00AM BLOOD CK(CPK)-96
___ 07:00AM BLOOD CK-MB-2 cTropnT-<0.01
Pertinent Studies:
==================
CXR ___
FINDINGS:
A lordotic view was obtained. The cardiac, mediastinal and hilar
contours are unremarkable. The pulmonary vasculature is normal.
There is minimal streaky atelectasis in the left lung base. No
focal consolidation, pleural effusion or pneumothorax is seen.
No acute osseous abnormalities identified.
IMPRESSION:
Left basilar atelectasis.
LLE ultrasound ___
IMPRESSION:
No evidence of deep venous thrombosis in the right lower
extremity to the
level of the popliteal vein. Evaluation of the calf veins is
somewhat limited due to body habitus.
CT abd/pelvis ___
IMPRESSION:
1. No evidence of retroperitoneal hematoma.
2. No acute intra-abdominal process.
3. Status post kyphoplasty at L1, with otherwise similar
appearance of the
spine compared to the to reference MRI L-spine dated ___
allowing for
differences in technique.
4. Hepatic steatosis.
5. Dilated fluid-filled distal esophagus may be related to
reflux.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. BuPROPion 100 mg PO BID
4. Furosemide 40 mg PO DAILY
5. Omeprazole 20 mg PO BID
6. Prazosin 2 mg PO HS
7. Simvastatin 40 mg PO DAILY
8. Tiotropium Bromide 1 CAP IH DAILY
9. Acetaminophen ___ mg PO Q6H:PRN pain
10. Bisacodyl ___AILY:PRN constipation
11. Docusate Sodium 100 mg PO BID constipation
12. Lidocaine 5% Patch 1 PTCH TD QPM back pain
13. OxycoDONE (Immediate Release) 15 mg PO Q3H:PRN pain; L1
compression fracture
14. Senna 8.6 mg PO BID:PRN constipation
15. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
16. Warfarin 5 mg PO DAILY16
17. NIFEdipine CR 90 mg PO DAILY
18. Milk of Magnesia 30 mL PO Q8H:PRN constipation
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain
2. Allopurinol ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Bisacodyl ___AILY:PRN constipation
5. BuPROPion 100 mg PO BID
6. Docusate Sodium 100 mg PO BID constipation
7. Furosemide 40 mg PO DAILY
8. Milk of Magnesia 30 mL PO Q8H:PRN constipation
9. NIFEdipine CR 90 mg PO DAILY
10. Omeprazole 20 mg PO BID
11. OxycoDONE (Immediate Release) 15 mg PO Q3H:PRN pain; L1
compression fracture
RX *oxycodone 15 mg 1 tablet(s) by mouth q3h Disp #*112 Tablet
Refills:*0
12. Prazosin 2 mg PO HS
13. Senna 8.6 mg PO BID:PRN constipation
14. Simvastatin 40 mg PO DAILY
15. Tiotropium Bromide 1 CAP IH DAILY
16. Warfarin 7.5 mg PO DAILY16
17. Enoxaparin Sodium 120 mg SC BID DVT/PE prevention
Start: Tomorrow - ___, First Dose: First Routine
Administration Time
Please overlap with warfarin 24hours once INR is therapeutic
(2.0-3.0).
RX *enoxaparin 120 mg/0.8 mL 120 mg SC every twelve (12) hours
Disp #*20 Syringe Refills:*0
18. Sarna Lotion 1 Appl TP TID:PRN itch
19. Lidocaine 5% Patch 1 PTCH TD QPM back pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
==================
Lumbar radiculopathy
Secondary Diagnoses:
====================
History of DVT/PE
COPD
Obstructive Sleep Apnea
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: Dyspnea, right leg swelling, right leg numbness.
TECHNIQUE: Upright AP view of the chest.
COMPARISON: ___.
FINDINGS:
A lordotic view was obtained. The cardiac, mediastinal and hilar contours are
unremarkable. The pulmonary vasculature is normal. There is minimal streaky
atelectasis in the left lung base. No focal consolidation, pleural effusion or
pneumothorax is seen. No acute osseous abnormalities identified.
IMPRESSION:
Left basilar atelectasis.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: History: ___ with recent surgery, recurrent DVT off coumadin for
operation, 12 hrs R leg swelling > L, R thigh parasthesia // r/o DVT R leg
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of the right common
femoral, superficial femoral, and popliteal veins. Evaluation of the calf
veins is somewhat limited due to body habitus.
There is normal respiratory variation in the common femoral veins bilaterally.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower extremity to the
level of the popliteal vein. Evaluation of the calf veins is somewhat limited
due to body habitus.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: Right femoral neuropathy, on couamdin, recent L1 kyphoplasty.
Assess for retroperitoneal hematoma.
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis without
administration of IV contrast.
DOSE: DLP: 1076 mGy-cm.
COMPARISON: Reference MRI L-spine dated ___.
FINDINGS:
CHEST:
There is minimal bibasilar atelectasis. No pericardial or pleural effusion.
Coronary artery calcifications are noted. The distal esophagus is
fluid-filled and distended which could be related to reflux.
ABDOMEN:
Evaluation of the solid organs and soft tissues is limited without intravenous
contrast. The liver is diffusely hypoattenuating consistent with hepatic
steatosis. There are no focal lesions or intrahepatic biliary dilatation. The
gallbladder, pancreas, spleen and adrenal glands are unremarkable. The
kidneys have a normal noncontrast appearance without stones or hydronephrosis.
The small and large bowel are normal in caliber without evidence of
obstruction. There is no retroperitoneal or mesenteric lymphadenopathy by CT
size criteria. No ascites, free air or abdominal hernia. The intra abdominal
vasculature demonstrates moderate atherosclerotic calcifications. The
abdominal aorta is normal in caliber. No retroperitoneal hematoma is
demonstrated.
PELVIS:
The urinary bladder is unremarkable. There is no evidence of pelvic or
inguinal lymphadenopathy. There is no free fluid in the pelvis.
BONES AND SOFT TISSUES:
No lytic or sclerotic lesion suspicious for malignancy is present.
Kyphoplasty of L1 and evidence of prior laminectomy at L4-5 are noted.
Multilevel degenerative changes are noted. Mild anterior compression deformity
of T12 is not significantly changed from prior MR
IMPRESSION:
1. No evidence of retroperitoneal hematoma.
2. No acute intra-abdominal process.
3. Status post kyphoplasty at L1, with otherwise similar appearance of the
spine compared to the to reference MRI L-spine dated ___ allowing for
differences in technique.
4. Hepatic steatosis.
5. Dilated fluid-filled distal esophagus may be related to reflux.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Leg swelling, Numbness
Diagnosed with SKIN SENSATION DISTURB, HYPOXEMIA, RESPIRATORY ABNORM NEC
temperature: 98.0
heartrate: 90.0
resprate: 16.0
o2sat: 93.0
sbp: 123.0
dbp: 55.0
level of pain: 7
level of acuity: 2.0 | ___ s/p spine surgery on ___ who presents from Rehab d/t
Right anterior thigh pain
#Lumbar radiculopathy
Leg pain was initially though to be DVT with possible PE as
patient was thought to be dyspneic with low SpO2 and therapy
initiated for presumed PE. However, on further discussion with
patient, his respiratory symptoms are chronic without any acute
change. He has long standing COPD/hypoventilation from habitus
and home SaO2 range high ___ to low ___ not on O2 at home. (Per
patient, wears night time O2 monitor). Right thigh pain not
consistent with DVT and has no exam or U/S findings to suggest
DVT. Pain was transient and patient reports having similar
episodes in the past. Seems more likely radiculopathic (L3) or
perhaps superfical femoral nerve impingement. Patient's post
surgical back pain is more symptomatic at this time.
-- pain control with home oxycodone
-- continue ___ at rehab facility
# History of Pulmonary Embolus - Patient did have moderate
probability on Wells ___ = 3 (Surgery < 4 wks, previous DVT),
Simp ___ = 4 (Age, Surgery < 1mo, Unilateral limb pain,
HR > 75). His h/o provoked PE is about ___ years ago, in the
setting of cellulitis and surgery, and on warfarin since with no
subsequent events. Of note patient's INR subtherapeutic since
___ in setting of reversal with Vitamin K d/t surgery.
-- Bridge with lovenox at discharge
-- Continue Warfarin and trend INR at rehab facility
CHRONIC ISSUES:
===============
# CKD: Cr 1.7 on arrival. Recent baseline 1.5-1.7.
-- Avoided nephrotoxic medications during admission
# COPD - not on O2 at home, per patient O2 at home 86- low ___.
Longtime former smoker.
-- continued home Tiotropium
-- titrated O2 to 88-93%
# OSA on CPAP:
-- Continued home CPAP settings
# Hypertension
-- Continued nifedipine
# Iron deficiency anemia - pt reporting recent normal endoscopy
at the ___. He does not take his iron pills because they cause
him constipation. Consider further work-up on follow up with PCP |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall, proximal R humerus fracture
Major Surgical or Invasive Procedure:
Linq recorder placement ___
History of Present Illness:
Patient is a ___ with history of recently diagnosed (___)
invasive carcinoma of the R breast with ductal/lobular features
on letrozole (ER+/PR+/HER2- Gr2 R, no surgical intervention
planned), EtOH use disorder (prior), known gait imbalance
(evaluated by neurology in ___, possible myelopathic process
in
the setting of cervical spondylosis), HTN, and dyslipidemia who
presents after a fall.
Patient was using her walker while out and about yesterday, it
became caught on some uneven ground causing her to lose her
balance and fall. Patient experienced acute R elbow pain, worse
with extension. No headstrike or loss of consciousness. Patient
denies any prodromal symptoms such as lightheadedness, nausea,
changes in vision, SOB, or CP/palpitations. Patient was brought
to the ___ ED for further evaluation and treatment.
Of note, patient was recently hospitalized at ___ ___
after being found down for a prolonged period at home (nearly
20hrs). Course was notable for mild rhabdomyolysis without any
renal impairment. Troponinemia and atrial tachycardia were
thought to be related to the acute stress/hypovolemia, no
concerning ECG findings. Otherwise, significant weakness seemed
to improve throughout her stay. Neurology was consulted given L
facial droop and L arm weakness. MRI brain was significant for
chronic small vessel ischemic disease/small chronic infarct in
the R frontal corona radiata, no acute findings of stroke.
Patient was eventually discharged to an ___ ___
___.
In the ED, initial vitals: 98.2 72 153/97 16 100% RA
- Exam notable for:
- Labs notable for:
CBC 15.0>12.4/38.1<235 (MCV 85, 80.4% PMNs)
BMP ___
proBNP 117
Troponin-T <.01
D-dimer ___
Urinalysis remarkable only for 40 ketones
- Imaging notable for:
Plain film of R humerus/elbow
IMPRESSION:
Minimally displaced fracture of the surgical neck of the
humerus.
CTA chest
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Nondisplaced right proximal humeral fracture.
3. Moderate hiatal hernia.
- Patient was given:
___ 19:03 PO Acetaminophen 1000 mg
___ 19:28 PO Lorazepam 1 mg
___ 08:15 PO/NG Lisinopril 2.5 mg
___ 08:15 PO Letrozole 2.5 mg
- Consults: Orthopedics
- Vitals prior to transfer: Afebrile, 98, 146/100, 17, 97% RA
On arrival to the floor, patient recounts the history as above.
She denies any acute issues with pain at rest, only mild
discomfort upon moving her R arm. No lightheadedness/dizziness,
no CP or SOB. Patient voices some concern about going to rehab
due to the fact that her cat will be left home alone and her
family is unreachable in ___. Ultimately, however, she
thinks that she will do better with the help provided at a
rehab.
Past Medical History:
Breast CA R breast ER+/PR+/HER2- with +axillary node
HTN
Atrial tachycardia
Pre-DM
HLD
Neuropathy
Overactive Bladder
Macular degeneration
Cervical spondylosis
Dry macular degeneration since ___
GERD.
Overactive bladder
Chronic candidiasis in the inframammary regions.
History of alcoholism. The patient drank up to six beers per
day, stopping in ___
Left bunion surgery in ___
Bilateral cataract surgery in ___
Left distal radius wrist and left distal radius fracture in
___, treated with conservative management with subsequent
continued deformity of the full function.
Social History:
___
Family History:
No breast or ovarian cancer. A second cousin had colon cancer
at
uncertain age. The patient is of ethnic ___ descent,
specifically from ___, without known ___
ancestors.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 99.5 119/77 80 20 94 RA
GENERAL: Pleasant, lying in bed comfortably
HEENT: NC/AT. PERRL, EOMI. OP clear with MMM.
NECK: Wide neck, no palpable thyromegaly. No appreciable JVP
elevation.
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly.
MSK: R arm in sling, no significant swelling or ecchymoses.
Mild
TTP with palpation of both proximal and distal humerus. Mild
pain with passive abduction and flexion/extension at the R
shoulder.
EXT: Warm, well perfused, no lower extremity edema.
PULSES: 2+ radial pulses.
SKIN: No significant rashes.
DISCHARGE PHYSICAL EXAM
VITALS: 98.0 PO 117 / 76 76 98% on RA
GENERAL: Comfortable appearing woman, pleasant, in no acute
distress
HEENT: No scleral icterus or injection. Moist mucous membranes.
CARDIAC: RRR, nl S1+S2, no M/R/G
LUNG: CTAB, no W/R/R
ABD: non-distended, soft, non-tender, normal bowel sounds
MSK: R upper arm with ecchymosis, tenderness. Mild TTP with
palpation of both proximal and distal humerus. Sling unhooked,
arm at side.
EXT: Warm, well perfused, no lower extremity edema
SKIN: No significant rashes.
Pertinent Results:
ADMISSION LABS
___ 07:20PM WBC-15.0* RBC-4.46 HGB-12.4 HCT-38.1 MCV-85
MCH-27.8 MCHC-32.5 RDW-13.0 RDWSD-40.2
___ 07:20PM NEUTS-80.4* LYMPHS-12.4* MONOS-5.7 EOS-0.6*
BASOS-0.4 IM ___ AbsNeut-12.09* AbsLymp-1.87 AbsMono-0.85*
AbsEos-0.09 AbsBaso-0.06
___ 07:20PM ___
___ 07:20PM cTropnT-<0.01 proBNP-117
___ 07:20PM GLUCOSE-112* UREA N-11 CREAT-0.5 SODIUM-139
POTASSIUM-3.7 CHLORIDE-99 TOTAL CO2-25 ANION GAP-15
___ 08:30PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-40* BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
PERTINENT/DISCHARGE LABS
___ 05:10AM BLOOD WBC-5.8 RBC-3.81* Hgb-10.6* Hct-32.7*
MCV-86 MCH-27.8 MCHC-32.4 RDW-13.4 RDWSD-41.9 Plt ___
___ 04:45AM BLOOD WBC-11.1* RBC-4.06 Hgb-11.2 Hct-34.8
MCV-86 MCH-27.6 MCHC-32.2 RDW-13.4 RDWSD-41.7 Plt ___
___ 12:14AM BLOOD ___ PTT-28.9 ___
___ 04:45AM BLOOD Glucose-103* UreaN-12 Creat-0.5 Na-141
K-4.5 Cl-107 HCO3-23 AnGap-11
___ 04:45AM BLOOD Calcium-8.7 Phos-4.2 Mg-2.1
___ 12:28AM BLOOD ___ pO2-118* pCO2-40 pH-7.40
calTCO2-26 Base XS-0 Comment-GREEN TOP
___ 12:28AM BLOOD Lactate-1.3
IMAGING/STUDIES
CTA chest ___- 1. No evidence of pulmonary embolism or
aortic abnormality.
2. Nondisplaced right proximal humeral fracture.
3. Moderate hiatal hernia.
TTE ___- The left atrial volume index is normal. There is
no evidence for an atrial septal defect by 2D/color Doppler. The
estimated right atrial pressure is ___ mmHg. There is normal
left ventricular wall thickness with a normal cavity size. There
is normal regional left ventricular systolic function.
Quantitative biplane left ventricular ejection fraction is 59 %.
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
mildly dilated ascending aorta. The aortic arch diameter is
normal. There is no evidence for an aortic arch coarctation. The
aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. There is no aortic regurgitation. The
mitral leaflets are mildly thickened with no mitral valve
prolapse. There is trivial mitral regurgitation. The tricuspid
valve leaflets appear structurally normal. There is physiologic
tricuspid regurgitation. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Adequate image quality. Normal biventricular cavity
sizes, regional/global systolic
function. No valvular pathology or pathologic flow identified.
Normal estimated pulmonary artery
systolic pressure
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amitriptyline 20 mg PO QHS
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain -
Mild
5. Letrozole 2.5 mg PO DAILY
6. LORazepam 0.5 mg PO Q12H:PRN agitation?
7. Omeprazole 20 mg PO DAILY
8. Oxybutynin 15 mg PO DAILY
9. Pravastatin 20 mg PO QPM
10. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral BID
11. Diltiazem Extended-Release 180 mg PO DAILY
Discharge Medications:
1. Amitriptyline 20 mg PO QHS
2. Aspirin 81 mg PO DAILY
3. Diltiazem Extended-Release 180 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. HYDROcodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN Pain
- Mild
6. Letrozole 2.5 mg PO DAILY
7. LORazepam 0.5 mg PO Q12H:PRN agitation?
8. Omeprazole 20 mg PO DAILY
9. Oxybutynin 15 mg PO DAILY
10. Pravastatin 20 mg PO QPM
11. PreserVision AREDS (vitamins A,C,E-zinc-copper)
___ unit-mg-unit oral BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Mechanical fall
Fractured humerus
Secondary:
Supraventricular tachycardia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with LINQ lead placement// LINQ lead placement
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest CT ___, chest radiograph ___.
FINDINGS:
There is been interval placement of a interval cardiac monitoring device which
projects over the left lung base with a configuration oriented towards the
right shoulder.
Lung volumes are persistently low. Patient's slightly more rotated than prior
radiograph. Allowing for this, the cardiomediastinal silhouette is unchanged.
The lungs are clear. No appreciable pneumothorax or pleural effusion.
IMPRESSION:
Cardiac monitoring device appears to be in appropriate positioning.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Unable to ambulate
Diagnosed with Encounter for examination and observation for unsp reason
temperature: 99.0
heartrate: 94.0
resprate: 19.0
o2sat: 99.0
sbp: 139.0
dbp: 110.0
level of pain: 0
level of acuity: 4.0 | SUMMARY STATEMENT
Ms. ___ is a ___ year-old woman with a history of
recently diagnosed (___) invasive carcinoma of the R breast
with ductal/lobular features on letrozole (ER+/PR+/HER2- Gr2 R,
no surgical intervention planned), EtOH use disorder (prior),
known gait imbalance (evaluated by neurology in ___, possible
myelopathic process in the setting of cervical spondylosis),
HTN, and dyslipidemia, who presented after a fall, and was found
to have arrhythmias on telemetry.
ACUTE ISSUES
#Fall
#Fractured humerus: The patient initially presented in the
setting of a mechanical fall, though she may have had prodromal
symptoms of dizziness. XR of the R arm ultimately showed a
proximal humeral fracture. Orthopedics determined that there was
no indication for operative management and recommended pain
control with physical therapy. She was made non-weight bearing
with the RUE. The patient was seen by physical and occupational
therapy and felt that the patient should undergo a period of
acute rehab. However, the patient preferred to go home with
additional services given poor experiences at rehab in the past.
#Supraventricular tachycardia: In-house, the patient was noted
to have intermittent increases in her heart rate to the 140s
that were intermittently symptomatic with lightheadedness and
palpitations. Electrophysiology was consulted and recommended
Linq recorder placement and addition of diltiazem for rate
control. The patient ultimately achieved excellent rate control
and her Linq recorder placed on ___ without incident.
CHRONIC ISSUES
# R breast with ductal/lobular features on letrozole
(ER+/PR+/HER2- Gr2 R, no surgical intervention planned): Patient
follows with Dr. ___ (hematology/oncology) and Dr. ___
___ (breast surgery). Letrozole was continued
in-house.
# HTN: Home ACE-i was held given normotension.
# Dyslipidemia: Continued home pravastatin.
# Insomnia: Continued home amitriptyline, though patient did
note dry mouth. (NB patient does complain of dry
mouth, should make this a transitional issue for her PCP)
# GERD: Continued home omeprazole
# Anxiety: Continued home lorazepam
# Urinary issues: Given immediate release oxybutynin while
inpatient.
TRANSITIONAL ISSUES
[]consider alternate sleep medication to amitryptiline given
patient reports dry mouth
[]consider home safety evaluation as an outpatient given
history of falls
[]patient is non-weight bearing on the R upper extremity
# CODE: Full with Limited trial of life-sustaining treatments
# CONTACT: ___, ___ (friend) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin
Attending: ___
Chief Complaint:
Altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ (EU Critical ___ is a ___ M with a history
of drug abuse (per wife, intranasal heroin and cocaine) who
presents after being found down and altered. Per the EMS reports
and OSH notes, Mr. ___ was found at a ___ clinic where he
had an intake appointment. He went into the bathroom and,
afterwards, was found slumped over and unresponsive. Per EMS, he
was found down with 2-3mm pupils, an intact gag, and a RR of 8.
He received Narcan 2mg IV with slight improvement in RR to teens
but he remained unresponsive. He was taken to ___ due to
concern for drug overdose. At ___, he was unresponsive,
with initial VS BP 80/60, HR 72, RR 8, 91% RA. He got 1L NS
bolus and was sent for CT scan, where he began having jerking of
his upper extremities. He was treated with Ativan 2mg x2 and
phenytoin 1360mg. His labs were unremarkable except a Cr of 2.2.
He was transferred to ___ for concerns of status epilepticus and
on the route over had lower BPs and again was less responsive.
He was reportedly given another dose of Narcan.
On arrival to this ED, he was noted to have reactive pupils,
absent corneals, absent EOM, a weak gag, and no spontaneous
movements or response to noxious stimuli. His reflexes were
brisk and toes were downgoing. In addition, he had episodes of
posturing with marked extension of the arms with
rolling-back/arching at the shoulders and neck lasting about 10
seconds each. He had multiple episodes. He had some foaming at
the mouth and was intubated. With the ETT in place, he did have
some spontaneous movements of his right leg antigravity.
In the ED, a repeat Cr was 1.6. Urine tox was positive for
cocaine. A head CT was negative for bleed and CTA head and neck
was preliminary unremarkable. CXR was normal. With propofol
lightened, patient purposeful and raises thumb when asked to do
so. He has hyperreflexia and ankle clonus. Prior to arrival, the
patient underwent an LP that showed normal protein and glucose,
3 WBC, and RBCs that cleared by tube 4. He was given empiric
acyclovir, vanc, and ceftriaxone.
On arrival to the MICU, the patient is intubated and sedated. He
is unarousable. Stable.
Review of systems:
(+) Per HPI, rest unobtainable
Past Medical History:
- Substance abuse: Heroin, recently enrolled at Habit Management
___ clinic
- Hypertension
- Hepatitis C
- Appendectomy
- Right leg tendon repair (___)
- Right knee arthroscopy with osteochondritis dessicans and
repeat meniscal tear
- Chronic low back pain
- Depression: suicidal ideation ___ but no attempts
- Post-traumatic stress disorder s/p GSW ___, s/p exporatory
laparotomy BWH
- Pancreatitis after abdominal surgery ___
- Syncope with possible seizure in the setting of intoxication
at ___ ___: MRI/MRA, EEG negative
- No seizure disorders, except in setting of substance abuse, no
known EtOH withdrawal seizures
Social History:
___
Family History:
- No family history of seizures, otherwise non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
General- intubated and sedated
HEENT- pupils 3mm reactive, MMM,
Neck- JVD not elevated, no neck stiffness
CV- RRR, no murmurs, no extra heart sounds, non-displaced PMI
Lungs- CTAB
Abdomen- soft, NT, ND, normal BS
GU- Foley with clear urine
Ext- no edema
Neuro- not responding to noxious stimuli, 3 beats clonus of
feet R>L, downgoing Babinski
DISCHARGE PHYSICAL EXAM:
Vitals: Tmax: 98.8 Tc: 98.2 BP 151/111 (ranging 123-181/92-123)
HR 66 RR 18 SaO2 99% RA
General- NAD
HEENT- pupils 3mm reactive, MMM
Neck- JVD not elevated, no neck stiffness
CV- RRR, no murmurs, no extra heart sounds, non-displaced PMI
Lungs- CTAB
Abdomen- soft, NT, ND, normal BS
Ext- no edema
Neuro- A+Ox3, anxious
Pertinent Results:
ADMISSION:
___ 02:28AM BLOOD WBC-3.3* RBC-3.75* Hgb-11.0* Hct-34.9*
MCV-93 MCH-29.3 MCHC-31.5 RDW-14.6 Plt ___
___ 02:28AM BLOOD Plt ___
___ 02:28AM BLOOD Glucose-95 UreaN-12 Creat-1.2 Na-138
K-4.6 Cl-110* HCO3-22 AnGap-11
___ 02:28AM BLOOD CK(CPK)-200
___ 07:30PM BLOOD Lipase-33
___ 02:28AM BLOOD CK-MB-3 cTropnT-<0.01
___ 09:53AM BLOOD Ammonia-59
___ 02:28AM BLOOD Phenyto-15.8
___ 03:28AM BLOOD Type-ART Temp-36.4 Rates-20/ Tidal V-450
PEEP-5 FiO2-40 pO2-113* pCO2-37 pH-7.43 calTCO2-25 Base XS-1
-ASSIST/CON Intubat-INTUBATED
IMAGING:
EKG:
Sinus rhythm. There are some anterolateral ST segment elevation
which is
likely early repolarization. Cannot exclude pericarditis or
ischemia.
Clinical correlation is suggested. No previous tracing available
for
comparison.
CXR:
IMPRESSION: Low-lying endotracheal tube for which retraction by
1 to 2 cm is advised. NG tube should be advanced for more
optimal positioning. Perihilar opacity which could reflect mild
edema or aspiration in the right clinical setting.
HEAD CT:
IMPRESSION: No acute intracranial abnormality.
CTA HEAD AND NECK:
IMPRESSION:
Study slightly sub optimal due to poor opacification of the
vessels, however there is no evidence of significant stenosis,
aneurysm, dissection or other vascular abnormality.
There is a focal area of consolidation within the superior
segment of the left upper lobe, incompletely imaged.
EEG:
IMPRESSION: Abnormal portable EEG due to the mild slowing of the
background rhythm. This suggests an encephalopathy. Medications,
metabolic disturbances, and infection are among the most common
causes. There were no areas of prominent focal slowing, and
there were no epileptiform features.
HOSPITALIZATION & DISCHARGE:
___ 02:28AM BLOOD WBC-3.3* RBC-3.75* Hgb-11.0* Hct-34.9*
MCV-93 MCH-29.3 MCHC-31.5 RDW-14.6 Plt ___
___ 04:07AM BLOOD WBC-3.7* RBC-4.00* Hgb-12.0* Hct-36.6*
MCV-92 MCH-30.0 MCHC-32.7 RDW-14.3 Plt ___
___ 06:05AM BLOOD WBC-3.9* RBC-4.05* Hgb-11.7* Hct-36.3*
MCV-90 MCH-29.0 MCHC-32.4 RDW-14.0 Plt ___
___ 02:28AM BLOOD ___ PTT-39.1* ___
___ 02:28AM BLOOD Glucose-95 UreaN-12 Creat-1.2 Na-138
K-4.6 Cl-110* HCO3-22 AnGap-11
___ 04:07AM BLOOD Glucose-90 UreaN-9 Creat-1.1 Na-144 K-3.9
Cl-109* HCO3-26 AnGap-13
___ 06:05AM BLOOD Glucose-93 UreaN-9 Creat-1.0 Na-141 K-3.9
Cl-103 HCO3-26 AnGap-16
___ 12:30AM BLOOD ALT-24 AST-57* AlkPhos-67 TotBili-0.2
___ 02:28AM BLOOD CK(CPK)-200
___ 07:55PM BLOOD ALT-25 AST-39 AlkPhos-76 TotBili-0.2
___ 04:07AM BLOOD ALT-23 AST-31 LD(LDH)-202 AlkPhos-85
TotBili-0.2
___ 02:28AM BLOOD CK-MB-3 cTropnT-<0.01
___ 08:45AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:30PM BLOOD Lipase-33
___ 02:28AM BLOOD Calcium-7.6* Phos-2.7 Mg-1.7
___ 07:55PM BLOOD Albumin-3.5
___ 04:07AM BLOOD Albumin-3.6 Calcium-9.1 Phos-3.0 Mg-1.8
___ 06:05AM BLOOD Calcium-9.1 Phos-3.6 Mg-1.7
___ 09:53AM BLOOD Ammonia-59
___ 01:17PM BLOOD HIV Ab-NEGATIVE
___ 07:30PM BLOOD ASA-NEG Ethanol-NEG Carbamz-<0.5*
Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 03:28AM BLOOD Lactate-0.9
___ 10:10PM URINE Color-Straw Appear-Hazy Sp ___
___ 10:10PM URINE Blood-MOD Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 10:10PM URINE RBC-3* WBC-<1 Bacteri-FEW Yeast-NONE
Epi-0
___ 2:27 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
___ 12:15 am CSF;SPINAL FLUID #3.
Note: Culture results may be compromised by the limited
volume (less
than 1ml) of specimen received.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Paroxetine 40 mg PO DAILY
2. Gabapentin 800 mg PO TID
3. Amlodipine 5 mg PO DAILY
4. ClonazePAM 1 mg PO BID:PRN anxiety
5. CloniDINE 0.3 mg PO TID
6. Lisinopril 40 mg PO DAILY
7. Ranitidine 150 mg PO BID
8. Ibuprofen 800 mg PO Q8H:PRN pain
9. Viagra (sildenafil) 25 mg oral 30 min prior to sexual
activity erectile dysfunction
10. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN Pain
Discharge Medications:
1. Gabapentin 800 mg PO TID
2. Lisinopril 40 mg PO DAILY
3. Paroxetine 40 mg PO DAILY
4. Ranitidine 150 mg PO BID
5. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Capsule
Refills:*0
7. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
8. ClonazePAM 1 mg PO BID:PRN anxiety
9. Ibuprofen 800 mg PO Q8H:PRN pain
10. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q4H:PRN Pain
11. Viagra (sildenafil) 25 mg oral 30 min prior to sexual
activity erectile dysfunction
12. Methadone 20 mg PO DAILY Duration: 5 Days
13. Amlodipine 7.5 mg PO DAILY
RX *amlodipine 2.5 mg 3 tablet(s) by mouth daily Disp #*90
Tablet Refills:*0
14. CloniDINE 0.3 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES: Heroin and cocaine intoxication and
withdrawal, acute kidney injury
SECONDARY: Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: None.
CLINICAL HISTORY: Posturing, intubated for airway protection, assess ET tube
position.
FINDINGS: Supine portable AP view of the chest provided. The tip of the
endotracheal tube resides 1.2 cm above the carina. Retraction by 1 to 2 cm is
advised for more optimal positioning. The NG tube is seen with its tip just
beyond the GE junction and advancement would be recommended for more optimal
positioning. There is subtle perihilar opacity, which could reflect
aspiration or mild congestion. No supine evidence for effusion or
pneumothorax. The heart size appears within normal limits. Bony structures
appear intact.
IMPRESSION: Low-lying endotracheal tube for which retraction by 1 to 2 cm is
advised. NG tube should be advanced for more optimal positioning. Perihilar
opacity which could reflect mild edema or aspiration in the right clinical
setting.
Radiology Report
INDICATION: Altered mental status. Evaluate for hemorrhage.
COMPARISONS: None.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Sagittal, coronal, and
thin-section bone reformatted images were obtained and reviewed.
TOTAL DLP: 947.96 mGy-cm.
FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or large
vascular territory infarction. The ventricles and sulci are normal in size
and configuration. The basal cisterns are patent. There is minimal
periventricular white matter hypodensity along the right lateral ventricle,
which is likely due tochronic small vessel ischemic disease.
No fracture is identified. There is moderate opacification of the ethmoidal
air cells. The remainder of the visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The soft tissues are unremarkable.
IMPRESSION: No acute intracranial abnormality.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK
INDICATION: History: ___ with AMS // eval for vessel occlusion
TECHNIQUE: CTA head and neck is obtained by performing rapid axial imaging
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 rendendered images, and maximum
intensity projection images.
DOSE: DLP: ___ MGy-cm
COMPARISON: Noncontrast head CT dated ___.
FINDINGS:
HEAD CTA: Study suboptimal due to poor opacification of the vessels likely
related to timing of the bolus. The anterior, mid and middle cerebral arteries
are unremarkable. The posterior communicating arteries are not identified.
The basilar tip is patulous, a normal variant. The posterior circulation is
otherwise unremarkable. There is no evidence of significant stenosis, vessel
occlusion or aneurysm.
[NECK CTA: There is a normal 3 vessel left-sided aortic arch. The origin the
great vessels is unremarkable. The common carotid, internal carotid and
external carotid arteries are widely patent without evidence of dissection or
significant stenosis (based on NASCET criteria).
The vertebral arteries are widely patent without evidence of significant
stenosis or dissection.
There is bilateral minimal dependent atelectasis and/or pleural-parenchymal
scarring there is also incompletely imaged focal area of consolidation within
the superior segment of the left lower lobe.
There are endotracheal and enteric tubes in place. Multilevel cervical
spondylosis without high-grade spinal canal narrowing.
IMPRESSION:
Study slightly sub optimal due to poor opacification of the vessels, however
there is no evidence of significant stenosis, aneurysm, dissection or other
vascular abnormality.
There is a focal area of consolidation within the superior segment of the left
upper lobe, incompletely imaged.
Gender: M
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: EU CRITICAL/UNRESPONSIVE
Diagnosed with SEMICOMA/STUPOR, MYOCLONUS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | This is a ___ yo M with PMH of substance abuse who presents with
altered mental status in the setting of opioid and cocaine
abuse, intubated for airway protection and admitted to the ICU.
# Altered mental status: A thorough workup performed prior to
the patients arrival in the ICU included a tox screen that was
positive for cocaine and opioids, a negative non-contrast head
CT, a negative CTA head and neck, and an LP that had normal WBC
and RBCs that cleared. This information all points towards acute
drug intoxication as the most likely cause of his initial
presentation (described as stupor, miosis, bradypnea which
improved with narcan). Patient admitted to snorting a bag of
heroin and taking cocaine 2 days prior to presentation once
extubated. He was initially evaluated by toxicology. Evaluation
by neurology given possible seziures and patient received EEG
and started on phenytoin 100mg BID. EEG returned negative and
phenytoin was stopped on ___. Spoke to PCP who corroborated no
history of seizure disorder (except in the presence of drug
intoxication). No history of EtOH withdrawal. Asterixis thought
to be due to phenytoin, no evidence of liver disease. Patient
was successfully extubated and mental status cleared after
extubation.
#Narcotic withdrawal: Patient began experiencing heroin
withdrawal morning of ___ and was scoring on ___. He was
placed on clonidine, dicyclomine, hydroxyzine, kaopectate,
triaminic, and methocarbamol per ___ ___ protocol. Spoke to
staff at ___ (below) who put us in contact with his
___ (had not yet actually seen MD) Dr. ___ ___ (cell), who felt it was okay and even preferable to
initiate methadone while hospitalized since this would mean
being in a monitored setting. He was started on methadone 20 mg
daily on ___. Dr. ___ that Mr. ___ come to the clinic
following discharge to continue his methadone titration - no
appointment necessary. Patient received 25 mg methadone on ___
and 25 mg methadone on ___ prior to discharge. He was not
scoring on ___ prior to discharge and his symptoms of anxiety
and HTN were likely related to craving. Dr. ___ was contacted
on ___ (the AM of patient's discharge) and he advised that
patient should follow up in the ___ clinic tomorrow
morning (___) between 6am and 11am (address as written below).
This was communicated to the patient and he understood and
expressed that he would likely have a ride to the ___
clinic tomorrow around 9am. Dicyclomine, hydroxyzine,
kaopectate, triaminic, and methocarbamol were discontinued prior
to discharge as patient was not requiring these medications and
his symptoms were likely related to craving rather than
withdrawal. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / probiotic / clindamycin /
lisinopril
Attending: ___.
Chief Complaint:
Fatigue, headache
Major Surgical or Invasive Procedure:
___ placement of catheter into hepatic abscess
ERCP with stent removal and replacement
History of Present Illness:
Ms. ___ is an ___ year old female with hx of pancreatic cancer
diagnosed ___ ___ s/p chemo and gamma knife radiation,type 2
diabetes, HLD, and recent history of GI bleed (admitted ___
___ presents with increased fatigue, headache, and poor oral
intake. She initially presented ___ to ___ urgent care
with chills, fever to 100.4 and generalized weakness. She felt
too weak to walk, and noticed very dark urine ___ the past few
days, very poor PO intake and was transferred to ___ ED.
___ the ED, initial VS were 97.7 79 131/43 18 100%. Spiked
temperature to 101 ___ ED. Exam was unremarkable with no
significant abdominal tenderness. Labs notable for Lactate 2.7,
UA w/ 15 WBCs and few bacteria, and 1000 glucose, Na 126 Cl 88,
BUN/Cr ___, CBC notable for WBC 21.7 w/ 88% PMNs, Hgb 8.0
(baseline 9.1), INR 1.5, AP 271, ALT/AST WNL. CT abdomen/pelvis
showed new "Large septated hypodense lesion within the left lobe
of the liver" and "innumerable hypodense lesions scattered
diffusely throughout the liver," suspicious for multiple hepatic
abscesses. Received Tylenol and Oxycodone for pain, and was
started on Ciprofloxacin + Metronidazole, and home medications
including Furosemide, Losartan, Labetalol, Amlodipine, and
Insulin. Surgery was consulted and recommended admission to
medicine for ___ drainage of multiple abscesses. Transfer VS
were 97.1 80 140/69 16 99% RA.
Past Medical History:
#recent diagnosis of periampullary adenocarcinoma (likely
pancreatic ductal carcinoma), s/p biliary stenting ___ ___
# Temporal Arteritis (distant)
# h/o DVT/PE after MVA(distant)
# DM - complicated by neuropathy and retinopathy
# GERD c/b Esophageal stricture s/p dilation (distant)
# s/p CCY
#Hypertension
#Hyperlipidemia
#Anxiety
#depression
#Morbid obesity
#Osteoarthritis
#Total abdominal hysterectomy
#Colostomy s/p reversal
Social History:
___
Family History:
Sister with GI cancer, pt not sure what kind.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
VS: 99.6 144/62 80 18 96% RA
GENERAL: Pleasant elderly female, lying ___ bed ___ NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: CARDIAC: RRR, S1/S2, ___ murmur loudest at LUSB
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender ___ 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, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
=========================
VS: 98.4 160/83 90 18 97%RA
GENERAL: Pleasant elderly female, lying ___ bed ___ NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: CARDIAC: RRR, S1/S2, ___ murmur loudest at LUSB
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles, CPAP machine at bedside
ABDOMEN: nondistended, +BS, non-tender, no rebound/guarding, no
hepatosplenomegaly; Percuratneous catheter ___ place.
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, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
===============
___ 07:40PM BLOOD WBC-21.7* RBC-3.06* Hgb-8.0* Hct-25.4*
MCV-83 MCH-26.1 MCHC-31.5* RDW-17.4* RDWSD-52.4* Plt ___
___ 07:40PM BLOOD Neuts-88.5* Lymphs-3.6* Monos-6.8
Eos-0.0* Baso-0.1 Im ___ AbsNeut-19.17*# AbsLymp-0.79*
AbsMono-1.48* AbsEos-0.00* AbsBaso-0.03
___ 06:50PM BLOOD ___ PTT-32.0 ___
___ 07:40PM BLOOD Glucose-421* UreaN-9 Creat-0.6 Na-126*
K-3.9 Cl-88* HCO3-26 AnGap-16
___ 07:40PM BLOOD ALT-24 AST-27 AlkPhos-271* TotBili-0.6
___ 07:40PM BLOOD Albumin-3.0*
PERTINENT FINDINGS
==================
___ ABSCESS Site: LIVER LIVER ABSCESS.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Preliminary):
ESCHERICHIA COLI. SPARSE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ =>16 R
TRIMETHOPRIM/SULFA---- =>16 R
IMAGING
ERCP ___:
- A previously placed fully covered metal stent was seen ___ the
major papilla. It was noted to be obstructed and distally
migrated. It was removed via snare.
-Cannulation of the biliary duct was successful and deep with a
balloon using a free-hand technique.
-Balloon cholangiogram revealed dilation of the CBD, CHD, left
and right hepatics and intrahepatics without a clear stricture.
-A ___ x 80mm Wallflex biliary fully covered metal stent was
placed successfully (REF ___ LOT ___
___ CT Abd/Pelvis W/ Contrast:
1. Large septated hypodense lesion within the left lobe of the
liver, measures
up to 5.5 cm, and is new compared to the prior exam from ___.
Additional innumerable hypodense lesions are seen scattered
diffusely
throughout the liver. Although this could be secondary to
metastatic disease,
given the patient's symptoms and absence of lesions on the
recent prior exam,
findings are highly concerning for multiple infectious hepatic
abscesses.
2. New small bilateral pleural effusions.
3. Patient's known pancreatic mass is incompletely evaluated on
this exam. If
there is further clinical concern, a dedicated pancreatic CTA
may be helpful
for further evaluation.
___ CT Head W/O:
There is no evidence of acute intracranial hemorrhage, midline
shift, mass
effect, or acute large vascular territorial infarct. Prominence
of the
ventricles and sulci is consistent with atrophy.
Periventricular and
subcortical white matter hypodensities are likely sequelae of
chronic small
vessel disease. Bilateral carotid calcifications are seen. The
visualized
paranasal sinuses are clear. The mastoid air cells are clear.
No acute
fracture is seen.
DISCHARGE LABS
===============
___ 05:15AM BLOOD WBC-14.6* RBC-3.31* Hgb-8.5* Hct-27.4*
MCV-83 MCH-25.7* MCHC-31.0* RDW-18.3* RDWSD-54.2* Plt ___
___ 05:15AM BLOOD Glucose-61* UreaN-8 Creat-0.7 Na-139
K-3.3 Cl-101 HCO3-29 AnGap-12
___ 05:15AM BLOOD ALT-15 AST-19 LD(LDH)-266* AlkPhos-262*
TotBili-0.3
___ 05:15AM BLOOD Albumin-2.9* Calcium-10.1 Phos-2.9 Mg-2.4
___ 05:37AM BLOOD CRP-275.2*
___ 09:05AM BLOOD CRP-151.6*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 500 mg PO Q8H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Citalopram 10 mg PO DAILY
4. Creon 12 1 CAP PO TID W/MEALS
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Labetalol 200 mg PO BID
7. Lorazepam 0.5 mg PO BID:PRN anxiety
8. Losartan Potassium 25 mg PO DAILY
9. Omeprazole 40 mg PO DAILY
10. Ondansetron 4 mg PO Q8H:PRN nausea
11. Furosemide 20 mg PO DAILY
12. Enoxaparin Sodium 90 mg SC Q12H
Discharge Medications:
1. Lorazepam 0.5 mg PO BID:PRN Anxiety Duration: 30 Days
2. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain Duration:
30 Days
3. Acetaminophen 500 mg PO Q8H:PRN pain
4. Citalopram 10 mg PO DAILY
5. Creon 12 1 CAP PO TID W/MEALS
6. Docusate Sodium 100 mg PO BID:PRN constipation
7. Enoxaparin Sodium 120 mg SC Q24H
Start: ___, First Dose: Next Routine Administration Time
8. Omeprazole 40 mg PO DAILY
9. Ondansetron 4 mg PO Q8H:PRN nausea
10. Losartan Potassium 25 mg PO DAILY
11. Labetalol 200 mg PO BID
12. Furosemide 20 mg PO DAILY
13. Amlodipine 10 mg PO DAILY
14. NPH 35 Units Breakfast
NPH 35 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
15. Ertapenem Sodium 1 g IV DAILY Duration: 1 Dose
Continue until instructed by your infectious disease doctor
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
- Hepatic abscess
- Biliary obstruction
- Hyponatermia
Secondary:
- Headache
- Anemia
- GERD
- OSA
- Depression
- Anxiety
- T2DM
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: Ultrasound done drainage.
INDICATION: ___ year old woman with hx pancreatic cancer, p/w multiple liver
abscesses. // Hypodense areas on Liver, concern for abscess, requesting
drainage and culture.
COMPARISON: CT abdomen and pelvis ___.
PROCEDURE: Ultrasound-guided drainage of the left hepatic lobe abscess. .
OPERATORS: Dr. ___ radiology fellow and Dr. ___,
___ radiologist. Dr. ___ supervised the trainee during
the key components of the procedure and reviewed and agree with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the US scan table. Limited
preprocedure ultrasound was performed to localize the left hepatic collection.
Based on the ultrasound findings an appropriate skin entry site was chosen.
The site was marked. Local anesthesia was administered with 1% Lidocaine
solution.
Using continuous sonographic guidance, ___ Flexema drainage catheter was
advanced via trocar technique into the liver abscess. A sample of fluid was
aspirated, confirming catheter position. The pigtail was deployed. The
position of the pigtail was confirmed within the abscess via ultrasound.
Approximately 50 cc of purulent fluid was drained with a sample sent for
microbiology evaluation. The catheter was secured by a StatLock. The catheter
was attached to bag. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
SEDATION: Moderate sedation was provided by administering divided doses of 1
mg Versed and 50 mcg fentanyl throughout the total intra-service time of 20
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
8.5 cm left hepatic collection.
Drainage yielded 50 cc of purulent fluid.
IMPRESSION:
Successful US-guided placement of an ___ pigtail catheter into the left
hepatic abscess.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Fatigue, Headache
Diagnosed with OTHER MALAISE AND FATIGUE, LEUKOCYTOSIS, UNSPECIFIED , ABDOMINAL PAIN GENERALIZED, MALIG NEO PANCREAS NOS
temperature: 97.7
heartrate: 79.0
resprate: 18.0
o2sat: 100.0
sbp: 131.0
dbp: 43.0
level of pain: 9
level of acuity: 3.0 | Ms. ___ is an ___ female with hx of pancreatic cancer (dx
___ s/p tx), T2DM, and recent history of GI bleed admitted with
fever, fatigue, headache, and anorexia; found to have a large
hepatic abscesses and biliary stent obstruction.
ACTIVE ISSUES
==============
# Hepatic Abscess:
Patient was admitted from urgent care with increased fatigue,
fevers, headaches, and poor PO tolerance. CT abdomen/pelvis with
contrast revealed a new "large septated hypodense lesion within
the left lobe of the liver" and "innumerable hypodense lesions"
scattered ___ the liver. labs were also notable for an isolated
alk phos elevation and normal T. Bili, concerning for early
obstruction. The patient remained hemodynamically stable, but
was started on Ampicillin/Sulbactam for coverage gram negative
and anaerobic bacteria. After spiking fever she was
transitioned to zosyn and a biliary percutaneous catheter was
placed, draining 50cc from the largest abscess. Initial gram
stain revealed gram negative and gram positive bacteria, so
Vancomycin was added. An ERCP investigation of a previous
biliary stent revealed migration and obstruction. It was
removed and successfully replaced with a full metal stent.
Cultures from the catheter placement revealed moderately
resistant E. Coli and gram positive cocci. The patient was
transitioned to meropenem and vancomycin with plan for ertopenem
antibioisis ___ the outpatient setting. The patient remained
afebrile and hemodynamically stable on following start of
meropenem. She was discharged with plans for close follow up
with infectious disease.
# Headache:
Patient presented with persistent bilateral headaches over the
past month, bilateral ___ front and back. she also reported
occasional vision blurriness, right temporal tenderness. She
denied lightheadedness/dizziness, significant change ___ vision,
and any tongue/jaw claudication with chewing. Given previous
history of temporal arteritis, rheumatology and ophthalmology
was consulted, but not found to have ocular involvement, and
symptoms of headaache and temporal tenderness self resolved.
Given low pretest probability, temporal biospy was deferred.
# Hyponatremia:
Na+ 126 on admission, with frank glycosuria on UA and
Fingerstick glucose ___ 400s. With tighter glucose control and
IVF hyponatremia self corrected without incident. Na+ on
discharge: 140
CHRONIC ISSUES
===============
# Type II Diabetes:
At home NPH 45 units breakfast and dinner. Her home regimen was
too aggressive, with some episodes of hyperglycemia, so she was
de-escalated to 35 units of NPH at breakfast and dinner, and a
less aggressive sliding scale.
# Anemia:
Patient was anemic on admission likely secondary to known
bleeding from hemorrhoids. Admitted ___ and underwent Flex sig
and colonoscopy which showed external hemorrhoids and
diverticulosis, but no active bleeding. Hemoglobin/HCT were
trended on this admission and remained stable.
# GERD:
Stable during this hospital stay. Continued home omeprazole.
# Hypertension:
Patient was hemodynamically stable ___ setting of infection. She
had multiple episodes of hypertension, requiring 1x dosing of
home labetolol. However, BP medications were generally ___
setting of infection, with normotensive vital signs. Will plan
to restartlosartan 25mg PO Qday, labetalol 200mg po BID,
amlodipine 10mg PO Qday on discharge
# DVT:
Patient had history of previous DVT, and was maintained on
weight dosed enoxparin 120mg daily (increased from home dose of
90 mg SubQ per pharmacy).
# OSA: Patient has history of OSA, and used nightly CPAP without
event.
# Anxiety: This issue was stable during this hospital stay.
Patient continued continued home medication lorazepam.
# Depression: This issue was stable during this hospital stay.
Patient continued will continue home medication of citalopram.
#DNR/DNI
HCP: ___ (daughter) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Subarachnoid hemorrhage
Major Surgical or Invasive Procedure:
None during this admission
History of Present Illness:
___ + for ETOH was walking down street looking at phone, saw a
car coming down street and was startled, took a step back and
fell striking head. She attempted to get up and had fallen back
down. Reports having a bottle of wine per day. She was taken to
___ ___ and workup revealed a Right sided traumatic
subarachnoid hemorrhage and a question of a small left sided
SDH.
Cervical collar was cleared at the OSH. She was subsequently
transferred to ___ for further management and care.
Past Medical History:
HTN
hyperlipidemia
EtOH abuse
seasonal allergies
Social History:
___
Family History:
Family Hx:
Skin Cancer in father
Physical ___ at presentation:
: T:98.1 BP: 145/93 HR:88 R:20 O2Sats: 96% RA
Gen: WD/WN, comfortable, NAD.
HEENT: ___ EOMs. chin laceration, multiple facial
lacerations.
Extrem: Warm and well-perfused. Palms of hands have lacerations.
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.
No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested
II: Pupils equally round and reactive to light, 3 to 2mm
bilaterally. Visual fields are full to confrontation.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout with exception of L
tricept ___. No pronator drift.
Sensation: Intact to light touch
Toes downgoing bilaterally
Exam at discharge:
VS: AVSS
GEN: AOx3, NAD
HEENT: laceration c/d/i
Neuro: CN2-12 intact
Pertinent Results:
___ 07:50AM BLOOD WBC-4.8 RBC-4.21 Hgb-14.5 Hct-41.0 MCV-98
MCH-34.5* MCHC-35.3* RDW-14.0 Plt ___
___ 04:00PM BLOOD WBC-5.4 RBC-4.50 Hgb-15.0 Hct-44.4
MCV-99* MCH-33.3* MCHC-33.7 RDW-14.2 Plt ___
___ 04:00PM BLOOD Neuts-70.4* ___ Monos-4.6 Eos-0.8
Baso-0.7
___ 07:50AM BLOOD Plt ___
___ 07:50AM BLOOD Glucose-107* UreaN-10 Creat-0.6 Na-142
K-3.6 Cl-104 HCO3-25 AnGap-17
___ 04:00PM BLOOD Glucose-92 UreaN-10 Creat-0.6 Na-145
K-5.4* Cl-108 HCO3-22 AnGap-20
___ 07:50AM BLOOD Calcium-8.3* Phos-2.3* Mg-1.5*
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: A ___ woman with traumatic right subarachnoid hemorrhage,
evaluate for interval changes.
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: 889.7 mGy-cm
CTDI: 53.71 mGy
COMPARISON: Unenhanced head CT obtained ___.
FINDINGS:
There are linear hyperdensities seen within right temporal gyri, consistent
with known right subarachnoid hemorrhage, unchanged in appearance from prior
CT. There is also a stable appearance of a small amount of linear hyperdense
material layering along the posterior falx cerebri and extending down along
the superior aspect of the right tentorium, compatible with subdural hematoma.
There are no additional areas of intracranial hemorrhage seen. There is no
evidence of brain edema or shift of normally midline structures. The there is
no ventriculomegaly. The basal cisterns are patent. The visualized paranasal
sinuses and mastoid air cells are clear. There is no evidence of fracture.
IMPRESSION:
Stable appearance of known small right temporal subarachnoid hemorrhage and
right parafalcine and right tentorial subdural hematoma. No new focus of
intracranial hemorrhage.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, SAH
Diagnosed with SUBDURAL HEM W/O COMA, SUBARACHNOID HEM-NO COMA, FALL ON STAIR/STEP NEC
temperature: 98.1
heartrate: 88.0
resprate: 20.0
o2sat: 96.0
sbp: 145.0
dbp: 93.0
level of pain: 2
level of acuity: 3.0 | Mrs. ___ was directly transferred from ___ for
traumatic subarachnoid hemorrhage and subdural hematoma. She was
admitted to the Neurosurgery service with Keppra 1000mg initial
load and Keppra 500mg BID. She was placed on a ___ protocol
given her history of EtOH abuse. Her neurovascular exam was
intact on admission.
___: She tolerated a regular diet. She was making adequate
urine output. Pain was well-controlled on PO pain meds. Her
neural exam remained to be intact. She was safe to be discharged
to home. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
jaundice
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is unable to provide history, so this has been obtained
from review of documentation and discussion with nursing home
and
guardian ___, ___
This is a ___ year old female ___ home resident (___ in
___ with past medical history of dementia, cerebral palsy,
hyperparathyroidism, hypertension, CAD, seizures, with complex
social situation relating to surrogate decision-making
(described
below), recent outpatient diagnosis of pancreatic mass in the
setting of progressive painless jaundice, who was referred to
the
hospital for additional workup.
2 or 3 weeks ago, patient was first noted to be jaundiced, found
to have elevated Tbili and alk phos. She had a CT scan that per
report raised concern re: gallbladder stone, possible pancreatic
head mass. Given her DNR/DNI/DNH status, her NP/MD team opted to
treat with antibiotics for any potential reversible cause. Her
jaundice did not improve and LFTs continued to rise. On day of
admission, patient was seen by NP, who noted new RUQ pain and
rising LFTs. Given pain, and concern for a reversible etiology,
patient was referred to ___ for additional workup.
At ___, LFTs similarly elevated. CT scan was repeated,
showing L ovarian mass with associated mild left-sided
hydroureteronephrosis secondary to compression; also showed
cholelithiasis, distended gallbladder without evidence of
cholesystitis, substantial diffuse intrahepatic biliary ductal
dilation and dilation of the proximal hepatic duct without
discernible porta hepatis mass, choledocholithiasis, or
pancreatic head mass. Per written report from OSH ED, they
spoke
with guardian who requested reversal of code status. ED
transferred patient to ___ for further workup and management.
At ___ ED, 97.8 83 130/86 15 97%RA. Later at 442 am HR 113,
___ 98%RA. Patient was unable to provide additional
history. Labs here were notable for WBC 7.1, ALT 182, AST 299,
AP 1509, Tbili 13.8, INR 2.1; albumin 2.7, Mg 1.4; lactate 1.3;
abdominal ultrasound showed 2.2cm hypoechoic lesion in the
region
of the pancreatic head concerning for malignancy, cholelithiasis
without evidence of cholecystitis, as well as L ovarian mass.
Patient was given IV CTX, flagyl and was admitted to medicine
service.
On arrival to floor, patient denied any pain. Full 10 point
review of systems positive where noted otherwise negative.
Past Medical History:
Dementia
Cerebral palsy
Hyperparathyroidism
Hypertension
CAD
Seizures
Social History:
___
Family History:
Per patient, no history of pancreatic or liver disease in her
family.
Physical Exam:
ADMISSION
VS: 97.9 PO 109 / 67 76 18 98 RA
Gen: supine in bed, comfortable, very jaundiced
Eyes - EOMI, +icterus
ENT - OP clear, MMM
Heart - irreg irreg no mrg
Lungs - CTA bilaterally
Abd - soft nontender, negative murphys sign, no
rebound/guarding,
normoactive bowel sounds, no flank pain;
Ext - no edema
Skin - no rashes
Vasc - 2+ DP/radial pulses
Neuro - AOx2-3 (full name, ___, moving all
extremities
Psych - appropriate
DISCHARGE
VS - 98.6 PO 118 / 62 84 18 97 RA
Gen - supine in bed, comfortable,
Eyes - EOMI, +icterus
Lungs - Breathing comfortably
Skin - +jaundice
Neuro - moving all extremities
Psych - appropriate
Pertinent Results:
ADMISSION
___ 03:07AM BLOOD WBC-7.1 RBC-3.33* Hgb-10.2* Hct-31.7*
MCV-95 MCH-30.6 MCHC-32.2 RDW-18.7* RDWSD-65.1* Plt ___
___ 04:35AM BLOOD ___ PTT-40.1* ___
___ 03:07AM BLOOD Glucose-81 UreaN-9 Creat-0.8 Na-133*
K-3.9 Cl-101 HCO3-17* AnGap-15
___ 03:07AM BLOOD ALT-182* AST-299* AlkPhos-1509*
TotBili-13.8*
___ 03:07AM BLOOD Albumin-2.7* Calcium-8.4 Phos-2.2*
Mg-1.4*
RUQ US
1. Moderate intrahepatic biliary dilation and CBD dilation up to
11 mm in
combination with a 2.2 cm hypoechoic lesion in the region of the
pancreatic head is concerning for a pancreatic head neoplasm
causing obstruction.
Recommend pancreas CTA of the abdomen and pelvis for further
evaluation.
2. 11.4 x 8.6 cm mixed solid cystic mass left adnexal mass is
concerning for malignancy/metastatic disease. This can be also
be evaluated on CTA of the abdomen pelvis.
3. Cholelithiasis without evidence of cholecystitis.
RECOMMENDATION(S): CT of the abdomen and pelvis for further
characterization of findings described in impression 1. and 2.
CXR (portable)
1. Mild pulmonary vascular congestion without frank pulmonary
edema.
2. An oval air-filled structure projects over the left heart and
may represent a large hiatal hernia or partial herniation of the
stomach through the left hemidiaphragm. Comparison with priors,
or the addition of a lateral view chest radiograph, would be
helpful.
3. Small left pleural effusion.
CXR PA/lat
Heart size is enlarged. Mediastinum is stable. There is
lateral views that represents elevation of left hemidiaphragm
that might potentially represent rupture and herniation and
bowel/stomach loops projecting in this location. Lungs are
clear. There is no appreciable pleural effusion. There is no
pneumothorax.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 2.5 mg PO DAILY
2. Loratadine 10 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Senior Tabs (multivit-min-FA-lycopen-lutein) 0.4-300-250
mg-mcg-mcg oral DAILY
5. Carvedilol 12.5 mg PO BID
6. Cinacalcet 30 mg PO BID
7. GuaiFENesin ER 600 mg PO Q12H
8. Florastor (Saccharomyces boulardii) 250 mg oral BID
Discharge Medications:
1. Ondansetron ODT 4 mg PO Q8H:PRN nausea
2. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*12 Tablet Refills:*0
3. GuaiFENesin ER 600 mg PO Q12H
4. Loratadine 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
# Biliary obstruction secondary to pancreatic Head Mass
# Hyperbilirubinemia
# Ovarian Mass
# Abnormal EKG
# Hydroureter
# Hyponatremia
# Hypomagnesemia
# Abnormal CXR
# Coagulopathy
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: CHEST (PORTABLE AP)
INDICATION: History: ___ with dyspnea// eval for pulmonary edema, fluid
TECHNIQUE: Portable AP chest
COMPARISON: None.
FINDINGS:
Lung volumes are low. The cardiac silhouette is moderately enlarged. An oval
air-filled structure projects over the left heart and may represent a large
hiatal hernia or partial herniation of the stomach through the left
hemidiaphragm. No focal consolidations are seen. There is mild pulmonary
vascular congestion without frank pulmonary edema. A small left pleural
effusion is noted. There is no pneumothorax.
IMPRESSION:
1. Mild pulmonary vascular congestion without frank pulmonary edema.
2. An oval air-filled structure projects over the left heart and may represent
a large hiatal hernia or partial herniation of the stomach through the left
hemidiaphragm. Comparison with priors, or the addition of a lateral view
chest radiograph, would be helpful.
3. Small left pleural effusion.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with abd pain, jaundice// eval for cholecystitis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is moderate intrahepatic biliary dilation. The CBD measures
11 mm.
GALLBLADDER: Cholelithiasis without gallbladder wall thickening.
PANCREAS: There is a heterogeneously hypoechoic 2.2 x 1.2 x 1.7 cm lesion in
the region of the pancreatic head, with minimal internal vascularity. There
is no main pancreatic ductal dilatation.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
PELVIS: A 11.4 x 8.6 cm mixed solid cystic left ovarian mass is seen.
IMPRESSION:
1. Moderate intrahepatic biliary dilation and CBD dilation up to 11 mm in
combination with a 2.2 cm hypoechoic lesion in the region of the pancreatic
head is concerning for a pancreatic head neoplasm causing obstruction.
Recommend pancreas CTA of the abdomen and pelvis for further evaluation.
2. 11.4 x 8.6 cm mixed solid cystic mass left adnexal mass is concerning for
malignancy/metastatic disease. This can be also be evaluated on CTA of the
abdomen pelvis.
3. Cholelithiasis without evidence of cholecystitis.
RECOMMENDATION(S): CT of the abdomen and pelvis for further characterization
of findings described in impression 1. and 2.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ w biliary obstruction and ovarian mass, CXR w oval
air-filled structure projecting over the left heart and may represent a large
hiatal hernia or partial herniation of the stomach through the left
hemidiaphragm.// please assess hiatal hernia versus stomach herniation
please assess hiatal hernia versus stomach herniation
IMPRESSION:
Heart size is enlarged. Mediastinum is stable. There is lateral views that
represents elevation of left hemidiaphragm that might potentially represent
rupture and herniation and bowel/stomach loops projecting in this location.
Lungs are clear. There is no appreciable pleural effusion. There is no
pneumothorax.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal CT, Jaundice, Transfer
Diagnosed with Unspecified jaundice
temperature: 97.8
heartrate: 83.0
resprate: 15.0
o2sat: 97.0
sbp: 130.0
dbp: 86.0
level of pain: 0
level of acuity: 3.0 | This is a ___ year old female nursing home resident with past
medical history of dementia, cerebral palsy,
hyperparathyroidism, hypertension, CAD, seizures, recent onset
of painless jaundice, referred for admission and found to have
evidence of pancreatic head mass and ovarian mass concerning for
metastatic abdominal malignancy, subsequently discussed with
patient's guardian who supported previous documentation that
patient was DNR/DNI/do-not-hospitalize, discharged back to
nursing home with plan to establish with hospice care
# Goals of Care
# Biliary obstruction secondary to pancreatic Head Mass
# Ovarian Mass
Patient referred for admission with painless jaundice, with
imaging at ___ concerning for ovarian mass, and imaging at
___ concerning for pancreatic mass. Reviewed patient's chart,
which included a MOLST form indicating do not attempt
resuscitation, do not intubate, do not transfer to hospitalize.
Situation was discussed with patient's guardian ___,
___ who agreed that initial MOLST form should be
upheld, and patient's wishes respected. Discussed with guardian
that imaging was concerning for metastatic abdominal malignancy,
but that diagnosis would require biopsy--per guardian, patient's
goals were palliative and comfort-oriented, and invasive biopsy
and other diagnostic procedures would not be consistent with
those goals. Reviewed patient's medications and modified her
regimen to reflect her comfort-oriented goals. Started prn
Zofran and oxycodone for symptoms.
# Abnormal EKG
Noted to have abnormal EKG with poor baseline, felt to represent
likely sinus with PACs; initial plan had been to repeat EKG, but
in setting of above described goals, further workup was not
indicated
# Hydroureter
On OSH CT scan, hydroureter was seen, felt to be secondary to
adjacent ovarian mass. In setting of above described goals,
further workup was not indicated
# Hyponatremia
# Hypomagnesemia
On labs noted to have electrolyte deficiencies. In setting of
above described goals, further workup and treatment was not
indicated
# Abnormal CXR
Noted to have elevation of left hemidiaphragm of unclear
etiology. In setting of above described goals, further workup
and treatment was not indicated
# Coagulopathy
Found to have INR 2 on admission. Unclear if nutritional versus
synthetic. In setting of above described goals, further workup
and treatment was not indicated
Transitional Issues
- Discharged to nursing home with plan to establish with hospice
services
- Per discussion with guardian, patient would only want to focus
on treatments that provided her with comfort; patient's
medication list was adjusted accordingly to only include
medications that might bring symptomatic benefit to patient;
added prn anti-emetic and pain medications (although patient did
not require any during her hospital stay here)
- Guardian is ___, ___
- Prior to discharge, provided warm hand-off to ___
provider NP ___ (___)
> 30 minutes spent on this discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right facial droop, word salad
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old woman
with a past medical history of HLD, hypothyroidism, and TIA in
___ with transient "word salad" + R facial droop, who
presents
today with progressive sleepiness and was found to have a large
R
frontal IPH.
She was last at her baseline yesterday evening (ambulatory, no
weakness, can speak in full sentences). This AM, she woke up
seeming more tired than usual per her daughter who thought this
was fatigue from a party they'd had the night before. Ms. ___
fell asleep repeatedly through church and again while eating
lunch. She also seemed to be gagging on her food during lunch.
Her persistent and apparently worsening sleepiness prompted her
daughters to take her to ___ where she was found to have a
large R frontal IPH on NCHCT at 13:00 (6x4 cm R frontal IPH with
9 mm midline shift; minimal increase in size on repeat NCHCT at
16:07).
Her BP at the OSH was 180s/70s for which she received a dose of
labetalol. Due to agitation with her foley, she also received 2
mg of IV Ativan at 2 ___ at OSH. She was transferred here for
further management. Here BPs here at ~16:00 were in 110s/60s.
Her
family notes that she seems to be improving after receiving
Ativan and is now moving around much more spontaneously.
She never complained of headache or vomiting. She did not have
any unilateral weakness, falls, or unsteadiness today. She had
no
trauma.
Past Medical History:
- Hypothyroidism
- Anxiety
- Hyperlipidemia
- Vitreal detachment left eye
Social History:
___
Family History:
Sister with stroke (early ___.
Physical Exam:
Admission exam:
Physical Exam:
Vitals: AF ___ 110s/70s ___ 98% ra
General: Eyes closed in bed, NAD
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR,
Abdomen: soft, NT/ND, normoactive bowel sounds
Extremities: No C/C/E bilaterally
Neurologic:
-Mental Status: OE to voice. Resists eye lid opening and
oculocephalics. Does not follow commands. No spontaneous speech.
-Cranial Nerves:
II: Pupils ~3mm irregular, minimally reactive (surgical).
III, IV, VI: Gaze conjugate. Resists oculocephalics and eyelid
opening
V: Intact corneals
VII: R NLFF (daughters note that this is her baseline)
VIII: Hearing intact to voice
IX, X: Intact gag
-Sensorimotor: Normal bulk, tone throughout. Withdraws all 4
extremities briskly to light tactile stimulation.
-DTRs:
___ Tri ___ Pat Ach
L 2 2 2 3 2
R 2 2 2 3 2
Plantar response was extensor bilaterally.
-Coordination: No dysmetria with pushing away examiner
-Gait: Not tested.
Discharge exam:
Limited exam to avoid patient discomfort, but notable for an
awake patient who attends to the examiner. She does follow some
simple commands. There is a left hemiparesis, the right arm and
leg moves well against gravity, spontaneously.
Pertinent Results:
___ 03:25PM BLOOD WBC-9.1# RBC-3.71* Hgb-11.2 Hct-33.7*
MCV-91 MCH-30.2 MCHC-33.2 RDW-13.6 RDWSD-45.3 Plt ___
___ 03:25PM BLOOD Neuts-83.5* Lymphs-6.7* Monos-9.3
Eos-0.1* Baso-0.1 Im ___ AbsNeut-7.56* AbsLymp-0.61*
AbsMono-0.84* AbsEos-0.01* AbsBaso-0.01
___ 03:25PM BLOOD Plt ___
___ 03:25PM BLOOD ___ PTT-23.2* ___
___ 03:25PM BLOOD Glucose-133* UreaN-13 Creat-0.6 Na-129*
K-5.3* Cl-95* HCO3-23 AnGap-16
___ 03:25PM BLOOD estGFR-Using this
___ 03:25PM BLOOD cTropnT-<0.01
___ 03:25PM BLOOD LtGrnHD-HOLD
___ 03:25PM BLOOD GreenHd-HOLD
___ 03:25PM BLOOD K-5.4*
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with tx for ICH // eval for progression of ICH
TECHNIQUE: Contiguous axial images of the brain were obtained
without
contrast. Coronal and sagittal reformations as well as bone
algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 2,007 mGy-cm.
COMPARISON: Outside noncontrast head CT from ___ at
13:20
FINDINGS:
The study is moderately degraded by motion artifact.
Redemonstrated, is a large right frontal acute parenchymal
hemorrhage with
interval development of a hematocrit level in the posterior
component,
measuring 61 x 43 mm, previously 59 x 42 mm. The hematoma
extends to the
cortex and minimal subarachnoid or subdural component cannot be
excluded.
There is substantial mass effect on the anterior horn of the
right lateral
ventricle with slightly increased shift of normally midline
structures to the
left, measuring up to 9 mm. The ventricles are overall stable
in size and
configuration. There is global atrophy. No new hemorrhage.
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:
Minimal increase in size and related mass-effect of a large
right frontal
parenchymal hemorrhage. Leftward midline shift measures 9 mm
without downward
herniation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 25 mcg PO DAILY
2. TraZODone 25 mg PO QHS:PRN insomnia
3. Omeprazole 20 mg PO DAILY
4. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen IV 1000 mg IV Q6H:PRN fever, pain Duration: 24
Hours
2. Glycopyrrolate 0.1 mg IV Q6H:PRN excess secretions
3. LORazepam 0.5-2 mg PO Q2H:PRN anxiety/distress
4. Morphine Sulfate ___ mg IV Q15MIN:PRN Pain or respiratory
distress
5. Ondansetron 4 mg IV Q8H:PRN nausea/vomiting
6. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Intraparenchymal Hemorrhage
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
INDICATION: ___ with tx for ICH // eval for progression of ICH
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 2,007 mGy-cm.
COMPARISON: Outside noncontrast head CT from ___ at 13:20
FINDINGS:
The study is moderately degraded by motion artifact.
Redemonstrated, is a large right frontal acute parenchymal hemorrhage with
interval development of a hematocrit level in the posterior component,
measuring 61 x 43 mm, previously 59 x 42 mm. The hematoma extends to the
cortex and minimal subarachnoid or subdural component cannot be excluded.
There is substantial mass effect on the anterior horn of the right lateral
ventricle with slightly increased shift of normally midline structures to the
left, measuring up to 9 mm. The ventricles are overall stable in size and
configuration. There is global atrophy. No new hemorrhage.
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:
Minimal increase in size and related mass-effect of a large right frontal
parenchymal hemorrhage. Leftward midline shift measures 9 mm without downward
herniation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ICH, Transfer
Diagnosed with Nontraumatic intracranial hemorrhage, unspecified
temperature: 96.7
heartrate: 74.0
resprate: 16.0
o2sat: 100.0
sbp: 135.0
dbp: 56.0
level of pain: 0
level of acuity: 2.0 | After discussion with the patient's family at the time of
presentation, the decision was made to pursue comfort measures
only and planning for discharge to hospice with palliative care
was initiated. On the morning following admission, the patient
was noted to be more awake than at the time of presentation,
likely due to clearing of lorazepam that was given at the OSH.
Symptomatic treatment of pain, nausea, distress, etc. were
continued and extraneous medications were stopped. Ms. ___
was discharged to inpatient hospice.
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? () Yes - (x) No -
Not consistent with GOC
2. DVT Prophylaxis administered? () Yes - (x) No - Not
consistent with GOC
3. Smoking cessation counseling given? () Yes - () No [reason ()
non-smoker - (x) unable to participate]
4. 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
5. Assessment for rehabilitation and/or rehab services
considered? () Yes - (x) Not consistent with ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
___
Right pleural pigtail catheter placement
History of Present Illness:
___ woman presents to ___, transferred
to
___ after developing 3 days of left-sided chest
pain that was radiating to her neck and left shoulder.
Underwent
evaluation at ___ where she was found to have an increase in
her chronic pneumomediastinum, therefore she was transferred.
Does endorse some intermittent palpitations as well. Other than
her pain and palpitations, patient denies any acute symptoms.
Does endorse chronic shortness of breath with exertion, however
does not report any acute changes in her breathing. Has a
history notable for spontaneous pneumothorax ___ status post
multiple video-assisted thoracoscopic surgeries with multiple
pleurodeses, most recently over ___ years ago. Denies any fevers
or chills. Followed by pulmonologist at ___, most recently seen here several years ago. In no
acute
distress, appears comfortable during interview. Thoracic
surgery
is consulted due to question of increasing size of pneumothorax
seen on CT scan and based on the size a pigtail catheter was
placed. he had an air leak, had symptomatic relief and her chest
xray was a bit better
Past Medical History:
PMH: Spontaneous R. PTX ___ that persisted, severe
endometriosis, pelvic pain syndrome
PSH:
PTX - Dx ___, Followed by Dr. ___. VATS apical bullectomy and mechanical pleurodesis ___
-R. US-guided thoracentesis and evacuation of PTX ___
-Reoperative R. VATS with LOA and bullectomy with talc ___
-R. US-guided thoracentesis ___
Appendectomy
Umbilical hernia repair
Social History:
___
Family History:
non-contributory
Physical Exam:
98.6 82 120/82 16 100% RA
GENERAL
[x] WN/WD [x] NAD [x] AAO [ ] abnormal findings:
HEENT
[x] NC/AT [x] EOMI [x] PERRL/A [x] Anicteric
[x] OP/NP mucosa normal [x] Tongue midline
[x] Palate symmetric [x] Neck supple/NT/without mass
[x] Trachea midline [x] Thyroid nl size/contour
[ ] Abnormal findings:
RESPIRATORY
[] CTA/P [x] Excursion normal [] No fremitus
[] No egophony [x] No spine/CVAT
[X] Abnormal findings: Decreased R sided breath sounds, TTP L
clavicular head and L sternal border
CARDIOVASCULAR
[x] RRR [x] No m/r/g [x] No JVD [x] PMI nl [x] No edema
[x] Peripheral pulses nl [x] No abd/carotid bruit
[ ] Abnormal findings:
GI
[x] Soft [x] NT [x] ND [x] No mass/HSM [x] No hernia
[ ] Abnormal findings:
GU [x] Deferred
[ ] Nl genitalia [ ] Nl pelvic/testicular exam [ ] Nl DRE
[ ] Abnormal findings:
NEURO
[x] Strength intact/symmetric [x] Sensation intact/ symmetric
[x] Reflexes nl [x] No facial asymmetry [x] Cognition intact
[x] Cranial nerves intact [ ] Abnormal findings:
MS
[x] No clubbing [x] No cyanosis [x] No edema [x] Gait nl
[x] No tenderness [x] Tone/align/ROM nl [x] Palpation nl
[x] Nails nl [ ] Abnormal findings:
LYMPH NODES
[x] Cervical nl [x] Supraclavicular nl [] Axillary nl
[] Inguinal nl [ ] Abnormal findings:
SKIN
[x] No rashes/lesions/ulcers
[x] No induration/nodules/tightening [ ] Abnormal findings:
PSYCHIATRIC
[x] Nl judgment/insight [x] Nl memory [x] Nl mood/affect
[ ] Abnormal findings:
Pertinent Results:
___ Chest CT :
Smaller right chronic pneumothorax since ___. New
right anterior
chest tube is in place in the right hemithorax.
New ground-glass opacities through right upper in lower lobes
can represent expansion edema or, less likely, pneumonia.
___ CXR :
In comparison with the study of ___, there is still a
substantial chronic right pneumothorax despite the presence of
the pigtail catheter. Continued filling of the costophrenic
angle with basilar opacification consistent with pleural fluid
and atelectatic changes. Left lung remains essentially clear
and the cardiac silhouette is stable.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6)
hours Disp #*100 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right pneumothorax
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with pigtail placed// ?pigtail placement
TECHNIQUE: Single portable view of the chest
COMPARISON: Chest x-ray from ___. Chest CT from ___.
FINDINGS:
There has been interval placement of a pigtail catheter which projects over
the right mid thoracic cavity. Lucency projecting over the right lung base on
prior exam compatible with a pneumothorax is now significantly smaller. Small
component of the pneumothorax is seen projecting over the apex. Right-sided
surgical chain sutures are again noted. Left lung is clear.
IMPRESSION:
Interval placement of a right-sided pigtail catheter with decrease in size of
the right-sided pneumothorax.
Previously seen intraperitoneal air is less clearly delineated but faintly
visualized below the left hemidiaphragm.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with R PTX// check interval change
IMPRESSION:
In comparison with the study of ___, there is little change in the
substantial right pneumothorax despite the presence of a pigtail catheter.
Indistinctness of the right hemidiaphragm with filling of the costophrenic
angle is consistent with pleural effusion and basilar atelectatic changes.
The left lung is clear and there is no evidence of pulmonary edema or
cardiomegaly.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old woman with R PTX// check for bullae
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 2.1 s, 33.7 cm; CTDIvol = 11.7 mGy (Body) DLP = 392.1
mGy-cm.
Total DLP (Body) = 392 mGy-cm.
COMPARISON: Multiple prior chest CTs, most recently ___.
FINDINGS:
NECK, THORACIC INLET, AXILLAE, CHEST WALL: There are no thyroid lesions that
warrant further imaging.
No lymphadenopathy in the thoracic inlet.
Right anterior chest tube, through the first intercostal space, with
associated mild subcutaneous emphysema.
No atherosclerosis in head and neck vessels.
UPPER ABDOMEN: This study was not tailored for evaluation of subdiaphragmatic
sections however it shows no adrenal lesions.
MEDIASTINUM: Esophagus unremarkable. Small subcarinal lymph node measuring
1.0 cm.
HILA: No hilar lymphadenopathy.
HEART and PERICARDIUM:
Heart is normal in size. No pericardial effusions.
No atherosclerotic calcifications in thoracic aorta and coronary arteries.
PLEURA: Small right pleural effusion. Moderate right pneumothorax, smaller
than in ___.
LUNG:
1. PARENCHYMA: New ground-glass opacities in the right upper lobe, more
prominent and consolidative in the right lower lobe. Left lung is clear.
No signs of pulmonary emphysema or bullae.
2. AIRWAYS: Patent to subsegmental levels.
3. VESSELS: Pulmonary arteries are not enlarged.
CHEST CAGE: No acute fractures. No lytic or sclerotic lesions.
IMPRESSION:
Smaller right chronic pneumothorax since ___. New right anterior
chest tube is in place in the right hemithorax.
New ground-glass opacities through right upper in lower lobes can represent
expansion edema or, less likely, pneumonia.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with right PTX// check interval change with
pneumostat in place
IMPRESSION:
In comparison with the study of ___, there is still a substantial chronic
right pneumothorax despite the presence of the pigtail catheter. Continued
filling of the costophrenic angle with basilar opacification consistent with
pleural fluid and atelectatic changes. Left lung remains essentially clear
and the cardiac silhouette is stable.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Abnormal xray, Chest pain, Dyspnea
Diagnosed with Other pneumothorax, Chest pain, unspecified, Dyspnea, unspecified
temperature: 97.6
heartrate: 87.0
resprate: 20.0
o2sat: 100.0
sbp: 131.0
dbp: 87.0
level of pain: 6
level of acuity: 2.0 | Ms. ___ was admitted to the hospital for further
management of her right pneumothorax. Her chest tube was on
suction and an air leak was present. Her chest xray showed an
apical , partially lateral pneumothorax but subjectively she
felt better and was able to walk without getting dyspneic. Her
chest xray remained the same on a waterseal trial and she
subsequently had a chest CT done to evaluate bullous disease
along with the extent of the pneumothorax.
He chest CT on ___ showed a smaller "chronic" right
pneumothorax compared to her CT scan in ___. Following 24
hours on waterseal her air leak was less but present therefore a
pneumostat was placed so that she could be more ambulatory and
return home while the leak resolved. Her chest xray with the
pneumostat in place showed the same stable right apical/lateral
pneumothorax. Her room air saturations were 97%. She was
instructed how to drain the device and ___ was set up for home
services. She was discharged home on ___ and will follow up
with Dr. ___ in one week to assess the leak/tube and hopefully
remove the pneumostat. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Carbapenem / Cephalosporins / Betalactams / Sulfa
(Sulfonamide Antibiotics) / Clindamycin
Attending: ___.
Chief Complaint:
ground level fall
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ Hx of CHF, CVA, Dementia AOx4, on ASA, multiple UTIs with hx
frequent falls requiring walker presents s/p fall, + head
trauma, unsure of LOC, unsure of events of fall, denies
preceding Sx, no chest pain/headache/SOB, reports being on the
floor for 30 minutes prior to being seen. In the ED, she
complained of R scalp pain, R hip pain with palpation only and R
distal posterior thigh pain with palpation only. Denies CP, SOB,
Headache, vision change, hearing change, weakness, numbness,
abdominal pain, nausea. Recently, she has had increased urinary
frequency and when she got up today to go to the bathroom, that
is when she fell. She denies lower abdominal pain, burning on
urination, or flank pain.
In the ED, initial VS 98.0 72 155/90 18 98% RA. Labs significant
for pyuria with stable anemia and CKD. CT head showed no
evidence of acute process and C-spine showed possible widening
of OA joint with spine recommended soft collar and 1-week follow
up with Dr. ___. Xray of Pelvis and R femur showed no
evidence of injury. Given
multiple falls, patient was given Nitrofurantoin for her UTI and
admitted to medicine.
On the floor, patient reports residual pain on right scalp, hip,
and arm.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, shortness of breath,
chest pain, abdominal pain, nausea, vomiting, diarrhea,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
#Frequent UTIs with multiple different resistant organisms.
#Urinary incontinence.
#Dementia
#Stroke with mild residual R sided deficits, such as a little
bit of foot drag, short term memory deficits, and is sometimes
confused.
#Hypertension.
#DM2
#Renal insufficiency (bl Cr 1.3).
#Depression.
#Basal cell carcinoma.
#Hypercholesterolemia.
#Uterine fibroids s/p hysterectomy.
#Cataracts.
Social History:
___
Family History:
Hypertension, her mother died of breast cancer, father died from
prostate cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals - T: 98.4 BP: 148/70 HR: 69 RR: 18 02 sat: 96%RA
GENERAL: NAD, hard of hearing
HEENT: tenderness on right scalp but without hematoma or
laceration, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, poor dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, +blowing holosystolic murmur heard best at
apex, radiating to the axilla
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
GU: Equivocal L > R CVA tenderness, no suprapubic tenderness, no
foley
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, mild excoriation on right elbow
DISCHARGE PHYSICAL EXAM
Vitals- Tm 98.7, Tc 98.4, P 69-88, BP 148-155/54-77, RR 18,
O2Sat 95-96% on RA
General- Alert, oriented x4, no acute distress, hard of hearing
HEENT- Sclera anicteric, MMM, oropharynx clear, tender to
palpation on R scalp w/o hematoma or laceration, EOMI, poor
dentition
Neck- supple, cervical spine tender to palpation, JVP not
elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, II/VI SEM heard
best at apex.
Abdomen- soft, mild tenderness to palpation in RLQ,
non-distended, bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU- no foley, no suprapubic tenderness, no cvat
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis, 2+
pitting edema in lower extremities (R slightly worse than L), R
hip tender to palpation.
Neuro- CNs2-12 intact, motor function grossly normal in lower
extremities, ___ DTRs at bilateral patellae
Skin - mild excoriation on R elbow
Pertinent Results:
ADMISSION LABS
--------------
___ 03:15PM BLOOD WBC-9.7 RBC-3.35* Hgb-10.0* Hct-31.9*
MCV-95 MCH-29.9 MCHC-31.5 RDW-16.8* Plt ___
___ 03:15PM BLOOD Neuts-83.7* Lymphs-11.6* Monos-3.3
Eos-0.9 Baso-0.5
___ 03:15PM BLOOD ___ PTT-42.1* ___
___ 03:15PM BLOOD Glucose-123* UreaN-31* Creat-1.3* Na-141
K-4.7 Cl-103 HCO3-27 AnGap-16
___ 08:20AM BLOOD Calcium-9.7 Phos-2.8 Mg-1.8
___ 03:15PM URINE Color-Straw Appear-Clear Sp ___
___ 03:15PM URINE Blood-NEG Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 03:15PM URINE RBC-<1 WBC-24* Bacteri-MOD Yeast-NONE
Epi-<1
DISCHARGE LABS
--------------
___ 08:20AM BLOOD WBC-14.7*# RBC-3.18* Hgb-9.5* Hct-29.6*
MCV-93 MCH-29.7 MCHC-32.0 RDW-16.4* Plt ___
___ 08:20AM BLOOD Glucose-116* UreaN-32* Creat-1.2* Na-141
K-3.6 Cl-102 HCO3-27 AnGap-16
MICROBIOLOGY
------------
___ URINE CX: PENDING AT DISCHARGE
IMAGING
-------
___ C-Spine:
Mild but newly apparent borderline widening of atlantodens
interval to 3 mm since ___ differential considerations
include underlying laxity, which could be seen with inflammatory
arthropathy but ligament injury is not excluded. No comparison
available for most of the cervical, but mild spondylolisthesis
of C7 on T1 is probably due to degenerative change. No fracture
identified.
___ CT Head:
No evidence of acute process
___ R Femur:
IMPRESSION: No evidence of injury.
___ Pelvis:
IMPRESSION: No evidence of injury.
EKG: none
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amlodipine 10 mg PO DAILY
3. Bisacodyl 10 mg PR HS:PRN constipation
4. Citalopram 20 mg PO DAILY
5. Furosemide 20 mg PO DAILY
6. Labetalol 300 mg PO BID
7. Losartan Potassium 100 mg PO DAILY
8. Senna 8.6 mg PO BID:PRN constipation
9. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
10. Aspirin 81 mg PO DAILY
11. GlipiZIDE 5 mg PO DAILY
12. Labetalol 100 mg PO DAILY
13. methenamine hippurate 1 gram oral BID
Discharge Medications:
1. Cefpodoxime Proxetil 400 mg PO Q12H Duration: 10 Days
please stop taking if you have a rash or allergic symptoms
RX *cefpodoxime 200 mg 2 tablet(s) by mouth every 12 hours Disp
#*20 Tablet Refills:*0
2. Acetaminophen 650 mg PO Q6H:PRN pain
3. Amlodipine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Bisacodyl 10 mg PR HS:PRN constipation
6. Citalopram 20 mg PO DAILY
7. Furosemide 20 mg PO DAILY
8. Labetalol 100 mg PO DAILY
9. Losartan Potassium 100 mg PO DAILY
10. Senna 8.6 mg PO BID:PRN constipation
11. GlipiZIDE 5 mg PO DAILY
12. methenamine hippurate 1 gram oral BID
13. PredniSONE 5 mg PO DAILY
14. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
#Complicated cystitis (urinary tract infection)
#Ground level fall, multifactorial etiology
Secondary:
#Mild new widening of the atlantodens interval
#Chronic congestive heart failure, compensated
#Chronic kidney disease
#Dementia
Discharge Condition:
Discharged in stable condition back to ___
living facility. Her mental status and ambulatory function are
at baseline (she require mobility assistance at baseline in the
form of a walker).
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
RADIOGRAPHS OF THE RIGHT FEMUR AND PELVIS
HISTORY: Fall from standing and with landing on to right side, presenting
with right hip and knee pain.
COMPARISONS: ___.
TECHNIQUE: Right femur, four views, and AP pelvis.
FINDINGS: Moderate degenerative changes are incompletely characterized along
the lower lumbar spine. The hip joint spaces appear mildly narrowed. There
are small ossific enthesophytes along each greater trochanter. There is a
small superior patellar spur. The medial compartment of the knee is probably
mildly narrowed. There is no evidence for fracture, dislocation or bone
destruction. No effusion is seen in the suprapatellar bursa at the right
knee. Patchy vascular calcifications are present.
IMPRESSION: No evidence of injury.
Radiology Report
HEAD CT
HISTORY: Head trauma status post fall. Possible loss of consciousness.
COMPARISONS: ___.
TECHNIQUE: Non-contrast head CT.
FINDINGS:
There is no evidence of intra- or extra-axial hemorrhage. There is no mass
effect, hydrocephalus or shift of the normally midline structures. Mild
age-related involutional changes. An oblong hypodense focus in the subinsular
white matter of the right frontal lobe suggests a small chronic lacunar
infarct that appears unchanged. Similarly, a small thalamic hypodense focus
suggests an unchanged prior lacunar infarct. More generally, there are patchy
areas of relative white matter hypodensity throughout each frontal and
parietal lobe, most suggestive of chronic small vessel ischemic disease that
appears unchanged. In addition, a small hyperdense extra-axial lesion along
the left frontal inner table, measuring 9 mm, including a small punctate
posterior calcification, is consistent with a stable benign meningioma.
Overlying the right parietal skull is a very small subgaleal hematoma with
overlying soft tissue swelling. Surrounding soft tissue structures are
otherwise unremarkable. The mastoid air cells appear clear. The partly
visualized left side of a bipartite sphenoid sinus shows new moderate mucosal
thickening. There is also similar mild-to-moderate bilateral ethmoid mucosal
thickening and a new small polypoid focus, probably a secretion within the
right side of the sphenoid sinus. These findings suggest inflammatory
paranasal sinus disease. No fracture is identified.
IMPRESSION: No evidence of acute process. Stable intracranial findings.
Small right parietal subgaleal hematoma with overlying soft tissue swelling.
Findings suggesting inflammatory disease of paranasal sinuses.
Radiology Report
CT OF THE CERVICAL SPINE
HISTORY: Status post fall with head trauma. Possible loss of consciousness.
COMPARISONS: Prior head CT studies are available from ___ and ___ as well as ___. However, there is no dedicated prior cervical spine
imaging available.
TECHNIQUE: Multidetector CT images of the cervical spine were obtained
without intravenous contrast. Sagittal and coronal reformations were also
performed.
FINDINGS:
Frontal scout view shows enlarged, but stable mediastinal contours compared to
prior chest radiograph from ___.
The head is turned slightly to the right.
There is no evidence for fracture, dislocation or bone destruction.
However, new on this study is borderline widening of the anterior atlantodens
relationship, which has an interval of 3-4 mm on this study compared to less
than 2 before. This could perhaps be a dynamic process that is associated
with ligamentous laxity, but this is an apparent change since the recent prior
head CT studies, which showed the dens approaching consistently within less
than 2 mm. Incomplete posterior closure of C1 is consistent with a normal
variant.
There is some straightening of the usual expected lordotic curvature. There
is slight spondylolisthesis of C2 on C3 and C3 on C4, similar to prior scout
radiographs from head CT studies. This appearance is probably due to
degenerative arthropathy at the C2-C3 facet joints. The posterior elements of
C3 and C4 are fused on the right side with degenerative changes that are
mild-to-moderate on the left at the facets. At the C4-C5 level, there is
moderate right-sided and moderate-to-severe left-sided neural foraminal
narrowing associated with osteophytes. Neural foraminal narrowing is mild
from C5-C6 through C7-T1 interspaces in association with uncovertebral
osteophytes. The C4-C5 through C6-C7 interspaces are all moderate to severely
narrowed with large anterior bridging osteophytes, as well as subchondral
sclerosis along endplates with small posterior osteophytes. Bilateral
mild-to-moderate facet joint degenerative changes are also present throughout
these levels.
At the C7-T1 interspace, there is mild spondylolisthesis and although there is
no direct prior comparison for this area, this can probably be attributed to
moderate bilateral facet joint degenerative disease.
Internal carotid arteries are very tortuous and course posterior to the
hypopharynx including at the midline.
IMPRESSION:
1. No fracture identified.
2. Apparent increase in atlantodens separation, which is borderline.
Although this may be due to underlying laxity at the joint which could be due
to senescence or inflammatory arthropathy, ligamentous injury is not excluded
by this examination. Correlation with physical findings and clinical
presentation is recommended. If C1-C2 ligamentous injury is a possible
clinical concern, MR may be of potential value.
3. Mild spondylolisthesis of C7 on T1, but probably explained by substantial
facet degenerative changes. Moderate-to-severe cervical spondylosis affecting
the whole cervical spine to varying degrees.
4. Bony demineralization.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with HEAD INJURY UNSPECIFIED, UNSPECIFIED FALL, MULTIPLE CONTUSIONS NEC, SEMICOMA/STUPOR
temperature: 98.0
heartrate: 72.0
resprate: 18.0
o2sat: 98.0
sbp: 155.0
dbp: 90.0
level of pain: 13
level of acuity: 3.0 | In brief, this patient is an ___ year old woman with a history of
CHF, stroke, dementia, diabetes mellitus type 2, multiple UTIs,
and a history of frequent falls who presents with a ground level
multifactorial fall and minor trauma.
#Ground level fall:
Presented to the ED after sustaining a fall at her assisted
living facility. Fall reportedly occurred after she attempted
to use the washroom at night, without assistance, in the dark,
and without her walker. She sustained head trauma and she
denied preceding symptoms and is unsure if she lost
consciousness. In the Emergency Department she was worked up to
assess for injury after the fall. CT head, pelvis film, and
right femur film did not show any significant findings.
However, a CT of the spine showed new apparent borderline
widening of atlantodens interval to 3 mm since ___.
Gerontology evaluated her on HD#1 and, after discussion, it was
felt that the etiology of her fall was multifactorial though
likely involved a mechanical component as she tried to walk
without her walker or shoes in the setting of long-standing
residual right sided weakness after her previous stroke. The
fall was considered unlikely to be due to syncopal episode (she
is on a number of antihypertensives though her blood pressure
has been 130s-170s systolic while she has been on the floor) and
given her lack of urinary symptoms (aside from increased
frequency over weeks to months in the setting of furosemide)it
was also considered unlikely to be related to complicated
cystitis. She is being discharged with a soft neck collar which
she is to wear for 1 week until she follows up with her
orthopedist Dr. ___ she ___ also get follow up
flexion-extension films).
#Complicated cystitis:
In addition, a urinalysis was performed in the ED which showed
signs of urinary tract infection. It was thought that urinary
tract infection may be a possible cause of fall and therefore
she was admitted for further work-up. While in the ED she
received one dose of nitrofurantoin and upon admission to the
floor she was given 1g IV ceftriaxone. Labs were drawn again on
the morning of ___ and she was found to have a new
leukocytosis (to 14.7) with left shift. Initially, there was
reservation to treat her for an infection given unreliable
symptoms, however, the leukocytosis made the case more
compelling so she was given a 10 day course of cefpodoxime. Her
allergy history is questionable and she tolerated this last
admission. Please monitor for signs of allergic reaction. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine / Darvocet-N 100 / Procardia
Attending: ___
___ Complaint:
Dizziness, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with PMH of afib on coumadin, CAD s/p PCI
with LAD stent ___, presents with severeal months of dizziness
and dyspnea, worsening in the past few days.
Pt has had intermittent lightheadness since Decemeber, worsening
over the last month. Describes the feeling as lightheadedness,
with feeling faint and occasional loss of balance. No vertigo.
Occurs intermittently with standing, lasting a few seconds, then
resolves with sitting or lying down. Today it has occurred while
at rest and took longer to resolve. No falls or LOC. Has
intermittent palpitations with high heart rates, however, not
correlated with the dizziness. No chest pain. Started advair
last week, but no other medication changes recently. Has been
eating and drinking normally.
The patient also complains of worsening dyspnea over the past
few months. She reports dyspnea on exertion when she walks
several blocks, and the SOB is relieved by rest. She had PFTs
done 2 weeks ago that showed mild COPD. She has been taking
combivent and advair the past few weeks, with some relief from
her inhalers. She denies any ___ edema. No fevers/chills/sweats.
Reports chronic non-productive cough getting worse the past
month.
In the ED, initial vitals were 97.4 71 99/48 18 96%. Labs showed
mildly elevated creatinine of 1.4 (baseline around 1.1),
elevated BUN to 26, bicarb of 20. INR 3.2 (on warfarin). No
imaging in the ED. EKG showed atrial fibrillation with rate 84,
no T wave inversions or ST changes. She received 1L IVF and was
admitted to cardiology for symptomatic afib and possible
adjustment of medications.
On arrival to the floor, the patient was in the 140s when
walking/standing, then in the ___ at rest. She c/o mild SOB and
is without dizziness.
Past Medical History:
Hypertension
- Hyperlipidemia
- Coronary artery disease s/p LAD PTCA/stent in ___ with
history of recurrent chest pain but negative cardiac work ups on
multiple admissions
- GERD
- Zoster
- Left rotator cuff small full thickness tear (___)
- Depression/anxiety
- Cataracts
- S/p cholecystectomy
- S/p appendectomy
- S/p tonsillectomy
- S/p tubal ligation
- S/p vitrectomy
Social History:
___
Family History:
Father died of lung CA age ___, Mother died at age ___ of TB.
Brother is bilateral amputee w/ peripheral vascular disease,
stroke starting in his ___. Positive family history for early
CAD in grandparents.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VSS, orthostatic
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI, MMM
Neck: supple, no JVD
CV: irregularly irregular rhythm, normal rate, +systolic murmur
at ___
Lungs: CTAB
Abdomen: soft, NT/ND, BS+
Ext: No edema
Neuro: CNII-XII intact, normal strength bilaterally, sensation
to light touch intact bilaterally
DISCHARGE PHYSICAL EXAMINATION:
VSS
General: NAD, comfortable, pleasant
HEENT: NCAT, PERRL, EOMI, MMM
Neck: supple, no JVD
CV: RRR, +systolic murmur at ___
Lungs: CTAB
Abdomen: soft, NT/ND, BS+
Ext: No edema
Neuro: CNII-XII intact, normal strength bilaterally, sensation
to light touch intact bilaterally
Pertinent Results:
ADMISSION LABS:
___ 06:20PM BLOOD WBC-9.8 RBC-4.01* Hgb-9.4* Hct-31.3*
MCV-78*# MCH-23.4* MCHC-30.0* RDW-18.5* Plt ___
___ 07:21PM BLOOD ___ PTT-41.0* ___
___ 06:20PM BLOOD Glucose-142* UreaN-26* Creat-1.4* Na-138
K-4.4 Cl-105 HCO3-20* AnGap-17
___ 06:20PM BLOOD CK-MB-1 cTropnT-<0.01 proBNP-3547*
___ 06:50AM BLOOD Calcium-8.9 Phos-3.8 Mg-1.9
___ 06:20PM BLOOD calTIBC-460 Ferritn-14 TRF-354
___ 06:20PM BLOOD Iron-27*
CARDIAC ENZYMES:
___ 06:20PM BLOOD CK-MB-1 cTropnT-<0.01 proBNP-3547*
___ 12:49AM BLOOD CK-MB-1 cTropnT-<0.01
___ 06:50AM BLOOD CK-MB-1 cTropnT-<0.01
___ 09:30PM BLOOD CK-MB-1 cTropnT-<0.01
DISCHARGE LABS:
___ 07:55AM BLOOD WBC-9.3 RBC-4.02* Hgb-9.3* Hct-31.1*
MCV-77* MCH-23.2* MCHC-30.0* RDW-18.9* Plt ___
___ 07:55AM BLOOD ___ PTT-43.2* ___
___ 07:55AM BLOOD Glucose-95 UreaN-15 Creat-1.3* Na-142
K-4.4 Cl-104 HCO3-28 AnGap-14
___ 07:55AM BLOOD proBNP-1226*
___ 07:55AM BLOOD Calcium-9.3 Phos-3.5 Mg-2.6
STUDIES:
EKG ___:
Atrial fibrillation. Compared to the previous tracing of ___
no change
CXR ___:
FINDINGS: Comparison is made to prior study from ___.
Heart size is within normal limits. There are calcifications of
thoracic
aorta. Lungs are grossly clear. There are no signs for pleural
effusion,
focal consolidation or overt pulmonary edema. No pneumothoraces
are
identified.
CXR ___:
FINDINGS: Interval improvement in extent of congestive heart
failure with decreased size of cardiac silhouette, decreased
vascular distention, and resolving interstitial edema. Very
small residual pleural effusions.
ECHOCARDIOGRAM ___:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. Left ventricular wall thickness, cavity size, and
global systolic function are normal (LVEF>60%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. The estimated cardiac index is normal
(>=2.5L/min/m2). Tissue Doppler imaging suggests an increased
left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets are mildly thickened. There is mild aortic
valve stenosis (valve area 1.4cm2). Mild to moderate (___)
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse.
Mild-moderate (___) mitral regurgitation is seen. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
cavity sizes with preserved global biventricular systolic
function. Pulmonary artery hypertension. Mild-moderate mitral
regurgitation. Mild to moderate aortic regurgitation. Increased
PCWP.
Compared with the prior study (images reviewed) of ___, the
estimated pulmonary artery systolic pressure is now higher.
MICRO: None
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atorvastatin 10 mg PO DAILY
2. Diltiazem Extended-Release 240 mg PO DAILY
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
SOB/dysnpea
6. Isosorbide Mononitrate 20 mg PO BID
7. Lidocaine 5% Patch 3 PTCH TD QAM prn pain
8. Lorazepam 0.5 mg PO HS:PRN insomnia
9. Metoprolol Tartrate 25 mg PO BID
10. Nitroglycerin SL 0.4 mg SL PRN chest pain
11. Omeprazole 40 mg PO DAILY
12. Warfarin 2.5 mg PO 5X/WEEK (___)
13. Aspirin 81 mg PO DAILY
14. Docusate Sodium 100 mg PO DAILY
15. Warfarin 5 mg PO 2X/WEEK (MO,FR)
16. Acetaminophen 650 mg PO QHS:PRN pain or pt request
17. Citalopram 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 10 mg PO DAILY
4. Diltiazem Extended-Release 240 mg PO DAILY
5. Docusate Sodium 100 mg PO DAILY
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
8. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
SOB/dysnpea
9. Isosorbide Mononitrate 20 mg PO BID
10. Lidocaine 5% Patch 3 PTCH TD QAM prn pain
11. Loratadine 10 mg PO DAILY
12. Lorazepam 0.5 mg PO HS:PRN insomnia
13. Metoprolol Tartrate 25 mg PO BID
14. Nitroglycerin SL 0.4 mg SL PRN chest pain
15. Omeprazole 40 mg PO DAILY
16. Warfarin 2.5 mg PO DAILY16
RX *warfarin [Coumadin] 2.5 mg one tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
17. Ferrous Sulfate 325 mg PO DAILY
RX *ferrous sulfate 325 mg (65 mg iron) one tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
18. Baclofen 10 mg PO HS
19. Multivitamins 1 TAB PO DAILY
20. Vitamin D 400 UNIT PO DAILY
21. Outpatient Physical Therapy
Physical therapy
Activity as tolerated
ICD 9 code 428.0 congestive heart failure
22. Furosemide 20 mg PO 3X/WEEK (___)
RX *furosemide 20 mg one tablet(s) by mouth every ___,
___ Disp #*30 Tablet Refills:*0
23. Citalopram 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Heart Failure with Preserved Ejection Fraction
Paroxysmal atrial fibrillation
Secondary:
Coronary Artery Disease
Mild Aortic Stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
STUDY: AP chest ___.
CLINICAL HISTORY: ___ woman admitted for shortness of breath.
Evaluate for pulmonary edema or effusions or pneumonia.
FINDINGS: Comparison is made to prior study from ___.
Heart size is within normal limits. There are calcifications of thoracic
aorta. Lungs are grossly clear. There are no signs for pleural effusion,
focal consolidation or overt pulmonary edema. No pneumothoraces are
identified.
Radiology Report
PORTABLE CHEST, ___
COMPARISON: ___.
FINDINGS: Interval improvement in extent of congestive heart failure with
decreased size of cardiac silhouette, decreased vascular distention, and
resolving interstitial edema. Very small residual pleural effusions.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dizziness, Dyspnea
Diagnosed with VERTIGO/DIZZINESS
temperature: 97.4
heartrate: 71.0
resprate: 18.0
o2sat: 96.0
sbp: 99.0
dbp: 48.0
level of pain: 0
level of acuity: 3.0 | ___ year old female with PMH of afib on coumadin, CAD s/p PCI
with LAD stent ___, presents with severeal months of dizziness
and dyspnea, likely due to CHF exacerbation and atrial
arrhythmia. |
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, decreased PO
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o F with ileocolonic Crohn's disease s/p colectomy and end
ileostomy in ___ on tofacitinib who presents with abdominal
pain, nausea, increased stool output, and decreased PO intake
after recent discharge from hospitalization for the same
symptoms.
Her abdominal pain is a sharp and crampy pain located between
her old ostomy site and her costal margin, in a vertical line,
spanning about 8 cm. It is worse about half an hour after she
eats, lasts about an hour, then resolves. Often it is followed
by a large volume of liquidy, brown stool into her ostomy bag.
She has been having between 4 and 8 full ostomy bags per day,
despite taking her Immodium BID. She has vomitted about once a
day for the past ___ days, and has several bouts of dry heaving.
It is non-bloody, non-billious vomit that occurs between 15 min
and one hour after eating. For the last few days, she has had
reduced PO intake. She thinks she has lost about 5 pounds in the
last week. During the day she has felt lightheaded, especially
when going from sitting to standing. She reports occasional
chills, and sweating, but has not had an objective fever.
Additionally, she ran out of her Tofacitinib two days ago.
She says that her Crohn's disease had been pretty well
controlled on Tofacitinib (Xaljenz), which she started ___.
This is her fourth admission since ___. Prior
admissions have been for concern of SBO seen on KUB, but after
bowel rest, ostomy output returned. The stoma has been evaluated
by Surgery who says that it is satisfactorily patent, ileoscopy
has not demonstrated any recurrent Crohn's disease or fixed
obstruction. Prior diagnoses have included partial SBO,
mechanical kinking, and delayed small bowel emptying secondary
to narcotic medications. Liquid oxycodone has helped more than
other medications. Infectious work-up including C diff,
campylobacter, salmonella, shigella, vibrio cholera, yersinia,
or giardia have been negative.
Past Medical History:
-Ileocolonic Crohn's Disease dx age ___, failed treatment with
Remicade, ___, Humira and Tysabri, rectovaginal fistula s/p
laparoscopic diverting ileostomy ___, laparoscopic left
hemicolectomy, proctectomy and excision of anus, with
end-colostomy and takedown ileostomy ___, s/p laparoscopic
completion colectomy with end-ileostomy ___, s/p revision
ilestomy ___ and s/p Revision of ileostomy and debridement
and drainage of abscess cavity ___. Currently on tofacitinib
5mg bid since ___.
-Pyoderma gangrenosum at stoma, resolved
-Migraines - were chronic, every other day. Has not has HA for
"a while," but reports feeling one coming the week before
admission on ___. Best treatments were diphenhydramine,
compazine, toradol. Triptans offered some relief.
-Osteomyelitis of left leg at age ___ due to complication of a
broken bone
-Remote history of H. Pylori
-Prior DVT ___ after ___ ostomy surgery, c/b ileous. 6 months
of anticoagulation.
-Allergic rhinitis
-TMJ
-Transvaginal revision of levatorplasty (release of mid vaginal
band) ___.
Social History:
___
Family History:
Mother and cousin with Crohn's disease. No family history of
colorectal cancer.
Physical Exam:
ADMISSION EXAM
Vitals: 98.4, 103/62, 73, 24, 100% RA
General: well-appearing Caucasian female, in NAD
HEENT: PERRL, dry mucous membranes, no oral ulcers
Neck: very ttp in neck bilaterally, full range of motion, no LAD
CV: RRR, systolic II/VI murmur that did not radiate
Lungs: CTAB, no wheezes, crackles, or rhonchi
Abdomen: prior ostomy site in LLQ well-healed, current ileostomy
bag containing only air. TTP between old ostomy site and costal
margin, no CVA tenderness
Ext: ttp in posterior right hip
Skin: no rash
DISCHARGE EXAM
Vitals: 98.0-98.3 96-100/58-64 ___ 96-98%RA
General: well-appearing Caucasian female, sitting up in bed
listening to pop music, in NAD
HEENT: EOMI, PERRL, moist mucous membranes, no oral ulcers
CV: RRR, normal S1,S2
Lungs: CTAB, no wheezes, crackles, or rhonchi
Abdomen: prior ostomy scar in LLQ well-healed. TTP between old
ostomy site and costal margin, ttp throughout abdomen, no
organomegaly, no CVA tenderness
Ext: ttp in posterior right hip
Pertinent Results:
ADMISSION RESULTS
___ 12:23PM BLOOD WBC-7.4 RBC-4.34 Hgb-11.1* Hct-34.2*
MCV-79* MCH-25.5* MCHC-32.4 RDW-15.2 Plt ___
___ 12:23PM BLOOD Neuts-87.7* Lymphs-7.9* Monos-3.5 Eos-0.8
Baso-0.2
___ 12:23PM BLOOD Plt ___
___ 12:23PM BLOOD Glucose-97 UreaN-7 Creat-0.8 Na-137 K-4.3
Cl-106 HCO3-20* AnGap-15
___ 12:23PM BLOOD ALT-14 AST-24 AlkPhos-82 TotBili-0.2
___ 12:23PM BLOOD Lipase-44
___ 12:23PM BLOOD Albumin-4.1 Calcium-9.0 Phos-2.0*# Mg-2.0
___ 12:23PM BLOOD CRP-26.2*
DISCHARGE RESULTS
___ 06:30AM BLOOD WBC-5.7 RBC-3.92* Hgb-10.2* Hct-30.8*
MCV-79* MCH-26.1* MCHC-33.3 RDW-15.1 Plt ___
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD Glucose-97 UreaN-6 Creat-0.8 Na-138 K-3.8
Cl-105 HCO3-25 AnGap-12
___ 03:00PM BLOOD Lipase-56
___ 06:30AM BLOOD Calcium-8.9 Phos-4.3 Mg-1.8
IMAGING
CXR ___: Non-specific, non-obstructive bowel gas pattern.
ABDOMINAL U/S ___: Transverse sagittal images were obtained
in the area of discomfort in the left abdomen as well as in the
midline adjacent to the ostomy site. No subcutaneous fluid
collection was identified. There is no evidence of fistula
however ultrasound is not sensitive in the detection of
fistulas. IMPRESSION: Limited ultrasound of the abdomen
demonstrates no sonographic abnormality.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Citalopram 40 mg PO DAILY
2. Lorazepam 1 mg PO BID:PRN anxiety
3. Multivitamins 1 TAB PO DAILY
4. Sumatriptan Succinate 100 mg PO DAILY:PRN headache
5. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500-125
mg-unit oral daily
6. OxycoDONE Liquid ___ mg PO Q4H:PRN pain
7. Xeljanz (tofacitinib) 5 mg oral BID
8. Probiotic
(B.breve-L.acid-L.rham-S.thermo;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 0 1 ORAL DAILY
9. Omeprazole 40 mg PO BID
10. Acetaminophen 325 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 325 mg PO Q6H:PRN pain
2. Citalopram 40 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. OxycoDONE Liquid ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg/5 mL 15 mL by mouth Every four hours
Refills:*0
5. Xeljanz (tofacitinib) 5 mg oral BID
6. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500-125
mg-unit oral daily
7. Lorazepam 1 mg PO BID:PRN anxiety
8. Omeprazole 40 mg PO BID
9. Probiotic
(B.breve-L.acid-L.rham-S.thermo;<br>L.acidophilus-Bif.
animalis;<br>L.rhamn ___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 0 1 ORAL DAILY
10. Sumatriptan Succinate 100 mg PO DAILY:PRN headache
11. Hyoscyamine SO4 (Time Release) 0.375 mg PO BID
RX *hyoscyamine sulfate 0.375 mg 1 tablet(s) by mouth Twice a
day Disp #*14 Tablet Refills:*0
12. Lidocaine 5% Patch 1 PTCH TD QAM Old ostomy site
RX *lidocaine 5 % (700 mg/patch) Apply 1 patch to affected area
every morning Disp #*7 Patch Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Abdominal pain, nausea, vomiting
Secondary: Ileocolonic Crohn's disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old woman with ileostomy, persistent pain around site and
intermittent ostomy output. // Please evaluate for developing fistula
disease.
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the left abdomen.
COMPARISON: None
FINDINGS:
Transverse sagittal images were obtained in the area of discomfort in the left
abdomen as well as in the midline adjacent to the ostomy site. No subcutaneous
fluid collection was identified. There is no evidence of fistula however
ultrasound is not sensitive in the detection of fistulas.
IMPRESSION:
Limited ultrasound of the abdomen demonstrates no sonographic abnormality.
Radiology Report
EXAMINATION: ABDOMEN (SUPINE ONLY)
INDICATION: ___ woman with crohn's s/p illeostomy, with intermittent
no ostomy output and large volume. Evaluate for partial SBO.
TECHNIQUE: Supine radiograph views of the abdomen were obtained.
COMPARISON: Abdominal radiograph dated ___.
FINDINGS:
The bowel gas pattern is non-specific and non-obstructive. There is overall
paucity of bowel gas. Visualized bowel is not abnormally dilated. There is no
evidence of pneumatosis or pneumoperitoneum on limited supine view. An IUD
projects over the midline in the pelvis and appears unchanged in position from
the prior exam. The surgical clip projecting over the right hemipelvis is
also unchanged. Levoconvex scoliosis centered at L1-L2 is unchanged.
IMPRESSION:
Non-specific, non-obstructive bowel gas pattern.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Dizziness
Diagnosed with ABDOMINAL PAIN UNSPEC SITE, NAUSEA WITH VOMITING, DEHYDRATION
temperature: 99.1
heartrate: 105.0
resprate: 18.0
o2sat: 100.0
sbp: 120.0
dbp: 72.0
level of pain: 6
level of acuity: 3.0 | PATIENT:
Mrs ___ is a ___ year old female with ileocolonic
Crohn's disease with many recent admissions for concern of
partial SBO who presents to the ___ ED with abdominal pain,
nausea, vomitting, intermittent liquidy ostomy output, decreased
PO, and lightheadedness.
ACUTE ISSUES
# Abdominal pain/N/V: Mrs ___ was admitted for
recurrent abdominal pain, nausea, vomitting, increased liquidy
stool output, and decreased PO intake. She had sharp pain at her
old ostomy site about ___ min after meals. KUB did not show
concern for obstruction, and abdominal U/S did not show any
abnormalities. She was given dilaudid for the pain. She was also
started on Hyoscyamine for abdominal pain and local lidocaine
patches for pain at her old ostomy site. Abdominal ultrasound
performed to evaluate for fistulous disease but was unable to
identify any developing pathology. She remained afebrile with
stable vital signs throughout and infectious work-ups were
negative. As she was able to eat and tolerate an oral pain
regimen she was discharged home with intent for outpatient
follow-up.
# Myalgias: Patient reported aches in her hips and legs at night
and is also tender to palpation in neck, sternocleidomastoid,
and right posterior hip. Treated symptomatically with her above
pain regimen.
# Pyuria: Patient's urinalysis had 100+ WBCs and bacturia on
admission although patient did not endorse urinary symptoms. She
was thought to have sterile pyuria and the medical team elected
not to treat with antibiotics. Her urine culture eventually grew
mixed flora consistent with contamination. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
chlorhexidine
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
Percutaneous nephrostomy tube placement (___)
HD line placement (___)
History of Present Illness:
___ with a history of 2 failed renal transplants status post IgA
nephropathy who presents with dyspnea and upper body swelling.
The patient states that ~1 week prior, he noted increasing
swelling in his face, upper extremities, and chest, which had
worsened until presentation. No associated skin lesion, chest
pain. He then notes increasing shortness of breath, primarily
with exertion, not exacerbated by lying supine, not associated
with a cough, fevers, chills, or recent travel. Patient reports
feeling weak as well (fatigued, no specific muscle weakness).
Denies recent travel, sick contacts.
His renal history is complicated, involving two failed
transplants. The updates from their records include a first
failed transplant in ___, and a ___ transplant 6 months later
in ___ for which he has been followed up by Dr. ___. His
post transplant course was remarkable for CMV viremia, transient
BK viremia which resolved with a reduction cellcept dosing and
an episode of transplant hydronephrosis secondary to a
lymphocele which was drained percutaneous. He developed
proteinuria(1.3g) and had increase in creatinine from 1.1 to 1.4
for which he underwent biopsy on ___ which showed
proliferative IgA without crescents. C4D and DSA were negative.
He was treated with prednisone which was ultimately tapered. He
developed leukopenia with detectable CMV viremia for which a
dose adjustment in his cellcept and prograf was made with
resolution of the viremia.
Per note, his last hospital visit was in ___. Patient was
then admitted to ___ in ___ during which
he was found to have creatinine 18, he was then transferred to
___. At that time, his tacrolimus level was non detectable,
patient reported that he has not taken his cellcept nor his
tacrolimus for at least 2 weeks at that time(according to his
pharmacy, he has not filled his cellcept and tacrolimus for
several months), he received pulse steroids of 1 g solu Medrol
daily for 3 days, the kidney biopsy at that time showed
resolving
acute rejection and recurrence of IgA nephropathy. His
creatinine
improved to 4.5, he was tapered down to prednisone 40mg po
daily.
He was discharged from his outpatient office in ___, as he
supposedly made threatening statements to his physician after
his nephrologist was unable to promise a transplant. He states
that he is still taking his rejection medication, prescribed
from ___.
In ED initial VS: T 98.1, HR 98, BP 190/100, RR 28, 97% RA
Labs significant for:
Hemoglobin/hematocrit 6.2/18.3
VBG ___
Lactate 0.7
Patient was given:
Lasix 160mg IV
Nitro drip
Imaging notable for:
CXR - Mod R/L pleural effusions
Consults:
Renal
VS prior to transfer: T 97.6, HR 106, BP 176/89, RR 15, 97%RA
On arrival to the MICU, patient is alert and oriented, stating
that he feels better. No current complaints aside from the
original swelling.
REVIEW OF SYSTEMS:
As per HPI
Past Medical History:
IgA nephropathy
Renal transplant x2, ___
Hypertension
Social History:
___
Family History:
Non contributory
Physical Exam:
ADMISSION PHYSICAL:
====================
VITALS: Reviewed in Metavision
___: 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: Tachycardic, regular 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. 2+ edema bilateral upper
extremities and chest, including facial plethora. ___ edema to
knee on LLE, 1+ edema RLE. No overlying skin changes. L forearm
AVF, no palpable thrill.
SKIN: No overlying skin changes.
NEURO: Moving all extremities, speech fluent.
DISCHARGE PHYSICAL:
====================
97.7 PO 164 / 85 60 18 98 Ra
___: Resting comfortably.
HEENT: Facial swelling improved. Right-sided tunneled cath in
place, dressing c/d/i.
NECK: ~3cm fluctuant collection around RIJ
CARDIAC: RRR no mrg
LUNGS: CTAbl. No wheezes, rales, rhonchi.
ABDOMEN: abdomen NTND. PCNU capped.
EXTREMITIES: RUE edema markedly improved from days prior.
NEUROLOGIC: AOx3.
SKIN: Warm, well-perfused, no obvious skin rashes, ulcerations,
or skin breakdown.
Pertinent Results:
ADMISSION LABS:
================
___ 12:20PM BLOOD WBC-4.6 RBC-2.20* Hgb-6.2* Hct-18.3*
MCV-83 MCH-28.2 MCHC-33.9 RDW-14.9 RDWSD-45.5 Plt Ct-59*
___ 12:20PM BLOOD Hypochr-NORMAL Anisocy-1+* Poiklo-2+*
Macrocy-NORMAL Microcy-2+* Polychr-NORMAL Schisto-1+* Tear
___
___ 12:20PM BLOOD Plt Ct-59*
___ 12:20PM BLOOD Glucose-105* UreaN-93* Creat-8.4* Na-139
K-4.1 Cl-107 HCO3-11* AnGap-21*
___ 11:21PM BLOOD calTIBC-225* VitB12-756 Folate-7
Ferritn-1156* TRF-173*
___ 12:20PM BLOOD tacroFK-<2.0*
___ 12:36AM BLOOD CMV VL-NOT DETECT
___ 02:00AM BLOOD HCV Ab-NEG
___ 12:26PM BLOOD ___ pO2-39* pCO2-30* pH-7.24*
calTCO2-13* Base XS--14
IMAGING:
========
___ US NECK:
IMPRESSION: 1. 3.4 cm avascular right neck complex fluid
collection within the subcutaneous fat of the right
supraclavicular region demonstrating layering fluid-fluid level
as described above likely represents an evolving hematoma. If
there is continued increase in size of this lesion a contrast
enhanced CT of the neck can be performed for better evaluation.
2. No communication with the adjacent jugular vein or common
carotid artery. 3. The adjacent vessels are patent.
___ CTV:
IMPRESSION: 1. Moderate narrowing of the proximal and marked
narrowing of the distal SVC. 2. Eccentric nonocclusive thrombus
within the mid to distal SVC, along the right lateral aspect of
the tunneled dialysis catheter. 3. Several areas of apparent
kinking of the dialysis catheter in the subcutaneous tissues.
Correlate clinically. 4. Occluded left radiobasilic fistula. 5.
Bilateral upper lobe centrilobular nodules ___ be
infectious/inflammatory or could be in keeping with aspiration
in the appropriate clinical setting. 6. Moderate right and small
left pleural effusion.
___ MRV:
FINDINGS: The brachiocephalic vein and SVC are widely patent,
without evidence of stenosis or thrombus. The visualized central
portions of the bilateral subclavian veins are also patent. A
dialysis catheter terminates at the cavoatrial junction. There
are moderate bilateral pleural effusions, right larger than
left, with associated compressive atelectasis. Heart size is
normal. There is no pericardial effusion. There is no aggressive
osseous lesion. Soft tissue structures of the visualized chest
wall are unremarkable. IMPRESSION: 1. Widely patent SVC, without
evidence of stenosis or thrombus. 2. Moderate bilateral pleural
effusions, right larger than left.
___ CXR:
IMPRESSION:
The right pleural effusion has slightly increased in volume. A
right-sided ___ catheter has been placed in the interim with
its tip projecting over the distal SVC, the part which projects
at the level of the clavicle appears to have a kink within it
which could be positional. Small left pleural effusion is also
stable. Cardiomediastinal silhouette is unchanged. No
pneumothorax is seen.
___
UE ultrasound:
IMPRESSION: 1. Occluded left cephalic vein in the mid forearm at
the site of the previous failed left radial to cephalic AV
fistula. 2. Patent right cephalic vein and bilateral basilic
veins, radial artery, and brachial arteries, with specific
measurements as detailed above.
___ RENAL TRANSPLANT U.S. LEFT
IMPRESSION:
1. Persistent moderate hydronephrosis of the left iliac fossa
transplant kidney, minimally improved compared to prior study.
2. Doppler evaluation of the intrarenal arteries demonstrating
appropriate resistive indices within the normal range.
___ LIVER OR GALLBLADDER US
IMPRESSION:
1. Patent hepatic vasculature. No evidence of biliary
dilatation.
2. No concerning hepatic lesions identified.
3. Moderate bilateral pleural effusions and small amount of
perihepatic ascites.
___ UNILAT UP EXT VEINS US RIGHT
IMPRESSION:
No evidence of deep vein thrombosis in the right upper
extremity.
CXR ___:
Moderate right and small to moderate left pleural effusions.
Superimposed
consolidation cannot be excluded.
___: ___
No evidence of acutedeep venous thrombosis in the right or left
lower
extremity veins.
___ Upper Extremity US:
1. No evidence of deep vein thrombosis in the bilateral upper
extremity veins.
2. Bilateral superficial edema noted.
Renal US ___:
1. Left iliac fossa transplant kidney demonstrating moderate
hydronephrosis.
2. Doppler evaluation of the renal arteries is technically
limited and the
resistive indices ___ not reflect the true resistance of the
renal parenchyma as they are measured at the level of the
segmental arteries. If there is persistent clinical concern,
___ repeat study at no additional cost.
MICRO:
========
___ 12:30 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
DISCHARGE LABS:
================
___ 07:52AM BLOOD WBC-4.1 RBC-2.81* Hgb-8.1* Hct-25.3*
MCV-90 MCH-28.8 MCHC-32.0 RDW-14.9 RDWSD-47.9* Plt ___
___ 07:52AM BLOOD Plt ___
___ 07:52AM BLOOD Glucose-80 UreaN-31* Creat-6.2*# Na-141
K-5.0 Cl-101 HCO3-26 AnGap-14
___ 07:52AM BLOOD Calcium-9.0 Phos-6.6* Mg-1.9
___ 07:52AM BLOOD ___ PTT-40.5* ___
___ 08:50AM BLOOD ___ PTT-88.9* ___
___ 01:00PM BLOOD ___ PTT-73.4* ___
___ 07:29AM BLOOD ___ PTT-77.3* ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Labetalol 200 mg PO BID
3. Tacrolimus 3 mg PO Q12H
4. Mycophenolate Mofetil 250 mg PO BID
5. PredniSONE 10 mg PO DAILY
Discharge Medications:
1. sevelamer CARBONATE 2400 mg PO TID W/MEALS
RX *sevelamer carbonate 800 mg 3 tablet(s) by mouth three times
a day Disp #*90 Tablet Refills:*0
2. Warfarin 3 mg PO DAILY16
Please start on ___. Please have INR drawn ___
RX *warfarin 3 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Labetalol 400 mg PO TID
RX *labetalol 200 mg 2 tablet(s) by mouth three times a day Disp
#*60 Tablet Refills:*0
4. PredniSONE 5 mg PO DAILY
RX *prednisone 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Tacrolimus 5 mg PO Q12H
RX *tacrolimus 5 mg 1 capsule(s) by mouth q12 Disp #*60 Capsule
Refills:*0
6. amLODIPine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7.Outpatient Lab Work
Please draw: INR on ___
Fax to:
(1) Dr. ___, fax ___
(2) Dr. ___, fax ___
ICD-10: ___.___
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
=========================
End stage renal disease secondary to IgA nephropathy
Chronic rejection with allograft renal failure
SECONDARY:
=========================
Immunosuppression
Anasarca
Hypertensive urgency vs emergency
Pancytopenia
Abnormal liver function tests
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: ___ year old man with IgA nephropathy s/p renal transplant c/b
failure leading to anasarca, with new swelling of RUE.
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
vein.
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: VENOUS MAPPING FOR DIALYSIS ACCESS
INDICATION: ___ year old man with renal failure. Venous mapping for fistula.
The patient has a history of a failed left radial to cephalic AV fistula.
TECHNIQUE: Real-time grayscale and Doppler ultrasound imaging of both
cephalic veins, radial artery, brachial artery, basilic vein and subclavian
veins was performed.
FINDINGS:
RIGHT:
The cephalic vein measures 0.29 cm at the wrist, 0.3 cm at the antecubital
fossa, and 0.28 cm at the mid arm. The basilic vein measures 0.30 cm at the
forearm, 0.34 cm at the antecubital fossa, 0.37 cm at its mid portion, and
0.43 cm at the proximal portion.
The radial artery measures 0.22 cm. The brachial artery measures 0.51 cm. No
arterial calcifications are present.
LEFT:
The left cephalic vein is occluded in the mid forearm. The basilic vein
measures 0.40 cm at the antecubital fossa, 0.64 cm at the distal portion, 0.53
cm at its mid portion, and 0.41 cm at the proximal portion.
The radial artery measures 0.37 cm. The brachial artery measures 0.57 cm. No
arterial calcifications are present.
IMPRESSION:
1. Occluded left cephalic vein in the mid forearm at the site of the previous
failed left radial to cephalic AV fistula.
2. Patent right cephalic vein and bilateral basilic veins, radial artery, and
brachial arteries, with specific measurements as detailed above.
Radiology Report
INDICATION: ___ year old man with renal transplant, ___, needs tunneled line.
Evaluate and place tunneled HD catheter.
COMPARISON: None.
TECHNIQUE: OPERATORS: Dr. ___ resident and Dr. ___,
___ radiologist performed the procedure. Dr. ___
supervised the trainee during the key components of the procedure and has
reviewed and agrees with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
75 mcg of fentanyl and 1.5 mg of midazolam throughout the total intra-service
time of 19 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: As above.
CONTRAST: None.
FLUOROSCOPY TIME AND DOSE: 3.4 min, 6 mGy
PROCEDURE: PROCEDURE DETAILS: Following the explanation of the risks,
benefits and alternatives to the procedure, written informed consent was
obtained from the patient. The patient was then brought to the angiography
suite and placed supine on the exam table. A pre-procedure time-out was
performed per ___ protocol. The right upper chest was prepped and draped in
the usual sterile fashion.
Under continuous ultrasound guidance, the patent right internal jugular vein
was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and a short ___ wire was
advanced distally into the IVC.
Next, attention was turned towards creation of a tunnel over the upper
anterior chest wall. After instilling superficial and deeper local anesthesia
using lidocaine, a small skin incision was made at the tunnel entry site. A
19cm tip-to-cuff length catheter was selected. The catheter was tunneled from
the entry site towards the venotomy site from where it was brought out using a
tunneling device. The venotomy tract was dilated using the introducer of the
peel-away sheath supplied. Following this, the peel-away sheath was placed
over the ___ wire through which the catheter was threaded into the right
side of the heart with the tip in the right atrium. The sheath was then peeled
away. The catheter was sutured in place with 0 silk sutures. Steri-strips were
also used to close the venotomy incision site. Final spot fluoroscopic image
demonstrating good alignment of the catheter and no kinking. The tip is in the
right atrium. The catheter was flushed and both lumens were capped. Sterile
dressings were applied. The patient tolerated the procedure well.
FINDINGS:
Patent right internal jugular vein. Final fluoroscopic image showing right
tunneled dialysis catheter with tip terminating in the right atrium.
IMPRESSION:
Successful placement of a 19cm tip-to-cuff length tunneled dialysis line.
The tip of the catheter terminates in the right atrium. The catheter is ready
for use.
Radiology Report
INDICATION: ___ year old man with recurrent IgA nephropathy s/p 2 renal
transplants, both c/b acute failure, on dialysis for past ___ years c/b SVC
stenosis, p/w hypertensive emergency, volume overload, and hydronephrosis.//
Screening prior to hemodialysis
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
IMPRESSION:
The right pleural effusion has slightly increased in volume. A right-sided
hickman catheter has been placed in the interim with its tip projecting over
the distal SVC, the part which projects at the level of the clavicle appears
to have a kink within it which could be positional. Small left pleural
effusion is also stable. Cardiomediastinal silhouette is unchanged. No
pneumothorax is seen.
Radiology Report
INDICATION: ___ year old man with ESRD and transplant kidney, currently with
LLQ PCN in place.// convert PCN to PCNU
COMPARISON: Percutaneous nephrostomy tube placement dated ___
TECHNIQUE: OPERATORS: Dr. ___, attending radiologist, performed
the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
50mcg of fentanyl and 1 mg of midazolam throughout the total intra-service
time of 8 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: Fentanyl, Versed, 1% lidocaine
CONTRAST: 10 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 2.5 min, for mGy
PROCEDURE:
1. Left transplant diagnostic antegrade nephrostogram.
2. Conversion of left transplant percutaneous nephrostomy tube 2 left
transplant 8 ___ nephroureterostomy tube.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient.The patient was then brought to the angiography suite and placed prone
on the exam table. A pre-procedure time-out was performed per ___ protocol.
The left lower quadrant transplant was prepped and draped in the usual sterile
fashion.
Diluted contrast was injected into the left transplant nephrostomy to confirm
catheter position. The image was stored on PACS. Local anesthesia was
administered and the tube was cut and removed over ___ wire. A Kumpe
catheter and Glidewire were advanced side-by-side into the kidney down into
the transplant ureter into the bladder. The ___ wire was then removed and
placed through the Kumpe catheter in exchange for the Glidewire the into the
bladder and the catheter was removed over the wire. An 8 ___ transplant
nephroureteral stent was advanced over the wire into position under
fluoroscopy with the distal pigtail formed in the urinary bladder and proximal
pigtail formed in the left lower quadrant transplant renal pelvis.
Fluoroscopic images were saved. Contrast was administered to confirm
appropriate positioning. The tube was then capped. The tube was secured with
0 silk suture, a Stat Lock and dressed with sterile dressings. The patient
tolerated the procedure well without any immediate complications.
FINDINGS:
1. Left transplant antegrade nephrostogram shows transit of contrast into the
urinary bladder.
2. Appropriate final position of new left transplant 8 ___ nephroureteral
stent.
IMPRESSION:
Technically successful conversion of an 8 ___ left transplant percutaneous
nephrostomy tube to an 8 ___ nephroureteral stent.
Radiology Report
EXAMINATION: ?occlusion/worsening stenosis of SVC?
INDICATION: ___ year old man with known SVC stenosis presumably from prior
line, UE edema at baseline, increased UE edema since placement of tunneled
line on ___. ___ aware. NO CONTRAST HD PATIENT.// ?occlusion/worsening
stenosis of SVC?
TECHNIQUE: T1 and T2-weighted images of the chest were obtained on a 1.5
Tesla magnet, without administration of intravenous contrast secondary to
renal failure.
COMPARISON: None
FINDINGS:
The brachiocephalic vein and SVC are widely patent, without evidence of
stenosis or thrombus. The visualized central portions of the bilateral
subclavian veins are also patent. A dialysis catheter terminates at the
cavoatrial junction.
There are moderate bilateral pleural effusions, right larger than left, with
associated compressive atelectasis.
Heart size is normal. There is no pericardial effusion.
There is no aggressive osseous lesion. Soft tissue structures of the
visualized chest wall are unremarkable.
IMPRESSION:
1. Widely patent SVC, without evidence of stenosis or thrombus.
2. Moderate bilateral pleural effusions, right larger than left.
Radiology Report
EXAMINATION: CT venogram of the thorax and upper extremities
INDICATION: ___ year old man with prior known SVC stenosis, apparently had
angioplasty at OSH, got tunneled line placed here by ___ on ___ and
subsequently had increasing RUE edema. MRV of SVC was patent.// PLEASE PERFORM
CTV. ___ aware of this case. please eval for obstruction that would cause
significant RUE edema. please image the upper extremities AND the chest.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.3 s, 36.2 cm; CTDIvol = 2.6 mGy (Body) DLP = 93.6
mGy-cm.
2) Spiral Acquisition 5.9 s, 77.7 cm; CTDIvol = 5.6 mGy (Body) DLP = 433.5
mGy-cm.
3) Spiral Acquisition 5.9 s, 77.7 cm; CTDIvol = 5.6 mGy (Body) DLP = 434.4
mGy-cm.
4) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
5) Stationary Acquisition 13.2 s, 0.5 cm; CTDIvol = 72.8 mGy (Body) DLP =
36.4 mGy-cm.
Total DLP (Body) = 1,000 mGy-cm.
COMPARISON: MR venogram dated ___.
FINDINGS:
HEART AND VESSELS: No evidence of central pulmonary embolus. The main
pulmonary trunk is normal in caliber, measuring 27 mm. Mild-to-moderate
cardiomegaly. The aorta and major vessels to the neck are unremarkable.
There is a right internal jugular tunneled dialysis catheter in situ, with
apparent kinking at the level of the skin surface, within the subcutaneous
tissues, and prior to entering the right internal jugular vein. There is
moderate narrowing of the proximal SVC (axial series 4, image 94; coronal
series 601, image 48). Within the mid to distal SVC, the caliber of the
vessel is normal however there is an eccentric filling defect along the right
lateral aspect of the catheter consistent with catheter associated thrombus
(axial series 4, image 71). There is severe apparent narrowing at the distal
SVC at the level of the cavoatrial junction (axial series 4, image 65).
Internal jugular veins are patent bilaterally, distended on the right. The
subclavian, brachial, and basilic veins are patent bilaterally. The left
cephalic vein is patent. The right cephalic is not visualized. Extensive
anterior body wall collaterals.
On the left side there is a radiobasilic fistula graft which appears occluded.
LUNGS AND AIRWAYS: Centrilobular nodules, some of which demonstrate a
___ configuration, are noted within bilateral upper lobes, right
greater than left. Bilateral lower lobe atelectasis. Right upper lobe
calcified granuloma. The tracheobronchial tree is otherwise patent.
PLEURA/PERICARDIUM: Moderate right and small left pleural effusion.
MEDIASTINUM: Calcified mediastinal and right hilar adenopathy.
ESOPHAGUS AND NECK: Unremarkable.
BONES AND SOFT TISSUES: No suspicious osseous or soft tissue lesion.
UPPER ABDOMEN: Early hyper enhancement of hepatic segment 4 on the arterial
phase images (hot quadrate sign), which is associated with SVC stenosis.
Calcified granuloma within hepatic segment 4A. Prominent left upper quadrant
collateral vessels. Subcentimeter hypodense lesion at the hepatic dome, too
small to characterize.
IMPRESSION:
1. Moderate narrowing of the proximal and marked narrowing of the distal SVC.
2. Eccentric nonocclusive thrombus within the mid to distal SVC, along the
right lateral aspect of the tunneled dialysis catheter.
3. Several areas of apparent kinking of the dialysis catheter in the
subcutaneous tissues. Correlate clinically.
4. Occluded left radiobasilic fistula.
5. Bilateral upper lobe centrilobular nodules may be infectious/inflammatory
or could be in keeping with aspiration in the appropriate clinical setting.
6. Moderate right and small left pleural effusion.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 6:32 pm, 5 minutes after discovery
of the findings.
Radiology Report
INDICATION: ___ year old man with mid-SVC thrombus around tunneled HD line,
resulting in RUE and facial swelling with portosystemic collaterals.// Please
perform SVC angioplasty +/- new R IJ tunneled HD line placement
COMPARISON: MRV ___, CTV ___
TECHNIQUE: OPERATORS: Dr. ___ Radiologist performed the
procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
100mcg of fentanyl and 2 mg of midazolam throughout the total intra-service
time of 60 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS:
CONTRAST: 135 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 8.7 minute, 271 mGy
PROCEDURE:
1. Over-the-wire right IJ tunneled line removal
2. SVC venogram
3. SVC angioplasty with 10, 12, 16, 18, 20 mm balloon
4. Over-the-wire replacement of a new 23 cm tip to cuff right IJ tunneled
dialysis line
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.
An Amplatz wire was advanced through the existing right IJ tunneled line into
the IVC. The line was removed over the wire. An 11 ___ sheath was
advanced over the wire. An SVC venogram was performed. Diagnostic venography
was necessary to identify the site of stenosis. Subsequently dilation of the
SVC was performed with a 10 mm Conquest balloon, and 10 12, 16, 18, 20 mm
atlas balloons. A new 23 cm tip to cuff right IJ tunnel dialysis line was
advanced over the wire into the right atrium. The line was secured to the
skin with 0 silk suture. A dry sterile dressing was applied.
FINDINGS:
1. Initial SVC diagnostic venogram demonstrated complete occlusion of the low
SVC and collateral drainage through a large azygos vein
2. Small waist during balloon angioplasty of the low SVC
3. Final venogram showing markedly improved drainage through the low SVC into
the right atrium.
IMPRESSION:
Technically successful balloon angioplasty of the SVC with good technical
result
RECOMMENDATION(S): Long-term dialysis access planning is necessary. SVC
stenosis will likely reoccur quickly while a tunneled dialysis catheter
remains cross the SVC.
Radiology Report
INDICATION: ___ with SOB, evaluate for intra-thoracic process
TECHNIQUE: Single portable frontal view radiograph of the chest.
COMPARISON: None.
FINDINGS:
Moderate right and small to moderate left pleural effusions are noted.
Superimposed consolidations cannot be excluded. There is no pulmonary edema
or pneumothorax. The cardiomediastinal silhouette is within normal limits.
IMPRESSION:
Moderate right and small to moderate left pleural effusions. Superimposed
consolidation cannot be excluded.
Radiology Report
EXAMINATION: US NECK, SOFT TISSUE
INDICATION: ___ year old man s/p angio with ___ for clot removal in ___ on ___
night. On heparin gtt. He is now complaining of increased pain at his R neck
(around IJ/EJ). Palpable cord/edema in R neck.// Please eval for thrombosis in
vasculatare of neck.
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the right neck.
COMPARISON: None
FINDINGS:
Transverse and sagittal images of the superficial tissues of the right
supraclavicular neck in the patient reported area of increased pain
demonstrates a complex 3.4 x 2.6 x 2.1 cm fluid collection demonstrating
layering fluid-fluid level without internal vascularity which likely
represents the evolving hematoma. This lesion is localized to the
subcutaneous fat of the supraclavicular neck region. The internal jugular
vein and common carotid artery are located deep and medial to this collection.
The external jugular vein is localized superficial and lateral to the
collection. There is no evidence of communication with the adjacent vessels
which appear patent and demonstrate normal color flow.
IMPRESSION:
1. 3.4 cm avascular right neck complex fluid collection within the
subcutaneous fat of the right supraclavicular region demonstrating layering
fluid-fluid level as described above likely represents an evolving hematoma.
If there is continued increase in size of this lesion a contrast enhanced CT
of the neck can be performed for better evaluation.
2. No communication with the adjacent jugular vein or common carotid artery.
3. The adjacent vessels are patent.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 11:48 am, 1 minutes after
discovery of the findings.
The findings and additional recommendations were discussed with ___, M.D.
by ___, M.D. on the telephone on ___ at 1:05 pm, 1 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with lower extremity swelling, R>L// 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 left common
femoral, femoral, and popliteal veins. The proximal right femoral vein and
right deep femoral vein were not visualized on grayscale imaging due to
overlying bandage but demonstrate normal color Doppler evaluation. The right
mid to distal femoral and popliteal veins demonstrate normal compressibility,
flow and augmentation. 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.
Right lower extremity subcutaneous edema is also noted.
IMPRESSION:
No evidence of acutedeep venous thrombosis in the right or left lower
extremity veins.
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: ___ year old man with renal transplant x2, last ___ complicated
by renal failure// Renal structure/flow
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: None.
FINDINGS:
There is moderate to severe hydronephrosis of the left iliac fossa transplant
kidney. The cortex is of normal thickness and echogenicity, pyramids are
normal, there is no urothelial thickening, and renal sinus fat is normal.
There is a 0.6 x 1.1 x 1.2 cm the simple hypoechoic cortical cyst within the
midpole. There is no perinephric fluid collection.
Doppler evaluation of the renal arteries is technically limited and the
resistive indices may not reflect the true resistance of the renal parenchyma
as they are measured at the level of the segmental renal arterial branches.
The resistive index of intrarenal arteries ranges from 0.66 to 0.79. The main
renal artery shows a normal waveform, with prompt systolic upstroke and
continuous antegrade diastolic flow, with peak systolic velocity of 76.3 cm
per second. Vascularity is symmetric throughout transplant. The transplant
renal vein is patent and shows normal waveform.
The urinary bladder is collapsed.
IMPRESSION:
1. Left iliac fossa transplant kidney demonstrating moderate hydronephrosis.
2. Doppler evaluation of the renal arteries is technically limited and the
resistive indices may not reflect the true resistance of the renal parenchyma
as they are measured at the level of the segmental arteries. If there is
persistent clinical concern, may repeat study at no additional cost.
Radiology Report
EXAMINATION: BILAT UP EXT VEINS US
INDICATION: ___ year old man with IgA nephropathy s/p renal transplant x2 in
___ c/b failure, presenting with ___ and swollen upper extremities// rule out
DVT
TECHNIQUE: Grey scale and Doppler evaluation was performed on the bilateral
upper extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
The bilateral internal jugular, axillary and brachial veins are patent, show
normal color flow and compressibility.
The bilateral basilic and cephalic veins are patent.
Bilateral superficial edema is noted.
IMPRESSION:
1. No evidence of deep vein thrombosis in the bilateral upper extremity veins.
2. Bilateral superficial edema noted.
Radiology Report
INDICATION: ___ year old man with left transplant kidney and elevated Cr with
moderate hydronephrosis of unknown duration
COMPARISON: Renal transplant ultrasound ___
TECHNIQUE: OPERATORS: Dr. ___ and Dr.
___ radiologist performed the procedure. Dr. ___
___ supervised the trainee during the key components of the procedure
and has reviewed and agrees with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
75 mcg of fentanyl and 0.5 mg of midazolam throughout the total intra-service
time of 17 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: None
CONTRAST: 15 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 4 min, 7 mGy
PROCEDURE: 1. Left lower quadrant transplant kidney ultrasound guided renal
collecting system access.
2. LLQ transplant kidney nephrostogram.
3. ___ nephrostomy tube placement.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The left lower quadrant was prepped and draped in the usual sterile
fashion.
After the injection of 5 cc of 1% lidocaine in the subcutaneous soft tissues,
the left lower quadrant transplant renal collecting system was accessed
through a posterior lower pole calyx under ultrasound guidance using a 21
gauge Cook needle. Ultrasound images of the access were stored on PACS. Prompt
return of urine confirmed appropriate positioning. Injection of a small amount
of contrast outlined a dilated renal collecting system. Under fluoroscopic
guidance, a Nitinol wire was advanced into the renal collecting system. After
a skin ___, the needle was exchanged for an Accustick sheath. Once the tip of
the sheath was in the collecting system; the sheath was advanced over the
wire, inner dilator and metallic stiffener. The wire and inner dilator were
then removed and diluted contrast was injected into the collecting system to
confirm position. A ___ wire was advanced through the sheath and coiled in
the collecting system. The sheath was then removed and a 8 ___ nephrostomy
tube was advanced into the renal collecting system. The wire was then removed
and the pigtail was formed in the collecting system. Contrast injection
confirmed appropriate positioning. The catheter was then flushed, 0 silk stay
sutures applied and the catheter was secured with a Stat Lock device and
sterile dressings. The catheter was attached to a bag.
Patient tolerated the procedure well and left in stable condition.
FINDINGS:
1. Moderate left lower quadrant transplant kidney hydronephrosis.
2. Antegrade nephrostogram demonstrates brisk flow of contrast from the
renal collecting system into the urinary bladder. Although there is mild
smooth tapering of the distal ureter, there is no stasis of contrast to
suggest obstruction.
IMPRESSION:
Successful placement of 8 ___ nephrostomy within the left lower quadrant
transplant kidney.
RECOMMENDATION(S): Keep PCN attached to bag.
Radiology Report
EXAMINATION: US ABD LIMIT, SINGLE ORGAN
INDICATION: ___ year old man with recent on left, with persistent drainage//
LLQ US- r/o urinoma or other collection at site of PCN
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Ultrasound from ___.
FINDINGS:
Targeted ultrasound of the left lower quadrant near the percutaneous
nephrostomy tube was performed. No focal collections were identified.
IMPRESSION:
No focal fluid or collections.
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S. LEFT
INDICATION: ___ year old man with acute on chronic renal failure s/p PCN
placement for obstruction, now capped ___. Evaluation for hydronephrosis.
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: Comparison to prior study from ___.
FINDINGS:
The left iliac fossa transplant kidney demonstrates moderate hydronephrosis,
minimally improved compared to prior study. 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 perinephric fluid collection. There
is a simple appearing hypoechoic cyst within the midpole measuring 0.9 x 0.7 x
0.5 cm. A percutaneous nephrostomy tube appears in good position.
The resistive index of intrarenal arteries ranges from 0.63 to 0.67, 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 71.8 cm/sec. Vascularity is symmetric throughout transplant. The
transplant renal vein is patent and shows normal waveform.
The urinary bladder is collapsed.
IMPRESSION:
1. Persistent moderate hydronephrosis of the left iliac fossa transplant
kidney, minimally improved compared to prior study.
2. Doppler evaluation of the intrarenal arteries demonstrating appropriate
resistive indices within the normal range.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old man with new transaminitis and hypercoagulability.
Evaluation for portal vein thrombus, hepatic vein thrombus, biliary
dilatation.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: No prior studies for comparison. Note left renal transplant
ultrasound performed earlier the same day on ___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of
the liver is smooth. There is a small echogenic focus in the right lobe
measuring 0.6 x 0.5 x 0.4 cm and a larger echogenic focus in the right lobe
measuring 1.0 x 0.4 x 0.3 cm, both likely compatible with granulomas. No
concerning hepatic lesions are identified. The main portal vein is patent
with hepatopetal flow. There are moderate to large bilateral pleural
effusions and a small amount of perihepatic ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 5 mm.
GALLBLADDER: The gallbladder appears contracted with no evidence of stones.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 11.8 cm.
KIDNEYS: The native right kidney appears atrophic and measures 6.1 cm. The
native left kidney appears atrophic and measures 6.1 cm. A right iliac fossa
transplant kidney measures 7.9 cm. There is no evidence of masses, stones, or
hydronephrosis in the kidneys.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Patent hepatic vasculature. No evidence of biliary dilatation.
2. No concerning hepatic lesions identified.
3. Moderate bilateral pleural effusions and small amount of perihepatic
ascites.
Gender: M
Race: ASIAN - CHINESE
Arrive by AMBULANCE
Chief complaint: Abnormal labs, Dyspnea
Diagnosed with Disorder of kidney and ureter, unspecified, Dyspnea, unspecified, Essential (primary) hypertension, Anemia, unspecified
temperature: 98.1
heartrate: 98.0
resprate: 28.0
o2sat: 97.0
sbp: 190.0
dbp: 100.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ man s/p 2 renal transplants c/b acute graft
rejection and recurrent IgA nephropathy, on chronic
immunosuppression, initially presenting with volume overload and
hypertensive emergency, found to have hydronephrosis, consistent
with acute on chronic renal failure, now s/p PCN placement ___,
converted to PCNU on ___, and initiated on HD on ___. Course
complicated by SVC syndrome s/p angioplasty as well as tunneled
HD line associated clot. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
fatigue
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M with hx HIV/AIDS (most recent CD4 count in 140s) and COPD
presenting with palpitations, dyspnea on exertion, generalized
weakness (worse over past 3 days). Denies fevers, sweats.
Reports chronic cough with some increased sputum production and
DOE.
Reports that he has had chronic N/V/D since stomach flu
approximately 1 months ago which lasted for 3 weeks, and has had
subsequent poor PO intake. Also reports that he had been having
a lot of back pain (chronic) over past 4 mo and he thinks that
this has "worn him out". Patient is vague about symptoms, and
admits to drinking etoh today.
In the ED intial vitals were: 8 98.1 68 161/97 16 100%
- Labs were significant for - EtOH 312, trop neg, K 3.1, lactate
1.7, AST 572 ALT 244. AP 201. wbc 5.5 w/ lymphocyte predominace
RUQ U/S with Dopplers Coarsened echogenic liver compatible with
cirrhosis. No biliary dilation.
EKG: looks similar to prior. sinus brady, 1st degree AV delay
no acute ischemia, trop neg
CXR: No acute cardiopulmonary abnormality. COPD
- Patient was given thiamine and oxycodone
On the floor, pt is comfortable and in NAD.
Denies f/c/night sweats. No headache. No diarrhea or vomiting
and no abd pain.
Past Medical History:
HIV+ ___,
rectal GC,
Kaposi's sarcoma (though path nondiagnostic and has not received
any treatment for KS),
HTN.
H/O GI bleed in ___ Angioectasias in duodenum requiring
partial small bowel resection
dx int and ext anal warts. OR removal: ___
repeat OR excision (Dr. ___ -- path AIN1: ___nd int anal warts in ___
Social History:
___
Family History:
non contributory
Physical Exam:
ADMISSION EXAM:
Vitals- 99, 71, 135/80, 20, 99% RA
General- cachectic appearance, no acute distress
HEENT- PERRL, EOMI, OP clear
Neck- No LAD, no JVD
Lungs- scattered end expiratory wheeze, distant breath sounds,
otherwise clear
CV- rrr no MRG
Abdomen- soft, nontender, nondistended. edge of spleen palpated
2cm below costal margin. Liver palpated 4cm below costal margin
GU- deferred
Ext- no c/c/e
Neuro- grossly intact
DISCHARGE EXAM:
Vitals: 99, 98.3, 135-164/80-108, 71-93, 18, 97-99RA
General: Alert, oriented, no acute distress, appears tired
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi, aeration throughout
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, liver palpated below costal
margin, no suprapubic nor epigastric discomfort
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: large U shaped well-healed incision to epigastric area
Neuro: moves all extremities, ambulates independently, ___
strength to bilateral upper and lower extremities
Pertinent Results:
___ 06:00PM BLOOD WBC-5.5 RBC-4.63 Hgb-14.7 Hct-42.4 MCV-92
MCH-31.8 MCHC-34.7 RDW-13.6 Plt Ct-84*
___ 06:00PM BLOOD Neuts-24* Bands-0 Lymphs-68* Monos-5
Eos-3 Baso-0 ___ Myelos-0 NRBC-1*
___ 06:00PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 06:00PM BLOOD ___ PTT-30.7 ___
___ 06:00PM BLOOD Glucose-87 UreaN-12 Creat-0.6 Na-140
K-3.1* Cl-98 HCO3-29 AnGap-16
___ 06:00PM BLOOD ALT-244* AST-572* AlkPhos-201*
TotBili-1.2
___ 06:00PM BLOOD cTropnT-<0.01
___ 06:00PM BLOOD Albumin-4.4 Calcium-8.9 Phos-3.8 Mg-1.6
___ 06:00PM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND IgM HAV-PND
___ 06:00PM BLOOD ASA-NEG ___ Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 06:00PM BLOOD HCV Ab-PND
___ 06:03PM BLOOD Lactate-1.7
___ CXR
No acute cardiopulmonary abnormality. COPD.
___ Liver U/S with Doppler
1. Echogenic liver which may be due to fatty infiltration
however other more severe forms of liver disease including
cirrhosis are not excluded.
2. Normal liver Doppler exam.
DISCHARGE LABS:
___ 06:45AM BLOOD WBC-3.1* RBC-4.11* Hgb-13.1* Hct-38.1*
MCV-93 MCH-31.8 MCHC-34.4 RDW-14.0 Plt Ct-62*
___ 06:45AM BLOOD Neuts-28.2* Lymphs-61.6* Monos-5.7
Eos-3.6 Baso-0.9
___ 06:45AM BLOOD Hypochr-NORMAL Anisocy-1+ Poiklo-NORMAL
Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 06:45AM BLOOD WBC-PND Lymph-PND Abs ___ CD3%-PND
Abs CD3-PND CD4%-PND Abs CD4-PND CD8%-PND Abs CD8-PND
CD4/CD8-PND
___ 06:45AM BLOOD Glucose-74 UreaN-11 Creat-0.6 Na-139
K-3.6 Cl-100 HCO3-28 AnGap-15
___ 06:45AM BLOOD ALT-201* AST-463* LD(LDH)-277*
AlkPhos-158* TotBili-1.4
___ 06:45AM BLOOD GGT-703*
___ 06:45AM BLOOD cTropnT-<0.01
___ 06:45AM BLOOD Albumin-4.1 Calcium-8.2* Phos-2.6*
Mg-1.4*
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Gabapentin 100 mg PO DAILY
2. LaMOTrigine 75 mg PO QHS
3. Mirtazapine 30 mg PO HS
4. Tiotropium Bromide 1 CAP IH DAILY
5. Dapsone 100 mg PO DAILY
6. ClonazePAM 1 mg PO QHS:PRN anxiety
7. Darunavir 600 mg PO DAILY
8. RiTONAvir 100 mg PO BID
9. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
10. OxycoDONE (Immediate Release) 10 mg PO BID:PRN pain
11. meloxicam uncertain oral qday
Discharge Medications:
1. ClonazePAM 1 mg PO QHS:PRN anxiety
2. Dapsone 100 mg PO DAILY
3. Darunavir 600 mg PO DAILY
4. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
5. Gabapentin 100 mg PO DAILY
6. LaMOTrigine 75 mg PO QHS
7. Mirtazapine 30 mg PO HS
8. OxycoDONE (Immediate Release) 10 mg PO BID:PRN pain
9. RiTONAvir 100 mg PO BID
10. Tiotropium Bromide 1 CAP IH DAILY
11. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
12. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet,chewable(s) by mouth daily Disp #*30
Capsule Refills:*0
13. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
14. meloxicam 7.5 mg ORAL QDAY
Please take per your home prescription dose
Discharge Disposition:
Home
Discharge Diagnosis:
Transaminitis
Chronic back pain
Alcohol intoxication
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: HIV, COPD and increased dyspnea.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
The lungs are hyperinflated. Cardiac silhouette size is normal. The aorta
remains mildly tortuous. Hilar contours are normal. Pulmonary vasculature is
normal. Lungs are clear. No pleural effusion or pneumothorax is present.
There are no acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary abnormality. COPD.
Radiology Report
INDICATION: Elevated transaminitis. Please evaluate for portal vein
thrombosis.
COMPARISONS: CT abdomen and pelvis from ___.
TECHNIQUE: Grayscale, color Doppler and spectral waveform analysis was
performed of the abdomen.
FINDINGS: The liver has an echogenic, heterogenous and coarsened echotexture.
There are no focal lesions or intra- or extra-hepatic biliary dilatation. The
common bile duct measures 5 mm. The gallbladder is unremarkable without
gallstones, pericholecystic fluid or gallbladder wall thickening. The
pancreas is visualized and is unremarkable. The spleen is not enlarged and
measures 8.5 cm. There is no ascites.
DOPPLER: The main, right and left hepatic veins are patent with normal
waveforms. The main portal vein, left portal vein, anterior and posterior
portal veins are patent with normal hepatopetal flow. There is normal
waveform within the hepatic artery, which is patent. The IVC, splenic vein
and SMV are patent with normal waveforms.
IMPRESSION:
1. Echogenic liver which may be due to fatty infiltration however other more
severe forms of liver disease including cirrhosis are not excluded.
2. Normal liver Doppler exam.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ILI
Diagnosed with ACUTE & SUBACUTE NECROSIS OF LIVER
temperature: 98.1
heartrate: 68.0
resprate: 16.0
o2sat: 100.0
sbp: 161.0
dbp: 97.0
level of pain: 8
level of acuity: 3.0 | ___ w/ hx of HIV, EtOH dependence and mild COPD, presents to ED
with 1 month hx of abdominal discomfort, nausea and recent hx of
DOE and cough w/o increased sputum production. Pt found to have
transaminitis. Pt has multiple complaints with no clear
unifying diagnosis.
# Transaminitis - Directly hepatocellular pattern w/ only
cholestatic evidence being mildly elevated alk phos. AST: ALT
elevated in 2:1 ratio c/w etoh toxicity. In OMR, has not had
this degree of transaminitis in past however. The RUQ US showed
cirrhotic liver without any acute finding. Pt's abdominal pain,
malaise and myalgias could be indicative of infectious
hepatitis, hepatitis panel and EBV/CMV was pending at discharge.
Tylenol level was negative. In conjunction with recent increase
in alcohol abuse, drug effect hepatotoxicity could be
compounded. LFTs currently downtrending. GGT was elevated to
703.
# Cough/DOE - No evidence of pneumonia/pulm edema on CXR, EKG
was unremarkable and first set of trops neg. In an
immunocompromised pt could consider atypical infection like PCP
but no radiological evidence and pt would likely be in more
acute respiratory distress. COPD exacerbation is possible given
increased cough, some mild expiratory wheezing and SOB, however
no increase in sputum. Shortly after admission did not complain
of shortness of breath. Did not require supplemental O2. Spiriva
and albuterol was continued.
# Thrombocytopenia - Has not had this degree of abnormality in
our OMR in the past. Could be evidence of ongoing alcoholism and
worsening cirrhosis over the years. Could also be from acute
infectious viral etiology. EBV/CMV and hepatitis serologies
pending.
# EtOH intoxication. Patient denies having history of
withdrawals. He also denies any regular drinking since he
started his antiretroviral therapy regimen. He was placed on a
CIWA scale, however did not exhibit any signs or symptoms of
withdrawal. He was started on folate, thiamine and a MVI.
# Hypokalemia- Likely nutritional as patient has had poor po
intake for at least a week or two. Was repleted this AM.
# Cirrhosis - Patient with evidence of cirrhosis on RUQ US.
Bili/cr/inr not elevated. Patient was encouragted to stop
dirnking alcohol, especially while he is on antiretroviral
therapies. He will follow-up hepatitis serologies as an
outpatient.
# HIV - Last CD4 140, pt reports that he is due for viral load
and CD4 check which are currently pending. Continued on home
medication regimen and dapsone.
# COPD - continud with home medications
# back pain - continued with oxycodone and gabapentin |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Abacavir / ritonavir / Lyrica
Attending: ___.
Chief Complaint:
shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr ___ is a ___ w/hx of HIV on HAART, asthma, COPD,
not on home O2 with recent hospitalization for Influenza c/b
intubation for hypercarbic respiratory failure who presents with
shortness of breath.
He was admitted from ___ to ___ after presenting with
cough and dyspnea. He had wheezing and low oxygen saturations
and ended up being positive for influenza. He required
intubation for hypercarbic respiratory failure and was treated
with steroids, Tamiflu, vancomycin, cefepime, and levofloxacin.
His MICU course was
notable for reintubation, but successful second extubation. He
was transferred to the floor and ultimately did very well. He
was discharged and completed all antimicrobials and steroids.
He was seen in Pulm follow-up on ___. He at that time said
his COPD was being well-controlled. PFT's at that visit showed a
somewhat worsened obtructive defect. He refused having Spiriva
added to his regimen.
Patient reports worsening shortness of breath and cough for last
2 days. Started ___ morning. Cough is productive of brownish
sputum. Denies hemoptysis. Some shortness of breath and chest
tightness with climbing stairs. Otherwise no chest pain. Denies
fevers but does endorse intermittent chills. Not aware of any
adenopaty.
In the ED, initial vitals were: 98.4 HR-95 BP-140/111 22 85%RA,
Given IV methylprednisone 125mg and Azithromycin PO. CXR
performed and blood cultures sent.
On the floor, patient reprots some mild shortness of breath and
cough. Otherwise no new complaints.
Review of systems:
(+) Per HPI
(-) Denies night sweats, recent weight loss or gain. Denies
headache, sinus tenderness, rhinorrhea or congestion. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias.
Past Medical History:
# HTN
# COPD: PFTs (___) FEV1 of 1.66 liters or 56% of
predicted, FVC of 3.35 liters or 87% of predicted with a ratio
that is reduced at 0.50, consistent with moderate obstruction.
# HIV: diagnosed in ___, no AIDS related complications (780 and
VL undetectable on ___
# Hepatitis C, not currently treated
# H/o IV drug use
# Herpes zoster infection with postherpetic neuralgia, on
Morphine and Pregabalin.
# episodes of myoclonic jerking in ___, admitted to
___ (etiology & treatment unknown), completely
resolved, thought to be due to med effect
Social History:
___
Family History:
father and sister with asthma, mother with DM, kids healthy
Physical Exam:
ADMISSION:
98.2, 136/98, P-81, RR-20, 100 4L
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Poor inspiratory effort and poor entry throughout, corase
breath sounds with scattered wheezes and crackles at the bases
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: midline abdominal scar noted with small reducible
umbilical hernia, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No rashes
DISCHARGE:
98.6, 170/100, P-70, RR-20, 92% RA 89-90% on RA ambulation
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: improved respiratory effort, coarse throughout with no
wheezes and crackles at bases, much improved air entry
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: midline abdominal scar noted with small reducible
umbilical hernia, 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
Pertinent Results:
LABS ON ADMISSION:
___ 07:45AM BLOOD WBC-11.2* RBC-5.00# Hgb-15.6# Hct-46.2#
MCV-93 MCH-31.3 MCHC-33.8 RDW-12.2 Plt ___
___ 07:45AM BLOOD Neuts-67.1 ___ Monos-6.2 Eos-0.9
Baso-0.6
___ 07:45AM BLOOD Plt ___
___ 07:45AM BLOOD Glucose-110* UreaN-12 Creat-1.1 Na-136
K-5.9* Cl-96 HCO3-26 AnGap-20
___ 07:45AM BLOOD LD(LDH)-802*
___ 07:53AM BLOOD ___ pO2-58* pCO2-56* pH-7.38
calTCO2-34* Base XS-5 Comment-GREEN TOP
___ 07:53AM BLOOD Lactate-1.6 K-4.1
___ SPUTUM CULTURE:
GRAM STAIN (Final ___:
>25 PMNs and <10 epithelial cells/100X field.
3+ ___ per 1000X FIELD): GRAM NEGATIVE DIPLOCOCCI.
SMEAR REVIEWED; RESULTS CONFIRMED.
RESPIRATORY CULTURE (Final ___:
MODERATE GROWTH Commensal Respiratory Flora.
___ 11:37 pm URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
CHEST PORTABLE AP:
FINDINGS: The patient has been extubated and a right internal
jugular catheter and orogastric tube removed. The cardiac,
mediastinal and hilar contours appear stable. The chest is
hyperinflated. There is no pleural effusion or pneumothorax.
In the right lower lung, there is persistent predominantly
streaky opacification, but very similar to the prior study. In
the left lower lung, there is an apparent increased opacity,
although a confounding factor is that there does seem to be
background opacity in the area, but the increase is worrisome
for developing pneumonia.
IMPRESSION: Vague increased left basilar opacification,
concerning for
developing pneumonia in the appropriate clinical setting.
CHEST PA AND LAT:
FINDINGS: In comparison with the earlier study of this date,
the patient has taken a much better inspiration. Mild
atelectatic changes are seen at the right base, though there is
no evidence of acute pneumonia or vascular congestion or pleural
effusion.
LABS ON DISCHARGE:
___ 07:50AM BLOOD WBC-10.9 RBC-4.47* Hgb-13.9* Hct-41.7
MCV-93 MCH-31.2 MCHC-33.4 RDW-11.8 Plt ___
___ 07:50AM BLOOD Glucose-93 UreaN-20 Creat-0.9 Na-139
K-4.6 Cl-101 HCO3-26 AnGap-17
___ 07:50AM BLOOD Calcium-8.7 Phos-4.2 Mg-2.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler ___ PUFF IH Q6H:PRN cough/wheeze
2. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
3. Etravirine 200 mg PO BID
4. Labetalol 300 mg PO BID
Hold for HR<55 or SBP<100
5. Lisinopril 5 mg PO DAILY
Hold for SBP<100
6. Morphine SR (MS ___ 100 mg PO Q12H
7. Raltegravir 400 mg PO BID
8. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation BID
Discharge Medications:
1. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
2. Etravirine 200 mg PO BID
3. Labetalol 300 mg PO BID
4. Lisinopril 5 mg PO DAILY
5. Morphine SR (MS ___ 100 mg PO Q12H
6. Raltegravir 400 mg PO BID
7. Symbicort *NF* (budesonide-formoterol) 160-4.5 mcg/actuation
Inhalation BID
8. PredniSONE 60 mg PO DAILY Duration: 2 Days
RX *prednisone 20 mg 3 tablet(s) by mouth Daily Disp #*6 Tablet
Refills:*0
9. Azithromycin 250 mg PO Q24H Duration: 2 Days
RX *azithromycin 250 mg 1 tablet(s) by mouth Daily Disp #*2
Tablet Refills:*0
10. Albuterol Inhaler ___ PUFF IH Q6H:PRN cough/wheeze
11. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1 CAP
INH Daily Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
COPD Exacerbation
HIV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH
HISTORY: Shortness of breath. History of asthma and HIV.
COMPARISONS: ___.
TECHNIQUE: Chest, portable AP upright.
FINDINGS: The patient has been extubated and a right internal jugular
catheter and orogastric tube removed. The cardiac, mediastinal and hilar
contours appear stable. The chest is hyperinflated. There is no pleural
effusion or pneumothorax. In the right lower lung, there is persistent
predominantly streaky opacification, but very similar to the prior study. In
the left lower lung, there is an apparent increased opacity, although a
confounding factor is that there does seem to be background opacity in the
area, but the increase is worrisome for developing pneumonia.
IMPRESSION: Vague increased left basilar opacification, concerning for
developing pneumonia in the appropriate clinical setting.
Radiology Report
HISTORY: HIV and COPD with worsening shortness of breath.
FINDINGS: In comparison with the earlier study of this date, the patient has
taken a much better inspiration. Mild atelectatic changes are seen at the
right base, though there is no evidence of acute pneumonia or vascular
congestion or pleural effusion.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: DYSPNEA
Diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION, ASYMPTOMATIC HIV INFECTION
temperature: nan
heartrate: nan
resprate: nan
o2sat: 85.0
sbp: nan
dbp: nan
level of pain: 8
level of acuity: 1.0 | Mr. ___ is a ___ w/hx of HIV on HAART, asthma, COPD (not on
home O2) with recent hospitalization for Influenza c/b
intubation for hypercarbic respiratory failure who presents with
shortness of breath due to COPD exacerbation.
.
# COPD exacerbation: Patient presented with history of shortness
of breath, cough with sputum production, and an increased oxygen
requirement. CXR ruled out pneumonia as there was no sign of
infiltrate. Patient showed rapid improvement with management of
COPD exacerbation. He will complete a 5-day course of
azithromycin (day ___ and prednisone 60mg PO X 5 days (day
___. The patient received education regarding COPD
management. Spiriva was added to his home regimen of Symbicort
daily and albuterol PRN. On discharge his ambulatory O2 sat was
89-90% on RA and 91-92% on room air at rest.
.
# HIV on HAART therapy: Last CD4 count 780, viral load
undetectable in ___.
We continued the patient's home regimen of
Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY, Etravirine 200
mg PO BID, and Raltegravir 400 mg PO BID.
.
# HTN: Home regimen of labetalol 300 mg PO BID and lisinopril 5
mg PO DAILY was continued. The patient remained hypertensive
throughout this admission with BPs as high as 170s/110s. The
patient remained hemodynamically stable and asymptomatic.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
morphine / Penicillins / codeine / prednisone
Attending: ___.
Chief Complaint:
Right distal femur fracture
Major Surgical or Invasive Procedure:
___: Right distal femur ORIF
History of Present Illness:
Mrs. ___ is a ___ year-old with a h/o sarcoidosis,
gastritis, HTN who presented as OSH transfer with right distal
femur fracture. Patient was exercising per her usual routine
when she bent over to pick up a weight, sustained a mechanical
fall onto her right knee. She had immediate pain and
inability to ambulate, was taken to OSH where x-rays revealed
right distal femur fracture and she was transferred to ___.
Past Medical History:
Sarcoidosis, gastritis, HTN
Social History:
___
Family History:
Non-contributory
Medications on Admission:
calan 240 daily
lisinopril 20 daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every six (6) hours Disp #*60 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
3. Lisinopril 20 mg PO DAILY
4. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone [Oxecta] 5 mg 1 tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*0
5. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 by mouth twice a day Disp #*60
Tablet Refills:*0
6. Verapamil SR 240 mg PO Q24H
7. Enoxaparin Sodium 40 mg SC QHS
Start: ___, First Dose: STAT
RX *enoxaparin 40 mg/0.4 mL 1 at bedtime Disp #*14 Syringe
Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right distal femur fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with right leg comminuted distal femur
fracture. // Determine if joint involvement
TECHNIQUE: MDCT axial images were acquired through the right knee, without
the administration of intravenous contrast material. Multiplanar reformats
were performed.
DOSE: Total DLP: 521 mGy-cm.
COMPARISON: Outside hospital knee radiographs from ___.
FINDINGS:
There is a comminuted fracture through the distal aspect of the right femur,
with mild impaction as well as mild posterior displacement and posterior
angulation of the dominant distal fracture fragment. A component of the
fracture extends through the lateral femoral condyle, reaching the articular
surface (401b:71). There is no significant cortical step-off along the
articular surface, however. Of note, there is also an incompletely imaged
fracture through the mid to distal aspect of the femoral diaphysis. There is
no dislocation. There is a moderate joint effusion containing a fat fluid
level, compatible with lipohemarthrosis.
The extensor mechanism is intact. Extensive degenerative changes are seen
throughout the knee including moderate to severe medial compartment narrowing
and tricompartmental osteophytosis. Note is made of chondrocalcinosis in both
the lateral and medial compartments. There is a moderate ___ cyst.
There is marked fatty atrophy of the soleus muscle. Moderate soft tissue edema
is seen about the knee.
IMPRESSION:
1. Comminuted fracture through the distal right femur extending through the
lateral femoral condyle, reaching the articular surface. No significant
articular surface cortical step-off.
2. Moderate right knee joint effusion with lipohemarthrosis. Moderate ___
cyst.
3. Extensive tricompartmental degenerative changes throughout the right knee.
Radiology Report
INDICATION: ___ year old woman with distal femur fracture // distal femur
fracture Surg: ___ (ORIF distal femur fracture)
TECHNIQUE: Single portable AP image of the chest.
COMPARISON: Comparison made with chest radiographs from ___.
FINDINGS:
The lungs are well expanded and clear. There is no pleural effusion or
pneumothorax. The cardiomediastinal silhouette is unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
FLUOROSCOPIC STUDY, ___
Fluoroscopic guidance was provided to Dr. ___ open reduction and
internal fixation of a known femoral fracture.
A series of fluoroscopic images document the procedure. Further details can
be obtained in the operative report. Total estimated dose is 250.88 mrad.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R FEMUR FX
Diagnosed with FX NECK OF FEMUR NOS-CL, OTHER FALL
temperature: 97.4
heartrate: 80.0
resprate: 18.0
o2sat: 98.0
sbp: 155.0
dbp: 89.0
level of pain: 7
level of acuity: 3.0 | ___ s/p fall with R distal femur fracture. Her imaging showed
x-rays show comminuted Right distal femur fracture with likely
intra-articular extension
CT shows comminuted Right distal femur fracture with
intra-articular fracture
She underwent an open reduction and internal fixation on ___.
The procedure was uncomplicated, her diet was advanced as
tolerated and she was transitioned to PO pain medications. She
will be touch down weight bearing, she has follow up in ___
days. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Statins-Hmg-Coa Reductase Inhibitors
Attending: ___
Chief Complaint:
Low Back Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH multiple sclerosis, CKD, hx PE, osteoporosis,
spinal stenosis, hx T12 compression fx, p/w severe low back pain
x 10 days. Patient reports had severe low back pain on getting
up from bed. She has difficulty walking due to the pain. She
denies fever/chills, lower extremity numbness/weakness, and
bowel/bladder incontinence.
She recently went to ___ ED where X-rays negative for fracture
and patient was sent home with pain meds. Pain was worsening
and not well-controlled with pain medication. Came to ___ ED
on ___ and had X-ray and CT scan which showed no acute
fractures. Was admitted to medicine service for pain control.
Past Medical History:
- T12 compression fx
- spinal stenosis
- osteoporosis
- MS ___. Uses cane)
- h/o bilat PE in ___ s/p 6 mos coumadin
- GERD
- CKD
- right tib/fib fracture (___)
- S/P bilateral cataract surgery
- DJD
- DEPRESSION
- DIASTOLIC DYSFUNCTION (LVEF > 55% in ___
- bilat ___ edema since ___
- gait disorder with frequent falls
- HLD
- microvascular disease ___
- urinary frequency and occasional incontinence
- hypothyroidism
Social History:
___
Family History:
Denies family history of heart disease and stroke.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Afebrile, BP: 120/70. Heart Rate: 70. RR 20. O2 Saturation%: 94.
Alert, oriented, in NAD elderly female
wears back brace
skin - intact , no rashes
Neck - no lymphadenopathy, no masses, no enlarged thyroid
Lungs - CTA
Heart - S1S2, no murmurs, no gallops, rubs
Abdomen - soft, nontender, positive BS at 4 quadrants, no
rebound or guarding
Extremities - warm, well-perfused, 2+DP, trace pedal edema,
spinal point tenderness to palpation over the lumbar vertebrae
Neuro - intact sensation at all extremities, muscle strength
___ at all extremities, gait is stable, good rectal tone
DISCHARGE PHYSICAL EXAM:
Afebrile, BP 120/80s, HR ___
Unchanged with improved spinal tenderness to palpation
Pertinent Results:
ADMISSION LABS:
___ 03:20AM BLOOD WBC-3.3* RBC-2.81* Hgb-9.6* Hct-31.2*
MCV-111* MCH-34.3* MCHC-30.9* RDW-15.7* Plt ___
___ 03:20AM BLOOD Neuts-62.3 ___ Monos-6.3 Eos-4.7*
Baso-0.2
___ 03:20AM BLOOD Glucose-81 UreaN-25* Creat-1.1 Na-140
K-3.9 Cl-107 HCO3-25 AnGap-12
___ 07:10AM BLOOD LD(LDH)-214
___ 03:20AM BLOOD TotProt-5.3* Calcium-8.4 Phos-3.4 Mg-1.8
___ 07:25AM BLOOD VitB12-1002*
___ 07:10AM BLOOD Hapto-123
___ 03:20AM BLOOD PEP-NO SPECIFI
DISHCARGE LABS:
___ 07:10AM BLOOD WBC-2.5* RBC-2.82* Hgb-9.8* Hct-31.1*
MCV-111* MCH-34.7* MCHC-31.3 RDW-15.0 Plt ___
___ 07:10AM BLOOD Glucose-71 UreaN-27* Creat-1.2* Na-141
K-4.8 Cl-107 HCO3-27 AnGap-12
MICRO:
None
IMAGING:
___ Plain Films ___
IMPRESSION: Chronic changes as described above. No findings
concerning for an acute fracture. If clinical concern for
fracture persists, MR is recommended for further evaluation.
MRI ___ ___
Loss of normal bone marrow signal with increased signal on the
fluid sensitive sequence of the L1 vertebral body with
associated mild enhancement concerning likely related to acute
superior compression fracture. Follow up is recommended.
Chronic T12 compression fracture with mild retropulsion of the
supraposterior aspect of the T2 vertebral body effacing the
ventral thecal sac and causing remodeling the ventral aspect of
the cord without significant spinal canal narrowing.
Multilevel spondylosis as above:
-Moderate to severe right L2-L3 neural foraminal narrowing
-Severe left L2-L3 neural foraminal narrowing
-Severe L3-L4 and L4-5 spinal canal narrowing with crowding of
nerve roots
predominantly related to markedly thickened ligamentum flavum
which may be
ossified/calcified.
Peripheral location of nerve roots in the inferior thecal sac
possibly related to arachnoiditis.
Pelvis Plain Films ___
No evidence of pelvic fracture is seen. All the bones appear
intact.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Famotidine 40 mg PO BID
2. Tricor (fenofibrate nanocrystallized) 145 mg oral daily
3. Hydrochlorothiazide 25 mg PO DAILY
4. Levothyroxine Sodium 25 mcg PO DAILY
5. Creon (lipase-protease-amylase) 5K-18.75K-16.6K unit oral
daily
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
8. pramipexole 0.125 mg oral daily
9. Torsemide 10 mg PO DAILY
10. TraMADOL (Ultram) 50 mg PO DAILY
11. Aspirin 325 mg PO DAILY
12. Calcium Carbonate 500 mg PO DAILY
13. Magnesium Oxide 400 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
15. FoLIC Acid 1 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. Potassium Chloride 20 mEq PO DAILY
18. Lorazepam 0.5 mg PO HS:PRN insomnia
19. Mirtazapine 30 mg PO HS
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Famotidine 40 mg PO BID
3. Hydrochlorothiazide 25 mg PO DAILY
4. Levothyroxine Sodium 25 mcg PO DAILY
5. Lorazepam 0.5 mg PO HS:PRN insomnia
6. Vitamin D 1000 UNIT PO DAILY
7. Torsemide 10 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Multivitamins 1 TAB PO DAILY
10. Mirtazapine 30 mg PO HS
11. FoLIC Acid 1 mg PO DAILY
12. Metoprolol Succinate XL 50 mg PO DAILY
13. Tricor (fenofibrate nanocrystallized) 145 mg oral daily
14. TraMADOL (Ultram) 50 mg PO DAILY
15. pramipexole 0.125 mg oral daily
16. Magnesium Oxide 400 mg PO DAILY
17. Potassium Chloride 20 mEq PO DAILY
18. Creon (lipase-protease-amylase) 5K-18.75K-16.6K unit oral
daily
19. Calcium Carbonate 500 mg PO DAILY
20. Outpatient Physical Therapy
Patient found to have acute compression fracture of L1
vertebrae. Patient was seen by Physical Therapy who recommended
outpatient physical therapy.
21. walker 1 walker miscellaneous Daily
Diagnosis: L1 compression fracture, Reason: ambulation,
Prognosis: good, Length of Use: Lifetime.
RX *walker Use walker with ambulation daily Disp #*1 Each
Refills:*0
22. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg Take ___ tablets by mouth every 6 hours Disp
#*60 Tablet Refills:*0
23. Acetaminophen 650 mg PO Q6H:PRN pain
RX *acetaminophen 325 mg Take 2 tablets by mouth every 6 hours
Disp #*50 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Acute T1 Vertebral Compression Fracture
Secondary Diagnosis: CKD, MS, GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Severe low back pain.
COMPARISON: Lumbar spine radiographs ___.
FINDINGS:
Single frontal and three lateral views of the lumbar spine were reviewed.
There are 5 lumbar type vertebral bodies. Severe multilevel degenerative
disease is again seen with grade 1 anterolisthesis of L4 on L5 and grade 1
retrolisthesis of L2 on L3. Again seen is a severe compression deformity of
T12 with loss of greater than 50% of height. The bony pelvic ring is intact.
The sacroiliac joints are unremarkable. Extensive aortic and vascular
calcifications are present.
IMPRESSION: Chronic changes as described above. No findings concerning for an
acute fracture. If clinical concern for fracture persists, MR is recommended
for further evaluation.
Radiology Report
HISTORY: ___ year old woman with osteoporosis, T12 compression fracture, CKD
p/w acute onset lower back pain.
TECHNIQUE: Multi planar multisequence MR images of the lumbar spine were
obtained before and after the administration of intravenous contrast.
COMPARISON: None
FINDINGS:
There is mild retrolisthesis of L4 over L5. The bone marrow is diffusely
heterogeneous which may be a function of marrow conversion.
There is a compression fracture of the superior endplate of T12 predominant
along the central portion of the vertebral body, likely chronic given the lack
of increased signal on the fluid sensitive sequence. There is mild
retropulsion of the supraposterior aspect of the T2 vertebral body effacing
the ventral thecal sac and causing remodeling the ventral aspect of the cord
without significant spinal canal narrowing.
There is loss of normal bone marrow signal with increased signal on the fluid
sensitive sequence of the L1 vertebral body with associated mild enhancement,
findings may be related to an acute superior L1 compression fracture.
There are also compression deformities at superior L3 and L4, and to a lesser
extent L2; as well as inferior L2. There is multilevel loss of disc space
height with disc desiccation most prominent at L1-2, L4-5, and L5-S1.
T12-L1: Disc bulge, facet joint arthrosis, and marked ligamentum flavum
thickening without significant spinal canal narrowing and mild/moderate
bilateral neural foraminal narrowing.
L1-L2: Disc bulge encroaching upon the right greater the left subarticular
recesses with posterior endplate osteophytosis, ligamentum flavum thickening,
and facet joint arthrosis without significant spinal canal narrowing.
Moderate right and mild/moderate left neural foraminal narrowing.
L2-L3: Disk bulge narrows the left greater than right subarticular recesses.
Posterior endplate osteophytosis, marked ligamentum flavum thickening, and
facet arthrosis cause mild spinal canal and moderate to severe right neural
foraminal narrowing. There is a left-sided facet joint osteophyte causing
severe left neural foraminal narrowing.
L3-L4: Disk bulge encroaching upon the subarticular recesses, facet joint
arthrosis, and markedly thickened ligamentum flavum which may be
ossified/calcified causes severe spinal canal narrowing with crowding of nerve
roots. Mild bilateral neural foraminal narrowing.
L4-L5: Prominent disc bulge with posterior osteophytosis, facet joint
arthrosis, and ligamentum flavum hypertrophy cause severe spinal canal
narrowing with crowding of nerve roots. Mild bilateral neural foraminal
narrowing.
L5-S1: No disc bulge, or spinal canal or neural foraminal narrowing.
The visualized portion of the spinal cord has normal contours and signal
characteristics. The lower thoracic cord and conus are within normal limits.
The conus is at the level of L1. There is peripheral location of the nerve
roots in the inferior thecal sac possibly related to arachnoiditis.
The paraspinal regions are unremarkable.
The visualized intra-abdominal viscera is grossly unremarkable.
IMPRESSION:
Loss of normal bone marrow signal with increased signal on the fluid sensitive
sequence of the L1 vertebral body with associated mild enhancement concerning
likely related to acute superior compression fracture. Follow up is
recommended.
Chronic T12 compression fracture with mild retropulsion of the supraposterior
aspect of the T2 vertebral body effacing the ventral thecal sac and causing
remodeling the ventral aspect of the cord without significant spinal canal
narrowing.
Multilevel spondylosis as above:
-Moderate to severe right L2-L3 neural foraminal narrowing
-Severe left L2-L3 neural foraminal narrowing
-Severe L3-L4 and L4-5 spinal canal narrowing with crowding of nerve roots
predominantly related to markedly thickened ligamentum flavum which may be
ossified/calcified.
Peripheral location of nerve roots in the inferior thecal sac possibly related
to arachnoiditis.
Findings discussed by Dr. ___ telephone with ___ and Dr.
___ at 4:45 p.m. on ___.
Radiology Report
CLINICAL HISTORY: L1 compression fracture. Standing lumbar films, patient
wearing brace.
LUMBAR SPINE, THREE VIEWS
Lateral view shows no significant alteration in appearance since the prior
plain film lateral of ___ the ___. The degree of collapse of L1 is
unchanged. Multilevel spondylosis and severe degenerative changes are present
elsewhere.
IMPRESSION: No change on standing in alignment or degree of compression of
the lumbar spine since ___.
Radiology Report
CLINICAL HISTORY: Acute L1 compression fracture, now with sacral and pelvic
pain. Evaluate for pelvic fracture.
PELVIS, AP:
No evidence of pelvic fracture is seen. All the bones appear intact.
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: Lower back pain
Diagnosed with BACKACHE NOS
temperature: 97.3
heartrate: 72.0
resprate: 18.0
o2sat: 95.0
sbp: 133.0
dbp: 64.0
level of pain: 10
level of acuity: 2.0 | ___ y/o female with a past medical history of MS, CKD stage II,
PE, osteoporosis, T12 compression fracture who presents to the
ED with severe low back pain.
# L1 Compression Fracture
Patient reports continued lower spinal pain with negative plain
film imaging at OSH. Repeat lumbar plain films negative for
acute fracture however patient with poorly controlled pain. No
concerning symptoms or exam findings for spinal compression.
Patient had an MRI ___ which showed a new acute L1
compression fracture. She was seen by Orthopedics who
recommended that she wear a TLSO brace. Her pain was controlled
with Tylenol and Oxycodone. She was evaluated by ___ and
discharged home in stable condition. She was continued on
calcium and Vitamin D.
# Hypertension
She was continued on HCTZ and Metoprolol. Her blood pressure was
well-controlled.
# Hypothyroidism
She was continued on home levothyroxine.
# Chronic Diastolic Heart Failure
She was continued on metoprolol and torsemide.
# GERD
She was continued on home omeprazole. |
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, face pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
Mr. ___ is a ___ year old male with a history of tobacco
abuse, major depressive d/o with psychosis, left MCA stroke in
___ with expressive aphasia who presents from his group home
via EMS for complains of face pain and chest pain. Per group
home staff, patient has been in "a bad mood" but otherwise at
his baseline and they were unaware that he was having
difficulties until the
ambulance came to the house. In the ER he was unable to give a
good history, whether due to psychiatric disease or his aphasia.
In the ER he was expressing suicidality, but indicated to the
psychiatric consultants that he had had SI for months and had a
plan he would not disclose. Per ED staff he denied
hallucinations and said he had been given his psych meds by
group home staff.
ED COURSE:
Time Pain Temp HR BP RR Pox Glucose
11:06 unable 98.6 106 103/70 20 97% 0
14:30 69 ___ Non-Rebreather
15:27 74 116/79 20 99% Non-Rebreather
15:30 97.9
15:30 97.9 74 116/79 16 99% Non-Rebreather
-Exam: wet cough, L-lung rhonchi, calm, intermittently
cooperative, oriented to place
-Labs showed leukocytosis of 12.3, normal lactate, normal chem7,
COHb of 17%, normal toxicology screen, negative TnT
-Tox and psych consulted
-Imaging: normal CXR, normal CT head
-Received: cefazolin 1g, 500mg azithromycin, 1L NS
REVIEW OF SYSTEMS:
Denies fever, chills, night sweats, headache, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
+tooth pain over ___ tooth #6
All other 10-system review negative in detail.
Past Medical History:
#L MCA stroke ___ with subsequentexpressive aphasia, impaired
gait, right hand weakness
#Depression with psychotic features:
-Several hospitalizations (last Deac 4 ___, Arbour HRI ___
-Psychiatrist at ___: Dr. ___ ___
-Currently treated with ziprasidone, venlafaxine, trazodone
-Medication and ECT trials: haloperidol decanoate, olanzapine,
ziprasidone, venlafaxine, ECT x 7 per OMR
-Self-injury: per OMR history of suicide attempts OD ___
#Hyperlipidemia
#History of malaria
#Gunshot wound ___ to the right groin
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION EXAM:
VS: 96.7 115/83 76 20 100% NRB mask
General: Middle-aged man wearing non-rebreather mask in bed
breathing with ease
HEENT: Multiple dental caries and missing teeth. Slight
asymmetry with swelling in R buccal region without tension or
TTP of the R buccal area. There is no TTP over parotid. He
points to ___ tooth #6 when asked where tender. There is no
swelling of submental, sublingual spaces. Oropharynx is clear.
There is no sinus tenderness. There is significant periodontal
disease but no suppuration. No trismus.
Neck: No neck swelling or deformity
CV: RRR, no m/r/g
Lungs: Has coarse BS over L lower posterior chest that clears
with cough. Breathing with ease, no wheezing or crackles.
Non-rebreather was removed and he still breathes easily
Abdomen: Soft, NT, ND
GU: No foley, normal external genitalia
Ext: Warm, xerotic tibial skin
Skin: Slight erythema without induration or pain in R suborbital
skin. No ulcers or rashes.
Psych: his affect is flat, appearance is fairly groomed; calm,
participatory, follows commands, not showing psychomotor
agitation, not clearly attending to visual or auditory
hallucinations.
Neuro: Alert, answers almost all questions with "yes" or "no"
and does not use phrases. He follows simple commands. He
sometimes requires multiple prompts for answering questions.
CN: PERRL, EOMI, face symmetric with smile except for R cheek
swelling, tongue midline, shoulder shrug equal. No facial
stereotypy
Motor: Delt Bic Tri WrFl WrEx IP Ham Quad TA
L 5 5 5 5 5 ___ 5
R 5 4 4 5 4 ___ 5
DTRs Bic Tri Patell Achil
L 2 2 2 1
R 3 3 3 2
Tone: normal without rigidity or clonus
Sensation: intact to touch bilaterally
DISCHARGE EXAM:
GENERAL: well-appearing middle aged man lying in bed in NAD
HEENT: dental caries, gingival inflammation, several missing
teeth, face slightly more symmetric in right cheek today. No
palatal or OP erythema, vessicles, ulcers. R cheek non-tender to
compression. No trismus. No conjunctivitis
CV: RRR, no m/r/g
PULM: breathing with ease on room air, no wheezes, rales,
rhonchi. Coarse breath sounds in right lung that clear with
cough.
ABD: non-tender, non-distended
PSY/NEURO: alert, responds to questions laconically with 2 word
answers that are appropriate. Normal intonation, with no
paraphasic errors, stuttering. Slightly high speech latency.
Pertinent Results:
ADMISSION LABS
--------------
___ 12:03PM BLOOD WBC-12.3*# RBC-4.97 Hgb-14.8 Hct-43.4
MCV-87 MCH-29.7 MCHC-34.0 RDW-14.0 Plt ___
___ 12:03PM BLOOD Neuts-66.1 ___ Monos-3.5 Eos-3.2
Baso-0.1
___ 01:51PM BLOOD ___ PTT-32.1 ___
___ 12:03PM BLOOD Glucose-89 UreaN-8 Creat-0.9 Na-140 K-4.1
Cl-104 HCO3-26 AnGap-14
___ 12:03PM BLOOD cTropnT-<0.01
___ 12:03PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 12:12PM BLOOD Lactate-2.0
___ 12:12PM BLOOD O2 Sat-70 COHgb-17*
___ 12:55PM BLOOD ___ pO2-29* pCO2-44 pH-7.39
calTCO2-28 Base XS-0
___ 04:20PM URINE Color-Yellow Appear-Clear Sp ___
___ 04:20PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 04:20PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
DISCHARGE LABS
--------------
___ 06:40AM BLOOD WBC-8.9 RBC-4.57* Hgb-14.0 Hct-40.0
MCV-88 MCH-30.6 MCHC-34.9 RDW-13.7 Plt ___
IMAGING
-------
CT HEAD WITHOUT CONTRAST ___
IMPRESSION:
No acute intracranial abnormality.
Moderate mucosal thickening with in the right maxillary sinus
without
air-fluid levels or aerosolized secretions to suggest an acute
process.
Mild to moderate soft tissue stranding and prominence anterior
to the right maxilla is noted suggestive of cellulitis in the
correct clinical setting. The lower limit is not completely
included is not targeted.
Periapical lucency noted around the right canine and premolar
teeth of the maxilla. Correlate clinically with dental
examination.
Consider dedicated CT imaging of the face and neck as needed for
better
assessment. These are not adequately assessed on the present CT
head study as not targeted. Mildly prominent adenoids.
PANOREX DENTAL SERIES: PATIENT REFUSED
MICROBIOLOGY
------------
___ BLOOD CULTURES x2: PENDING at discharge
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Benztropine Mesylate 1 mg PO QHS
4. Docusate Sodium 100 mg PO BID
5. Omeprazole 20 mg PO DAILY
6. Simvastatin 20 mg PO QPM
7. Venlafaxine XR 150 mg PO DAILY
8. ZIPRASidone Hydrochloride 80 mg PO BID
9. TraZODone 50 mg PO QHS:PRN insomnia
10. DiphenhydrAMINE 25 mg PO QHS:PRN insomnia
11. Haloperidol 1 mg IM Q12H:PRN agitation
12. Aluminum-Magnesium Hydrox.-Simethicone 15 mL PO TID:PRN acid
reflux/chest pain
Discharge Medications:
1. Aluminum-Magnesium Hydrox.-Simethicone 15 mL PO TID:PRN acid
reflux/chest pain
2. Acetaminophen 1000 mg PO Q8H:PRN pain
3. Aspirin 81 mg PO DAILY
4. Benztropine Mesylate 1 mg PO QHS
5. DiphenhydrAMINE 25 mg PO QHS:PRN insomnia
6. Docusate Sodium 100 mg PO BID
7. Haloperidol 1 mg IM Q12H:PRN agitation
8. Omeprazole 20 mg PO DAILY
9. Simvastatin 20 mg PO QPM
10. TraZODone 50 mg PO QHS:PRN insomnia
11. Venlafaxine XR 150 mg PO DAILY
12. ZIPRASidone Hydrochloride 80 mg PO BID
13. Nicotine Patch 14 mg TD DAILY
14. Chlorhexidine Gluconate 0.12% Oral Rinse 15 mL ORAL BID
Duration: 7 Days
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
#Major depressive disorder, recurrent, severe with psychotic
symptoms
with psychotic features
#Expressive aphasia
#History of left ischemic stroke with residual deficits
#Encephalomalacia
#Dental caries
Discharge Condition:
Mental Status: Alert, responsive, expressive aphasia
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ man with chest pain and cough.
COMPARISON: Chest radiograph from ___.
FINDINGS:
The lungs are clear. The hilar and cardiomediastinal contours are normal.
There is no pneumothorax. There is no pleural effusion. Pulmonary vascularity
is normal.
IMPRESSION:
Normal radiographs of the chest.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with face pain, known cocaine-induced stroke, expressive
aphasia, face pain, chest pain.
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: DLP: 1338 mGy-cm
CTDI: 56 mGy
COMPARISON: CT dated ___
FINDINGS:
There is no acute hemorrhage, edema, or mass effect. Encephalomalacia
involving the left parietal, frontal, and temporal lobes in the MCA territory
is again identified with associated ex vacuo dilatation of the left lateral
ventricle. Right cerebellar encephalomalacia is compatible with prior
infarction, unchanged. There is no shift in midline structures. Basal cisterns
are clear. Gray-white matter differentiation is preserved.
Mild-moderate Soft tissue prominence and stranding anterior to the right
maxillary bone is noted. Limited assessment for facial fractures given the
technique.
There is moderate mucosal thickening with no air-fluid levels or aerosolized
secretions is noted in the right maxillary sinus. The remaining paranasal
sinuses, mastoid air cells and middle ear cavities are clear. No acute
fracture is identified. Periapical lucency noted around the right canine and
and premolar teeth of the maxilla.
Study somewhat limited due to motion related artifacts.
IMPRESSION:
No acute intracranial abnormality.
Moderate mucosal thickening with in the right maxillary sinus without
air-fluid levels or aerosolized secretions to suggest an acute process.
Mild to moderate soft tissue stranding and prominence anterior to the right
maxilla is noted suggestive of cellulitis in the correct clinical setting.
The lower limit is not completely included is not targeted.
Periapical lucency noted around the right canine and premolar teeth of the
maxilla. Correlate clinically with dental examination.
Consider dedicated CT imaging of the face and neck as needed for better
assessment.
These are not adequately assessed on the present CT head study as not
targeted.
Mildly prominent adenoids.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dental pain, Facial swelling
Diagnosed with TOXIC EFFECT OF CARBON MONOXIDE, ACC POIS-CARBN MONOX NOS, ACUTE SINUSITIS NOS, SUICIDAL IDEATION
temperature: 98.6
heartrate: 106.0
resprate: 20.0
o2sat: 97.0
sbp: 103.0
dbp: 70.0
level of pain: unable
level of acuity: 3.0 | =====================================================
___ case manager: ___ ___
___ Nurse coordinator: ___ ___
___ including ___ ___
=====================================================
ASSESSMENT AND PLAN: ___ year old Ethipian male with past history
of left MCA stroke in ___ with lasting expressive aphasia as
well as severe major depression with psychotic features
requiring ___ guardianship who presents from his group home
with complaints of facial swelling & dental pain. In the ER he
complained of suicidalilty so ___ initiated. Because of
carboxyhemoglobinemia and mild leukocytosis was admitted to
medicine for workup.
#Leukocytosis: White blood cell count was 12 in the ER. He
received cefazolin and azithromycin. There was concern for acute
bacterial rhinosinusitus or pneumonia. He was afebrile with
normal vital signs. He did not have bacterial sinusitis or
pneumonia clinically or radiographically. He did not have a
clear skin or soft-tissue infection of the face or neck to
warrant antibiotics. He most likely has an odontogenic infection
that lead to his leukocytosis, however, he had no pain or
purulence on exam and interval exam showed improvement of mild
facial asymmetry. Therefore, antibiotics were not continued and
when his WBC count was then normal the day after admission he
was felt to be medically cleared for discharge. A panorex dental
series was done for dental consultants to evaluate for any teeth
that would require extraction if he goes to an inpatient
psychiatric facility.
The dental consultant said that he would place a note in OMR
based on the Panorex dental imaging and could do inpatient
extractions, but not more complicated treatment planning such as
fillings. However, the patient refused to get dental X-rays.
Dental consult can see patient while on ___ 4 if necessary
for dental pain. They would be more insightful as to how
necessary the Panorex images are in the short term, rather than
deferring any tooth extraction to the outpatient setting.
Encourage oral hygiene with chlorhexidine oral rinse if
tolerated.
#Major depressive disorder with psychotic features, recurrent:
He has a history of complex psychiatric disease with psychotic
features associated with his depression. He has a ___
guardianship with ___ (___). He has been
hospitalized multiple times in the past and has had ECT in
addition to multiple antidepressants and antipsychotics. He saw
his psychiatrist (Dr. ___ last on ___ at which time
haloperidol PO was stopped in favor of higher dose ziprasidone.
Since then he may have had changing behavior and worsening
auditory hallucinations.
He was seen by psychiatry in the ER and ___ was
initiated prior to admission. Upon obtaining collateral from
community based flexible support (___) team and outpatient
psychiatrist, the psychiatry consult service concluded that Mr.
___ was off of his baseline because of recent refusal of care
and behavior changes. It was therefore recommended that he have
inpatient psychiatric admission for stabilization of his
psychiatric disease for fear of further decompensation if he
were to return home.
He otherwise appeared cognitively at baseline in terms of
answering questions with ___ word answers compared to his ___
neurology discharge exam in our documentation. He had no
findings of serotonin syndrome, neuroleptic malignant syndrome,
nor tardive dyskinesia.
He was continued on his home medications of venalafaxine XR
150 mg po qam, benztropine 1 mg po qhs, ziprasidone 80 mg po
BID, trazodone 50 mg po qhs.
#History of left ___ territory ischemic stroke: He had an
ischemic stroke in ___ with subsequent expressive aphasia,
encephalomalacia, gait instability, and right hand weakness. He
is able to speak in short answers, but responds appropriately to
questions. His speech is laconic, but without dysarthria or
paraphasic errors. He was continued on aspirin 81 mg daily.
#Carboxyhemoglobinemia: Presented with COHb ___. He is a
smoker and the most likely contributor is tobacco smoke
inhalation. He was treated with oxygen in the ER, which was
discontinued when he was admitted because the carbon monoxide
source had been removed.
#Tobacco abuse: Long-standing tobacco use. He was given a
nicotine patch 14 mg daily
#Hyperlipidemia: On simvastatin 20mg daily at home. This was
continued.
#GERD: On a proton-pump inhibitor at home. This was continued.
#CODE STATUS: FULL
TRANSITIONAL ISSUES
-------------------
-please contact the patient's guardian with any medication
changes as these must conform to a treatment plan
-if he does not have inpatient tooth extraction by BID dental
consultants, he requires close follow up with a dentist after
discharge from inpatient psychiatry for tooth extraction |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
L acetabulum fracture
Major Surgical or Invasive Procedure:
___: L acetabulum ORIF
History of Present Illness:
Ms. ___ is an otherwise healthy ___ yo F visiting
from
___, who tripped over 1 step while doing laundry and sustained a
Left acetabular fracture. Immediate onset of pain and inability
to bear weight. She was initially taken to ___, then
transferred here. No HS or LOC. Denies pain elsewhere. No
numbness or pareshesias. Active, independent community ambulator
at baseline. Minimal pain in left hip previously.
Past Medical History:
Osteoporosis
HLD
Social History:
___
Family History:
n/c
Physical Exam:
PHYSICAL EXAMINATION:
General: Well-appearing female in no acute distress.
Left lower extremity:
- Pelvis stable to compression
- Tender to palpation
- Minor skin contusions around incision, dressing c/d/I with
some serous drainage
- No deformity, edema, ecchymosis, erythema, induration
- Soft, non-tender thigh and leg
- Full, painless ROM at ankle
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
Pertinent Results:
___ 07:20PM GLUCOSE-144* UREA N-16 CREAT-0.5 SODIUM-136
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-24 ANION GAP-14
___ 07:20PM estGFR-Using this
___ 07:20PM WBC-13.0* RBC-3.04* HGB-9.5* HCT-29.1* MCV-96
MCH-31.3 MCHC-32.6 RDW-13.7 RDWSD-47.8*
___ 07:20PM PLT COUNT-189
___ 06:30AM GLUCOSE-138* UREA N-22* CREAT-0.6 SODIUM-137
POTASSIUM-4.1 CHLORIDE-100 TOTAL CO2-25 ANION GAP-16
___ 06:30AM estGFR-Using this
___ 06:30AM URINE HOURS-RANDOM
___ 06:30AM WBC-9.4 RBC-3.77* HGB-11.6 HCT-35.8 MCV-95
MCH-30.8 MCHC-32.4 RDW-13.5 RDWSD-46.8*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tretinoin 0.025% Cream 1 Appl TP EVERY OTHER NIGHT
2. Alendronate Sodium 70 mg PO QWED
3. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Atorvastatin 10 mg PO QPM
3. Calcium Carbonate 500 mg PO TID
4. Docusate Sodium 100 mg PO BID
5. Heparin 5000 UNIT SC BID
RX *heparin (porcine) 5,000 unit/mL (1 mL) 1 cartridge
subcutaneous twice a day Disp #*28 Cartridge Refills:*0
6. Multivitamins 1 TAB PO DAILY
7. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain
RX *oxycodone [Oxaydo] 5 mg ___ tablet(s) by mouth every 4
hours as needed for pain Disp #*40 Tablet Refills:*0
8. Senna 8.6 mg PO BID
9. Vitamin D 400 UNIT PO DAILY
10. Alendronate Sodium 70 mg PO QWED
11. Aspirin 81 mg PO DAILY
12. Tretinoin 0.025% Cream 1 Appl TP EVERY OTHER NIGHT
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L acetabulum fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman fr OSH with left hip fracture // ? fracture
TECHNIQUE: AP, inlet, outlet, and oblique views of the pelvis.
COMPARISON: ___ at 00:44.
FINDINGS:
Comminuted left acetabular fracture is again noted. Left superior and
inferior pubic rami fractures are also noted. Pubic symphysis and SI joints
are preserved. Proximal femurs demonstrate no acute fracture. Degenerative
changes are noted at the hips, right greater than left with joint space loss
and subchondral sclerosis.
IMPRESSION:
Acute fractures involving the left acetabulum, left superior and inferior
pubic rami.
Radiology Report
EXAMINATION: PELVIS (AP ONLY)
INDICATION: ORIF left acetabular fracture.
TECHNIQUE: Screening provided knee operating room without a radiologist
present. Total fluoroscopy time 4.1 seconds.
COMPARISON: ___.
FINDINGS:
Images demonstrate fixation of left acetabular fracture with plates and
screws. For details of the procedure please see the procedure report.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, L Hip fracture
Diagnosed with Disp fx of anterior column of left acetabulum, init, Fall on same level, unspecified, initial encounter
temperature: 99.0
heartrate: 110.0
resprate: 18.0
o2sat: 97.0
sbp: 137.0
dbp: 63.0
level of pain: 7
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a L acetabulum fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for a L acetabulum orif, which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient began
experiencing continued bleeding from the incisional site during
POD#1 for which her lovenox was put on hold from POD1-3. The
bleeding stopped and the patient was restarted on
anticoagulation. The patient's home medications were continued
throughout this hospitalization. The patient worked with ___ who
determined that discharge to rehab was appropriate. The
___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
touch down weight bearing in the left extremity, and will be
discharged on 5000 units subcutaneous heparin for DVT
prophylaxis. The patient will follow up with Dr. ___
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course
including reasons to call the office or return to the hospital,
and all questions were answered. The patient was also given
written instructions concerning precautionary instructions and
the appropriate follow-up care. The patient expressed readiness
for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amoxicillin / Iodinated Contrast- Oral and IV Dye / Percodan
Attending: ___.
Chief Complaint:
Dyspnea, weakness/fatigue
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ y/o female with a history of COPD, PE on
lovenox, and metastatic SCLC with prior hospitalization for
pericardial effusion who now presents for weakness, dyspnea, and
poor appetite.
Pt called into clinic today with complaints of exhaustion and
poor appetite. She reported that she has spent the last two days
in bed and has not had anything to eat or drink during this
time.
She also reported worsening dyspnea. She felt that all of her
symptoms worsened after immunotherapy on ___. Due to
concern for failure to thrive and possibly autoimmune
hypothyroidism or panhypopituitarism, she was asked to present
to
the ED.
In the ED, initial VS were: T 98.6, HR 80, BP 122/72, RR 18, O2
98% RA
Exam notable for fatigued appearing female, diminished left
sided
lung sounds and bilateral crackles, normal bowel sounds.
Labs notable for:
- WBC 7.3, Hgb 12.6, Plt 115
- INR 1.1
- Cr 1.1, Na 143, K 3.2 (received 40 PO K), Bicarb 34, AG 14,
Glucose 164
- ALT 22, AST 37, Alk phos 85, Tbili 0.7, lipase 72
- Trop 0.01
- Albumin 3.3
- TSH pending, cortisol pending
- Stox negative
- VBG 7.48/49
- Lactate 2.0
- Blood cultures pending
Imaging notable for:
CXR ___:
New elevation of left hemidiaphragm with stomach seen beneath
and
with rightward shift of the mediastinum, new since PET-CT from
___ and chest radiograph from ___. Correlate
with any interval procedure or injury versus other region for
left diaphragmatic hernia or diaphragmatic paralysis.
Left pleural thickening better assessed on preceding CT.
Possible
small left pleural effusion.
She was given 40 mEq of potassium.
Upon arrival to the floor, the patient reports that she
currently
feels tired but has no acute complaints. She confirms the above
history, and reports that she has had poor appetite, fatigue,
and
weakness all worse since her most recent immunotherapy
appointment. She says it takes her significant energy to even
stand up and go to the restroom. She has not eaten anything in
the last 24 hours due to poor appetite, although she denies
nausea/vomiting. She reports feeling colder than usual. She also
reports that she is being treated for thrush. She denies recent
fevers, travel, cough, chest pain, abdominal pain,
diarrhea/constipation, and dysuria.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
PAST ONCOLOGIC HISTORY:
___: Presented with chest pain, CT Chest notable for left
upper lobe endobronchial impaction with peripheral consolidation
and hilar adenopathy. PCP documented ___ reluctance to pursue
treatment with chemotherapy if cancer.
___ Presented to IP with dry cough, dyspnea fatigue and
weight loss with Chest CT revealing 9cm nodal conglomeration in
the prevascular and left hilar region, encasing the left upper
lobe bronchus and left hilar vessels.
___ EBUS bx of endobronchial lesion and lymph node
with
pathology revealing poorly differentiated malignant neoplasm,
immunohistochemistry negative. Level 7 lymph node negative for
malignant cells.
___ Admitted to CCU after PET-CT demonstrated large
pericardial effusion with e/o tamponade, additionally notable
for
invasive LUL lung mass significantly increased in size from
prior
CT chest now with invasion of left hilum, mediastinum,
pericardium, and pleura with occlusion of LUL bronchus. Also
with
large mass at lower pole of left kidney measuring 4.5cm. MRI
head
showing numerous intracranial mets with vasogenic edema.
Pericardial effusion was drained with cytology positive for
malignant cells. Remained in hospital until ___ following C1
carboplatin/etoposide (___) c/b febrile neutropenia treated
with cefepime until count recovery (no source identified).
Hospital course additionally notable for AF, for which
transitioned from nadolol to 100mg metoprolol tartrate BID.
Discharged on therapeutic lovenox for PE iso malignancy, AF.
___ - C2D1 Carboplatin (AUC 4)/Etoposide (80mg/m2),
neulasta
given
___ - PR on PET/CT, bMRI (no new lesions, or areas of
progression)
___ - C3D1 Carboplatin (AUC 4)/Etoposide (80mg/m2),
neulasta given
___ - C4D1 Carboplatin (AUC 3.5)/Etoposide (60mg/m2),
neulasta given
___ - ___ - Pt had been considering SRS/CK rather
than WBRT, but interval bMRI demonstrated several enlarging
brain
metastases. Dr. ___ this excluded her from SRS/CK
and pt declined WBRT.
___ - PET/CT Torso with marked disease progression
as evidenced by a new 5.3 cm FDG avid subpleural mass along the
left anterolateral chest wall, several new subcentimeter FDG
avid
nodules in the lingula, worsening mediastinal and left hilar
lymphadenopathy and increased size and FDG avidity of a 4.0 cm
mass at the left lower renal pole. Same day brain MRI with
worsening infratentorial and supratentorial metastatic disease
with new lesions and enlargement of the previously seen lesions.
___ - Evaluated in ED for hematuria iso known renal mass
(suspected metastasis) on lovenox. She was evaluated and felt
safe for d/c on lovenox
Past Medical History:
1. CVD Risk Factors
- family history- heart disease in father
- obesity
2. Cardiac History
- none
3. Other PMH
- COPD
- PE in ___, on warfarin
- osteopenia
- colonic adenoma
- diverticulosis
Social History:
___
Family History:
- Father- heart disease
- Mother- lung disease, osteoporosis
- sister- lung cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.1, BP 168 / 80, HR 88, RR 20, ___ NC
GENERAL: NAD, appears comfortable
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, mild systolic murmur
PULM: Diminished breath sounds at left base. Clear to
auscultation in right lung fields, no wheezing
ABD: abdomen soft, nondistended, nontender in all quadrants
EXT: wwp, no cyanosis, clubbing, or edema, 2+ radial pulses
bilaterally
SKIN: Warm and well perfused
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
Discharge:
GENERAL: NAD, appears comfortable, alert
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, no LAD
CV: RRR, S1/S2, mild systolic murmur
PULM: CTAB anteriorly
ABD: abdomen soft, nondistended, nontender in all quadrants
EXT: wwp, no cyanosis, clubbing, or edema, 2+ radial pulses
bilaterally
SKIN: Warm and well perfused
NEURO: Alert, oriented x3 but with some word finding
difficulties, moving all 4 extremities with purpose, face
symmetric. Appears very frustrated today.
Pertinent Results:
ADMISSION LABS:
===============
___ BLOOD WBC-7.3 RBC-3.82* Hgb-12.6 Hct-37.1 MCV-97
MCH-33.0* MCHC-34.0 RDW-12.7 RDWSD-45.4 Plt ___
___ BLOOD Glucose-164* UreaN-28* Creat-1.1 Na-143 K-3.2*
Cl-95* HCO3-34* AnGap-14
___ BLOOD ALT-22 AST-37 AlkPhos-85 TotBili-0.7
___ BLOOD Albumin-3.3* Calcium-9.0 Phos-2.4* Mg-2.0
___ BLOOD TSH-1.9
___ BLOOD Cortsol-73.3*
MICROBIOLOGY:
==============
___ Blood Culture, Routine (Pending)
IMAGING:
=========
PET/CT scan ___:
Compared to ___, there is marked disease
progression
as evidenced by a new 5.3 cm FDG avid subpleural mass along the
left anterolateral chest wall, several new subcentimeter FDG
avid
nodules in the lingula, worsening mediastinal and left hilar
lymphadenopathy and increased size and FDG avidity of a 4.0 cm
mass at the left lower renal pole.
CXR ___:
New elevation of left hemidiaphragm with stomach seen beneath
and
with rightward shift of the mediastinum, new since PET-CT from
___ and chest radiograph from ___. Correlate
with any interval procedure or injury versus other region for
left diaphragmatic hernia or diaphragmatic paralysis.
Left pleural thickening better assessed on preceding CT.
Possible
small left pleural effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 1500 mg PO BID
2. Multivitamins 1 TAB PO DAILY
3. Tiotropium Bromide 1 CAP IH DAILY
4. Metoprolol Tartrate 100 mg PO DAILY
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
6. Enoxaparin Sodium 80 mg SC DAILY Hx of PE
Start: ___, First Dose: Next Routine Administration Time
7. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
8. Prochlorperazine 10 mg PO Q8H:PRN Nausea/Vomiting - Second
Line
9. Magnesium Oxide 400 mg PO Frequency is Unknown
10. Nystatin Oral Suspension 5 mL PO TID
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
2. Enoxaparin Sodium 80 mg SC DAILY Hx of PE
Start: ___, First Dose: Next Routine Administration Time
3. Prochlorperazine 10 mg PO Q8H:PRN Nausea/Vomiting - Second
Line
4. Tiotropium Bromide 1 CAP IH DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
#metastatic SCLC
# Failure to thrive
# Weakness
# Malnutrition
Secondary:
# Oral candidiasis:
# Atrial fibrillation:
# History of pulmonary embolism
# COPD:
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with sob, cancer// sob, cancer
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___ chest radiograph from PET-CT from ___
FINDINGS:
There is elevation of the left hemidiaphragm with stomach seen beneath, new
since the prior study. There is subsequent rightward shift of the
mediastinum. There is also likely a small to moderate left pleural effusion
with overlying atelectasis. No focal consolidation or pleural effusion is
seen on the right.
IMPRESSION:
New elevation of left hemidiaphragm with stomach seen beneath and with
rightward shift of the mediastinum, new since PET-CT from ___ and
chest radiograph from ___. Correlate with any interval procedure
or injury versus other region for left diaphragmatic hernia or diaphragmatic
paralysis.
Left pleural thickening better assessed on preceding CT. Possible small left
pleural effusion.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Weakness
Diagnosed with Other fatigue, Adult failure to thrive
temperature: 98.6
heartrate: 86.0
resprate: 17.0
o2sat: 96.0
sbp: 158.0
dbp: 67.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ y/o female with a history of COPD, PE on
lovenox, and metastatic SCLC with prior hospitalization for
pericardial effusion who now presents for weakness, dyspnea, and
poor appetite.
# Failure to thrive
# Weakness
# Malnutrition
Pt presents with subacute failure to thrive characterized by
weakness, exhaustion, poor appetite, and dyspnea. She had few
lab abnormalities on admission except for hypokalemia and
hypoalbuminemia. She met with her outpatient oncology team while
inpatient who felt that these symptoms were due mostly to
progression of her cancer, and recommended hospice. The patient
agreed, and decision was made to go to a hospice house.
# Hypoxia
# Dyspnea
Her worsening dyspnea and hypoxia are likely secondary to
progression of her SCLC. PET/CT in ___ demonstrated new
subpleural mass along anterolateral chest wall, new nodules in
lingual, and worsening mediastinal and left hilar
lymphadenopathy. No wheezing or evidence to suggest active COPD
exacerbation. No CXR evidence of infection. She was given
supplemental O2 to maintain oxygen saturation > 92% which will
continue at hospice and her home inhalers were continued. There
is no indication to start antibiotics.
# Extensive stage SCLC: Pt with diagnosis of SCLC in ___,
now s/p 4 cycles of carboplatin/etoposide. Pt excluded from
SRS/CK due to enlarging brain metastases and patient declined
WBRT. PET/CT scan in ___ showed overall disease
progression. Pt was initiated on nivolumab in ___ and
received her ___ cycle on ___ and second cycle on ___. No
further treatments are planned and the patient is transitioned
to hospice hospice.
For nausea, she was given Zofran prn and prochlorperazine prn
For pain, she was given Acetaminophen prn
# Oral candidiasis: stopped nystatin since going to hospice
# Atrial fibrillation: holding rate control with metoprolol
given hospice. Continuing lovenox but if patient decides she
doesn't want to take it she can refuse.
# History of pulmonary embolism: continuing lovenox.
# COPD: Continue home albuterol and tiotropium
More than 30 minutes were spent preparing this discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
erythromycin base
Attending: ___
Chief Complaint:
word finding difficulty, difficulty ambulating
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ F w recent admission to neurosurgery
service for traumatic SDH and SAH from ___ (no
operative management required) and PMHx of Afib (off coumadin
since fall and bleeds), HTN, and HLD who presents to ___ ED as
a transfer from ___ after she was noted to
have word finding difficulty and difficulty ambulating at around
14:00 on ___. Deficits noted to be resolved within 5
minutes.
She was transferred to ___ ED at the request of her family
members for further evaluation.
Ms. ___ reports that on the afternoon of ___, she was
helping prepare dinner and clean the house up for her daughter's
birthday. She admits "I may have overdid it." Dinner was served
around 1PM(?) and she ate and conversed at the dinner table
without any difficulty. At about 2PM, after she had finished her
meal, she got up to go "sit in a soft chair" because she was
feeling tired. As she got up, she felt as if she was having
trouble standing and "felt funny." Her daughter reports, "it
looked like she had forgotten how to put one foot in front of
the
other." She told her family "I don't think I can walk" and her
son-in-law brought her a chair to sit down in. While she was
sitting in the chair, she tried to talk to her family but felt
like she was having difficulty getting her words out. She states
that she had no difficulty in comprehending what was being said
to her, she knew what she wanted to say, but "it was taking
longer" to get the right words out. Her family was unable to
appreciate a specific speech disturbance, but they did note that
Ms. ___ was not acting like herself. Her daughter called ___
and EMS arrived shortly.
Ms. ___ believes that her deficits resolved completely within
___ minutes and states that by the time EMS arrived, she was
back to her baseline.
Ms. ___ states that on the morning of her presentation, she
had a very mild headache but that it had resolved by the time of
her deficits. She reports that both of her legs felt "weak" but
denies any focal motor or sensory deficits. She denies visual
changes, difficulty swallowing, or problems with her bowel or
bladder.
Past Medical History:
- traumatic small right-sided SDH and left parietal SAH
- atrial fibrillation (off coumadin since ___
- silent L cerebellar CVA (seen on imaging, patient denies this)
- hypertension
- hyperlipidemia
- osteoarthritis
- L knee replacement
- R hip replacement
Social History:
___
Family History:
Mother - CVA in her ___
Father - MI in his ___
Physical Exam:
ADMISSION PHYSICAL EXAMINATION
VS T98.2 HR81 BP153/88 RR21 Sat95%RA
GEN - elderly F, pleasant and cooperative, NAD
HEENT - NC/AT, MMM
NECK - full ROM, no meningismus
CV - irregularly irregular
RESP - normal WOB
ABD - soft, NT, ND
EXTR - atraumatic, warm and well perfused
NEUROLOGICAL EXAMINATION
MS ___, MOYB are slow but correct; able to recount remote and
recent medical history; language is fluent with normal prosody
and no paraphasic errors; naming, repetition, and comprehension
are all intact; appropriate fund of knowledge; no evidence of
apraxia or neglect
CN - VFF to finger counting, EOMI without nystagmus, facial
sensation intact to LT and temperature; face symmetric at rest
and with activation; hearing intact to voice; palate elevates
symmetrically; no dysarthria; SCMs and traps are full power;
tongue is midline with full ROM
MOTOR - normal tone, age appropriate decrease in bulk; some
orbiting about the LUE (though LUE has pulse ox and PIV); no
focal weakness appreciated on confrontational strength testing
SENSORY - intact to LT and temperature throughout
REFLEXES - 2+ throughout, absent at ankles, toes are mute
COORD - no gross evidence of truncal or appendicular ataxia
GAIT - deferred
DISCHARGE EXAM:
Bilateral pattern of LMN weakness and wasting in upper
extremities, UMN weakness in BLE consistent with cervical
myelopathy.
Pertinent Results:
ADMISSION LABS ___
WBC-4.9 RBC-3.77* Hgb-12.8 Hct-39.4 MCV-105* RDW-13.3 Plt
___
Neuts-57.7 ___ Monos-10.2 Eos-1.8 Baso-0.6 Im ___
AbsNeut-2.84 AbsLymp-1.44 AbsMono-0.50 AbsEos-0.09 AbsBaso-0.03
___ PTT-18.9* ___
Glucose-106* UreaN-25* Creat-1.1 Na-142 K-3.5 Cl-102 HCO3-25
AnGap-19
Albumin-4.0 Calcium-9.6 Phos-3.8 Mg-1.7
ALT-7 AST-20 LD(LDH)-184 CK(CPK)-26* AlkPhos-69 TotBili-0.5
Lipase-47
___ 08:50PM cTropnT-<0.01
___ 06:02AM CK-MB-2 cTropnT-<0.01
UA: Bland
Urine/serum tox: Negative
STROKE RISK FACTORS:
Cholest-145 Triglyc-154* HDL-41 CHOL/HD-3.5 LDLcalc-73
%HbA1c-5.9 eAG-123
TSH-2.0
IMAGING
___ CXR
In comparison with the study of ___ from an outside
facility, there is again extensive opacification involving the
lower half of the right hemithorax, consistent with pleural
effusion and substantial volume loss in the right middle and
lower lobes. In the appropriate clinical setting, superimposed
pneumonia would be impossible to exclude. No evidence of
abnormality involving the left hemithorax or pulmonary vascular
congestion.
___ CT Chest
Large, layering, nonhemorrhagic right pleural effusion
responsible for right lower lobe collapse. Multiple nondisplaced
right upper rib fractures. No associated bleeding. Borderline
enlarged lymph node at the thoracic outlet raises concern if the
patient has a history of head and neck malignancy. 14 mm left
thyroid lesion should be evaluated with ultrasound.
RECOMMENDATION(S): Borderline enlarged lymph node at the
thoracic outlet raises concern if the patient has a history of
head and neck malignancy. 14 mm left thyroid lesion should be
evaluated with ultrasound.
___ MRI
1. No evidence of infarction or hemorrhage.
2. Moderate periventricular, subcortical, and deep white matter
T2/FLAIR
signal hyperintensity which is nonspecific but likely on the
basis of chronic small vessel ischemic disease.
3. Unremarkable MRA of the head and neck.
RECOMMENDATION Multiple bilateral thyroid nodules. Further
evaluation with ultrasound could be performed on a non urgent
basis.
___ CXR
As compared to the previous radiograph, the patient has received
a right-sided chest tube. The tube is in correct position.
Almost all the right pleural effusion was drained. The might be
a minimal pneumothorax at the site of tube insertion, at the
medial bases of the right lung. No apical pneumothorax. Normal
appearance of the heart and of the left lung.
___ ECHO
The left atrial volume index is moderately increased. No left
atrial mass/thrombus seen (best excluded by transesophageal
echocardiography). No atrial septal defect is seen by 2D or
color Doppler. 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 leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. Moderate [2+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. Moderate
pulmonary artery systolic hypertension. Mild mitral
regurgitation. The rhythm appears to be atrial fibrillation.
CLINICAL IMPLICATIONS:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
___ CT Chest
IMPRESSION:
New airspace abnormality in the right middle and lower lobes has
developed progressively following right pleural drainage. There
is no evidence of lung trauma or cavitation to indicate a
necrotizing infection. This still could be pneumonia, or
nontraumatic hemorrhage, for example if the patient has
dilutional thrombocytopenia from multiple transfusions. It
could also be progressive re-expansion edema particularly if the
chest is subjected to high negative pressure.
Right basal pleural drainage catheter which drained nearly all
of the previous right pleural effusion, is fissural which could
lead to dysfunction, explaining moderate right anterior
pneumothorax.
___ CXR Chest PA/Lat
IMPRESSION:
As compared to the previous radiograph: The consolidation at
the right lung base is substantially smaller. There is an
unchanged 2 cm right apical pneumothorax without evidence of
tension. Normal appearance of the left lung. Unchanged shape
and size of the cardiac silhouette.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 20 mg PO DAILY
2. Carvedilol 12.5 mg PO BID
3. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
4. Vitamin D 1000 UNIT PO DAILY
5. Vitamin B Complex 1 CAP PO DAILY
6. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Carvedilol 25 mg PO BID
RX *carvedilol 25 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*5
2. Apixaban 2.5 mg PO BID
RX *apixaban [Eliquis] 2.5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*5
3. Multivitamins 1 TAB PO DAILY
4. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
5. Vitamin B Complex 1 CAP PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
transient ischemic attack
exudative pleural effusion
atrial fibrillation
hypertension
suspected cervical stenosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK
INDICATION: ___ year old woman with TIA vs complex partial seizure // stroke
eval
TECHNIQUE: Three dimensional time of flight MR arteriography was performed
through the brain with MIP reconstructions. Dynamic MRA of the neck was
performed during administration of 15cc of Multihance intravenous contrast.
Brain imaging was performed with sagittal T1 and axial FLAIR, T2, gradient
echo and diffusion technique.
COMPARISON: No prior MRI or MRA available for comparison. Prior head CT
without contrast dated ___.
FINDINGS:
Image quality is mildly degraded by artifact.
MRI Brain: There is no evidence of hemorrhage, edema, masses or infarction.
Ventricles and sulci are moderately prominent likely related age-related
parenchymal volume loss. There is periventricular subcortical, and deep white
matter T2/FLAIR signal hyperintensity which is nonspecific but likely on the
basis of chronic small vessel ischemic disease. There is similar T2/FLAIR
signal hyperintensity in the central pons also likely reflective of chronic
small vessel ischemic disease. Major vascular flow voids are preserved.
Patient is status post bilateral lens replacement. There is minimal mucosal
thickening within the ethmoid air cells. Remaining paranasal sinuses and
mastoid air cells are clear.
MRA brain: The intracranial vertebral and internal carotid arteries and their
major branches appear normal without evidence of stenosis, occlusion, or
aneurysm formation. Incidentally noted is an accessory anterior cerebral
artery.
MRA neck: The common, internal and external carotid arteries appear normal.
There is no evidence of stenosis by NASCET criteria. The origins of the great
vessels, subclavian and vertebral arteries appear normal bilaterally.
There are bilateral nonenhancing nodules noted in the thyroid gland.
IMPRESSION:
1. No evidence of infarction or hemorrhage.
2. Moderate periventricular, subcortical, and deep white matter T2/FLAIR
signal hyperintensity which is nonspecific but likely on the basis of chronic
small vessel ischemic disease.
3. Unremarkable MRA of the head and neck.
RECOMMENDATION Multiple bilateral thyroid nodules. Further evaluation with
ultrasound could be performed on a non urgent basis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with speech disturbance // r/o infection
r/o infection
IMPRESSION:
In comparison with the study of ___ from an outside facility, there is
again extensive opacification involving the lower half of the right
hemithorax, consistent with pleural effusion and substantial volume loss in
the right middle and lower lobes.
In the appropriate clinical setting, superimposed pneumonia would be
impossible to exclude.
No evidence of abnormality involving the left hemithorax or pulmonary vascular
congestion.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old woman with history of atrial fibrillation, fall and
intracranial hemorrhage who presents w/ TIA, found to have large R pleural
effusion // evaluate for hemothorax vs underlying mass
TECHNIQUE: Multi detector helical scanning of the chest was coordinated with
intravenous infusion of nonionic iodinated contrast agent and reconstructed as
5 and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP
axial images. All images were reviewed.
DOSAGE: TOTAL DLP 240mGy-cm
COMPARISON: There no prior chest CT scans available.
FINDINGS:
There are no pathologically enlarged supraclavicular or axillary lymph nodes,
no soft tissue abnormalities in the chest wall suspicious for malignancy,
infection, or trauma. Breast evaluation requires mammography.
The larger of 2 well-circumscribed hypodensities in the left thyroid lobe is
14 mm, warranting further evaluation with ultrasound.
Atherosclerotic calcification in head and neck vessels is moderate, but not
apparent in the coronary arteries.
Aorta and pulmonary arteries are normal caliber. Small pericardial effusion
is physiologic.
A large nonhemorrhagic right pleural effusion is collected predominantly
posteriorly and at the base of the right hemi thorax. It is probably
responsible for right lower lobe collapse and milder atelectasis in the right
middle lobe. Small nonhemorrhagic left pleural effusion layers posteriorly as
well. This study is not designed for subdiaphragmatic diagnosis, but the
adrenal glands are normal and there is no explanation for right pleural
effusion in the upper abdomen. A 10 mm hypodensity in the left lobe of the
liver is too small to evaluate.
Multiple fractures of the right second and third ribs and the right second
costo chondral junction are minimally displaced, but there is no associated
hematoma.
Aside from a solitary a 9 mm calcification in the right middle lobe, lungs are
clear of focal abnormalities. Sub cm lymph nodes are numerous in the
mediastinum, but not pathologically enlarged. The largest, 8 x 14 mm at the
thoracic inlet, 03:10 would warrant further evaluation if the patient has a
known history of head and neck malignancy.
.
IMPRESSION:
Large, layering, nonhemorrhagic right pleural effusion responsible for right
lower lobe collapse.
Multiple nondisplaced right upper rib fractures. No associated bleeding.
Borderline enlarged lymph node at the thoracic outlet raises concern if the
patient has a history of head and neck malignancy. 14 mm left thyroid lesion
should be evaluated with ultrasound.
RECOMMENDATION(S):
Borderline enlarged lymph node at the thoracic outlet raises concern if the
patient has a history of head and neck malignancy. 14 mm left thyroid lesion
should be evaluated with ultrasound.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with large right effusion s/p chest tube
placement // ? PTX
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, the patient has received a right-sided
chest tube. The tube is in correct position. Almost all the right pleural
effusion was drained. The might be a minimal pneumothorax at the site of tube
insertion, at the medial bases of the right lung. No apical pneumothorax.
Normal appearance of the heart and of the left lung.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with large pleural effusion drained ___ //
6:00am, eval pleural effusion
TECHNIQUE: Chest PA and lateral
COMPARISON: ___, and 30
FINDINGS:
Since ___ the moderate right pleural effusion has resolved, with an
underlying heterogeneous opacity in the right lower lobe that has increased in
density, concerning for pulmonary parenchymal contusion/hemorrhage or
developing pneumonia. Heart size is normal and the lungs are otherwise clear.
Trace left pleural effusion is again seen.
IMPRESSION:
1. Heterogeneous parenchymal opacity in the right lower lobe has increased in
density since the prior study, concerning for pulmonary hemorrhage or
increasing pneumonia.
2. Right pleural effusion has been drained and there is trace left pleural
fluid.
NOTIFICATION: Findings discussed with Dr. ___ by Dr. ___ at 1048AM.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ year old woman with right pleural effusion s/p chest tube with
residual consolidation. evaluate for etiology of pleural effusion. //
evaluate for pneumonia, malignancy
TECHNIQUE: Multi detector helical scanning of the chest was coordinated with
intravenous infusion of nonionic iodinated contrast agent and reconstructed as
5 and 1.25 mm thick axial, 2.5 mm thick coronal and parasagittal, and 8 mm MIP
axial images. All images were reviewed.
DOSAGE: TOTAL DLP 257.0mGy-cm
COMPARISON: Contrast chest CT ___, and conventional chest
radiographs ___ through ___ at 08:23. .
FINDINGS:
Since ___, a right basal pigtail pleural drainage catheter has been
inserted, from a lateral approach, cannulating the right major fissure,
terminating against the mediastinum at the level of the inferior cavoatrial
junction. There is no associated hemorrhage either in the lung, mediastinum,
pleura, or chest wall nor any fluid loculation. A moderate volume of right
pleural air is collected anteriorly.
Extensive ground-glass opacification with coalescence to near consolidation
has developed in the right middle lobe, mostly lateral segment, but
predominantly in the right lower lobe superior, anterior and lateral basal
segments. There is no cavitation. Left lung is clear. Tiny left pleural
effusion is stable. There is only physiologic pericardial effusion,
unchanged.
Multiple minimally displaced right upper rib fractures are stable, also free
of local bleeding.
Aorta and pulmonary arteries are unremarkable, with no filling defects.
Left lung is essentially clear.
This study is not designed for subdiaphragmatic diagnosis but shows hepatic
steatosis.
IMPRESSION:
New airspace abnormality in the right middle and lower lobes has developed
progressively following right pleural drainage. There is no evidence of lung
trauma or cavitation to indicate a necrotizing infection. This still could be
pneumonia, or nontraumatic hemorrhage, for example if the patient has
dilutional thrombocytopenia from multiple transfusions. It could also be
progressive re-expansion edema particularly if the chest is subjected to high
negative pressure.
Right basal pleural drainage catheter which drained nearly all of the previous
right pleural effusion, is fissural which could lead to dysfunction,
explaining moderate right anterior pneumothorax.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with asymptomatic pleural effusion, s/p chest
tube, with trapped lung with residual pneumothorax // evaluate for interval
accumulation of flid or air
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph: The consolidation at the right lung
base is substantially smaller. There is an unchanged 2 cm right apical
pneumothorax without evidence of tension. Normal appearance of the left lung.
Unchanged shape and size of the cardiac silhouette.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status, Transfer
Diagnosed with TRANS CEREB ISCHEMIA NOS, ATRIAL FIBRILLATION
temperature: 97.4
heartrate: 97.0
resprate: 18.0
o2sat: 99.0
sbp: 211.0
dbp: 125.0
level of pain: 3
level of acuity: 1.0 | ___ is an ___ right-handed woman with atrial
fibrillation off coumadin due to recent traumatic SDH and SAH,
who presented to an OSH with a transient episode of word-finding
difficulties and difficulty ambulating. She was transferred to
___ for further workup. On examination she had no aphasia or
dysarthria as well as a symmetric pattern of lower extremity
weakness most consistent with myelopathy. Her history is most
concerning for TIA secondary to atrial fibrillation. MRI
demonstrated no acute infarct, MRA showed patent vasculature.
Neurosurgery cleared her to resume anticoagulation. She was
started on apixaban 2.5 mg BID (given age and weight) and her
aspirin was stopped.
She was found to have a right pleural effusion in the context of
multiple rib fractures as well as several borderline lymph
nodes. A chest tube was placed with uncomplicated removal of 2.5
liters of exudative effusion. CT chest after drainage showed
trapped lung with residual pneumothorax but no effusion. She
will follow up in pulmonology clinic. Her lasix which was
started for the effusion was discontinued.
She was hypertensive to the 150-170s and her carvedilol dose was
increased.
============================================
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 = 73) - () No
5. Intensive statin therapy administered? (simvastatin 80mg,
simvastatin 80mg/ezetemibe 10mg, atorvastatin 40mg or 80 mg,
rosuvastatin 20mg or 40mg, for LDL > 100) () Yes - (x) No [if
LDL >100, reason not given: ]
6. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? () Yes - (x) No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: ()
Antiplatelet - (x) Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? (x) Yes - () No - () N/A |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
Penicillins / clindamycin / amoxicillin
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
LAPAROSCOPIC BILATERAL OOPHORECTOMY, RIGHT URETEROLYSIS,
ENTEROLYSIS; PLACEMENT OF RIGHT DOUBLE-J STENT; RIGID
PROCTOSCOPY/SIGMOIDOSCOPY & CYSTOSCOPY
History of Present Illness:
___ s/p TLH, BS in ___ presenting with lower
abdominal pain x 7 days. Patient reports that she was seen by
her
PCP over the weekend and was prescribed antibiotics for a UTI.
Symptoms worsened and she went to her PCP again yesterday and
was
started on Cipro and Bactrim. The pain has progressed and moved
into her left flank and LLQ. Describes her pain as constant,
radiating to her back and has a pulling nature to it. Was
initially having nausea but that has resolved. Endorses chills
and some discomfort with urination and defecation, but no blood
in her stool or urine, dysuria, urgency or other urinary
symptoms. Denies CP/SOB, N/V, VB, abnormal vaginal discharge,
weight changes.
In the ED she was found to have a mildly elevated WBC of 12 and
a
CT scan abdomen and pelvis showing a large 12x9x9cm complex
fluid
collection deep in the pelvis. General surgery was consulted for
concern for abscess and she has received ceftriaxone and flagyl.
Her pain is much improved after receiving IV morphine and
toradol
and is now ___ from ___.
Past Medical History:
POBHx:
- 3 x SVD
- 1 x LTCS c/b menorrhagia requiring TLH/BS
PGYNHx:
Fibroids: denies
Cysts: denies
STIs: denies
Sexually active: yes, monogamous with male partner
___: no
Contraception: n/a
Last pap: ___. Had TAH. Denies h/o abnormal Paps
Past medical history:
1. Postpartum cardiomyopathy (LVEF 25%, currently 50-55%).
2. Hypertension.
3. Dyslipidemia.
4. Valvular heart disease ___ MR).
5. Morbid obesity.
6. Diabetes
Past surgical history:
1. TLH, BS
2. C-section
3. Tubal ligation
Social History:
___
Family History:
Non-contributory
Pertinent Results:
ADMISSION LABS
___ 10:52PM BLOOD WBC-12.7* RBC-4.02 Hgb-11.5 Hct-35.1
MCV-87 MCH-28.6 MCHC-32.8 RDW-12.8 RDWSD-40.4 Plt ___
___ 10:52PM BLOOD Glucose-277* UreaN-24* Creat-0.9 Na-135
K-5.3 Cl-97 HCO3-25 AnGap-13
___ 10:52PM BLOOD ALT-19 AST-11 AlkPhos-79 TotBili-0.3
___ 10:52PM BLOOD Albumin-3.8
___ 09:00AM BLOOD Calcium-8.3* Phos-3.2 Mg-1.8
___ 11:00PM BLOOD Lactate-1.___bdomen/Pelvis ___
IMPRESSION:
1. Status post hysterectomy with large heterogeneous structure
in the pelvis measuring 12.9 x 9.1 x 9.1 cm (AP x TV x CC,
series 602:46, series 2:69, and series 602:39) which could
represent a mass or fluid collection. Pelvic ultrasound can be
considered for further characterization. Clinical correlation
with signs and symptoms of infection is recommended. 2. This
large complex pelvic structure abuts sigmoid colonic loops which
demonstrate wall thickening and submucosal edema compatible with
focal colitis which is likely reactive.
3. 7 mm subpleural nodule in the right lower lobe.
Pelvic Ultrasound ___
IMPRESSION:
In the pelvis, there is a complex structure without internal
vascularity with both solid and fluid components measuring up to
12.4 cm across maximal diameter. There is no peripheral
hyperemia. The differential for this structure could be large
hematoma with a clot versus combination mass with superimposed
hematoma or less likely an atypical peritoneal inclusion cyst or
abscess. Given the lack of internal vascularity, this is less
likely to be a mass. However, pelvic MRI can be considered for
further characterization.
Pelvic MRI ___
IMPRESSION:
1. Enlarged right ovary which is encompassed by various stages
of blood
products, without discrete enhancing ovarian parenchyma.
Differential
diagnoses considerations include a torsed ovary with hemorrhage,
a ruptured hemorrhagic cyst, or given various stages of blood
product ruptured endometrioma, as there is no mass-like
enhancement an ovarian neoplasm is felt to be less likely,
although not completely excluded given that it could be complete
by masked by overlying blood products.
2. Peritoneal inclusion cyst surrounding the left ovary with
internal
hemorrhage.
3. Abnormal T2 hypointense signal in the left ovary, raises the
possibility of underlying endometriosis.
4. Subcentimeter pelvic sidewall lymph nodes are likely
reactive.
Medications on Admission:
Carvedilol, lisinopril, simvastatin, metformin, glipizide.
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 6 hours as
needed Disp #*50 Tablet Refills:*3
2. Cefpodoxime Proxetil 200 mg PO Q12H
RX *cefpodoxime 100 mg 1 tablet(s) by mouth twice per day Disp
#*20 Tablet Refills:*0
3. Ibuprofen 600 mg PO Q6H
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 8 hours as
needed Disp #*50 Tablet Refills:*2
4. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole 500 mg 1 tablet(s) by mouth three times per
day Disp #*30 Tablet Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Severe
RX *oxycodone 5 mg ___ or 1 tablet(s) by mouth every 4 hours as
needed Disp #*15 Tablet Refills:*0
6. Carvedilol 25 mg PO BID
7. Lisinopril 40 mg PO DAILY
8. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
RIGHT OVARIAN TORSON, ENCASED LEFT OVARY
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: PELVIS, NON-OBSTETRIC
INDICATION: History: ___ with pelvic mass. Evaluate for vascularity.
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach.
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
The uterus is surgically absent. Above the vaginal cuff, there is a complex
heterogeneous structure with a solid component component that measures
approximately 11.6 x 5.7 x 10 cm and a fluid component anteriorly with
internal debris that measures 5.9 x 4.8 x 12.4 cm. There is no internal
vascularity. There is no peripheral hyperemia.
IMPRESSION:
In the pelvis, there is a complex structure without internal vascularity with
both solid and fluid components measuring up to 12.4 cm across maximal
diameter. There is no peripheral hyperemia. The differential for this
structure could be large hematoma with a clot versus combination mass with
superimposed hematoma or less likely an atypical peritoneal inclusion cyst or
abscess. Given the lack of internal vascularity, this is less likely to be a
mass. However, pelvic MRI can be considered for further characterization.
Radiology Report
EXAMINATION: MRI of the Pelvis
INDICATION: ___ year old woman with pelvic mass.// better characterize pelvic
mass seen on TVUS
TECHNIQUE: T1- and T2-weighted multiplanar images of the pelvis were acquired
in a 1.5 T magnet.
Intravenous contrast: 8 mL Gadavist.
COMPARISON: Pelvic ultrasound ___, CT abdomen and pelvis ___
FINDINGS:
UTERUS AND ADNEXA:
The uterus and fallopian tubes are surgically absent.
There is a multiseptated T2 hyperintense serpiginous fluid collection in the
left hemipelvis with a fluid-fluid level conforming to the shape of the
peritoneum and surrounding the left ovary which likely represents a peritoneal
inclusion cyst (series 4, image 21). The left ovary demonstrates a more
hypointense signal than is expected with a single follicle noted inferiorly.
Size of the left ovary is normal.
There is a multilobulated 7.4 x 4.2 x 5.2 cm heterogeneously T2 hypointense
lesion in the right hemipelvis with multiple areas of mild intrinsic
hyperintense signal. While the majority of this lesion lacks enhancement
there is wispy enhancement along the superomedial aspect, likely related to
enhancing adnexal vessels (series 17, image 29). No solid enhancement seen.
There is no enhancement within the right ovarian parenchyma. There is a
well-defined rounded T2 hyperintense, likely follicle measuring 1.8 cm within
this lesion (series 5, image 14). There may be an additional follicle located
more superiorly and along the periphery of the ovary (series 4, image 15).
There are scattered T1 hyperintense foci in the deep pelvis. This collection
is seen displacing the sigmoid colon to the left side.
There is a small amount of simple free fluid in the pelvis.
LYMPH NODES: There are scattered bilateral pelvic sidewall lymph nodes with
the largest in the right external iliac station measuring 0.7 cm.
BLADDER AND DISTAL URETERS: The bladder is partially distended.
RECTUM AND INTRAPELVIC BOWEL: The rectum and the intrapelvic bowel loops are
unremarkable. Rectosigmoid is displaced to the left by the right pelvic
lesion.
VASCULATURE: The pelvic vasculature is patent.
OSSEOUS STRUCTURES AND SOFT TISSUES: There is no suspicious bony lesion.
IMPRESSION:
1. Enlarged right ovary which is encompassed by various stages of blood
products, without discrete enhancing ovarian parenchyma. Differential
diagnoses considerations include a torsed ovary with hemorrhage, a ruptured
hemorrhagic cyst, or given various stages of blood product ruptured
endometrioma, as there is no mass-like enhancement an ovarian neoplasm is felt
to be less likely, although not completely excluded given that it could be
complete by masked by overlying blood products.
2. Peritoneal inclusion cyst surrounding the left ovary with internal
hemorrhage.
3. Abnormal T2 hypointense signal in the left ovary, raises the possibility of
underlying endometriosis.
4. Subcentimeter pelvic sidewall lymph nodes are likely reactive.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 12:21 pm, 5 minutes after
discovery of the findings.
Radiology Report
INDICATION: Stent placement in the OR
COMPARISON: None available.
FINDINGS:
Intraoperative spot fluoroscopic images were obtained during insertion of a
ureteral double-J stent.
Please refer to OR report for further detail.
IMPRESSION:
Intraoperative fluoroscopic images during insertion of a ureteral double-J
stent.
Gender: F
Race: SOUTH AMERICAN
Arrive by WALK IN
Chief complaint: R Flank pain, Suprapubic pain
Diagnosed with Unspecified abdominal pain
temperature: 98.7
heartrate: 99.0
resprate: 16.0
o2sat: 98.0
sbp: 152.0
dbp: 81.0
level of pain: 10
level of acuity: 3.0 | Ms. ___ was admitted to the general surgery service for
further workup of her pelvic fluid collection seen on CT and its
associated abdominal pain. She was initially kept NPO on IV
fluids in case of potential drainage or surgical procedure. She
remained hemodynamically stable with stable hematocrits. Her
pain was controlled with IV medications given her NPO status and
she underwent serial abdominal exams, which revealed stable
lower abdominal discomfort, but no peritoneal signs. Imaging was
discussed with interventional radiology and it was felt that the
mass appeared to be primarily clot and therefore would not be
amenable or advisable for percutaneous drainage.
Ms. ___ then underwent further imaging of the collection
with pelvic sonogram and pelvic MRI (full radiology impressions
are elsewhere in this document). On ___ her pelvic MRI was read
and discussed with radiology. At this time it was felt that the
mass likely originated from the patient's right ovary and was
possibly a hemorrhagic ruptured cyst vs. endometrioma vs. torsed
ovary vs. less likely ovarian mass. Given these imaging findings
it was felt that she would be ___ served on the gynecology
service and transfer was arranged.
MRI revealed a right adnexal mass concerning for ovarian torsion
versus ruptured endometrioma. She was transferred to the
gynecology service and on ___, she underwent a laparoscopic
bilateral oophorectomy, right ureteral lysis, anterior lysis,
placement of right double-J stent, rigid proctoscopy and
sigmoidoscopy, and cystoscopy. Please see operative report for
full details.
Immediately postoperatively, her pain was controlled with IV
morphine. She was subsequently transitioned to oral oxycodone,
Tylenol, and ibuprofen. The right ureteral stent placed
intraoperatively remained in place for a planned 14 days. Her
Foley catheter was removed on postoperative day 1 and she voided
without difficulty. She was ambulating and tolerating a regular
diet. For her hypertension, she was maintained on carvedilol
and lisinopril. For her type 2 diabetes, she was maintained on
an insulin sliding scale, metformin, and glipizide when she
resumed her regular diet. On postoperative day 1, she was
discharged home with close follow-up. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
"Strobing" of vision, loss of vision on the right
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: The patient is a ___ old overweight man with a history
of CAD, T2DM, HTN and dyslipidemia presenting from ___
Ophthalmology with a complaint of a dense right homonymous
hemianopsia and flashing lights in his right eye for the past
three days.
He reports seeing flashing lights since ___ morning in his
right eye. He reports it looks like the right side of the world
is strobing. When it is flashing, he can see the world with
normal vision. When it flashes away, the world is black. His
vision will strobe alternating from his normal visual field to
black for about three minutes at a time. This has been happening
every ___ minutes for the past three days. With the flashing,
he denies any blurring of his vision or any double vision.
Colors
appear the same. No extra lights or extra colors. He denies
seeing any additional shapes or forms. He also sees flashing
when
he closes his eyes and describes it as "black flashing." He has
never had these symptoms before.
He went to see Ophthalmology at ___ today where visual field
testing revealed a R homonymous hemianopsia. ___ denied
having any symptoms in his left eye initially. During our
encounter, he actually had an episode of flashing and was able
to
report having flashing in the right visual field of both eyes.
He has also had a constant dull ache in his L cheek that feels
like a toothache. This has also come and gone, but it has not
correlated with the flashing episodes. He also has had a left
frontal headache on and off. When it is on, it is constant and
aching. It has been rather mild, but he has taken ibuprofen a
couple times with good results. Again, the headache does not
correlate with the flashing episodes.
He has had no pain in his eye, no sensation of pressure, no
discomfort with eye movements.
He denies any trouble speaking, thinking or understanding
others.
He did get lost today when he was taking a cab to see his
doctor.
He had to go to both ___ and ___ today, but he
accidentally told the cab drive the wrong destination. He had a
conversation with the cab drive which was otherwise normal. He
denies any issues walking or moving around. No issues with his
balance, but he admits that when the lights are flashing, he is
scared to walk too far on his own.
He has never had symptoms like this before. He endorses symptoms
of language issues back in ___. He was at dinner with a friend
and she had trouble understanding him. He does not remember if
he
was speaking in syllables or saying words that did not make
sense. He is not sure if he had any trouble understanding his
friend. He was taken to ___ where a workup showed that he
"needed
stents in my heart." He then had two stents placed (circumflex
and PDA) and was discharged home on Plavix. He was on Plavix
until ___ years ago and then was transitioned to 325 mg aspirin,
then to 81 mg aspirin.
He was seen at ___ Ophthalmology on the day of presentation
where visual field testing revealed a R homonymous hemianopsia
with some central
sparing on of the R superior quadrant in the left eye only.
On neurologic review of systems, the patient endorses a mild
L-sided headache, L cheek ache and vision loss per HPI. He
denies
lightheadedness, or confusion.
Denies difficulty with producing or comprehending speech.
Denies blurred vision, diplopia, vertigo, tinnitus, hearing
difficulty, dysarthria, or dysphagia.
Denies muscle weakness.
Denies loss of sensation.
He has baseline issues with urination related to his other
urologic issues (erectile dysfunction).
Denies difficulty with gait.
On general review of systems, the patient denies fevers, rigors,
night sweats, or noticeable weight loss.
Denies chest pain, palpitations, dyspnea, or cough.
Denies nausea, vomiting, diarrhea, constipation, or abdominal
pain.
Denies dysuria or hematuria.
Denies myalgias, arthralgias, or rash.
Allergies: NKDA
Past Medical History:
DM (diabetes mellitus), type 2 with renal complications
Diabetic retinopathy
HTN
CAD: cath in ___, TAXUS stent x 2 (circumflex and PDA) in ___.
Obesity
Hypercholesterolemia
GOUT
HYPERTENSION
Erectile dysfunction
Social History:
___
Family History:
Mother with T2DM and hypertension. Father with a
"heart disorder," MI at age ___ and a stroke. Brother with
asthma.
Physical Exam:
***ADMISSION PHYSICAL EXAMINATION***
Physical Examination:
VS T: 97.1 HR: 55 BP: 150/83 RR: 20 SaO2: 99% on RA
General: NAD, lying in bed comfortably.
Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity, no meningismus, no bruits
appreciated
Cardiovascular: RRR
Pulmonary: Equal air entry bilaterally, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: WWP
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status -
Awake, alert, oriented x 3. Attention to examiner easily
attained
and maintained. Concentration maintained when recalling months
backwards. Recalls a coherent history. Structure of speech
demonstrates fluency with full sentences, intact repetition, and
intact verbal comprehension. Content of speech demonstrates
intact naming (high and low frequency) and no paraphasias.
Normal
prosody. No dysarthria. Reading intact. Able to narrate story in
picture card, but started with the image in the left visual
field
(boy on stool, girl reaching up), then moved the card over to
his
left visual field to discover the woman washing dishes. No
left-right agnosia.
- Cranial Nerves -
I. not tested
II. Pupils 5.5 mm, minimally reactive (pharmacologically
dilated). He did not tolerate the fundascopic exam due to the
bright light in his dilated pupils. Acuity pre-dilation at
ophthalmology today was ___ R, ___ L. Visual field testing
revealed a dense R homonymous hemianopsia. He experienced
flashing of the R field during our exam and actually was able to
see the right visual field while the flashing occurred. After
the
flashing ended, the R homonymous hemianopsia was back.
III, IV, VI. smooth and full extraocular movements without
diplopia or nystagmus.
V. facial sensation was intact, muscles of mastication with full
strength. No pain or sensory loss over left cheek.
VII. face was symmetric with full strength of facial muscles
VIII. hearing was intact to finger rub bilaterally.
IX, X. symmetric palate elevation and symmetric tongue
protrusion
with full movement.
XI. SCM and trapezius were of normal strength and volume.
- Motor -
Muscule bulk and tone were normal. No pronation, no drift. No
tremor or asterixis. Strength ___ throughout.
- Sensation -
Intact to light touch and temperature throughout.
- DTRs -
Bic Tri ___ Quad Gastroc
L 2 2 2 1 1
R 2 2 2 1 1
Plantar response flexor bilaterally.
- Cerebellar -
No dysmetria with finger to nose testing bilaterally.
- Gait -
Normal initiation. Narrow base. Normal stride length and arm
swing. Stable without sway. No Romberg.
***DISCHARGE PHYSICAL EXAMINATION***
General: Awake, alert, NAD
HEENT: AT, conjunctivae clear, MMM
Resp: breathing comfortably in RA
CV: No cyanosis. Pulses regular
Abd: ND
Ext: WWP
Neuro:
MS: Awake, alert, conversant. Speech fluent. No paraphasic
errors. Follows commands.
CN: EOMI. R homonymous hemianopsia. Face grossly symmetric.
Motor: Moves all 4 extremities spontaneously and symmetrically
at least anti-gravity. No pronator drift.
Sensory: grossly intact to light touch in all 4 extremities
Pertinent Results:
CXR ___:
CT/CTA Head & neck:
1. Acute infarction of the medial left occipital lobe, with no
evidence of
hemorrhage.
2. Focal cut off of the the left P2 posterior cerebral artery,
likely
secondary to thrombus.
3. Focal narrowing of the left P1 posterior cerebral artery and
high-grade
narrowing of the mid basilar artery.
4. No evidence of aneurysm greater than 3 mm, dissection or
vascular
malformation.
EEG ___:
This is an abnormal awake and asleep EEG. There is nearly
continuous slowing in the left posterior quadrant which is
accentuated during hyperventilation, consistent with an
underlying subcortical dysfunction. There are no electrographic
seizures. The tracing suggests a broader area of cerebral
dysfunction and compromise that the clinical requisition implied
with only occipital lobe involvement. Deeper structures may also
be compromised.
MRI brain without contrast ___:
1. Subacute infarction involving the left occipital lobe with no
hemorrhage and mild associated local mass effect with sulcal
effacement but no midline shift.
2. Normal appearance of the hippocampal formations .
Transthoracic Echo ___:
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. Late saline contrast is seen in
left heart suggesting intrapulmonary shunting. The estimated
right atrial pressure is ___ mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with focal severe
hypokinesis to akinesis of the basal to mid inferior and
inferolateral walls. The remaining segments contract normally
(LVEF = 45-50 %). Doppler parameters are indeterminate for left
ventricular diastolic function. There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. 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. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
regional left ventricular systolic dysfunction c/w CAD.
Borderline normal left ventricular function. No intracardiac
source of embolism identified. No ASD by 2D and color flow
doppler. However, the appearance of late bubbles in the left
heart suggests intrapulmonary shunting.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Verapamil SR 240 mg PO Q24H
2. Atenolol 50 mg PO DAILY
3. Allopurinol ___ mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. Sildenafil Dose is Unknown PO DAILY:PRN Erectile Dysfunction
6. MetFORMIN (Glucophage) 850 mg PO BID
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Atenolol 50 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. MetFORMIN (Glucophage) 850 mg PO BID
5. Verapamil SR 240 mg PO Q24H
6. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*3
7. LevETIRAcetam 750 mg PO BID
To prevent seizures. Please take this unless told to stop by a
neurologist.
RX *levetiracetam 250 mg 3 tablet(s) by mouth twice a day Disp
#*180 Tablet Refills:*4
8. Sildenafil Dose is Unknown PO DAILY:PRN Erectile Dysfunction
9. Outpatient Occupational Therapy
For vision services
Discharge Disposition:
Home
Discharge Diagnosis:
Left occipital stroke
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with new neurological changes // eval for
infiltrate, edema
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: None.
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes are
unremarkable. No pulmonary edema is seen.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK.
INDICATION: History: ___ with intermittent neuro symptoms // eval for CVA.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
897.1 mGy-cm.
2) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 49.0 mGy (Head) DLP =
24.5 mGy-cm.
3) Spiral Acquisition 5.2 s, 41.0 cm; CTDIvol = 32.0 mGy (Head) DLP =
1,310.9 mGy-cm.
Total DLP (Head) = 2,233 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is loss of gray-white matter differentiation in the medial left
occipital lobe. No acute hemorrhage is seen at this site. Dense dural
calcifications are noted throughout the falx.
There is focal encephalomalacia and gliosis in the right frontal lobe, likely
secondary to prior insult.
There is no evidence of no evidence of hemorrhage, or mass. The ventricles
and sulci are normal in size and configuration. Multiple chronic appearing
lacunar infarctions are noted in the basal ganglia.
The visualized portion of the mastoid air cells, and middle ear cavities are
clear. The visualized portion of the orbits are unremarkable. A 0.8 cm
incisive canal cyst is seen. There is mild mucosal thickening in the
bilateral maxillary sinuses.
CTA HEAD: There is atherosclerosis of the cavernous internal carotid
arteries. There is congenital absence of the left A1 anterior cerebral
artery. There is focal narrowing of the left P1 PCA with a focal cut off in
the left P2 PCA with no distal reconstitution. In addition, there is focal
high-grade narrowing of the mid basilar artery, seen best on series 656, image
25. The remainder of the vessels of the circle of ___ and their principal
intracranial branches appear normal without aneurysm formation. The dural
venous sinuses are patent.
CTA NECK: There is atherosclerotic calcification of the aortic arch.
Atherosclerotic calcification of the carotid bulbs is also seen. The
remainder of the carotid and vertebral arteries and their major branches
appear normal with no evidence of stenosis or occlusion. There is no evidence
of internal carotid stenosis by NASCET criteria.
OTHER:
The visualized portion of the lungs are clear. The visualized portion of the
thyroid gland is within normal limits. There is no lymphadenopathy by CT size
criteria. Mild multilevel degenerative changes are visualized throughout the
cervical spine, consistent with anterior and posterior spondylosis.
IMPRESSION:
1. Acute infarction of the medial left occipital lobe, with no evidence of
hemorrhage.
2. Focal cut off of the the left P2 posterior cerebral artery, likely
secondary to thrombus.
3. Focal narrowing of the left P1 posterior cerebral artery and high-grade
narrowing of the mid basilar artery.
4. No evidence of aneurysm greater than 3 mm, dissection or vascular
malformation.
NOTIFICATION: The findings were discussed with Dr. ___, M.D. by
___, M.D. on the telephone on ___ at 11:26 AM, 5 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD
INDICATION: ___ year old man with R homonymous hemianopsia and flashing of R
visual field // Stroke, seizure focus
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 9 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: CT/CTA from ___.
FINDINGS:
There is encephalomalacia and gliosis in the right frontal lobe, from prior
insult. A chronic infarct is noted in the right centrum semiovale. FLAIR
hyperintense signal is noted in the medial left occipital lobe with associated
restricted diffusion and sulcal effacement. No associated midline shift or
hemorrhage is identified at this site. There is focal linear gyral
enhancement along the posterior medial left occipital lobe, series 900, image
59.
The hippocampal formations are symmetric bilaterally with no abnormal signal
or configuration identified.
There is no evidence of hemorrhage, masses, or midline shift. The ventricles
and sulci are normal in caliber and configuration.
There is mucosal thickening in the bilateral maxillary sinuses. The orbits
and visualized soft tissues are normal.
IMPRESSION:
1. Subacute infarction involving the left occipital lobe with no hemorrhage
and mild associated local mass effect with sulcal effacement but no midline
shift.
2. Normal appearance of the hippocampal formations .
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Visual changes, Headache
Diagnosed with Unspecified visual disturbance
temperature: 97.1
heartrate: 55.0
resprate: 20.0
o2sat: 99.0
sbp: 150.0
dbp: 83.0
level of pain: 4
level of acuity: 2.0 | Mr. ___ is a ___ year old gentleman with DMII, history of
CAD s/p stents in ___, HTN, dyslipidemia who presented from
___ Ophthalmology with complaint of three days of flashing
lights in his right visual field and vision problems and was
found to have a dense right homonymous hemianopsia. Upon
admission, he had a CT/CTA of his head and neck which showed
evidence of acute infarction of the medial left occipital lobe
with a P2 cutoff of the left posterior cerebral artery felt
secondary to a thrombus. Patient then had an MRI which showed
the corresponding area FLAIR hypertensity within the medial L
occipital lobe with associated restricted diffusion consistent
with subacute left occipital infarct. This also showed right
frontal gliosis presumably from a prior infarct as well as a
chronic infarct in the right centrum semiovale. Possible
etiologies of the stroke included cardioembolic (though no
evidence of thrombus on echo)vs artery to artery/atheroembolic.
Patient is not known to have atrial fibrillation and was
monitored on telemetry throughout his stay. He will have ___
___ Hearts monitor as an outpatient (arranged on day of
discharge) to monitor for atrial fibrillation. Patient had a
transthoracic echo which showed mild symmetric left ventricular
hypertrophy with regional left ventricular systolic dysfunction
c/w CAD, LVEF 45-50%, no evidence of intracardiac embolism or
septal defect. On admission labs were notable for HbA1c 6.2, LDL
103 TSH 2.0, CRP 0.8. Patient was on aspirin 81 mg daily and
atorvastatin 80mg daily at the time of admission. His aspirin
was stopped, and he was started on clopidogrel, instead. He was
continued on his atorvastatin. He should continue atorvastatin
as an outpatient.
Patient's blood pressure medications were reduced or held during
hospitalization to allow him to autoregulate his blood pressures
post-stroke. He was resumed on his home antihypertensives at
their prior doses upon discharge.
Patient was given acetaminophen given that he had a headache and
with the thought that the strobing may represent stroke-induced
migraine. Despite acetaminophen, the strobing/flashing
continued. He had an EEG to evaluate whether the flashing might
be due to seizure. EEG showed focal slowing over the area of
infarct, did not show seizure but patient did not have
flashing/"strobing" of his vision during the EEG. Patient was
started on Keppra (levetiracetam) 750 mg BID for empiric
treatment of possible seizure. After starting levetiracetam,
patient had much less prominent flashing.
Mr. ___ should have outpatient clinic followup with a
Neurologist. Mr. ___ should continue his levetiracetam for
several months, at least until he is seen in Neurology clinic.
He should continue this until he is told to discontinue by a
Neurologist.
Mr. ___ should have outpatient followup in cardiology
given his Echo findings as well as his history of intracardiac
stents.
Mr. ___ was evaluated by occupational therapy who felt he
should have outpatient occupational therapy for vision services.
He should also have follow up with an ophthalmologist as an
outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Erythromycin Base / Zoloft / Optiray 350 / Bactrim
Attending: ___.
Chief Complaint:
Chills and sweats
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo M with incomplete quadriplegia, frequent urinary tract
infections with urosepsis, and recurrent nephrolithiasis who
presents with fever and chills.
Pt reports feeling well this morning. At work today, he
developed chills and sweats which he describes as his only
reliable indicator of illness or injury. He developed
progressive chills and sweats over the course of the day, and
was found to have a temp to 101.5. He denies sore throat,
rhinorrhea, cough, shortness of breath, diarrhea, trauma. Pt
reports his urine is often cloudy when he has an infection, but
has been clear. He went to the ED for evaluation.
Of note, he has a history of recurrent UTIs with were thought to
be related to neurogenic bladder and indwelling suprapubic tube.
He has grown multiple different organisms in the past including
pseudomonas, Klebsiella, E. coli and enterococcus. He is
followed by Dr. ___ infectius disease and is on
fosfomycin suppression. He also has had 2 previous percutaneous
nephrolithotomies and a ureteroscopy with stent placement. In
the past he has not sensed kidney stones due to his neurologic
disabilities. He replaced his suprapubic catheter at home on
___, and took his fosfomycin prior to the procedure as
directed. He reports taking him home fosfomycin as directed.
In the ED, initial vitals: 102.8 80 150/110 22 95% ra
Labs significant for WBC of 10.5, Na 123, lactate 1.3, positive
UA.
He was given 1L NS and cefepime and admitted to medicine for
further management.
Currently, VS 97.7 120/79 82 20 97% on RA. Pt denies chills or
sweats, and reports feeling well overall. He reports developing
a cough in the ED, and states that he believes this may be a
respiratory infection.
Past Medical History:
-tetraplegia - C5-C6 incomplete quadriplegia secondary to a
waterskiing injury in ___, C2 odontoid fracture
-restrictive lung disease ___ PFTs with FEV1/FVC 72, FEV1
28%, FVC 29%)
-DVT: chronic DVT of the Left Lower extrmity (___), persistent
on repeat ___ Venous Dupplex on ___, warfarin stopped ___.
-vertebral osteomyelitis- S. aureus MSSA (___)
-neurogenic bladder
-recurrent urinary tract infection
-OSA on Auto titrating CPAP or BIPAP
-depression
-anxiety
-pleural effusions- refractory left pleural effusion in setting
of osteo in ___, underwent talc pleurodesis x3
-osteoporosis
-erectile dysfunction
-colonic polyps- found on screening colonoscopy in ___.
-s/p right hip fracture- MVA ___, s/p ORIF
-superficial thrombophlebitis
-osteoporosis
-hypertension
Social History:
___
Family History:
Father died of prostate CA in his ___. Mother died of MI in her
___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
======================
Vitals - 97.7 120/79 82 20 97% on RA
General - Alert, oriented, no acute distress
HEENT - Sclerae anicteric, MMM, oropharynx clear
Neck - supple, JVP not elevated, no LAD
Lungs - CTAB on right, decreased breath sounds on the right ___
way up
CV - S1 S2, RRR, ___ SEM at apex
Abdomen - soft, NT/ND bowel sounds present, unable to sense
palpation of abdomen, no organomegaly
GU- Suprapubic catheter in place without evidence of infection
at the site. Urine bag with yellow urine.
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, ___ strength in ___ bilaterally, no
sensation in ___. Weakness in arms bilaterally, but able to
move.
DISCHARGE PHYSICAL EXAM:
=======================
Vitals - 100.___.7 ___ 18 100% on RA
General - Alert, oriented, no acute distress
HEENT - Sclerae anicteric, MMM, oropharynx clear
Neck - supple, JVP not elevated, no LAD
Lungs - CTAB on right, decreased breath sounds on the right ___
way up
CV - S1 S2, RRR, ___ SEM at apex
Abdomen - soft, NT/ND bowel sounds present, unable to sense
palpation of abdomen, no organomegaly
GU- Suprapubic catheter in place without evidence of infection
at the site. Urine bag with yellow urine, not cloudy.
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- CNs2-12 intact, ___ strength in ___ bilaterally, no
sensation in ___. Weakness in arms bilaterally, but able to
move.
Pertinent Results:
ADMISSION LABS:
===============
___ 02:55PM BLOOD WBC-10.5# RBC-4.85 Hgb-14.0 Hct-42.3
MCV-87 MCH-28.8 MCHC-33.1 RDW-13.7 Plt ___
___ 02:55PM BLOOD Neuts-92.7* Lymphs-2.1* Monos-4.1 Eos-0.5
Baso-0.6
___ 02:55PM BLOOD Plt ___
___ 02:00PM BLOOD Glucose-101* UreaN-31* Creat-0.7 Na-123*
K-4.1 Cl-87* HCO3-23 AnGap-17
___ 02:00PM BLOOD ALT-61* AST-46* AlkPhos-95 TotBili-1.0
___ 02:00PM BLOOD Albumin-4.2 Calcium-9.3 Phos-3.2 Mg-1.5*
DISCHARGE LABS:
================
___ 05:35AM BLOOD WBC-8.5 RBC-4.37* Hgb-12.7* Hct-38.1*
MCV-87 MCH-29.1 MCHC-33.4 RDW-13.6 Plt ___
___ 05:35AM BLOOD Plt ___
___ 05:35AM BLOOD Glucose-81 UreaN-22* Creat-0.6 Na-129*
K-3.9 Cl-95* HCO3-23 AnGap-15
___ 05:35AM BLOOD Calcium-7.8* Phos-2.1* Mg-1.9
MICRO:
========
___ 6:11 am Influenza A/B by ___
Source: Nasopharyngeal swab.
**FINAL REPORT ___
DIRECT INFLUENZA A ANTIGEN TEST (Final ___:
Negative for Influenza A.
DIRECT INFLUENZA B ANTIGEN TEST (Final ___:
Negative for Influenza B.
___ 2:00 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 2:10 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH FECAL
CONTAMINATION.
STUDIES:
=========
Chest X-Ray AP ___
FINDINGS: Thoracic scoliosis is again noted. There is
persistent blunting of
the left costophrenic angle which may be related to pleural
thickening,
although a trace pleural effusion is not excluded.
Atelectasis/scarring and
underlying aspiration is not excluded. The right lung appears
clear. The
cardiac and mediastinal silhouettes are stable. Battery pack
overlies the
left mid hemithorax.
Renal Ultrasound ___
IMPRESSION:
Known atrophic right kidney with no evidence of hydronephrosis
in either
kidney. The bladder is decompressed, impairing evaluation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q6H:PRN fever, pain
2. Diphenoxylate-Atropine ___ TAB PO ___ TIMES DAILY PRN
diarrhea
3. Docusate Sodium 100 mg PO BID
4. Fluoxetine 60 mg PO DAILY
5. Lorazepam 0.5 mg PO Q8H:PRN anxiety
6. Metoprolol Tartrate 25 mg PO BID
7. Oxybutynin 5 mg PO BID:PRN bladder spasm
8. Quetiapine Fumarate 25 mg PO QHS
9. AndroGel (testosterone) 1 %(50 mg/5 gram) Transdermal Daily
10. calcium citrate-vitamin D3 200 -250 unit ORAL DAILY
11. Sildenafil 50-100 mg ORAL PRN one hour before sexual
activity
12. Triamterene-Hydrochlorothiazide 1 CAP PO EVERY OTHER DAY
13. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
14. Biafine Emulsion (emollient combination no.10) topical
BID
15. Fluticasone Propionate 110mcg 2 PUFF IH BID only during
bronchitis
16. Fosfomycin Tromethamine 3 g PO Q4 DAYS
17. Ketoconazole 2% 1 Appl TP BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN fever, pain
2. Docusate Sodium 100 mg PO BID
3. Fluoxetine 60 mg PO DAILY
4. Fluticasone Propionate 110mcg 2 PUFF IH BID only during
bronchitis
5. Ketoconazole 2% 1 Appl TP BID
6. Lorazepam 0.5 mg PO Q8H:PRN anxiety
7. Metoprolol Tartrate 25 mg PO BID
8. Oxybutynin 5 mg PO BID:PRN bladder spasm
9. QUEtiapine Fumarate 50 mg PO QHS
10. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheezing
11. AndroGel (testosterone) 1 %(50 mg/5 gram) Transdermal Daily
12. Biafine Emulsion (emollient combination no.10) 0 TOPICAL
BID
13. calcium citrate-vitamin D3 200 -250 unit ORAL DAILY
14. Diphenoxylate-Atropine ___ TAB PO ___ TIMES DAILY PRN
diarrhea
15. Fosfomycin Tromethamine 3 g PO Q4 DAYS
16. Sildenafil 50-100 mg ORAL PRN one hour before sexual
activity
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
primary diagnosis: fever, hyponatremia
secondary diagnosis: neurogenic bladder
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
EXAM: Chest, supine AP portable view.
CLINICAL INFORMATION: Quadriplegia, fever.
___.
FINDINGS: Thoracic scoliosis is again noted. There is persistent blunting of
the left costophrenic angle which may be related to pleural thickening,
although a trace pleural effusion is not excluded. Atelectasis/scarring and
underlying aspiration is not excluded. The right lung appears clear. The
cardiac and mediastinal silhouettes are stable. Battery pack overlies the
left mid hemithorax.
Radiology Report
HISTORY: History of quadriplegia and suprapubic catheter with new fevers and
concern for bladder infection.
Technique: Grayscale and color Doppler ultrasound images of the genitourinary
system.
COMPARISON: MRI of the abdomen from ___ and CT of the abdomen from
___. Renal ultrasound from ___.
FINDINGS:
The right kidney is atrophic, measuring 7.3 cm, with normal echotexture and a
few cortical hypoechoic lesions which correspond to cysts on recent MRI.
There is no evidence of hydronephrosis. Normal color flow is demonstrated
within the right kidney.
The left kidney measures 13 cm and contains normal echotexture and
corticomedullary differentiation. No masses or hydronephrosis identified.
The bladder contains a suprapubic catheter and is decompressed, impairing
evaluation.
IMPRESSION:
Known atrophic right kidney with no evidence of hydronephrosis in either
kidney. The bladder is decompressed, impairing evaluation.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with URIN TRACT INFECTION NOS
temperature: 102.8
heartrate: 80.0
resprate: 22.0
o2sat: 95.0
sbp: 150.0
dbp: 110.0
level of pain: 0
level of acuity: 2.0 | ___ yo M with incomplete quadriplegia, frequent urinary tract
infections with urosepsis, and recurrent nephrolithiasis who
presents with fever and chills. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
LP ___
A-line ___
L subclavian CVL ___
TEE ___
Extubation ___
History of Present Illness:
Ms. ___ is a ___ with history of IVDU in remission who
presents following a seizure:
Pt was reportedly at her ___ clinic when she had a ~8 min
seizure. This self-resolved w/o medication. She seized again
during transport to ED and was given 1mg Ativan. In the ED, she
was post-ictal, but endorsed marijuana use and mentioned that
she recently started Zoloft 2 days ago. ___ in the ED, she had
another seizure, so was given 2mg ativan and was intubated for
airway protection. Some blood was noted in ET tube after
intubation. She was started on fent/propofol, but BPs dropped.
She was given a total of 4L of fluid without improvement, so was
started on levophed. Sedation was switched to midazolam gtt. She
was also given vecuronium. Exam in the ED was notable for a
fever of 101.4, dilated pupils, tachycardia, MMM, no
hyperreflexia or clonus.
Labs in ED were remarkable for WBC 16.0, initial lactate 20.8,
PTT 52, bicarb 6, AG 34, glucose 300, negative serum and urine
tox screens, ABG post-intubation 6.75/58/140. CT head showed 4
mm hyperdense thickening of the posterior falx, suspicious for
subdural hemorrhage. Neurosurgery was consulted and recommended
serial imaging. Also methanol and ethylene glycol level, blood
cultures sent, LP performed.
Given the severe acidosis, she was given bicarbonate amps and a
drip was started. She was given vancomycin, cefepime, and
acyclovir for empiric antibiotic coverage. Also started on
keppra, as well as fomepizole pending ethanol and methylene
glycol levels. A-line and L subclavian were placed in ED. LP was
performed with 0 WBCs in tube 4, protein 71, glucose 125. Repeat
lactate decreased to 2.1 with improvement in acidosis to
7.38/44.
On transfer, vitals were: 101.6 114 120/71 26 100%
Intubation
On arrival to the MICU, pt was intubated and sedated. Levophed
was stopped given improvement in blood pressures. Further
history obtained from mother and father; she has a history of
IVDU but reportedly has been in remission x ___ years. No ETOH use
or benzo use to their knowledge, but they speak to her only
about once per month.
Review of systems:
Intubated and sedated, unable to obtain
Past Medical History:
-Anxiety/Depression
-History of IVDU, in remission x ___ years, on suboxone
Social History:
___
Family History:
No family history of seizures. Brother had a stroke ___ in
___, but in context of blow to neck at ___; likely
vertebral dissection. No other FH of stroke or MI at young ages,
or HLD difficult to control. Mother had MI at ___.
Physical Exam:
ADMISSION PHYSICAL EXAM:
============================
Vitals: T: 98.7 BP: 112/70 P: 111 R: 26 O2: 100% on AC 430x26,
12, 1
GENERAL: intubated, sedated, grimaces to noxious stimuli
HEENT: Sclera anicteric, MMM
NECK: supple, JVP not elevated
CHEST: L subclavian line in place
LUNGS: Rhoncorous bilaterally
CV: Tachycardic, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Arterial line R radial.
SKIN: warm, dry
NEURO: Pupils reactive, +gag, +corneals (when off sedation). On
propofol does not withdraws to noxious stimuli. Hyperreflexia in
BLE, ___ beats ankle clonus.
DISCHARGE PHYSICAL EXAM:
==============================
VS: 98.1-98.6, 120-143/80-100, 62-88, ___, 97-100 RA
General: AOx3, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: CTAB, no wheezes, rales, ronchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact; motor function grossly normal; 3+
patellar reflexes b/l. No clonus in arms or feet b/l.
Pertinent Results:
ADMISSION LABS:
===============
___ 03:59PM BLOOD WBC-16.0* RBC-5.02 Hgb-14.8 Hct-50.3*
MCV-100* MCH-29.5 MCHC-29.4* RDW-12.1 RDWSD-44.8 Plt ___
___ 03:59PM BLOOD ___ PTT-52.1* ___
___ 03:59PM BLOOD Glucose-308* UreaN-19 Creat-1.2* Na-139
K-4.2 Cl-97 HCO3-6* AnGap-40*
___ 03:59PM BLOOD ALT-23 AST-36 AlkPhos-97 TotBili-0.1
___ 03:59PM BLOOD Albumin-4.7 Calcium-9.9 Phos-7.9* Mg-2.5
___ 03:59PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:54PM BLOOD Type-ART pO2-140* pCO2-58* pH-6.75*
calTCO2-9* Base XS--30
___ 03:59PM BLOOD Lactate-20.8*
INTERVAL LABS:
==============
___ 06:10AM BLOOD WBC-7.4 RBC-3.56* Hgb-10.6* Hct-31.9*
MCV-90 MCH-29.8 MCHC-33.2 RDW-13.5 RDWSD-40.7 Plt ___
___ 06:20AM BLOOD WBC-9.6 RBC-3.70* Hgb-11.1* Hct-33.0*
MCV-89 MCH-30.0 MCHC-33.6 RDW-12.7 RDWSD-39.2 Plt ___
___ 06:20AM BLOOD WBC-11.5*# RBC-3.88* Hgb-11.7 Hct-33.9*
MCV-87 MCH-30.2 MCHC-34.5 RDW-12.3 RDWSD-38.5 Plt ___
___ 06:40AM BLOOD WBC-7.3 RBC-3.86* Hgb-11.4 Hct-34.0
MCV-88 MCH-29.5 MCHC-33.5 RDW-12.1 RDWSD-39.0 Plt ___
___ 05:55AM BLOOD WBC-8.1 RBC-4.05 Hgb-12.0 Hct-35.7 MCV-88
MCH-29.6 MCHC-33.6 RDW-12.2 RDWSD-39.7 Plt ___
___ 06:10AM BLOOD Glucose-88 UreaN-22* Creat-1.5* Na-139
K-4.4 Cl-105 HCO3-23 AnGap-15
___ 04:07PM BLOOD UreaN-22* Creat-1.9* Na-137 K-3.8 Cl-102
HCO3-26 AnGap-13
___ 09:00PM BLOOD UreaN-22* Creat-2.0* Na-136 K-3.9 Cl-101
HCO3-23 AnGap-16
___ 06:40AM BLOOD Glucose-95 UreaN-10 Creat-0.7 Na-140
K-3.9 Cl-105 HCO3-25 AnGap-14
___ 05:55AM BLOOD Glucose-90 UreaN-8 Creat-0.7 Na-138 K-4.0
Cl-102 HCO3-23 AnGap-17
___ 06:10AM BLOOD Calcium-8.9 Phos-5.0* Mg-1.8
___ 06:20AM BLOOD Calcium-9.6 Phos-6.2* Mg-1.8
___ 06:20AM BLOOD Albumin-4.2 Calcium-9.4 Phos-4.2 Mg-1.7
___ 06:40AM BLOOD Albumin-4.2 Calcium-9.0 Phos-3.6 Mg-1.9
___ 05:55AM BLOOD Calcium-9.6 Phos-4.0 Mg-1.8
___ 06:10AM BLOOD ALT-49* AST-29 CK(CPK)-270* AlkPhos-64
TotBili-0.3
___ 06:20AM BLOOD ALT-67* AST-48* CK(CPK)-553* AlkPhos-66
TotBili-0.6
___ 06:20AM BLOOD ALT-92* AST-70* LD(LDH)-336*
CK(CPK)-1033* AlkPhos-66 TotBili-0.5
___ 06:40AM BLOOD ALT-130* AST-150* LD(LDH)-386*
CK(CPK)-2439* AlkPhos-64 TotBili-0.6
___ 06:40AM BLOOD CRP-8.8*
___ 11:01AM BLOOD C3-72* C4-27
___ 11:01AM BLOOD CARDIOLIPIN ANTIBODIES (IGG, IGM)-Test
___ 11:01AM BLOOD BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA,
IGM, IGG)-Test
___ 08:38AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 04:28PM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 04:28PM URINE RBC-2 WBC-8* Bacteri-FEW Yeast-NONE Epi-9
___ 04:15PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 08:19PM CEREBROSPINAL FLUID (CSF) WBC-0 RBC-64* Polys-2
___ ___ 08:19PM CEREBROSPINAL FLUID (CSF) WBC-1 RBC-835*
Polys-36 ___ ___ 08:19PM CEREBROSPINAL FLUID (CSF) TotProt-71*
Glucose-125
IMAGING:
========
MRI HEAD ___:
1. Numerous scatter areas with slow diffusion suggestive of
acute to subacute infarcts in the bilateral cerebral hemispheres
and thalami, without evidence of mass effect or edema, as
described above. The largest of these foci exists in the
bilateral occipital lobes. Recommend evaluating for evidence of
thromboembolic disease.
2. There is no evidence of intracranial hemorrhage or enhancing
mass.
3. Paranasal sinus disease as described above.
TEE ___:
No spontaneous echo contrast or thrombus is seen in the body of
the left atrium/left atrial appendage or the body of the right
atrium/right atrial appendage. Left atrial appendage and right
atrial appendage ejection velocities are good (>20 cm/s). No
atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast at rest x 2 (unabnle to
cooperate with maneuvers). The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. No masses or vegetations are
seen on the aortic valve. The mitral valve leaflets are
structurally normal. No mass or vegetation is seen on the mitral
valve. No mitral regurgitation is seen.
IMPRESSION: No TEE evidence of valvular pathology or pathologic
flow. No definite cardiac source of embolism identified.
CTA NECK ___:
1. Patent cervical vasculature without stenosis, occlusion or
dissection.
2. 12 x 8 mm right thyroid lobe nodule. The ___ College of
Radiology
guidelines suggest thyroid ultrasound for further evaluation.
3. Paranasal sinus disease as described.
RECOMMENDATION(S): 12 x 8 mm right thyroid lobe nodule. The
___ College of Radiology guidelines suggest thyroid
ultrasound for further evaluation.
MRA BRAIN ___:
1. Study is mildly degraded by motion, with artifact limiting
evaluation of right inferior M2 division.
2. Grossly patent intracranial vasculature without occlusion,
stenosis,
suggestion of dissection or aneurysm greater than 3 mm.
3. Paranasal sinus disease concerning for acute sinusitis, as
described.
MICROBIOLOGY:
=============
___ URINE URINE CULTURE-FINAL {GRAM POSITIVE BACTERIA}
- negative UA
___ BLOOD CULTURE Blood Culture, Routine-FINAL
___ URINE URINE CULTURE-FINAL
___ BLOOD CULTURE Blood Culture, Routine-FINAL
___ BLOOD CULTURE Blood Culture, Routine-FINAL
___ BLOOD CULTURE Blood Culture, Routine-FINAL
___ MRSA SCREEN MRSA SCREEN-FINAL
___ SPUTUM GRAM STAIN-FINAL; RESPIRATORY
CULTURE-PRELIMINARY {ASPERGILLUS SPECIES}
___ CSF;SPINAL FLUID GRAM STAIN-FINAL; FLUID
CULTURE-FINAL ___ BLOOD CULTURE Blood Culture,
Routine-FINAL
___ BLOOD CULTURE Blood Culture, Routine-FINAL
DISCHARGE LABS:
===============
___ 06:10AM BLOOD WBC-7.4 RBC-3.56* Hgb-10.6* Hct-31.9*
MCV-90 MCH-29.8 MCHC-33.2 RDW-13.5 RDWSD-40.7 Plt ___
___ 06:10AM BLOOD Glucose-88 UreaN-22* Creat-1.5* Na-139
K-4.4 Cl-105 HCO3-23 AnGap-15
___ 06:10AM BLOOD ALT-49* AST-29 CK(CPK)-270* AlkPhos-64
TotBili-0.3
Radiology Report
EXAMINATION: MRA BRAIN W/O CONTRAST T___ MR HEAD
INDICATION: ___ woman with new bilateral occipital, parietal and
thalamic infarcts. Evaluate for vascular abnormality, atherosclerotic disease
or dissection.
TECHNIQUE: 3 dimensional time-of-flight MRA was performed through the brain.
No contrast was administered. Three dimensional maximum intensity projection
and segmented images were generated. This report is based on interpretation of
all of these images. No contrast was administered.
COMPARISON: ___ contrast head MR.
___ noncontrast head CT.
FINDINGS:
Study is mildly degraded by motion.
Anterior communicating artery is not visualized, which can be a normal
variant. Artifact limits evaluation of right M2 inferior division the (see
2:132, 102:13). Otherwise, the intracranial vertebral and internal carotid
arteries and their major branches appear normal without evidence of stenosis,
occlusion, or aneurysm formation. Bilateral posterior communicating
arteries are noted. There is infundibular origin of the bilateral superior
cerebellar arteries, a normal variant. The known infarcts are not well
visualized on the 3D time-of-flight images.
Layering fluid is noted in the right sphenoid air cell.
IMPRESSION:
1. Study is mildly degraded by motion, with artifact limiting evaluation of
right inferior M2 division.
2. Grossly patent intracranial vasculature without occlusion, stenosis,
suggestion of dissection or aneurysm greater than 3 mm.
3. Paranasal sinus disease concerning for acute sinusitis, as described.
Radiology Report
EXAMINATION: CTA NECK WANDW/OC AND RECONS Q25 CT NECK
INDICATION: ___ female with bilateral posterior circulation infarcts
on MR. ___ for vertebral artery dissection or vasospasm.
TECHNIQUE: Rapid axial imaging was performed from the aortic arch through the
skull base during infusion of 70 mL of Omnipaque intravenous contrast
material. Three-dimensional angiographic volume rendered, curved reformatted
and segmented images were generated. This report is based on interpretation of
all of these images.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.5 s, 0.5 cm; CTDIvol = 49.0 mGy (Head) DLP =
24.5 mGy-cm.
2) Spiral Acquisition 3.4 s, 26.9 cm; CTDIvol = 34.9 mGy (Head) DLP = 940.0
mGy-cm.
Total DLP (Head) = 964 mGy-cm.
COMPARISON: ___ contrast head MR.
___ noncontrast brain MRA.
FINDINGS:
The carotid and vertebral arteries and their major branches are patent with no
evidence of stenoses. No evidence for dissection is seen.
There is no internal carotid artery stenosis by NASCET criteria.
There is mild bilateral dependent atelectasis. The visualized lung apices are
otherwise grossly clear. There is a 12 x 8 mm hypodense right thyroid nodule
(2:90). A left internal jugular approach central venous catheter is partially
imaged.
Partially visualized sinuses demonstrate air-fluid levels and sphenoid sinuses
and bilateral ethmoid air cell mucosal thickening.
IMPRESSION:
1. Patent cervical vasculature without stenosis, occlusion or dissection.
2. 12 x 8 mm right thyroid lobe nodule. The ___ College of Radiology
guidelines suggest thyroid ultrasound for further evaluation.
3. Paranasal sinus disease as described.
RECOMMENDATION(S): 12 x 8 mm right thyroid lobe nodule. The ___ College
of Radiology guidelines suggest thyroid ultrasound for further evaluation.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman presenting with seizures and intubated for
respiratory failure, now extubated. Recent CXR showing pleural effusions, want
to reevaluate by repeat imaging. // Persistent pleural effusions?
Persistent pleural effusions?
IMPRESSION:
Comparison to ___. All monitoring and support devices are removed.
Normal size of the cardiac silhouette. Normal hilar and mediastinal contours.
No pneumonia, no pulmonary edema, no pleural effusions.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with new ___ and elevated LFTs //
Hydronephrosis and ascites
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 11.1 cm. The left kidney measures 12.1 cm. There is
no hydronephrosis, stones, or masses bilaterally. Bilaterally the kidneys are
mildly increased in echogenicity with reduced corticomedullary
differentiation.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
1. Bilaterally the kidneys are mildly increased in echogenicity with reduced
corticomedullary differentiation which can be seen in diffuse parenchymal
disease.
2. No hydronephrosis.
3. No evidence of ascites.
Radiology Report
INDICATION: ___ with s/p intubation // eval ETT placement
TECHNIQUE: Single portable view of the chest.
COMPARISON: None.
FINDINGS:
Endotracheal tube tip is 4.4 cm from the carina. Enteric tube passes below
the inferior field of view. There is increased opacity projecting over the
left lung. While some of this can be accounted for by overlying breast
tissue, there is superimpose underlying opacity in the hemithorax which could
represent of layering fluid and/or parenchymal consolidation.
IMPRESSION:
Appropriate position of the ET and enteric tubes.
Hazy left mid lung opacity, likely consolidation and/or layering effusion
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ female with new seizures. Evaluate for hemorrhage or
mass.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is mild hyperdense thickening of the left posterior falx measuring up to
4 mm (02:24), likely representing small acute left subdural hemorrhage. No
other intracranial hemorrhage.
There is no evidence of acute vascular territorial infarction, edema, or mass.
The ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. There is mild mucosal thickening in the
ethmoid air cells. Remainder of the visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The visualized portion of the
orbits are unremarkable.
IMPRESSION:
Probable small left parafalcine acute subdural hematoma. Recommend short
interval follow-up head CT in ___ hours.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 5:31 ___, 1 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with left subclavian CVL, status post seizure.
COMPARISON: Prior radiograph performed several hr earlier.
FINDINGS:
AP portable semi upright view of the chest.
ETT unchanged with tip located approximately 3.6 cm above the carina. The
orogastric tube descends into the left upper abdomen beyond the field of view.
A left subclavian central venous catheter terminates in the mid SVC region.
Worsening airspace opacities concerning for effusions and edema. Superimposed
pneumonia difficult to exclude. Cardiomediastinal silhouette is stable. Bony
structures appear intact.
IMPRESSION:
Pulmonary edema likely with pleural effusions, overall demonstrating
progression from prior. Lines and tubes positioned adequately.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman who presented with seizure and respiratory
failure // please evaluate interval change in bilateral opacities please
evaluate interval change in bilateral opacities
IMPRESSION:
Comparison to ___. The bilateral pleural effusions have decreased in
extent and severity. Borderline size of the cardiac silhouette persists. No
pulmonary edema. No pneumonia. Stable mild retrocardiac atelectasis. The
monitoring and support devices are in correct position.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ female with onset seizures. Evaluate for
intracranial lesion.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 7 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: Noncontrast head CT ___.
FINDINGS:
There are multiple regions of slow diffusion with associated FLAIR
hyperintensity, indicative of acute to subacute infarcts as follows:
The largest infarcts exist in the bilateral occipital lobes (series 602, image
17 and series 602, image 13). A second region of slow diffusion in the left
occipital lobe (series 602 image 22). There is also a small region of slow
diffusion in the right parietal lobe (series 602, image 14 disease). There is
a punctate focus of slow diffusion in the right anterior thalamus (series 602,
image 16). There is a focus of effusion in the left pulvinar (series 602,
image 17). These lesions are not enhancing after contrast administration.
There is no evidence of edema, mass effect or midline shift. There is no
evidence of intracranial hemorrhage or mass.
The ventricles and sulci are normal in caliber and configuration. There is no
abnormal enhancement after contrast administration.
There is left maxillary sinus and anterior ethmoid air cell mucosal
thickening, and a sphenoid sinus mucocele. The visualized orbits are
unremarkable.
IMPRESSION:
1. Numerous scatter areas with slow diffusion suggestive of acute to subacute
infarcts in the bilateral cerebral hemispheres and thalami, without evidence
of mass effect or edema, as described above. The largest of these foci exists
in the bilateral occipital lobes. Recommend evaluating for evidence of
thromboembolic disease.
2. There is no evidence of intracranial hemorrhage or enhancing mass.
3. Paranasal sinus disease as described above.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 3:06 ___, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with hypoxemic respiratory failure // eval for
pleural effusions
TECHNIQUE: Single frontal view of the chest
COMPARISON: Chest radiograph from ___.
FINDINGS:
A left-sided central line terminates in the mid to low SVC, unchanged in
position compared to prior radiograph. In comparison to the study from ___, there has been substantial decrease in the hazy opacifications
previously silhouetting the hemidiaphragms. The cardiomediastinal silhouette
is unchanged. No pulmonary edema or focal consolidations. No pneumothorax.
IMPRESSION:
Improved bibasilar opacifications. This may be related to improved pleural
effusion, but could be a manifestation of a more upright positioning of the
patient. If the patient's clinical status permits, PA and lateral chest
radiograph may be considered for accurate assessment of pleural effusion.
RECOMMENDATION(S): PA and lateral chest radiograph for accurate assessment of
pleural effusion.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Seizure
Diagnosed with Unspecified convulsions
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: unable
level of acuity: 1.0 | ___ is a ___ y/o F with history of IVDU in remission
who presents following a seizure with severe lactic acidosis and
acute hypoxic respiratory failure. No history of prior
seizures, no FH epilepsy or hypercholesterolemia or early
stroke/MI. CT and MRI and LP collectively form picture of acute,
bilateral, posterior infarcts (septic emboli vs. cardioembolic
vs. cocaine) without prior neurologic disease. EEG showed no
seizure activity throughout MICU stay and was discontinued. She
was maintained on Keppra, empirically treated with antibiotics
and acyclovir. Negative TTE and TEE for valvular vegetation,
with bubble studies showing no PFO. Daily blood cultures were
sent, and antibiotics were discontinued with plan to send
additional blood cultures if she became febrile. CTA/MRA
head/neck were negative for bilateral vertebral dissection or
vasospasm. She had repeated episodes of agitation on multiple
sedation drips but was weaned and extubated without incident. On
the medicine floor, she was stable with no seizure episodes, and
telemetry did not reveal any arrhythmias. She developed ___
which may be attributed to acyclovir toxicity, hypovolemia,
rhabdomyolysis, or CIN. Her ___ was resolving after
discontinuing acyclovir and increasing fluid intake, with
decreasing CK throughout her stay. She will have a repeat lab
check after discharge and see nephrology in ___. For continued
concern for cardiac source of embolic stroke, she was sent home
with ___ of Hearts event monitor to detect any cardiac
arrhythmias. The acyclovir was never restarted given pt had
received 7 days at the time of discharge and given low suspicion
for HSV infection.
========================
Active issues
========================
#Seizure: She had multiple seizures initially with no reported
past history of seizures, etiology unclear. She was noted to
have hyperreflexia and clonus on exam which raised the question
of serotonergic excess, especially as a SSRI was recently added
to her meds. LP excluded bacterial meningitis. HSV PCR sample
was inadequate, but clinical suspicion was low. MRI showed
bilateral nonenhancing posterior lesions, TEE showed no PFO
(repeat TTE showed same result) or endocarditis, MRA/CTA showed
no vertebral artery disease. ___ be related to the possibility
of paroxysmal atrial fibrillation or other abnormal heart
rhythm, although no arrhythmias have been noted on tele.
Hypercoagulable state less likely given negative b2-glycoprotein
and anti-cardiolipin. She was started on keppra and scheduled
to follow up with the stroke service at the time of discharge.
___: Cr up to 2.2 on ___ from baseline 0.7. Possibly
drug-induced from acyclovir vs CIN. Initial UA showed blood with
minimal RBCs consistent with rhabdo. Repeat UA on ___ showed no
blood. Renal US showed no hydronephrosis. An embolic etiology of
the renal failure was considered as well, however, the rapid
improvement in function made this less likely. Ultimately
nephrology assisted with management, recommending IVF which led
to improvement in patient's renal function. Pt is scheduled for
repeat labs as an outpt and renal ___.
#Elevated CK: elevated to 2439 and 270 on dc, indicating
resolving rhabdomyolysis likely due to seizure.
#Abnormal LFTs: ALT/AST peak at 136/164 on ___, downtrended
during the hospitalization. ___ have been drug-induced, although
Keppra and acyclovir are not common hepatotoxic agents vs
ischemic vs rhabdo. Hepatitis panel was negative and RUQ US was
WNL.
#History of Opioid Abuse - Stable, ___ clinic confirmed
dosage of 1.25 tabs. Pt was on 1 tab during the hospitalization
and did well with this, could consider decreasing dose as an
outpt.
#Depression - Stable, has not been receiving home medications
due to initial concern for serotonin syndrome in the ICU.
Patient was feeling well without medications and so these were
held at discharge. She should see her psychiatrist after
discharge.
# Shock, likely septic: She was febrile, tachycardic, with
leukocytosis in ED. She was initially hemodynamically stable,
then became hypotensive refractory to fluids after intubation,
requiring levophed. This was subsequently discontinued as BPs
improved. Most likely etiology of shock is sepsis given the
fevers and leukocytosis. Possible sources include pulmonary in
the setting of aspiration. UA was unremarkable and LP did not
demonstrate meningitis. Medication effect is also possible given
the temporal relationship with sedation and intubation. She was
weaned from pressors and sedation and extubated. She was treated
broadly on vancomycin/zosyn.
#Acute hypercarbic/hypoxic respiratory failure / Mild ARDS: She
was intubated due to inability to protect airway in setting of
seizures. Chest x-ray showed rapidly worsening bilateral
effusions and edema, which was concerning for ARDS vs.
aggressive fluid resuscitation. P/F ratio was 264. She was
maintained on low tidal volume ventilation, covered on
antibiotics as above. She had improving chest x-rays and was
extubated.
#Anion gap metabolic acidosis due to lactic acidosis: Initial
gas post intubation was 6.75/58. Gap rapidly closed and pH
normalized as lactate cleared. Lactate was likely elevated due
to seizure given the rapid clearance. She was initially treated
with fomepizole for concern for ethylene glycol poisoning, but
assay was negative. This resolved as she improved.
# Leukocytosis: WBC was 16 on admission, without neutrophilic
predominance. ___ be reactive in the setting of seizures or due
to infection. She was covered on antibiotics as above.
#Subdural hemorrhage: Initial CT imaging showed a 4mm hyperdense
thickening of posterior falx concerning for subdural hemorrhage
and neurosurgery was consulted. MRI showed no evidence of bleed
and subsequent course did not suggest
#Anemia: 14->9->9->10.4->12. Possibly dilutional i/s/o initially
resuscitation. Trending upward prior to discharge (see lab
section).
======================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aspirin / Compazine / Zocor / Procardia / Heparin Agents /
Insulin,Beef / Insulin,Pork / Levofloxacin / Tape ___ /
Prednisone
Attending: ___
Chief Complaint:
nausea, vomiting
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENT ILLNESS: ___ year old man with a history of
Type 1 DM leading to L BKA, ESRD s/p LRD ___, CAD, PAD and
osteoporosis who presents with 2 days of poor PO intake,
vomiting, and difficult to control hyperglycemia. The vomiting
has been all day including dry heaves NBNB. He noted blood
sugars in the 600s yesterday. He believes this was either due to
a malfunction of his insulin pump or a bad batch of insulin. He
has been unable to take his PO medications for the past 2 days
including his renal tx meds. He denies any fevers/ chills. No
cp/abd pain/sob.
In the ED, initial VS: 99.4 81 170/77 18 97%. Blood sugar 278.
Lactate 1.3, CXR WNL. Leukocytosis to 15.8. Urinalysis without
evidence of a urinary tract infection. Blood cultures were sent.
He was evaluated by renal transplant, who recommended tacrolimus
sublnigual and cellcept IV. He was admitted to ___ for
further workup of his fever. VS prior to transfer: 99.0 78
148/86 17 99%.
REVIEW OF SYSTEMS:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, nausea, vomiting,
constipation, BRBPR, melena, hematochezia, dysuria, hematuria.
Past Medical History:
1. Diabetes mellitus: Type 1, diagnosed age ___ (___), variable
control throughout the years; complicated by triopathy
ultimately
leading to renal TXP; in addition has gastroparesis. Has
recently initiated care at ___. Has extremely labile blood
sugars and hypoglycemic unawareness. Referred recently for
ophthalmologic evaluation (has retinopathy, but no followup in ___
years, S/P laser, no known visual loss); also sees a podiatrist
regularly.
2. Status post renal transplant: ___ diabetic induced ESRD; has
elevated creatinine C/W chronic rejection versus medication
effect, but stable times years. Managed by ___.
3. PVD: S/P right pop-pedal bypass (___).
4. Gastroparesis.
5. Osteoporosis: Diagnosed elsewhere. No BMD since transfer of
care here in ___. On Fosamax.
6. H/O DVT: In the setting of sedentary lifestyle greater than
___ year ago ___ still on anticoagulation at the
patient's preference due to his current wheelchair bound state.
7. Chronic immunosuppression.
8. BP issues: Records state H/O HTN, it is unclear if this is
truly the case, not on medications.
9. Chronic RT heel ulcer: ___ years. Initially presented with
nonhealing ulcer, osteo S/P surgery C/P recurrence, S/P second
surgery, S/P skin grafts (___), C/P vascular insufficiency,
complicated suture removal, wound dehiscence, recurrent osteo,
debridement. Currently, now receiving care through Dr. ___
___ in ___. Previously followed by ___ and
___ and ___ at ___. Now undergoing aplografting
last done 1 week ago.
10. CAD: Asymptomatic, multivessel disease noted on
preoperative cardiac catheterization. Not on ASA, D/T personal
concerns regarding worsening of retinopathy. Normotensive and
not on beta-blocker. Has been educated regarding CAD symptoms.
11. H/O zoster: Sounds disseminated, last ___,
hospitalization required, no post-herpetic neuralgia.
12. Gastroparesis.
13. Status post cholecystectomy.
14. Cataracts, prednisone induced, awaiting foot healing prior
to surgery.
Social History:
___
Family History:
Mother deceased age ___ breast cancer; father
deceased age ___ with pancreatic cancer or metastatic prostate
cancer. No other malignancies. One whole brother, 7 half
siblings, all of whom are healthy.
Physical Exam:
ADMISSION EXAM:
VS: Tc: 99.6 Tm: 99.6 BP:131/39 HR: 76 rr: 16 02: 97% RA
GENERAL: thin man in no apparent distress in NAD
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: +ve bs, soft/NT/ND, no masses or HSM, no
rebound/guarding. Pump in place.
EXTREMITIES: WWP, 1+ pitting edema bilaterally in lower
extremities, distal pulses all intact, right leg is mildy tender
to palpation , no erythema, induration, or evidence of injury or
infection. Stable chronic healed ulcer right ventral foot
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, gait deferred.
DISCHARGE EXAM:
GENERAL: thin man in no apparent distress in NAD
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: +ve bs, soft/NT/ND, no masses or HSM, no
rebound/guarding. Pump in place.
EXTREMITIES: WWP, 1+ pitting edema bilaterally in lower
extremities, distal pulses all intact, right leg without
tenderness to palpation, no erythema, induration, or evidence of
injury or infection. Stable chronic healed ulcer right ventral
foot
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, gait deferred.
Pertinent Results:
ADMISSION LABS: ___ 08:55AM GLUCOSE-116* UREA N-43*
CREAT-2.0* SODIUM-141 POTASSIUM-4.5 CHLORIDE-106 TOTAL CO2-25
ANION GAP-15
___ 08:55AM CALCIUM-9.0 PHOSPHATE-3.4 MAGNESIUM-1.9
___ 08:55AM tacroFK-12.1
___ 08:55AM WBC-16.3* RBC-4.52* HGB-12.2* HCT-38.5*
MCV-85 MCH-27.1 MCHC-31.9 RDW-14.1
___ 08:55AM WBC-16.3* RBC-4.52* HGB-12.2* HCT-38.5*
MCV-85 MCH-27.1 MCHC-31.9 RDW-14.1
___ 08:55AM NEUTS-79.4* LYMPHS-14.9* MONOS-5.4 EOS-0.2
BASOS-0.2
___ 08:55AM PLT COUNT-199
___ 08:55AM ___ PTT-23.3* ___
___ 03:51AM LACTATE-1.3
___ 03:45AM URINE HOURS-RANDOM CREAT-144 SODIUM-47
POTASSIUM-44 CHLORIDE-31
___ 03:45AM URINE UHOLD-HOLD
___ 03:45AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:45AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-1000 KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 03:45AM URINE RBC-<1 WBC-<1 BACTERIA-FEW YEAST-NONE
EPI-<1
___ 03:45AM URINE HYALINE-11*
___ 03:41AM ___ PTT-25.4 ___
___ 01:10AM GLUCOSE-243* UREA N-46* CREAT-2.1* SODIUM-141
POTASSIUM-4.9 CHLORIDE-101 TOTAL CO2-28 ANION GAP-17
___ 01:10AM ALT(SGPT)-22 AST(SGOT)-26 ALK PHOS-107 TOT
BILI-0.8
___ 01:10AM ALBUMIN-4.5 CALCIUM-9.8 PHOSPHATE-3.0
MAGNESIUM-2.1
___ 01:10AM WBC-15.8*# RBC-4.93 HGB-13.6* HCT-42.4 MCV-86
MCH-27.6 MCHC-32.0 RDW-13.9
___ 01:10AM NEUTS-87.7* LYMPHS-8.2* MONOS-3.6 EOS-0
BASOS-0.5
___ 01:10AM PLT COUNT-217
DISCHARGE LABS:
___ 06:15AM BLOOD WBC-10.2 RBC-4.31* Hgb-12.0* Hct-38.1*
MCV-88 MCH-27.9 MCHC-31.6 RDW-14.2 Plt ___
___ 06:15AM BLOOD Plt ___
___ 06:15AM BLOOD ___ PTT-23.4* ___
___ 06:15AM BLOOD Glucose-144* UreaN-26* Creat-1.5* Na-143
K-4.5 Cl-107 HCO3-27 AnGap-14
___ 06:15AM BLOOD Calcium-8.6 Phos-3.0 Mg-1.8
___ 06:20AM BLOOD tacroFK-5.3
MICRO:
___ URINE URINE CULTURE-FINAL INPATIENT <10,000
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
___ BLOOD CULTURE Blood Culture, Routine-PENDING
EMERGENCY WARD
CXR ___
fINDINGS:
Frontal and lateral views of the chest were obtained. The heart
size and
cardiomediastinal contours are normal. Linear density in the
left lobe is
unchanged and consistent with scarring. The lungs are otherwise
clear. No
focal consolidation, pleural effusion, or pneumothorax. The
osseous structures
are unremarkable. No radiopaque foreign body.
IMPRESSION:
No acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Insulin Pump SC (Self Administering Medication)Insulin
Aspart (Novolog) (non-formulary)
Target glucose: 80-180
3. Mycophenolate Mofetil 500 mg PO BID
4. Pravastatin 20 mg PO DAILY
5. Alendronate Sodium 70 mg PO QSAT
6. Ascorbic Acid ___ mg PO DAILY
7. Vitamin D 50,000 UNIT PO 1X/WEEK (SA)
8. Tacrolimus 2 mg PO Q12H
9. Glucagon 1 mg IM DAILY as directed
for hypoglycemia
10. Vitamin E 400 UNIT PO DAILY
Discharge Medications:
1. Alendronate Sodium 70 mg PO QSAT
RX *alendronate 70 mg 1 tablet(s) by mouth oncee a week Disp #*4
Tablet Refills:*0
2. Ascorbic Acid ___ mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Glucagon 1 mg IM DAILY as directed
for hypoglycemia
RX *glucagon (human recombinant) [Glucagon Emergency] 1 mg give
1 injection once Disp #*4 Syringe Refills:*0
5. Mycophenolate Mofetil 500 mg PO BID
6. Pravastatin 20 mg PO DAILY
7. Tacrolimus 2 mg PO Q12H
8. Vitamin E 400 UNIT PO DAILY
9. Glargine 10 Units Breakfast
RX *insulin glargine [Lantus] 100 unit/mL 10 units before
breakfast Disp #*1 Unit Refills:*0
10. Insulin Pump SC (Self Administering Medication)Insulin
Aspart (Novolog) (non-formulary)
Basal rate minimum: 0.55 units/hr
Basal rate maximum: 0.85 units/hr
Bolus minimum: 1.29 units
Bolus maximum: 1.33 units
Target glucose: ___
Fingersticks: QAC and HS
RX *insulin aspart [Novolog] 100 unit/mL please use to replenish
insulin pump per insulin pump settings Disp #*1 Unit Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Primary
Hyperglycemic HyperOsmolar Nonketotic State
Secondary
Type I diabetes
End Stage Renal Disease s/p transplant
Chronic transplant rejection
Left leg amputation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent (with left leg
prosthesis)
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with hypoglycemia. Evaluate for pneumonia.
COMPARISON: Multiple prior chest radiographs, most recently ___.
FINDINGS:
Frontal and lateral views of the chest were obtained. The heart size and
cardiomediastinal contours are normal. Linear density in the left lobe is
unchanged and consistent with scarring. The lungs are otherwise clear. No
focal consolidation, pleural effusion, or pneumothorax. The osseous structures
are unremarkable. No radiopaque foreign body.
IMPRESSION:
No acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: VOMITING AND/OR NAUSEA
Diagnosed with RENAL & URETERAL DIS NOS, AORTOCORONARY BYPASS, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, KIDNEY TRANSPLANT STATUS
temperature: 99.4
heartrate: 81.0
resprate: 18.0
o2sat: 97.0
sbp: 170.0
dbp: 77.0
level of pain: 4
level of acuity: 2.0 | BRIEF HOSPITAL COURSE
___ year old man with a history of Type 1 DM leading to L BKA,
ESRD s/p LRD ___, CAD, PAD and osteoporosis who presents with 2
days of poor PO intake, vomiting, and difficult to control
hyperglycemia.
Nausea/vomiting: Patient presented with 2 day hx of nausea,
vomiting which was none bloody, non bilious, non projectile in
setting of replacing pump insulin with ? expired batch of
insulin. He was seen by ___ who evaluated the pump and
confirmed its proper function and agreed that the most likely
etiology of his nausea and vomiting was indeed refilling with a
bad bunch of insulin, leading to HONK state with subsequenty
osmotic diuresis and dehydration. He recieved IVF inhouse, was
quickly able to tolerate a regular diet without nausea/vomiting,
with the initial complaint that his stomach felt "raw" with p.o
however this sensation resolved. He restarted his insulin pump
with the correction factor changed to 1.55. He was discharged
with a prescription for lantus 10Units to use in the event of
pump failure for basal coverage.
.
ESRD s/p transplant: pt with hx of ESRD s/p transplant with
chronic rejection. Cr elevated from recent baseline 1.3-1.4 to
2.0 on initial admission. Elevated Cr likely prerenal in
setting of dehydration, and improved with initial IVF and oral
hydration, 1.5 on discharge. Rejection was not suspected given
that he only missed 2 doses of cellcept/tacrolimus when he was
having nausea/vomiting. His tacrolimus level was 5.3 on
discharge and he continued his home tacro 2mg q12 and cellcept
500mg BID.
.
Leukocytosis: pt with leukocytosis of unclear etiology. Exam non
focal. DDx includes infection, gastroperesis flare. Infectious
workup was negative and leukocytosis resolved. Blood cultures
were pending at the time of discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ man with a reported history of
cardiomyopathy status post PPM who was BIBA after witnessed fall
from standing earlier today.
EMS found him sitting on a rolling walker with bystanders and
his son on scene who reported seeing the patient pass out on the
sidewalk. He was noted to be lethargic and nonverbal during
evaluation and transport. On arrival to the
hospital, he became more alert.
Mr. ___ says he fell from standing while trying to mail a
letter after feeling dizzy and falling backwards onto his
bottom. He denies any head strike, loss of consciousness, nausea
or vomiting. Patient denies any associated chest pain or
shortness of breath. Patient denies any cough, dysuria,
abdominal pain, or dizziness now. Patient ambulates without
assistive devices at baseline.
In the ED, initial VS were:
Temp 98.2F HR 61 BP 104/49 RR 17 SaO2 99% RA
Exam notable for:
Some crepitus of left shoulder but full range of motion
bilaterally. Exam negative for any apparent trauma
Labs showed:
Negative Utox, STox, unremarkable UA, Hgb 10.4, ___ to 1.3,
Troponin to 0.03->0.02. Initial fingerstick 111.
EKG:
Atrial paced rate @60bpm, NA, NI, Early R-wave progression, STE
V2
Imaging showed:
Left shoulder XR: No fracture or dislocation.
CXR: No acute cardiopulmonary process, no focal consolidation
CT Head:
1. No acute intracranial process.
2. A peripherally calcific 1.2 cm suprasellar structure which is
not acute in nature. Differential considerations include mass
such as craniopharyngioma versus meningioma. An aneurysm is less
likely but not entirely excluded.
CT Spine: No acute fracture or traumatic malalignment of the
cervical spine.
CTA Head/Neck preliminary read without acute abnormality
Received:
___ 22:40 IV OLANZapine 10 mg
___ 00:40 IM LORazepam 1 mg
Neurosurgery were consulted. "CTA reviewed, no evidence of
aneurysm or vascular abnormality. They recommended scheduling
outpatient MRI w/wo contrast and follow up in clinic with neuro
oncology.
On arrival to the floor, first with phone translator and then
with translator in person, patient reports feeling fine with no
pain and confirms history above. He says that he did not have
any odd feelings before he fell besides dizziness, denies
palpitations, sweating, chest pain, nausea/abdominal pain.
Reports he remembers falling, denies feeling unbalanced or
seeing his surroundings spinning. He reports loss of
consciousness. He had to be repeatedly prompted to answer
questions and often answered incompletely or inappropriately to
questioning (e.g. "this is my finger" when asked to touch
doctor's finger during cerebellar testing, at one time notes his
son has a PPM, later denies having a son).
Attempted to contact daughter in law for more information, was
unable to reach her or leave a message.
Past Medical History:
1. Dementia of unknown etiology (vascular vs. EtOH vs.
Alzheimer)
2. CKD stage III
3. Sick sinus syndrome status post PPM placement
4. Colon cancer
5. DVTs status post IVC filter placement
Social History:
___
Family History:
Denies family history of stroke, heart attack, syncope.
Physical Exam:
===============================
ADMISSION PHYSICAL EXAMINATION:
===============================
VS: Temp 97.7 BP 165/50 HR 63 RR 18 SaO2 100% RA
Orthostatics: lying 175/70, standing 138/69
GENERAL: NAD, appears chronically ill
HEENT: AT/NC, anicteric sclera, pink conjunctiva, dry mucous
membranes. Prominent opacity of left eye lens. Was not able to
prompt ocular tracking. Pupillary reflex difficult to ascertain.
Patient endorses ability to see a bright light.
NECK: supple, no LAD, no JVD
HEART: RRR, S1 difficult to assess, prominent S2, no murmurs,
gallops, or rubs
LUNGS: CTAB with poor air movement, no wheezes, rales, rhonchi,
breathing comfortably without use of accessory muscles
ABDOMEN: Scar from ?exlap and another ~6cm scar in LLQ visible.
3-4cm diameter region of erythema with ?hemorrhagic crust
directly above umbilicus. Abdomen soft, nondistended, nontender
in all quadrants, no rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox1-2, limited by patient ?deafness/blindness and
communication, face appears symmetric, eye movement grossly
intact, CN IX-XII intact, ___ strength b/l in UEs,
plantarflexion, dorsiflexion.
SKIN: warm and well perfused, multiple patches of dark
erythema/purpura along arms bilaterally
===============================
DISCHARGE PHYSICAL EXAMINATION:
===============================
VS: T 97.0 BP 138/65 HR 66 RR 18 SaO2 95% RA
GENERAL: lying comfortably in bed, no apparent distress
HEENT: anicteric sclera, no conjunctival pallor, MMM
NECK: supple, non-tender no LAD, no elevated JVD
CV: RRR, normal S1 and S2, no murmurs/rubs/gallops
RESP: CTAB but with poor air movement due to poor respiratory
effort, no wheezes, rales, or rhonchi
___: soft, non-tender, non-distended. No HSM. Multiple old
abdominal surgical scars.
EXTREMITIES: warm and well perfused, no cyanosis, clubbing, or
edema
NEURO: Alert, oriented only to self. Otherwise grossly intact,
with no focal neurological deficits.
Pertinent Results:
===============
ADMISSION LABS:
===============
___ WBC-6.2 RBC-3.56* Hgb-10.4* Hct-33.3* MCV-94 MCH-29.2
MCHC-31.2* RDW-13.9 RDWSD-47.2* Plt ___
___ Neuts-68.0 ___ Monos-10.0 Eos-1.6 Baso-0.6 Im
___ AbsNeut-4.22 AbsLymp-1.20 AbsMono-0.62 AbsEos-0.10
AbsBaso-0.04
___ ___ PTT-27.6 ___
___ Glucose-91 UreaN-28 Creat-1.3 Na-143 K-4.8 Cl-102
HCO3-22 AnGap-19
___ ALT-22 AST-30 AlkPhos-85 TotBili-<0.2
___ Lipase-59
___ 03:19PM cTropnT-0.03*
___ 10:50PM cTropnT-0.02*
___ Albumin-3.8 Calcium-8.7 Phos-3.7 Mg-2.4
___ VitB12-615
___ %HbA1c-5.9 eAG-123
___ TSH-0.88
___ ASA-NEG Ethanol-NEG Acetmnp-NEG Bnzodzp-NEG Barbitr-NEG
Tricycl-NEG
___ URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG GLUCOSE-NEG
KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0 LEUK-NEG
___ URINE COLOR-Straw APPEAR-Clear SP ___
___ URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
======
MICRO:
======
___ URINE
URINE CULTURE:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION
___ BLOOD CULTURE 1.
Blood Culture: No growth to date of discharge
___ BLOOD CULTURE 2.
Blood Culture: No growth to date of discharge
================
IMAGING/REPORTS:
================
___ CT C-SPINE WITH CONTRAST
No acute fracture or traumatic malalignment of the cervical
spine.
Degenerative changes resulting in moderate canal narrowing at
the C3-4 and
C4-5 levels with probable remodeling of the cord at these
levels.
___ CT HEAD WIHTOUT CONTRAST
No acute intracranial process, no hemorrhage. A lobulated
partially calcific 1.2 cm suprasellar structure which is not
acute in nature. Differential considerations include mass such
as craniopharyngioma versus meningioma. An aneurysm is less
likely but not entirely excluded. Nonemergent MR is recommended
for further evaluation.
___ CXR
Lungs are clear without consolidation, effusion, or edema. Left
chest wall dual lead pacing device is noted. Cardiomediastinal
silhouette is within
normal limits. Atherosclerotic calcifications noted at the
aortic arch. IVC filter is partially visualized.
___ LEFT GLENO-HUMERAL XRAY
There is no fracture. Glenohumeral joint is anatomically
aligned. Moderate degenerative changes noted at the
acromioclavicular joint which is otherwise within normal limits.
Included portion of the left hemithorax is unremarkable where
not obscured by overlying pacer device.
___ CTA HEAD AND CTA NECK
12 mm mass within the suprasellar cistern, with areas of
peripheral and
internal calcification. The mass results in superior
displacement of the
optic chiasm and floor of hypothalamus. The differential
includes
craniopharyngioma, dermoid, and/or thrombosed aneurysm. Moderate
intracranial atherosclerosis moderate narrowing of the
supraclinoid segment of the right internal carotid artery.
Moderate extracranial atherosclerosis, with 50-70% narrowing of
the bilateral carotid arteries at the carotid bulbs by NASCET
criteria. Dental caries. Recommend nonemergent dental
consultation.
___ TTE
There is mild symmetric left ventricular hypertrophy. 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 = 70%). There is no left ventricular outflow obstruction
at rest or with Valsalva. 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 to
moderate (___) aortic regurgitation is seen. The mitral valve
leaflets are mildly thickened. Trivial mitral regurgitation is
seen. Moderate [2+] tricuspid regurgitation is seen. [Due to
acoustic shadowing, the severity of tricuspid regurgitation may
be significantly UNDERestimated.] The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
===============
DISCHARGE LABS:
===============
Patient refusing labs
Medications on Admission:
Unable to verify home medications, but informed patient is
non-compliant with medications at home.
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth Two times daily
Disp #*60 Tablet Refills:*0
2. Midodrine 10 mg PO TID
RX *midodrine 10 mg 1 tablet(s) by mouth Three times a day Disp
#*90 Tablet Refills:*0
3. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides [senna] 8.6 mg 1 tablet by mouth Two times daily
as required Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Syncope - likely orthostatic hypotension
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: CTA HEAD AND CTA NECK Q16 CT NECK.
INDICATION: History: ___ with brain mass// ? Aneurysm.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 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 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Stationary Acquisition 2.0 s, 0.5 cm; CTDIvol = 21.8 mGy (Head) DLP =
10.9 mGy-cm.
3) Spiral Acquisition 4.9 s, 38.4 cm; CTDIvol = 31.0 mGy (Head) DLP =
1,191.0 mGy-cm.
Total DLP (Head) = 2,005 mGy-cm.
COMPARISON: ___ CT head from the same date and time.
FINDINGS:
CTA HEAD:
There is a 12 mm round lesion within the suprasellar cistern. The lesion
results in superior displacement of the optic chiasm and floor of the
hypothalamus. The inferior surface sits on top of the dorsum sella. The
bilateral A1 segments and anterior communicating artery abut the anterior
surface of the mass.
There is atherosclerotic plaque within the bilateral internal carotid
arteries, with moderate narrowing supraclinoid segment of the right internal
carotid artery. The anterior and middle cerebral arteries are patent, without
stenosis.
There is an infundibular origin of the right posterior communicating artery
(series 5, image 236). There is a fetal origin of the bilateral posterior
cerebral arteries. The posterior cerebral arteries otherwise patent, without
stenosis.
The intracranial vertebral arteries and basilar artery are patent without
stenosis.
CTA NECK:
There is a 3 vessel aortic arch. There is moderate atheromatous and
atherosclerotic plaque within the aortic arch.
There is mild atheromatous plaque within the right common carotid artery.
There is moderate atheromatous and atherosclerotic plaque at the right carotid
bulb and within the proximal common carotid artery, with 50-70% stenosis by
NASCET criteria.
There is mild atheromatous plaque within the left common carotid artery. There
is moderate atheromatous and atherosclerotic plaque at the left carotid bulb
and within the proximal common carotid artery, with 50-70% stenosis by NASCET
criteria.
The origin of the bilateral vertebral arteries is difficult to evaluate due to
photon starvation artifact. There are areas of mild to moderate narrowing
within the bilateral extracranial vertebral arteries, likely secondary to
atheromatous plaque.
OTHER:
No enlarged cervical lymph nodes are identified.
Note is made of a left scleral band and bilateral senescent scleral
calcifications. There are bilateral lens implants.
There is moderate to severe degenerative disc disease within the cervical
spine, with moderate spinal canal narrowing at multiple levels and severe
neural foraminal narrowing at multiple levels.
There are multiple dental caries and periapical lucencies.
There is a 3 mm subpleural nodule within the right upper lobe (series 5, image
29). An area of reticulation within the anterior segment of the right upper
lobe may reflect scarring related to prior infection. Left chest pacemaker
device is incompletely imaged.
IMPRESSION:
1. 12 mm mass within the suprasellar cistern, with areas of peripheral and
internal calcification. The mass results in superior displacement of the
optic chiasm and floor of hypothalamus. The differential includes
craniopharyngioma, dermoid, and/or thrombosed aneurysm.
2. Moderate intracranial atherosclerosis moderate narrowing of the
supraclinoid segment of the right internal carotid artery.
3. Moderate extracranial atherosclerosis, with 50-70% narrowing of the
bilateral carotid arteries at the carotid bulbs by NASCET criteria.
4. Dental caries. Recommend nonemergent dental consultation.
RECOMMENDATION(S): Recommend nonemergent dental consultation.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Dizziness
Diagnosed with Altered mental status, unspecified
temperature: 98.2
heartrate: 61.0
resprate: 17.0
o2sat: 99.0
sbp: 104.0
dbp: 49.0
level of pain: uta
level of acuity: 2.0 | ___ with advanced dementia, stage III CKD, sick sinus syndrome
with PPM placement in ___, and a background history of colon
cancer and DVT status post IVC filter placement, who was BIBA
following an episode of syncope.
==================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lisinopril / sulfamethoxazole-trimethoprim / Atorvastatin /
Compazine / Amitriptyline / Lactose / Tetanus / Pneumococcal
Vaccine / Nitroglycerin
Attending: ___
Chief Complaint:
Lower back pain, lightheadedness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F w/ h/o CAD s/p RES in RCA, DM2, COPD/Asthma, pulmonary
HTN, fibromyalgia, who presented for back pain and
lightheadedness. Pt has chronic lower back pain, however in the
past two weeks, her pain has been more frequent. The pain
located in the midline, lower back, sharp in quality, ranging
from ___, and does wake her up at night. Pt complained of
numbness, "pins and needles" sensation over her bilateral calf
recently. She occasional experience stress incontinence and
stool accidents, but those symptoms have not worsened. Pt
reported lightheadedness, frequently associated with the onset
of backpain. Her worst symptoms frequently occur in the morning
when she woke up on the bed, with associated nausea and
headache. She denies vision changes, focal weakness, or slurred
speech. Of note, pt was recently started on Lyrica two weeks
ago, and has stopped the medication three days ago because of
these symptoms. Pt was also given 20 tablets of Meclizine two
weeks ago for her "dizziness", which did not appear to have
helped her symptoms. She occasionally takes oxycodone and ultram
for pain, but did not report association to her symptoms. Pt
recently were only on metformin for her diabetes, and her
morning fasting ___ were 70-90s.
Pt reported fever to 102 the day prior to admission. She also
reported "coarse" throat, but no productive cough. There were
also development of several tender nodes over her neck. Pt
routinely experiences nonexertional chest pain that were felt to
be ___ fibromyalgia as prior workup has always been negative. Pt
denies significant weight changes, night sweats, joint pain,
dysuria, diarrhea.
In the ED, initial vitals 99.2 78 172/80 16 100% ra. As pt c/o
short episode of chest pain after admission, cardiac enzymes
were obtained with troponin 0.03. Pt was given 325 mg asa and
600 mg plavix. Cardiology consult initiated in the ED, who
recommended d/c home if cardiac enzymes remain negative. Her ___
troponin downtrended to0 0.02 ___KMB. However, pt then
complained of feeling weak with two weeks of vertigo symptoms.
Rectal temperature was elevated at 100.6. Pt was subsequently
admitted to medicine floor for further workup.
.
Pt was admitted to the medicine floor for fever of unknown
origin and concerning UA. Her initial VS were 98.6, 118/58, 60,
16, 100% on 3L
.
ROS: per HPI
Past Medical History:
Hypertension
Hyperlipidemia
Diabetes mellitus, Type II
Coronary artery disease s/p DES to the RCA, with chronic
atypical chest pain (repeat cath in ___ showing patent stent,
pMIBI ___ with normal cardiac perfusion and possible anginal
symptoms in the absence of ST segment changes).
Chronic diastolic CHF
Pulmonary hypertension (PA systolic 54 in ___
History of tobacco abuse
COPD and asthma on 3L home oxygen
Chronic pain/Fibromyalgia
Chronic pancreatitis, with pancreatic cystic lesion.
GERD
Stroke in ___ with trace residual weakness of right arm and
face
Obesity
Spinal stenosis
Hx tongue cancer s/p resection in ___
Social History:
___
Family History:
Extensive history of MIs (ages ___) in siblings and mother.
___ throughout. Sister with CHF. Another sister with pulmonary
fibrosis.
Physical Exam:
ADMISSION PHYSICAL EXAM
VS - Temp 98.6, BP 118/58, HR 60, RR 16, O2 sat 100% on 3L O2
GENERAL - well-appearing man in NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, JVD ~8 cm, cervical lymph nodes tender on
palpation
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/ND, TTP over RUQ, no masses or HSM, no
rebound/guarding, no ___ sign
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
MSK - lumbar spine tender on palpation, straight leg sign
negative, no saddle anesthesia
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, although R side slightly weak than L, tactile
sensation diminished over RLE.
.
DISCHARGE PHYSICAL EXAM
VS: TEMP 98.1, HR 57 BP 121/80, RR 18, O2 sat 100% on 2L
GEN: A & OX3, NAD
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, JVD ~8 cm, right cervical lymph nodes tender on
palpation
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/ND, TTP over RUQ, no masses or HSM, no
rebound/guarding, no ___ sign
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
MSK - lumbar spine tender on palpation, straight leg sign
negative, no saddle anesthesia
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, although R side slightly weak than L, tactile
sensation diminished over RLE.
Pertinent Results:
ADMISSION LABS
___ 06:43PM BLOOD WBC-5.4 RBC-3.37* Hgb-9.9* Hct-30.2*
MCV-90 MCH-29.4 MCHC-32.8 RDW-13.3 Plt ___
___ 06:43PM BLOOD Neuts-64.5 ___ Monos-5.2 Eos-1.7
Baso-0.5
___ 06:43PM BLOOD ___ PTT-24.6* ___
___ 06:43PM BLOOD Glucose-111* UreaN-15 Creat-0.9 Na-141
K-3.9 Cl-101 HCO3-31 AnGap-13
.
CARDIAC LABS
___ 06:43PM BLOOD cTropnT-<0.01
___ 12:10AM BLOOD cTropnT-0.03*
___ 06:09AM BLOOD cTropnT-0.02*
___ 06:43PM BLOOD CK-MB-3
___ 06:43PM BLOOD CK(CPK)-166
.
PERTINENT LABS
___ 06:43PM BLOOD TSH-1.1
.
DISCHARGE LABS
___ 07:59AM BLOOD WBC-5.0 RBC-3.23* Hgb-9.5* Hct-28.1*
MCV-87 MCH-29.4 MCHC-33.9 RDW-13.5 Plt ___
___ 07:59AM BLOOD Glucose-111* UreaN-16 Creat-1.0 Na-140
K-3.6 Cl-99 HCO3-31 AnGap-14
.
MICROBIOLOGY
URINE
___ 02:25PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-TR
___ 02:25PM URINE RBC-1 WBC-16* Bacteri-FEW Yeast-NONE
Epi-19 TransE-<1
.
RADIOLOGY
CXR AP/LAT (___)
FINDINGS: Comparison with prior studies is complicated due to
magnifying
effect of AP view on the heart. Allowing for those limitations,
there lung
volumes are low, but there is no definite focal opacity. The
left lower lung field cannot be assessed in the frontal view due
to obliteration by magnified heart shadow, but the lateral view
does not demonstrate focal opacities or pleual effusion at this
level. There is no pleural effusion or pneumothorax.
IMPRESSION: No definite evidence of acute intrathoracic process.
Unchanged
compared with ___ allowing for difference in
techniques
Medications on Admission:
- carvedilol 25 mg 1 in the morning, 2 at night .
- albuterol sulfate q6 prn
- fluticasone-salmeterol 250-50 mcg/dose Disk qd
- furosemide 10 mg qd
- isosorbide mononitrate 60 mg qhs
- metformin 1g qhs
- levalbuterol tartrate tid prn wheeze
- lipase-protease-amylase 6,000-19,000 -30,000 unit Capsule,
Delayed Release(E.C.) tid w/ meals
- olmesartan 40 mg qAM
- oxycodone 5 mg Tablet bid prn pain
- ranitidine HCl 150 mg qd
- rosuvastatin 40 mg qd
- pantoprazole 40 mg qd
- tramadol 50 mg q8
- sucralfate 1 gram tid
- aspirin 81 mg qd
- coenzyme Q10 100 mg qd
- calcium carbonate-vitamin D3 500 mg(1,250mg) -400 unit bid.
.
Discharge Medications:
1. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
2. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day.
3. fluticasone-salmeterol 250-50 mcg/dose Disk with Device Sig:
One (1) Disk with Device Inhalation Q 24H (Every 24 Hours).
4. metformin 1,000 mg Tablet Extended Rel 24 hr Sig: One (1)
Tablet Extended Rel 24 hr PO qam.
5. multivitamin Tablet Sig: One (1) Tablet PO DAILY (Daily).
6. oxycodone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for back pain.
7. tramadol 50 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours) as needed for pain.
8. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Cap PO TID W/MEALS (3 TIMES A
DAY WITH MEALS).
9. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO BID (2 times a day).
10. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO BID (2 times a day).
11. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q24H (every 24 hours).
12. carvedilol 25 mg Tablet Sig: One (1) Tablet PO twice a day.
13. isosorbide mononitrate 30 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO QAM (once a day
(in the morning)).
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*2*
14. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
15. furosemide 20 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
16. sucralfate 1 gram Tablet Sig: One (1) Tablet PO TID (3 times
a day).
17. olmesartan 40 mg Tablet Sig: One (1) Tablet PO once a day.
18. albuterol sulfate 2.5 mg /3 mL (0.083 %) Solution for
Nebulization Sig: One (1) nebulizer treatment Inhalation every
six (6) hours as needed for shortness of breath or wheezing.
19. Atrovent HFA 17 mcg/actuation HFA Aerosol Inhaler Sig: One
(1) puff Inhalation twice a day as needed for shortness of
breath or wheezing.
20. levalbuterol tartrate 45 mcg/actuation HFA Aerosol Inhaler
Sig: One (1) puff Inhalation three times a day as needed for
shortness of breath or wheezing.
Discharge Disposition:
Home With Service
Facility:
___
___:
Primary diagnosis:
- Chronic lower back pain
Secondary diagnosis:
- coronary artery disease
- chronic obstructive pulmonary disease
- fibromyalgia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with weakness and fever. Evaluate for acute
cardiopulmonary process.
COMPARISON: PA and lateral chest radiograph on ___ and ___.
TECHNIQUE: Upright AP and lateral radiographs of the chest.
FINDINGS: Comparison with prior studies is complicated due to magnifying
effect of AP view on the heart. Allowing for those limitations, there lung
volumes are low, but there is no definite focal opacity. The left lower lung
field cannot be assessed in the frontal view due to obliteration by magnified
heart shadow, but the lateral view does not demonstrate focal opacities or
pleual effusion at this level. There is no pleural effusion or pneumothorax.
IMPRESSION: No definite evidence of acute intrathoracic process. Unchanged
compared with ___ allowing for difference in techniques.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: CP/SOB
Diagnosed with CHEST PAIN NOS, VERTIGO/DIZZINESS, BACKACHE NOS, CHRONIC AIRWAY OBSTRUCTION, CAD UNSPEC VESSEL, NATIVE OR GRAFT, DIABETES UNCOMPL ADULT
temperature: 99.2
heartrate: 78.0
resprate: 16.0
o2sat: 100.0
sbp: 172.0
dbp: 80.0
level of pain: 4
level of acuity: 3.0 | ___ yo F w/ h/o CAD s/p RES in RCA, DM2, COPD/Asthma, pulmonary
HTN, fibromyalgia, who presented for back pain and
lightheadedness.
.
# Lightheadedness: Pt's light headedness is subacute, likely
multifactorial. Temporally, it is associated with the initiation
of Lyrica in the past two weeks. Other iatrogenic causes
included meclizine. Hypotension from qhs use of imdur with
higher dose carvedilol as well as hypoglycemia from qhs use of
metformin can both cause morning lightheadedness. Other
medications include meclizine, flexeril, Ultram, oxycodone,
lasix. There is no evidence of orthostatic hypotension on the
physical exam. URI and overall deconditioning could also be
contributing factors. We continued her pain medication,
including oxycodone and ultram, held her flexeril, meclizine,
and decreased imdur from 60 mg qhs to 30 mg qAM, and decreased
her carvedilol to 25 mg bid. We would recommend taking the
medication in the morning rather than at night.
.
# Back pain: Pt has chronic lower back pain managed with
epidural injection every three months and chronic pain
medication. There were no red flag signs concerning for cord
compression on the exam. She has known anterolisthesis of L4/L5,
and prior diagnosis of spinal stenosis. Her chronic pancreatitis
could potentially contribute to her pain. Depression is a
potential cause/contributor to her symptoms. The resolution of
her back pain is unlikely during his hospitalization. We
continued her pain medication, and had social worker to help
patient deal with the social stresses.
.
# Fever: She self reported fever at home to 102. She also had a
documented rectal temperature of 100.6 in the ED. She had
cervical tender lymphadenopathy, likely suggesting an URI. There
were no evidence of pneumonia on CXR. There was a qusetion of
pyuria, but urine culture showed skin flora . Pt remained
afebrile with no leukocytosis during this admission.
.
# Coronary artery disease: Pt has DES in RCA. She had some chest
pain in the ED with no EKG changes and her cardiac enzymes were
negative. This has been consistent with her prior presentations,
most likely secondary to fibromyalgia. We continued her home
medication, with the exception of decreasing isosorbide
mononitrate to 30 mg qd and carvedilol to 25 mg bid.
.
CHRONIC ISSUES
# Diabetes mellitus: Pt has diagnosis of type II diabetes,
currently only on metformin 1g per day. She was switched on
sliding scale insulin during this hospitalization.
.
# Chronic diastolic CHF: likely secondary to hyertension. We
held her furosemide for one day during this admission.
.
# COPD and asthma: Pt is obstructive airway disease likely ___
smoking. She uses 3L O2 at baseline. Her O2 sat drops to 91%
on RA. We continued the equivalence of her inhalers.
.
# Chronic pancreatitis: Pt carries diagnosis of chronic
pancreatitis. We continued her Creon with meal.
.
# GERD: Pt carries diagnosis of GERD and is on pantoprazole,
ranitidine and sucralfate. We continued all three medication,
however, given the dizziness, will consider discontinuing
ranitidine.
.
TRANSITIONAL ISSUES
# CODE STATUS: FULL
# CONTACT: ___ (___) and ___
(___)
# PENDING STUDIES AT DISCHARGE: none
# MEDICATION CHANGES
- STOPPED meclizine
- STOPPED cyclobenzaprine
- DECREASED Imdur dose to 30 mg in the AM from 60 mg qHS
- DECREASED Carvediolol to 25 mg bid from 25 qAM & 50 qHS
# FOLLOWUP PLAN
- Pt will arrange followup with Dr. ___
- She has appointment on ___ at HCA with NP ___
- will recommend consolidate GERD medication, especially
ranitidine
- Sleep studies pending |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
nausea, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o woman with a PMH of alcoholic
cirrhosis (c/b SBP, ascites, HE), non-variceal UGIB, s/p RNYGB,
current G-tube for enteral feedings, recent admissions for
abdominal wall abscess with EC fistula and recurrent ileus/SBO
c/b ATN, encephalopathy, and recurrent clogging of G-tube, who
now presents with diffuse abdominal pain and nausea. She
described the pain as ___, constant, non-radiating, with no
mitigating or aggravating factors. She has been having bowel
movements. She has not been vomiting. She denied headache,
fevers, chills, hematemesis, coffee-ground emesis, hematochezia,
melena, diarrhea, or constipation. She was referred to the ___
ED.
Upon arrival to the ED, her initial vital signs were: T 97.5F BP
102/48 mmHg P 87 RR 16 O2 100% RA. Examination was notable for
hepatic encephalopathy, no scleral icterus, no sublingual
jaundice, normal S1/S2, RRR, clear lungs, soft abdomen, TTP
diffusely, distended, no masses, no lower extremity edema.
Bedside ultrasound did not demonstrate an accessible pocket for
paracentesis. Labs were notable for Na 133, K 4.3, Cl 95, HCO3
21, BUN/Cr 35/1.0, WBC 4.5, H/H 7.3/21.9 (MCV 107), PLT 61,000,
INR 1.9, ALT 14, AST 54, alk phos 151, Tbili 2.4, albumin 2.8.
UA
with moderate leukocyte esterase, 8 WBC, few bacteria, lactate
1.8. CT of the abdomen and pelvis was performed with oral
contrast, which demonstrated distended distal small bowel with
extensive fecalized material suggesting slow transit. No
discrete
transition point identified nor decompressed distal small bowel
loops to support obstruction. Colon moderately distended with
stool. No evidence of abscess. Pigtail catheter seen along left
anterior abdominal wall without associated collection. Nodular
liver with small volume ascites. She received 1L IV NS, morphine
4 mg x2 and 2 mg x2, as well as ondansetron 4 mg IV. She was
admitted to the hepatology service.
On arrival to the floor, she reports that her pain was of the
same quality as usual, but was persistent. She stopped her tube
feeds, but that did not help the pain. She otherwise endorsed
the
narrative as above. She has not been taking tramadol at home and
has been taking Dilaudid once per day. She denied fevers,
chills,
chest pain, shortness of breath. She reports that she has been
having three bowel movements per day
Past Medical History:
- ETOH cirrhosis complicated by ascites, HE, SBP
- Obesity
- s/p gastric bypass c/b stricture of the gastrojejunal
anastomosis and internal hernia causing SBO s/p multiple
endoscopic dilations c/b perforation (as detailed below)
- SBO as above
- Exploratory laparotomy, takedown old gastrojejunostomy,
gastrogastrostomy, feeding jejunostomy ___ ___ for
perforated gastrojejunal anastomosis site with reopening of
recent laparotomy and closure of gastrostomy ___ ___
- Epileptiform discharges concerning for possible seizure in
setting of altered mental status, started on keppra ___
- numerous hospitalizations for abdominal pain, requiring
paracenteses
- depression/anxiety
- GERD
- hx of Cdiff
- IBS
- Chronic fatigue syndrome
- Hypertriglyceridemia
- Hyponatremia
- Right breast lesions s/p U/S guided core biopsy on ___ -
pathology showing fibroadipose tissue with blood, fibrin, and
predominantly acute inflammatory cell infiltrate, karyorrhectic
debris, and scattered calcifications
Social History:
___
Family History:
Per prior discharge summary
- father w/ diabetes
- maternal grandfather has unknown cancer
- She has no family history of liver disease, hemochromatosis,
autoimmune diseases, or non-smoker emphysema
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.9F BP 100/63 mmHg P 88 RR 20 O2 92% RA
General: Comfortable, NAD.
HEENT: Anicteric sclerae; EOMs intact.
Neck: Supple.
CV: RRR, III/VI holosystolic murmur best heard over LUSB with
prominent S2 component; no thrills or heaves. No rubs or
gallops.
Pulm: Scant crackles at base; no wheezes. No accessory muscle
usage.
Abd: Obese, soft, moderate diffuse tenderness predominantly in
RLQ, RUQ with firmness, no rebound or guarding. Well-healed
midline incision. G-tube in place, c/d/I. JP drain with minimal
serosanguinous output; no surrounding erythema or tenderness.
Extremities: Warm and well-perfused. L>R ___ edema, well-healed
ankle scar, chronic asymmetry per patient report.
Neuro: A&Ox3; no asterixis.
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 513)
Temp: 98.3 (Tm 98.3), BP: 93/56 (81-98/36-60), HR: 82
(75-90), RR: 18 (___), O2 sat: 95% (95-97), O2 delivery: Ra
GENERAL: NAD. Oriented x3. Mood, affect appropriate.
HEENT: NCAT. Sclera anicteric. Conjunctiva pink.
NECK: Supple with no LAD or JVD.
CARDIAC: RRR, normal S1, S2. III/VI systolic murmur best heard
over the LUSB.
LUNGS: Resp unlabored, no accessory muscle use. Lungs CTA
bilaterally. No crackles, wheezes or rhonchi.
ABDOMEN: Obese, very mild diffuse tenderness predominantly in
lower abdomen, soft, RUQ with firmness, no rebound or guarding.
JP drain with serosanguinous output; no surrounding erythema or
tenderness. G-tube site in place, no drainage or surrounding
erythema.
EXTREMITIES: Trace edema. Distal pulses palpable and symmetric.
SKIN: Warm, dry, no rashes or obvious lesions.
Pertinent Results:
ADMISSION LABS:
___ 04:50PM BLOOD Neuts-64.2 ___ Monos-13.8*
Eos-0.9* Baso-0.0 Im ___ AbsNeut-2.89 AbsLymp-0.93*
AbsMono-0.62 AbsEos-0.04 AbsBaso-0.00*
___ 04:50PM BLOOD WBC-4.5 RBC-2.04* Hgb-7.3* Hct-21.9*
MCV-107* MCH-35.8* MCHC-33.3 RDW-18.5* RDWSD-73.0* Plt Ct-61*
___ 04:50PM BLOOD ___ PTT-38.0* ___
___ 04:50PM BLOOD Glucose-91 UreaN-35* Creat-1.0 Na-133*
K-4.3 Cl-95* HCO3-21* AnGap-17
___ 04:50PM BLOOD ALT-14 AST-54* AlkPhos-151* TotBili-2.4*
___ 04:50PM BLOOD Albumin-2.8*
IMAGING:
CT ABD & PELVIS WITH CONTRAST (___):
IMPRESSION:
1. Enteric contrast reaches the mid-distal small bowel. The
more
distal small bowel is distended, perhaps slightly worse compared
to prior and now contains more extensive fecalized material
suggesting slow transit. No discrete transition point
identified
nor decompressed distal small bowel loops to further support an
obstruction. Colon is also moderately distended with stool.
Could consider repeat abdominal radiographs to confirm enteric
contrast passage through the bowel as clinically warranted.
2. No evidence of abscess. Pigtail catheter seen along the left
anterior abdominal wall without associated collection in this
region.
3. Nodular liver with small volume ascites.
4. Persistent moderate right hydronephrosis with mild dilation
of
proximal right ureter, unchanged.
5. Cholelithiasis.
6. Persistent small left pleural effusion with some left lower
lobe
atelectasis.
DISCHARGE LABS:
___ 07:22AM BLOOD WBC-4.3 RBC-2.05* Hgb-7.3* Hct-22.5*
MCV-110* MCH-35.6* MCHC-32.4 RDW-18.6* RDWSD-74.9* Plt Ct-69*
___ 07:22AM BLOOD Plt Ct-69*
___ 07:22AM BLOOD Glucose-106* UreaN-36* Creat-1.4* Na-135
K-4.2 Cl-96 HCO3-21* AnGap-18
___ 07:22AM BLOOD ALT-12 AST-44* AlkPhos-150* TotBili-2.3*
___ 07:22AM BLOOD Calcium-8.4 Phos-5.8* Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO BID:PRN Pain - Mild
2. Bisacodyl ___ mg PO DAILY:PRN Constipation
3. Ciprofloxacin HCl 500 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Lactulose 30 mL PO Q6H
6. LevETIRAcetam Oral Solution 1000 mg PO BID
7. Midodrine 10 mg PO TID
8. Rifaximin 550 mg PO BID
9. Thiamine 100 mg PO DAILY
10. Vitamin D ___ UNIT PO 1X/WEEK (___)
11. HYDROmorphone (Dilaudid) 2 mg PO DAILY PRN Pain - Moderate
12. Multivitamins 1 TAB PO DAILY
13. Neutra-Phos 2 PKT PO TID
14. Omeprazole 40 mg PO DAILY
15. Polyethylene Glycol 17 g PO DAILY
16. TraMADol 50 mg PO BID
17. Metoclopramide 5 mg PO Q6H
18. Escitalopram Oxalate 20 mg PO DAILY
19. Simethicone 40-80 mg PO QID:PRN bloating
20. Torsemide 20 mg PO DAILY
Discharge Medications:
1. Linzess (linaCLOtide) 145 mcg oral DAILY
2. Methylnaltrexone 12 mg Subcut ONCE Duration: 1 Dose
3. Senna 17.2 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablets by mouth daily Disp #*60
Tablet Refills:*0
4. Acetaminophen 650 mg PO BID:PRN Pain - Mild
5. Ciprofloxacin HCl 500 mg PO DAILY
6. Escitalopram Oxalate 20 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. HYDROmorphone (Dilaudid) 2 mg PO DAILY PRN Pain - Moderate
RX *hydromorphone 2 mg 1 tablet(s) by mouth daily Disp #*15
Tablet Refills:*0
9. Lactulose 30 mL PO Q6H
10. LevETIRAcetam Oral Solution 1000 mg PO BID
11. Metoclopramide 5 mg PO Q6H
12. Midodrine 10 mg PO TID
13. Multivitamins 1 TAB PO DAILY
14. Neutra-Phos 2 PKT PO TID
15. Omeprazole 40 mg PO DAILY
16. Polyethylene Glycol 17 g PO DAILY
17. Rifaximin 550 mg PO BID
18. Simethicone 40-80 mg PO QID:PRN bloating
19. Thiamine 100 mg PO DAILY
20. Torsemide 20 mg PO DAILY
21. TraMADol 50 mg PO BID
22. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Abdominal pain
Constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent. - sometimes holds on
to walls/furniture for support
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen and pelvis
INDICATION: ___ woman with abdominal tenderness on palpation.
Evaluate for infection and evaluate the liver. +PO contrast.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were
acquired through the abdomen and pelvis following intravenous contrast
administration with split bolus technique.
Oral contrast was 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 7.1 s, 56.1 cm; CTDIvol = 27.5 mGy (Body) DLP =
1,542.9 mGy-cm.
Total DLP (Body) = 1,555 mGy-cm.
COMPARISON: CT abdomen and pelvis dated ___.
FINDINGS:
LOWER CHEST: A trace left pleural effusion with adjacent homogeneously
enhancing atelectasis is similar to the prior exam. No right pleural
effusion. No evidence of a pericardial effusion. Opacity in the lingula is
probably atelectasis.
ABDOMEN:
HEPATOBILIARY: Nodular appearing liver, unchanged. No evidence of focal liver
lesions. No evidence of intrahepatic or extrahepatic biliary dilation. The
gallbladder contains several calcified gallstones. No gallbladder wall
thickening. Ascites is small volume, predominantly around the liver.
PANCREAS: Pancreas is slightly atrophic. The pancreas has normal attenuation
throughout, without evidence of focal lesions or pancreatic ductal dilatation.
No peripancreatic stranding.
SPLEEN: The spleen remains enlarged measuring up to 15.5 cm. No evidence of a
focal splenic lesion.
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.
Mild-to-moderate right hydronephrosis and prominence of the proximal right
ureter is similar to the prior exam. No evidence focal renal lesions. No
perinephric abnormality.
GASTROINTESTINAL: Postsurgical anatomy of the stomach is stable. Ingested
enteric contrast is seen within this is. There is a G-tube that appears well
positioned within the stomach lumen. Enteric contrast is seen up to the mid
to distal small bowel. The small bowel loops with oral contrast are not
markedly distended. There are however distended loops of more distal small
bowel with fecalized material. No discrete transition point identified nor
decompressed small bowel loops. Overall the degree of dilation is perhaps
slightly worse compared to prior. No definite transition point. The colon is
moderately distended with stool. The rectum is unremarkable. No organized
fluid collection or free air. Appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is a
small amount of free fluid in the pelvis related to ascites.
REPRODUCTIVE ORGANS: An intrauterine device is seen within the uterus.
LYMPH NODES: No retroperitoneal or mesenteric lymphadenopathy. No pelvic or
inguinal lymphadenopathy.
VASCULAR: No abdominal aortic aneurysm. Extensive collaterals seen in the
anterior abdominal wall.
BONES: No evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: There is soft tissue edema, unchanged. Pigtail catheter
projects over the left mid abdomen, not definitively intraperitoneal and
appears along the anterior abdominal wall. No drainable collection in this
area.
IMPRESSION:
1. Enteric contrast reaches the mid-distal small bowel. The more distal small
bowel is distended, perhaps slightly worse compared to prior and now contains
more extensive fecalized material suggesting slow transit. No discrete
transition point identified nor decompressed distal small bowel loops to
further support an obstruction. Colon is also moderately distended with
stool. Could consider repeat abdominal radiographs to confirm enteric
contrast passage through the bowel as clinically warranted.
2. No evidence of abscess. Pigtail catheter seen along the left anterior
abdominal wall without associated collection in this region.
3. Nodular liver with small volume ascites.
4. Persistent moderate right hydronephrosis with mild dilation of proximal
right ureter, unchanged.
5. Cholelithiasis.
6. Persistent small left pleural effusion with some left lower lobe
atelectasis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, N/V
Diagnosed with Unspecified abdominal pain, Nausea with vomiting, unspecified
temperature: 97.5
heartrate: 87.0
resprate: 16.0
o2sat: 100.0
sbp: 102.0
dbp: 48.0
level of pain: 8
level of acuity: 2.0 | Ms. ___ is a ___ y/o woman with a PMH of alcoholic
cirrhosis (c/b SBP, ascites, HE), non-variceal UGIB, s/p RNYGB,
current G-tube for enteral feedings, recent admissions for
abdominal wall abscess with EC fistula and recurrent ileus/SBO
c/b ATN, encephalopathy, and recurrent clogging of G-tube, who
now presents with diffuse abdominal pain and nausea.
#Acute on chronic abdominal pain
#Opioid induced constipation
#Concern for ileus
Recently admitted with abdominal pain, nausea, and emesis
thought secondary to recurrent ileus or intermittent small bowel
obstruction and now presents with similar symptoms; main
presenting symptom right now is abdominal pain. CT abdomen and
pelvis negative for acute obstruction but did demonstrate
extensive fecalization and findings consistent with slow
transit. Her symptoms are likely worsened by chronic opioid use,
and on her prior admission, she was placed on simethicone and
advised to limit her opioid use. Has not taken tramadol in 1
week due to her pharmacy not having it. Unlikely SBP, on ppx.
Unlikely to represent complication of prior abdominal wall
abscess given the reassuring CT findings. Med rx refill history
shows that she was started on methylnaltrexone and Linzess,
however patient is unsure if she has been getting these. These
meds were not on her pre-admission or discharge medication lists
on her last admission. After speaking with patient's boyfriend
who manages her medications, it was determined that she does
have a Linzess as well as methylnaltrexone at home, however was
not being given these medications because he was following the
last discharge paperwork medication list. Spoke with transplant
surgery regarding her JP drain, they will not see her on this
admission as her drain is functioning well and there is no
purulent drainage or complications currently. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Benadryl / Contrast Dye
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
The pt is a ___ year-old male with hx of OSA on CPAP who presents
with 4 days of R temporal head pain, neck pain, and R eye visual
changes; starting after he lifted weights 4 days ago. He reports
that he hadn't lifted weights for around ___ years but was
previously very active. He started lifting weights again 4 days
ago and "over-did it". Since that time he has had neck pain over
his right shoulder/neck pain on palpation and exacerbated by
head turning to right, palpation.
The morning after weight lifting, he was lying on his right side
in the morning and realized that his head, neck, and shoulder
were painful when touching the pillow or painful on palpation.
He also noted R eye blurry vision. The right-sided headache is
localized to a "quarter-sized" area above the ear that is tender
to palpation. He notices the discomfort only slightly when not
touching it. His neck pain is exacerbated by turning his head to
the right. His blurry vision seems to be associated with
exacerbations of the head pain. He has had intermittent right
eye watering and redness for many years, and is not associated
with the same blurriness that he has experienced over the past
week. He has not had any tinnitus, double vision, or loss of
vision. He has not had any dysphagia or jaw claudication. No
focal numbness, weakness, or difficulties with gait.
He has a history of sleep apnea, and has daily headaches for
which he takes Advil 4 tabs every 8 hours DAILY.
Past Medical History:
Sleep apnea
Social History:
___
Family History:
Noncontributory.
Physical Exam:
ADMISSION EXAMINATION:
Physical Exam:
Vitals: T:97.9 P:73 R:16 BP:136/83 SaO2:97%
General: Awake, cooperative, NAD.
HEENT: Tender right trapezius, neck musculature, and skin 1-2 cm
above right auricle. NC/AT, no scleral icterus noted, MMM, no
lesions noted in oropharynx. Right eyelid ptosis ~1mm, but
similar to photographs from ~1.5 weeks ago.
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.
Extremities: No ___ edema. Multiple tattoos.
Skin: No rashes or lesions noted. Cholesteatomata on medial
eyelids.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
without difficulty. Language is fluent.Normal prosody. There
were no paraphasic errors. 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: Mild R eye periorbital edema and conjunctival
injection. PERRL 5 to 3mm and brisk. EOMI without nystagmus.
Normal saccades. VFF to confrontation. Fundoscopic exam revealed
no papilledema, exudates, or hemorrhages.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 5 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Plantar response was flexor bilaterally.
-Coordination: No intention tremor. No dysmetria on FNF.
-Gait: Good initiation. Narrow-based, normal stride and arm
swing. Able to walk in tandem without difficulty. Romberg
absent.
DISCHARGE EXAMINATION:
Unchanged.
Pertinent Results:
ADMISSION LABS: ___
BLOOD WBC-7.4 Hgb-16.0 Hct-46.7 Plt ___
Neuts-57.0 ___ Monos-8.0 Eos-1.8 Baso-0.5 Im ___
AbsNeut-4.20 AbsLymp-2.39 AbsMono-0.59 AbsEos-0.13 AbsBaso-0.04
BLOOD ___ PTT-30.8 ___
Glucose-92 UreaN-10 Creat-0.9 Na-138 K-4.2 Cl-99 HCO3-27
AnGap-16
ALT-55* AST-30 LD(LDH)-171 CK(CPK)-119 AlkPhos-58 TotBili-1.0
Albumin-4.8
Stroke Risk Factors: ___
Cholest-207* Triglyc-130 HDL-34 CHOL/HD-6.1 LDLcalc-147*
%HbA1c-5.3 eAG-105
TSH-2.2
CRP-2.2
SED RATE-2
Imaging:
MRI/MRA head and neck ___
IMPRESSION:
1. Study is mildly degraded by motion.
2. Please note that patient refused further imaging after
acquisition of the first set of upper axial T1 fat sat images
and refused contrast due to
apparent history of contrast dye allergy.
3. No acute intracranial abnormality including infarct,
hemorrhage or
suggestion of mass.
4. Patent intracranial vasculature without significant stenosis,
occlusion or aneurysm. No evidence of carotid cavernous
fistula.
5. Patent visualized portion of the cervical vasculature without
evidence of significant stenosis, or occlusion. Note that the
great vessel origins and proximal cervical arterial vasculature
were not imaged. Within limits of study, there is no evidence
of dissection in the visualized upper portion of the cervical
vasculature, though the majority of the proximal vasculature was
not imaged utilizing T1 fat saturation technique.
6. Grossly stable low lying cerebral tonsils again noted.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 400 mg PO Q6H:PRN Pain - Moderate
Discharge Medications:
1. Ibuprofen 400 mg PO Q6H:PRN Pain - Moderate
Discharge Disposition:
Home
Discharge Diagnosis:
musculoskeletal pain
chronic right ptosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ man with temporal head pain, neck pain and right eye
blurry vision. Evaluate for carotid dissection or carotid cavernous fistula.
TECHNIQUE: Three dimensional time of flight MR arteriography was performed
through the brain with maximum intensity projection reconstructions.
2D time of flight MR angiography of the neck was performed. Additional axial
T1 fat sat images were acquired per dissection protocol.
Brain imaging was performed with sagittal T1 and axial FLAIR, T2, gradient
echo and diffusion technique.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images. The
examination was performed using a 1.5T MRI.
Please note this is an incomplete examination as patient refused further
imaging after acquisition of the upper set of axial T1 fat sat images as well
as postcontrast images due to apparent history of allergy. The lower portion
was not imaged.
COMPARISON: ___, noncontrast head CT.
FINDINGS:
Study is mildly degraded by motion.
MRI Brain:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. The ventricles and sulci are normal in caliber and
configuration. There is abnormal focus of slow diffusion. The principal
intracranial vascular flow voids are preserved. The paranasal sinuses are
grossly clear. The orbits are grossly unremarkable. Low-lying cerebellar
tonsils are again noted. Small nonspecific right mastoid fluid is noted.
MRA brain: There is normal variant fetal type origin of the left posterior
cerebral artery. The intracranial vertebral and internal carotid arteries and
their major branches appear patent without evidence of significant stenosis,
occlusion, or aneurysm formation. There is no abnormal flow related signal
within the cavernous sinuses bilaterally.
MRA neck: The visualized portion of the common, internal and external carotid
arteries appear normal. There is no evidence of internal carotid artery
stenosis by NASCET criteria. The great vessel origins are not imaged. There
is no evidence of dissection.
IMPRESSION:
1. Study is mildly degraded by motion.
2. Please note that patient refused further imaging after acquisition of the
first set of upper axial T1 fat sat images and refused contrast due to
apparent history of contrast dye allergy.
3. No acute intracranial abnormality including infarct, hemorrhage or
suggestion of mass.
4. Patent intracranial vasculature without significant stenosis, occlusion or
aneurysm. No evidence of carotid cavernous fistula.
5. Patent visualized portion of the cervical vasculature without evidence of
significant stenosis, or occlusion. Note that the great vessel origins and
proximal cervical arterial vasculature were not imaged. Within limits of
study, there is no evidence of dissection in the visualized upper portion of
the cervical vasculature, though the majority of the proximal vasculature was
not imaged utilizing T1 fat saturation technique.
6. Grossly stable low lying cerebral tonsils again noted.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Headache
Diagnosed with Headache
temperature: 97.9
heartrate: 73.0
resprate: 16.0
o2sat: 100.0
sbp: 138.0
dbp: 79.0
level of pain: 10
level of acuity: 3.0 | ___ presented with neck pain and intermittent blurry
vision in the setting of recent weight lifting. On examination
he had a right ptosis which was present prior to the weight
lifting as well as tenderness over the right temple and neck.
Given the concern for a potential carotid dissection, he was
admitted to the Neurology service for vessel imaging. MRI showed
not acute stroke. MRA was incomplete due difficulty completing
the study and the origins of the vessels were not visualized.
However, there was good flow within all of the cerebral
vasculature which was imaged and there was no evidence of
dissection. Given his reassuring examination, his MRA was not
repeated and he was discharged home with supportive care. As
there was no evidence of stroke, secondary stroke prevention was
not necessary. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left oblique tibial shaft fracture
Major Surgical or Invasive Procedure:
left tibial IMN
History of Present Illness:
___ female with h/u hypertension, narcolepsy presents with the
above fracture s/p mechanical fall off of skateboard about one
hour prior to arrival. Reports she fell off the board, hit her
leg on the ground and had immediate severe pain in the left
lower leg. Denies numbness/paresthesias. Denies other injuries.
Past Medical History:
narcolepsy
hypertension
Social History:
___
Family History:
non-contributory
Physical Exam:
Temp: 98.5 PO BP: 119/58 HR: 86 RR: 16 O2
sat: 100% O2 delivery: 2l
General: Well-appearing female, uncomfortable due to injury,
awake and alert
Left lower extremity:
- Dressing c/d/i
- Soft, non-tender thigh, compartments soft, no pain w/ passive
stretch of the toes
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
Pertinent Results:
___ 12:00AM ___ PTT-26.6 ___
___ 10:20PM GLUCOSE-106* UREA N-15 CREAT-0.7 SODIUM-140
POTASSIUM-3.8 CHLORIDE-104 TOTAL CO2-20* ANION GAP-16
___ 10:20PM estGFR-Using this
___ 10:20PM CALCIUM-9.7 PHOSPHATE-2.0* MAGNESIUM-1.8
___ 10:20PM WBC-12.1* RBC-4.05 HGB-12.2 HCT-37.3 MCV-92
MCH-30.1 MCHC-32.7 RDW-13.5 RDWSD-46.1
___ 10:20PM NEUTS-66.2 ___ MONOS-7.0 EOS-0.9*
BASOS-0.4 IM ___ AbsNeut-8.02* AbsLymp-3.06 AbsMono-0.85*
AbsEos-0.11 AbsBaso-0.05
___ 10:20PM PLT COUNT-360
Medications on Admission:
Adderall
losartan
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC QPM
4. HYDROmorphone (Dilaudid) 2 mg PO Q4H:PRN Pain - Moderate
RX *hydromorphone 2 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
5. Senna 8.6 mg PO BID
6. Amphetamine-Dextroamphetamine 10 mg PO BID
7. Valsartan 160 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
left oblique tibial shaft fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) LEFT; ANKLE (AP, MORTISE AND LAT) LEFT
INDICATION: History: ___ with ___ swelling s/p fall from skateboard// r/o
acute process
TECHNIQUE: Left tibia and fibula, two views and left ankle, three views
COMPARISON: None.
FINDINGS:
An oblique fracture of the distal tibial diaphysis is demonstrated with
approximately 4 mm of distraction and 10 mm of dorsal displacement. Overlying
soft tissue swelling is noted.
No dislocations are seen. There are no significant degenerative changes.
Tiny knee joint effusion is present. The ankle mortise is congruent. The
tibial talar joint space is preserved and no talar dome osteochondral lesion
is identified. No suspicious lytic or sclerotic lesion is identified. No soft
tissue calcification or radiopaque foreign body is identified.
IMPRESSION:
1. Mildly displaced oblique fracture of the distal tibial diaphysis.
2. No acute fracture or dislocation involving the ankle.
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) LEFT; ANKLE (AP, MORTISE AND LAT) LEFT
INDICATION: History: ___ with ___ swelling s/p fall from skateboard// r/o
acute process
TECHNIQUE: Left tibia and fibula, two views and left ankle, three views
COMPARISON: None.
FINDINGS:
An oblique fracture of the distal tibial diaphysis is demonstrated with
approximately 4 mm of distraction and 10 mm of dorsal displacement. Overlying
soft tissue swelling is noted.
No dislocations are seen. There are no significant degenerative changes.
Tiny knee joint effusion is present. The ankle mortise is congruent. The
tibial talar joint space is preserved and no talar dome osteochondral lesion
is identified. No suspicious lytic or sclerotic lesion is identified. No soft
tissue calcification or radiopaque foreign body is identified.
IMPRESSION:
1. Mildly displaced oblique fracture of the distal tibial diaphysis.
2. No acute fracture or dislocation involving the ankle.
Radiology Report
EXAMINATION: Intraoperative radiographs of the lower extremity.
INDICATION: ___ male undergoing ORIF of left tibia fracture.
TECHNIQUE: Intraoperative AP and lateral radiographs of left tibia and
fibula.
COMPARISON: Radiographs of the left tibia and fibula dated ___.
FINDINGS:
Intraoperative images were acquired without a radiologist present. There has
been interval placement of a intramedullary rod within the tibia with proximal
and distal interlocking screws. Please refer to operative report for further
details.
IMPRESSION:
Intraoperative images were obtained during open reduction and internal
fixation of the left tibia. Please refer to the operative note for details of
the procedure.
Gender: F
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: L Leg injury
Diagnosed with Oth fracture of lower end of left tibia, init for clos fx, Fall from skateboard, initial encounter
temperature: 97.4
heartrate: 115.0
resprate: 18.0
o2sat: 100.0
sbp: 141.0
dbp: 86.0
level of pain: 9
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left oblique tibial shaft fracture and was admitted to
the orthopedic surgery service. The patient was taken to the
operating room on ___ for left tibial IMN, which the patient
tolerated well. For full details of the procedure please see the
separately dictated operative report. The patient was taken from
the OR to the PACU in stable condition and after satisfactory
recovery from anesthesia was transferred to the floor. The
patient was initially given IV fluids and IV pain medications,
and progressed to a regular diet and oral medications by POD#1.
The patient was given ___ antibiotics and
anticoagulation per routine. The patient's home medications were
continued throughout this hospitalization. The patient worked
with ___ who determined that discharge to home was appropriate.
The ___ hospital course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weight bearing as tolerated in the left lower extremity, and
will be discharged on Lovenox for DVT prophylaxis. The patient
will follow up with Dr. ___ routine. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course including reasons to call the
office or return to the hospital, and all questions were
answered. The patient was also given written instructions
concerning precautionary instructions and the appropriate
follow-up care. The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
- Shortness of breath
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ w h/o CAD, recent MI s/p PCI w stent failure and repeat PCI,
ischemic cardiomyopathy w reported prior EF 25% following MI,
recent course of treatment for pyelonephritis, DM2, HTN, tobacco
use who presents w CAP and acute heart failure.
He has had progressive mild SOB over the past few days, worse w
lying flat which acutely worsened overnight the evening of ___.
He was put on non-rebreather at his rehab and BP at the time was
160s systolic. He denies any chest pain, fevers, chills, cough,
___ edema. Says at the time his breathing was better w sitting
up.
He was taken to ___ where bedside echo showed EF ___
and he was in respiratory distress with accessory muscle use. He
was placed on BiPAP, given a neb, and 40 mg IV Lasix w
improvement and eventually was weaned to RA over the next few
hours following transfer to ___.
He recently had an MI in ___ and had a stent placed at ___ in ___. A week later he had in-stent thrombosis
and had repeat PCI performed at ___. He was
subsequently discharged to rehab and after a few weeks was taken
to ___ where he was treated for a "kidney
infection". There he was given what sounds like a PCN and
treated
with a 6 week course of cefazolin and metronidazole which ended
___.
Past Medical History:
Per patient:
DM2
CAD
MI s/p PCI x2
Pyelonephritis s/p PCN
HTN
tobacco use
Social History:
___
Family History:
Father with possible heart attack at ___
Physical Exam:
=============ADMISSION PHYSICAL EXAM===================
Vital Signs: ___ ___ Temp: 98.0 PO BP: 117/69 L Lying HR:
83 RR: 16 O2 sat: 92% O2 delivery: Ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, poor dentition,
EOMI, PERRL, neck supple, JVP mid neck at 30 degrees, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: fine crackles in bilateral lung bases
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII grossly intact, ___ strength upper/lower
extremities, grossly normal sensation, 2+ reflexes bilaterally,
gait deferred.
=============DISCHARGE PHYSICAL EXAM===================
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, poor dentition
CV: Reduced heart sounds. Regular rate and rhythm, no murmurs
appreciated
Lungs: Bilateral inspiratory/expiratory wheeze, R>L, improved
from prior
Abdomen: Soft, non-tender, non-distended, no rebound or guarding
Ext: Muscle wasting but no lower ext edema
Neuro: Alert and appropriately oriented, moving all extremities
purposefully.
Psych: Anxious affective and repetitive speech patterns, though
coherent.
Pertinent Results:
ADMISSION LABS:
===============
___ 12:42PM CK(CPK)-45*
___ 12:42PM CK-MB-4 cTropnT-0.10*
___ 07:58AM LACTATE-1.5 K+-3.3*
___ 07:32AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 05:59AM ___ PO2-26* PCO2-49* PH-7.36 TOTAL
CO2-29 BASE XS-0
___ 05:50AM GLUCOSE-145* UREA N-7 CREAT-0.8 SODIUM-140
POTASSIUM-5.5* CHLORIDE-103 TOTAL CO2-23 ANION GAP-14
___ 05:50AM cTropnT-0.11* proBNP-8629*
___ 05:50AM WBC-15.1* RBC-4.15* HGB-10.7* HCT-35.8*
MCV-86 MCH-25.8* MCHC-29.9* RDW-22.1* RDWSD-68.3*
___ 05:50AM NEUTS-86.4* LYMPHS-7.4* MONOS-4.5* EOS-0.1*
BASOS-0.5 IM ___ AbsNeut-13.00* AbsLymp-1.12* AbsMono-0.68
AbsEos-0.02* AbsBaso-0.07
___ 05:50AM PLT COUNT-454*
DISCHARGE LABS:
===============
___ 07:49AM BLOOD WBC-8.3 RBC-3.90* Hgb-9.9* Hct-32.2*
MCV-83 MCH-25.4* MCHC-30.7* RDW-22.1* RDWSD-65.3* Plt ___
___ 07:17AM BLOOD Glucose-142* UreaN-13 Creat-0.8 Na-146
K-3.9 Cl-106 HCO3-25 AnGap-15
___ 07:17AM BLOOD Calcium-8.7 Phos-4.8* Mg-1.8
IMAGES:
TTE ___:
CONCLUSION:
The left atrial volume index is normal. The estimated right
atrial pressure is ___ mmHg. There is normal left ventricular
wall thickness with a normal cavity size. There is SEVERE
regional left ventricular systolic
dysfunction with extensive anteroseptal and apical akinesis with
severe hypokinesis of the inferior and inferoseptal walls and
relative preservation of the basal to mid lateral wall (see
schematic).
The left ventricular apex is heavily trabeculated, but without
definte thrombus. The visually estimated left ventricular
ejection fraction is ___. Left ventricular cardiac index is
low normal (2.0-2.5 L/min/m2). There is no resting left
ventricular outflow tract gradient. No ventricular septal defect
is seen. Normal right ventricular cavity size with mild global
free wall hypokinesis. 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. There is no evidence for an aortic arch coarctation.
The aortic valve leaflets (3) are mildly thickened. There is no
aortic valve stenosis. There is no aortic regurgitation. The
mitral valve leaflets are mildly thickened with no mitral valve
prolapse. There is mild [1+] mitral regurgitation. The pulmonic
valve leaflets are normal. The tricuspid valve leaflets appear
structurally normal. There is physiologic tricuspid
regurgitation. The pulmonary artery systolic pressure could not
be estimated. There is no pericardial effusion. A right pleural
effusion is present
IMPRESSION: Severe regional left ventricular systolic
dysfunction c/w multivessel CAD (prominent LAD territory
dysfunction). Mild right ventricular hypokinesis. Mild mitral
regurgitation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
5. TiCAGRELOR 90 mg PO BID
6. Cyanocobalamin 1000 mcg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. NPH 5 Units Breakfast
NPH 5 Units Bedtime
9. Lisinopril 5 mg PO DAILY
10. MetFORMIN (Glucophage) 850 mg PO BID
11. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - First
Line
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
14. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
15. Metoprolol Succinate XL 50 mg PO DAILY
16. Trulicity (dulaglutide) 1.5 mg/0.5 mL subcutaneous 1X/WEEK
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
5. TiCAGRELOR 90 mg PO BID
6. Cyanocobalamin 1000 mcg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. NPH 5 Units Breakfast
NPH 5 Units Bedtime
9. Lisinopril 5 mg PO DAILY
10. MetFORMIN (Glucophage) 850 mg PO BID
11. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - First
Line
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
14. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
15. Metoprolol Succinate XL 50 mg PO DAILY
16. Trulicity (dulaglutide) 1.5 mg/0.5 mL subcutaneous 1X/WEEK
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Bisacodyl 10 mg PR QHS:PRN Constipation - Second Line
5. TiCAGRELOR 90 mg PO BID
6. Cyanocobalamin 1000 mcg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. NPH 5 Units Breakfast
NPH 5 Units Bedtime
9. Lisinopril 5 mg PO DAILY
10. MetFORMIN (Glucophage) 850 mg PO BID
11. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - First
Line
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
14. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
15. Metoprolol Succinate XL 50 mg PO DAILY
16. Trulicity (dulaglutide) 1.5 mg/0.5 mL subcutaneous 1X/WEEK
Discharge Medications:
1. Losartan Potassium 25 mg PO DAILY heart failure
RX *losartan 25 mg 25 mg(s) by mouth once a day Disp #*30 Tablet
Refills:*0
2. Spironolactone 25 mg PO DAILY
RX *spironolactone 25 mg 25 mg by mouth once a day Disp #*30
Tablet Refills:*0
3. Torsemide 40 mg PO DAILY
RX *torsemide 20 mg 2 tablets by mouth once a day Disp #*60
Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 80 mg PO QPM
6. Cyanocobalamin 1000 mcg PO DAILY
7. Ferrous Sulfate 325 mg PO DAILY
8. NPH 5 Units Breakfast
NPH 5 Units Bedtime
9. MetFORMIN (Glucophage) 850 mg PO BID
10. Metoprolol Succinate XL 50 mg PO DAILY
11. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - First
Line
12. Multivitamins W/minerals 1 TAB PO DAILY
13. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
14. TiCAGRELOR 90 mg PO BID
15. Trulicity (dulaglutide) 1.5 mg/0.5 mL subcutaneous 1X/WEEK
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
- Fluid overload due to ischemic cardiomyopathy
- Community Acquired Pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with dyspnea, eval pulm edema, pna or effusion//
History: ___ with dyspnea, eval pulm edema, pna or effusion
TECHNIQUE: Frontal and lateral views
COMPARISON: None
FINDINGS:
Dense right lower lobe posterior basal segment consolidation with associated
loss. There is a trace pleural effusion tracking within the right minor
fissure, which is inferiorly displaced due to volume loss. The remainder of
the lungs are clear. No pneumothorax. Heart size is normal. The mediastinal
silhouette is unremarkable.
IMPRESSION:
Dense right lower lobe posterior basal segment consolidation concerning for
pneumonia, possibly aspiration pneumonia given its location.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Transfer
Diagnosed with Non-ST elevation (NSTEMI) myocardial infarction, Hyperkalemia, Acute pulmonary edema, Pneumonitis due to inhalation of food and vomit, Dyspnea, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: uanble
level of acuity: 1.0 | ==========PATIENT SUMMARY==========
Mr. ___ is a ___ year-old male with a history of coronary
artery disease, recent MI s/p PCI w stent failure and repeat
PCI, ischemic cardiomyopathy with reported prior EF 35%
following MI, recent course of treatment for pyelonephritis,
DM2, HTN, tobacco use who presented with shortness of breath and
hypoxia and found to have CAP and acute heart failure, treated
with a course of antibiotics and diuretics, now with improved
shortness of breath and hypoxia.
==========ACUTE ISSUES ADDRESSED==========
#Acute on chronic systolic heart failure (EF 25%): Presentation
consistent with flash pulmonary edema in the setting of
hypertension at rehab given ischemic cardiomyopathy. Initially
required O2, but quickly weened to room air. Though overall
improved, continues to have shortness of breath with ambulation,
though sats consistently >90 during ambulation on room air. EF
on TTE this admission at 25% severe regional left ventricular
systolic dysfunction. Previous TTE ___ ___ with EF
35-40% with hypokinesis of anteroseptal and inferoseptal WMA.
Given possible worsening, outpatient cardiologist spoken with;
overall, reassured by clinical status and felt this change on
echo EF prediction was likely just difference in estimation, and
new area of reversible infarct was exceedingly unlikely,
recommending swift outpatient follow up with Dr. ___
against possible recathetritization/viability studies
(scheduled, see follow-up). Patient treated with IV Lasix to
good effect, losartan, PO toresamide, and spironolactone started
for heart failure management. Continued on metoprolol succ 50mg.
Discharge weight 150 lbs.
#CAP
Dense consolidation in RLL w leukocytosis. Though patient denies
cough, fevers upon admission or during hosptial stay, he did
have episode of diaphoresis with shortness of breath; he was
treated with CTX/azitho x5d (___), and upon discharge was
without cough, sputum or fever.
#CAD
#NSTEMI ___ demand
No chest pain at presentation, or during stay. No concerning ECG
changes. Trop peaked at 0.11. Likely ___ increased demand in the
setting of HF exacerbation and infection. The patient was
continued on ASA, ticagrelor, metop. and lisinopril.
===============CHRONIC ISSUES=====================
#DM2
Discharged on NPH 5 twice daily.
#Tobacco Use
Offered smoking cessation assistance, declined
===============TRANSITIONAL ISSUES================
1. Appointment with Dr. ___ care) on ___.
2. Please obtain electrolytes and renal function at follow up
appointment.
3. Please monitor diuretic dosages and weights (patient plans to
keep daily weight journal; dry weight of 150lbs).
4. Appointment with Dr. ___ on ___ for
cardiac follow-up, changed from lisinopril to losartan per Dr.
___. Can consider initiation of Entresto
given heart failure with reduced EF.
5. Please consider additional work up given EF reduction from
40% to 25% with outpatient cardiologist. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / penicillin G
Attending: ___
Chief Complaint:
Back pain, numbness and weakness
Major Surgical or Invasive Procedure:
___: L1 laminectomy; T11-L4 fusion
History of Present Illness:
___ yo F on ASA 325mg hx kyphoplasty at L1 4 weeks ago who
presents with numbness and weakness. ___ pt had L5-S1
steroid injection and subsequently felt an abnormal sensation in
her rectum that developed in to numbness in her groin/labia. She
had worsening back and leg pain ___ and ___ into the
anterior thighs and lateral leg into lateral foot, worse on the
right. The numbness in her groin is worse on the left. Yesterday
she was dragging her right leg according to family due to pain.
Today her right leg gave out from weakness. She had foley placed
at OSH bc MRI showed distended bladder. Last urinated at
10:30am, MRI was performed at 22:30. Denies fecal incontinence.
Past Medical History:
- dilated cardiomyopathy
- hypercholesterolemia
- hypertension
- left bundle branch block
- nonrheumatic mitral regurgitation
- chronic idiopathic constipation
- cystocele
- incomplete uterovaginal prolapse
- L1 compression fracture
- major depression
- squamous cell carcinoma
- unspecified osteoarthritis
Social History:
___
Family History:
Father and uncles with coronary artery disease.
No other significant family history.
Physical Exam:
======================
ADMISSION EXAM
======================
Gen: WD/WN, comfortable, NAD.
HEENT: normocephalic, atruamatic
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.
Motor:
D B T WE WF IP Q H AT ___ G
R 5 5 5 5 5 4 5 4 5 4 5
L 5 5 5 5 5 4- 5 4 5 4 5
Sensation:
Decareased sensation to light touch in bilat lateral legs, into
lateral foot and bottom of feet and heels right worse than left,
decreased perianal sensation with numbness in the labia left
worse than right.
Rectal tone present
Reflexes: B T Br Pa Ac
Right unable to obtain reflexes
Left unable to obtain reflexes
No clonus
No hoffmans
======================
DISCHARGE EXAM
======================
VS: ___ 0741 Temp: 99.0 PO BP: 117/56 L Lying HR: 83 RR: 18
O2 sat: 96% O2 delivery: Ra
GEN: AOx1, in no acute distress
HEENT: Eyes anicteric, MMM
CV: RRR, II/VI HSM at ___, JVP <8cm
Resp: CTAB
GI: Soft, NTND
GU: No foley
Ext: Nor peripheral edema
Skin: no rash grossly visible
Neuro: A&O to person only, unable to perform days of week
backwards
CN II-XII intact, strength ___ and SILT in bilateral lower
extremities
Psych: normal affect, pleasant
Pertinent Results:
=====================
ADMISSION LABS
=====================
___ 06:00AM BLOOD WBC-6.5 RBC-3.65* Hgb-12.1 Hct-36.3
MCV-100* MCH-33.2* MCHC-33.3 RDW-13.4 RDWSD-47.9* Plt ___
___ 06:00AM BLOOD Neuts-71.0 ___ Monos-7.9 Eos-1.2
Baso-0.3 Im ___ AbsNeut-4.61 AbsLymp-1.25 AbsMono-0.51
AbsEos-0.08 AbsBaso-0.02
___ 06:00AM BLOOD ___ PTT-27.6 ___
___ 06:00AM BLOOD Glucose-93 UreaN-12 Creat-0.6 Na-147
K-3.7 Cl-107 HCO3-28 AnGap-12
___ 02:51AM BLOOD Calcium-8.2* Phos-4.2 Mg-1.8
=====================
PERTINENT RESULTS
=====================
MICROBIOLOGY
=====================
___ 06:00AM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-TR*
___ 06:00AM URINE RBC-2 WBC-4 Bacteri-FEW* Yeast-NONE
Epi-<1
===
___ 08:00AM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR*
___ 08:00AM URINE RBC-5* WBC-5 Bacteri-NONE Yeast-NONE
Epi-<1
===
___ 04:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-SM*
___ 04:00PM URINE RBC-1 WBC-8* Bacteri-FEW* Yeast-NONE
Epi-0
====
Urine cultures ___: Finalized without growth
====
Blood cultures ___: No growth to date
=====================
IMAGING
=====================
CT L-spine without contrast (___):
1. Study is limited secondary to diffuse osteopenia.
2. Nondisplaced bilateral proximal T12 rib fractures as
described.
3. Acute compression fracture of L1 with retropulsion of the
posterior fracture fragments resulting in moderate to severe
vertebral canal narrowing.
4. Redemonstration of known L2 vertebral body probable chronic
compression
deformity with superior endplate minimal bony retropulsion and
at mild vertebral canal narrowing.
5. Mild-to-moderate bilateral L5-S1 bony neural foraminal
narrowing.
6. Patient's known multilevel lumbar spondylosis better
demonstrated on recent outside lumbar spine MRI.
7. High-density material within L1 and L2 vertebral bodies as
described,
question history of vertebroplasty.
===
Intraoperative lumbar spine films (___):
Osteopenia and multilevel degenerative changes of the lumbar
spine, with fractures and retropulsion of the L1 and L2
vertebral bodies, and methylmethacrylate from
kyphoplasty/vertebroplasty at L1 and L2, are again
noted, in keeping with findings on the same day CT scan.
Intraoperative radiographs show multiple steps during posterior
spinal fusion procedure, including vertical spinal rod, and
pedicle screws at the
presumptive T11, T12, L2, L3, and L4 levels, on view # 4.
Correlation with real-time findings is requested for further
assessment.
Please see operative note for additional details.
===
CXR (___): There is no focal consolidation. The heart is
mildly enlarged. There is no consolidation. The aorta is
atherosclerotic and tortuous. Postoperative changes are evident
in the spine. There are no large pleural effusions.
IMPRESSION: Mild cardiomegaly. Postoperative changes.
===
TTE (___): The left atrial volume index is mildly increased.
The estimated right atrial pressure is ___ mmHg. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is top normal/borderline dilated. There is moderate
to severe global left ventricular hypokinesis (LVEF = 30 %).
Global longitudinal strain is depressed (-12.5%). Doppler
parameters are most consistent with Grade II (moderate) left
ventricular diastolic dysfunction. Right ventricular chamber
size and free wall motion are normal. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets are mildly thickened. Mild (1+) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION:
1) Moderate to severe global LV systolic dysfunction with
significant myocardial regional wall motion abnormalities not
following a specific coronary artery distribution suggestive of
diffuse cardiomyopathic process with regional variation in
myocardial contractility.
2) Grade II LV diastolic dysfunction with elevated LVEDP.
===
Lumbosacral plain films (___): Posterior fusion hardware
between T11 through L4, without evidence of hardware
complication.
===
CXR (___): Heart size is enlarged. Mediastinum is stable.
Lungs are clear.
===
NCHCT (___): No acute intracranial abnormality identified.
Atrophy and probable chronic small vessel disease.
=====================
DISCHARGE LABS
=====================
___ 06:14AM BLOOD WBC-8.7 RBC-3.08* Hgb-10.0* Hct-30.1*
MCV-98 MCH-32.5* MCHC-33.2 RDW-15.1 RDWSD-51.0* Plt ___
___ 06:14AM BLOOD Glucose-86 UreaN-11 Creat-0.5 Na-144
K-4.1 Cl-105 HCO3-26 AnGap-13
___ 06:14AM BLOOD Calcium-8.6 Phos-4.7* Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Valsartan 160 mg PO BID
2. Gabapentin 300 mg PO TID
3. Carvedilol 25 mg PO BID
4. Atorvastatin 80 mg PO QPM
5. Ferrous Sulfate 325 mg PO DAILY
6. Aspirin 325 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Calcium Carbonate 500 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Miconazole Powder 2% 1 Appl TP TID:PRN rash
5. Ramelteon 8 mg PO QHS
6. Senna 8.6 mg PO BID
7. TraMADol 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth Every 8
hours Disp #*5 Tablet Refills:*0
8. Aspirin 81 mg PO DAILY
9. Gabapentin 100 mg PO Q8H
10. Valsartan 80 mg PO BID
11. Atorvastatin 80 mg PO QPM
12. Carvedilol 25 mg PO BID
13. Ferrous Sulfate 325 mg PO DAILY
14. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY:
- L1 compression fracture
- Lumbar spinal stenosis
- Cauda Equina Syndrome
SECONDARY:
- Toxic-metabolic encephalopathy
- Orthostatic hypotension
- Acute kidney injury
- Asymptomatic bacteriuria
- Chronic systolic congestive heart failure
- Hypertension
- Hyperlipidemia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with pmh chf, receiving fluids, new confusion//
?pulm effusions/overload or infiltrates ?pulm effusions/overload or
infiltrates
IMPRESSION:
Heart size is enlarged. Mediastinum is stable. Lungs are clear.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with acute mental status change// ? acute
injury
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.3 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute major vascular territory
infarction,hemorrhage,edema, or mass. There is prominence of the ventricles
and sulci suggestive of involutional changes. Moderate bilateral
periventricular and subcortical white matter hypodensities are nonspecific,
but likely represent a sequela of chronic small vessel ischemic disease.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
No acute intracranial abnormality identified. Atrophy and probable chronic
small vessel disease.
Radiology Report
EXAMINATION: CT L-SPINE W/O CONTRAST Q331 CT SPINE
INDICATION: History: ___ with L1 compression found on OSH MR// Preoperative
planning; OSH MR reports L1 compression
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) = 802 mGy-cm.
COMPARISON: ___ outside noncontrast lumbar spine MRI.
FINDINGS:
For the purposes of numbering, the lowest rib bearing vertebral body was
designated the T12 level.
Lumbar spine alignment is grossly preserved.
There is diffuse osseous demineralization throughout the lumbar spine.
Minimally displaced proximal bilateral T12 rib fractures at the costovertebral
junctions are noted (see 02:11).
Again is noted patient's known acute comminuted compression fracture of L1
vertebral body with retropulsion of the posterior fracture fragments resulting
in moderate to severe vertebral canal stenosis. High density material is
noted in the L1 vertebral body, question history of vertebroplasty.
Superior endplate probable Schmorl's nodes are again seen. Chronic L2
vertebral body compression deformity is again noted with minimal superior
endplate bony retropulsion and mild vertebral canal narrowing. High-density
material is noted within the anterior L2 vertebral body. Question history of
L2 vertebroplasty.
There is mild prevertebral soft tissue swelling of L1.
L5-S1 bilateral mild to moderate bony neural foraminal narrowing is noted.
Additional multilevel lumbar spondylosis are suggested on current exam and are
better demonstrated on prior outside lumbar spine MRI.
Within the limits of this noncontrast study, there is no evidence of infection
or neoplasm. Moderate atherosclerotic disease is identified throughout the
aorta and its major branch vessels.
IMPRESSION:
1. Study is limited secondary to diffuse osteopenia.
2. Nondisplaced bilateral proximal T12 rib fractures as described.
3. Acute compression fracture of L1 with retropulsion of the posterior
fracture fragments resulting in moderate to severe vertebral canal narrowing.
4. Redemonstration of known L2 vertebral body probable chronic compression
deformity with superior endplate minimal bony retropulsion and at mild
vertebral canal narrowing.
5. Mild-to-moderate bilateral L5-S1 bony neural foraminal narrowing.
6. Patient's known multilevel lumbar spondylosis better demonstrated on recent
outside lumbar spine MRI.
7. High-density material within L1 and L2 vertebral bodies as described,
question history of vertebroplasty.
NOTIFICATION: Insert-
Radiology Report
EXAMINATION: LUMBAR SINGLE VIEW IN OR
INDICATION: Posterior T11-12 fusion
TECHNIQUE: 4 intraoperative lateral views lumbar spine.
COMPARISON: Targeted review of lumbar spine CT from ___
FINDINGS:
Osteopenia and multilevel degenerative changes of the lumbar spine, with
fractures and retropulsion of the L1 and L2 vertebral bodies, and
methylmethacrylate from kyphoplasty/vertebroplasty at L1 and L2, are again
noted, in keeping with findings on the same day CT scan.
Intraoperative radiographs show multiple steps during posterior spinal fusion
procedure, including vertical spinal rod, and pedicle screws at the
presumptive T11, T12, L2, L3, and L4 levels, on view # 4.
Correlation with real-time findings is requested for further assessment.
Please see operative note for additional details.
Radiology Report
EXAMINATION: LUMBO-SACRAL SPINE (AP AND LAT)
INDICATION: ___ year old woman with T11-L4 fusion// post-op post-op
TECHNIQUE: Frontal and lateral view radiographs of the lumbar spine.
COMPARISON: Intraoperative radiographs performed on ___
FINDINGS:
There is posterior spinal fusion hardware extending from T11 through L4.
There is no evidence of hardware loosening. High density material in L1 and
L2 vertebral bodies likely represents methylmethacrylate. Chronic compression
fracture of L1 and L2 or are unchanged. Moderate atherosclerotic
calcifications are noted throughout the abdominal aorta. There is no
unexplained soft tissue calcification or radiopaque foreign body. Mild
degenerative changes about the bilateral hip joints. Skin staples are
evident.
IMPRESSION:
Posterior fusion hardware between T11 through L4, without evidence of hardware
complication.
Radiology Report
EXAMINATION: Chest x-ray
INDICATION: ___ y/o female ___ s/p L1 laminectomy; T11-L4 fusion. CXR to
evaluate for source of infection given elevated WBC.// CXR to evaluate for
source of infection given elevated WBC.
TECHNIQUE: Portable chest x-ray
COMPARISON: None
FINDINGS:
There is no focal consolidation. The heart is mildly enlarged. There is no
consolidation. The aorta is atherosclerotic and tortuous. Postoperative
changes are evident in the spine. There are no large pleural effusions.
IMPRESSION:
Mild cardiomegaly. Postoperative changes.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Back pain, R Leg numbness, Transfer
Diagnosed with Unspecified cord compression
temperature: 97.8
heartrate: 76.0
resprate: 18.0
o2sat: 99.0
sbp: 148.0
dbp: 68.0
level of pain: 2
level of acuity: 2.0 | Ms. ___ is a ___ y/o woman with history of dilated
cardiomyopathy (LVEF ___, HTN, HLD, nonrheumatic MR, history
of kyphoplasty at L1 4 weeks prior to presentation who presented
with lower extremity numbness and weakness, found to have L1
compression fracture and severe lumbar spinal stenosis with
compression of the thecal sac on MRI s/p urgent decompression
with laminectomy, reduction, and fusion T11-L4 on ___, with
post-operative course complicated by acute on chronic anemia,
hypotension, ___, and toxic-metabolic encephalopathy.
============================
ACUTE ISSUES
============================
# L1 compression fracture:
# Severe lumbar stenosis:
# Cauda equina syndrome: On ___, Ms. ___ presented with
back pain and lower extremity weakness after an outpatient
epidural steroid injection. MRI at an outside hospital showed
severe stenosis; Foley catheter was placed for urinary retention
and the patient was transferred to ___ for further care. She
was initially admitted to the neurosurgical service, and whe was
taken urgently to the OR on ___ with Dr. ___ L1
laminectomy and T11-L4 fusion. Her operative course was
uncomplicated; drain was placed in the OR. Postoperatively, she
was extubated and monitored in PACU before transfer back to the
floor. Post-op x-ray was performed on POD#1. Hemovac remained in
place POD#1 due to high output and she was fit with a TLSO
brace. On POD#3, ___, the Hemovac drain was removed. She
mobilized with ___. The patient's Foley was removed and she was
able to void spontaneously. The patient's pain was treated with
scheduled Tylenol and Tramadol as needed. She should continue to
wear TLSO brace when out of bed. She will need her staples
removed and wound check in ___ days post-operatively, as well
as spine follow up with AP/lateral spinal plain films in 4
weeks.
# Toxic-metabolic encephalopathy: ___ hospital course was
complicated by waxing and waning mental status consistent with
delirium in setting of surgery and acute illness. NCHCT was
obtained without acute intracranial abnormality. The patient's
pain was treated as above. Her gabapentin dose was decreased.
The patient was given Ramelteon to help promote a normal
sleep-wake cycle.
# Acute on chronic anemia: Patient with history of iron
deficiency anemia, found to have worsened anemia on ___ and
transfused 2 units PRBCs with appropriate increase in
hemoglobin. Likely related to procedural blood losses.
Hemoglobin subsequently remained stable and the patient did not
require further transfusions. Hb 10 on day of discharge. Patient
continued on home iron supplement.
# Bacteriuria: Urinalysis from ___ notable for 4 WBC, small
amount of bacteria, trace leukocytes, urine culture negative,
without clear symptoms of urinary tract infection. She was
initially started on ciprofloxacin, but this was stopped on ___
as culture was negative and patient was asymptomatic. The
patient complained of urinary frequency after Foley was removed;
multiple repeat urinalysis and cultures were negative for
infection.
# ___: Cr 1.1 initially from baseline of 0.6. Resolved with
fluids. Cr 0.5 on day of discharge.
# HTN: The patient had an episode of symptomatic orthostatic
hypotension on post-operative day 1, likely secondary to
hypovolemia and anemia. The patient's antihypertensives were
initially held, and she was given intravenous fluids and blood
transfusions as above with resolution of her hypotension. Her
antihypertensives were slowly re-introduced, with stable blood
pressures. Her home carvedilol was resumed, and half her home
dose of valsartan. Please continue to monitor blood pressures
and titrate medications as appropriate.
# Chronic sCHF: LVEF ___. TTE from ___ unchanged from prior.
Cardiology was consulted for assistance with management. Patient
was initially hypovolemic and was given intravenous fluids to
good effect. She was subsequently euvolemic throughout the rest
of her course and did not require further fluids or diuresis.
Her carvedilol and valsartan were resumed as above. Unable to
obtain true discharge weight as patient unable to stand without
TLSO brace.
=============================
CHRONIC/STABLE ISSUES
=============================
# HLD: Continued atorvastatin. Resumed aspirin (81 mg daily
decreased from home 325 mg daily) in discussion with
neurosurgery.
# Depression: Patient no longer taking escitalopram
>30 minutes spent on care/coordination on day of discharge.
=============================
TRANSITIONAL ISSUES
=============================
- Discharge weight: unable to obtain as patient in TLSO brace
- Monitor volume status and consider diuresis if needed (LVEF
25%)
- Patient should wear TLSO brace when out of bed
- Patient will need an appointment for suture/staple removal and
wound check in ___ days postoperatively (surgery on ___.
Please call ___ to make this appointment.
- Patient to follow up with Dr. ___ in 4 weeks, and
will need AP/Lateral X-rays at the time of this appointment.
Please call ___ to make this appointment.
- Discharged on scheduled Tylenol and low-dose tramadol as
needed for pain control. Please continue to assess pain and
adjust regimen as appropriate. Patient has required very little
tramadol while hospitalized.
- Please check blood pressure and adjust antihypertensive
regimen as appropriate. Discharged on half of home valsartan
dose, uptitrate to home dose as appropriate.
- Gabapentin dose decreased from 300 TID to ___ TID due to
confusion; please continue to assess mental status and adjust
dose as appropriate.
- Started on Ramelteon at night for sleep; continue to assess
need for this medication.
- Continued home vitamin D and started on calcium
supplementation for bone health.
- Patient on ASA 325 as an outpatient; restarted on ASA 81 mg
daily given no clear indication for full-dose aspirin
- Communication: ___, daughter, ___
- Code: Full (confirmed) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Dypsnea
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ with HFrEF (EF 40%), CAD, bicuspid AV s/p AVR, AF on
warfarin/digoxin, CAD s/p redo CABG/MV replacement/TV repair,
COPD, and asthma presenting with 3 day history of dyspnea and
productive cough.
Three days ago he started experiencing non-productive cough and
progressive dyspnea. He had continued taking his home inhalers
and montelukast, but felt that his symptoms continued to
progress. He came into the ED for further evaluation as he was
concerned he was having an asthma exacerbation. He denies
fevers, CP, abdominal pains, N/V, diarrhea or constipation.
In the ED he was noted to have sats stable in the upper 90's,
but
had diffuse rhonchi and wheezing. BNP was at baseline, flu
negative, and no evidence of myocardial ischemia. He was given
magnesium x2, methylprednisone x2 (125 mcg and 60 mcg), and
stacked albuterol/ipratropium negbulizer treatments. He was
observed overnight for improvement in respiratory status. There
was initial concern for PNA and he started on CTX/Azithromycin
for CAP coverage, but discontinued after CXR and labs
inconsistent with PNA. Flu swab negative. His condition
overall
improved and had no evidence of desaturations with ambulation.
He overall had persistent wheezing and unwell feeling, and did
not feel safe to return home. Decision was made to admit for
continued treatment and monitoring.
- Exam notable for: Diffuse rhonchi and wheezing, peak flow from
250-280
- Labs notable for: INR 3.2, nml WBC, ABG 7.41/43/28, Flu
negative
- Imaging notable for: CXR w/o evidence of focal consolidation
- Vitals prior to transfer: Temp 98.4 HR 92 BP 115/41 RR 18 SpO2
96% RA
Upon arrival to the floor, the patient reports the above
history,
although is unclear on how long his symptoms have been present.
He states he may have had SOB and cough since 7 days ago, but
did
not come to the hospital because he "has been to the hospital
for
too long". He came as his cough and wheezing have worsened in
the last few days. As above, denies fevers, CP, abdominal
pains,
N/V, URI symptoms.
Past Medical History:
Coronary artery disease
-- h/o MI in ___
-- s/p 1v-CABG (SVG-RPDA) on ___
- Bicuspid aortic valve
-- s/p 23mm ___ mechanical AVR on ___
-- Dilated aortic root (39mm) seen on TTE on ___, new from ___
(36mm)
-- s/p redo sternotomy, redo CABG, mitral valve replacement and
tricuspid valve repair, ___
- Longstanding persistent atrial fibrillation
- Congestive heart failure HFrEF, NYHA class II, stage C
- Hypertension
- Dyslipidemia
- Chronic obstructive pulmonary disease
- Asthma
- Osteoarthritis
- h/o MSSA bacteremia, negative TEE for endocarditis
- Former smoker, quit ___ years ago
- GI bleeding
- CA prostate: Diagnosed in ___, s/p hormonal and radiation
treatment, currently in remission.
Social History:
___
Family History:
- Mother: CAD, died of myocardial infarction at age ___
- Father - ___
- No family history of premature CAD, cardiomyopathies, valvular
disease, arrhythmias, sudden or unexpected death.
- His children have not been screened for valvular disease.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VITALS: 24 HR Data (last updated ___ @ 1639)
Temp: 98.5 (Tm 98.5), BP: 120/66, HR: 96, RR: 18, O2 sat:
96%, O2 delivery: Ra
General: Alert, oriented, breathing well, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Irregularly irregular, normal S1 with distinct S2 at apex,
no
murmurs, rubs, gallops
Lungs: Rhonchorous breath sounds ___, Rhonchi on R. mid-posterior
lung field.
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
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact
DISCHARGE PHYSICAL EXAM
=======================
Vitals: Temp: 97.7 PO BP: 115/61 HR: 89 RR: 18 O2 sat: 97% O2
delivery: Ra
General: Alert, oriented, breathing well, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Irregularly irregular, normal S1 with distinct S2 at apex,
no
murmurs, rubs, gallops
Lungs: Rhonchorous breath sounds ___, Rhonchi on R. mid-posterior
lung field.
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
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact
Pertinent Results:
ADMISSION LABS
==============
___ 01:25PM BLOOD WBC-4.8 RBC-3.71* Hgb-11.4* Hct-35.1*
MCV-95 MCH-30.7 MCHC-32.5 RDW-15.5 RDWSD-54.0* Plt ___
___ 01:25PM BLOOD ___ PTT-33.9 ___
___ 01:25PM BLOOD Glucose-126* UreaN-12 Creat-0.8 Na-142
K-4.1 Cl-103 HCO3-25 AnGap-14
___ 01:50PM BLOOD pO2-141* pCO2-43 pH-7.41 calTCO2-28 Base
XS-2
DISCHARGE LABS
==============
___ 04:50AM BLOOD WBC-6.1 RBC-3.24* Hgb-9.9* Hct-30.6*
MCV-94 MCH-30.6 MCHC-32.4 RDW-15.4 RDWSD-53.4* Plt ___
___ 04:50AM BLOOD ___ PTT-33.2 ___
___ 04:50AM BLOOD Glucose-165* UreaN-25* Creat-0.8 Na-141
K-4.7 Cl-102 HCO3-26 AnGap-13
___ 04:50AM BLOOD Calcium-8.4 Phos-3.0 Mg-2.4
RELEVANT IMAGING
================
___ CXR
FINDINGS:
Patient is status post median sternotomy and cardiac valve
replacement.
Enlargement of the cardiomediastinal silhouette is relatively
stable given
differences in technique. No focal consolidation, large pleural
effusion, or
evidence of pneumothorax is seen. There is no pulmonary edema.
IMPRESSION:
No focal consolidation to suggest pneumonia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
2. AtroVENT HFA (ipratropium bromide) 17 mcg/actuation
inhalation Q6H:PRN SOB
3. Albuterol Inhaler ___ PUFF IH Q4H:PRN Cough/SOB/Wheeze
4. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
5. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB/Cough
6. Digoxin 0.125 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. Metoprolol Succinate XL 25 mg PO BID
9. Montelukast 10 mg PO DAILY
10. rOPINIRole 0.25 mg PO QPM Restless Leg Syndrome
11. Spironolactone 12.5 mg PO DAILY
12. Torsemide 10 mg PO DAILY
13. Warfarin 6.5 mg PO DAILY16
14. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID
15. Magnesium Oxide 500 mg PO DAILY
16. ipratropium bromide 0.02 % inhalation QID:PRN
17. Fluticasone Propionate NASAL 2 SPRY NU DAILY
18. Tamsulosin 0.4 mg PO QHS
Discharge Medications:
1. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth Daily Disp #*4 Tablet
Refills:*0
2. Warfarin 3 mg PO DAILY16
Please continue until you have your INR drawn ___.
3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
4. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB/Cough
5. Albuterol Inhaler ___ PUFF IH Q4H:PRN Cough/SOB/Wheeze
6. Atorvastatin 40 mg PO QPM
7. AtroVENT HFA (ipratropium bromide) 17 mcg/actuation
inhalation Q6H:PRN SOB
8. Digoxin 0.125 mg PO DAILY
9. Fluticasone Propionate NASAL 2 SPRY NU DAILY
10. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
11. ipratropium bromide 0.02 % inhalation QID:PRN wheezing
12. Magnesium Oxide 500 mg PO DAILY
13. Metoprolol Succinate XL 25 mg PO BID
14. Montelukast 10 mg PO DAILY
15. rOPINIRole 0.25 mg PO QPM Restless Leg Syndrome
16. Sacubitril-Valsartan (24mg-26mg) 1 TAB PO BID
17. Spironolactone 12.5 mg PO DAILY
18. Tamsulosin 0.4 mg PO QHS
19. Torsemide 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
=======
Asthma exacerbation
SECONDARY
=========
Atrial Fibrillation
Heart Failure with Reduced Ejection Fraction
Coronary artery disease
Hyperlipidemia
Normocytic Normochromic Anemia
Prostate Cancer
Restless Leg Syndrome
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 asthma in respiratory distress// Pneumonia
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
FINDINGS:
Patient is status post median sternotomy and cardiac valve replacement.
Enlargement of the cardiomediastinal silhouette is relatively stable given
differences in technique. No focal consolidation, large pleural effusion, or
evidence of pneumothorax is seen. There is no pulmonary edema.
IMPRESSION:
No focal consolidation to suggest pneumonia.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Unspecified asthma with (acute) exacerbation
temperature: 98.8
heartrate: 62.0
resprate: 26.0
o2sat: 100.0
sbp: 93.0
dbp: 49.0
level of pain: 0
level of acuity: 2.0 | ___ with extensive cardiac history, presenting for asthma
exacerbation. His symptoms markedly improved with nebulizer
treatments and steroids.
ACUTE ISSUES
============
#Acute Asthma Exacerbation
Patient's history and symptoms were concerning for asthma
exacerbation. In the ED, patient was started on ipratriopium and
albuterol, and given a dose of methylprednisolone. He was
brought to ED obs for further monitoring, but had marked
improvement after initial therapy. However, while boarding he
was still symptomatic, and tachypnic while talking. There was
initial concern for a possible PNA, and thus patient was started
on Ceftriaxone and azithromycin, but this was discontinued given
final read of his CXR. Though his sats continued to remain
stable on RA, he continued to report subjective dyspnea, and had
tachycardia to the 100s with ambulation. He was brought up to
the floor were inhalers and steroids were continued, along with
his home montelukast and advair. By the morning, the patient's
symptoms had markedly improved, with ambulatory O2 sats ~94.
There was low concern this was a HF exacerbation, as his CXR,
BNP, and exam were not consistent with this.
[] Patient should have close monitoring of his asthma, and
discussion whether this is an appropriate regiment for him.
CHRONIC ISSUES
==============
#. Atrial Fibrillation
INR goal 2.5-3.5 in setting of mechanical valve. INR 4.1 on
morning of discharged. Was given 3mg, and instructed to
follow-up closely for further monitoring of his INR. He was
continued on metoprolol and digoxin.
[] Patient will need close follow-up for monitoring of his INR,
preferably ___
#. HFrEF
Continued home Torsemide, Entresto, Spironolactone, and Digoxin.
#. CAD/HLD
Continued home atorvastatin
#. Normocytic Normochormic Anemia
Hemoglobin at baseline
#. H/o Prostate CA
Continued home tamsulosin 0.4mg PO QHS
#RESTLESS LEG SYNDROME
Continued ropinirole
TRANSITIONAL ISSUES
===================
[] Patient should have close monitoring of his asthma, and
discussion whether this is an appropriate regimen for him.
[] Patient had supratherapeutic INR at discharge in setting of
receiving antibiotics for possible pneumonia. Consulted with
pharmacy and decided to decrease warfarin from home 6.5mg to 3mg
daily. He will need repeat INR drawn on ___, and
adjustment to his warfarin dosing based on the result.
#CODE: FULL
#Health care proxy/emergency contact: ___ (wife):
___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is a ___ with PMH of CAD s/p CABG (___), CHF (EF
40%), DM2, HTN, CLL (stable), stroke x3 with residual
hemiparesis and CKD (baseline Cr 2.0) who presents with
productive cough and wheezing over the past 5 days associated
with body weakness, rhinitis and n/v (non-bloody emesis x3
today). Diagnosed with bronchitis by PCP, and was started on
levofloxacin. Came to hospital for increased wheezing and
difficulties breathing. She reports very mild ___ swelling, not
worse than normal. She does not weigh herself daily. Denies
fevers or myalgias. Denies CP, abd pain, diarrhea or dysuria.
States she has been compliant with her medications and follows a
low salt diet. No recent travel or sick contacts. Of note, she
was recently admitted in ___ with a fever, SOB and cough and
was found to have E. coli bacteremia (likely ___ to urinary
source) and a left lower lobe pneumonia.
In the ED intial vitals were: 98.5 78 166/69 18 100%. Labs were
notable for: proBNP: 5434, Trop-T: 0.20 (baseline), Cr 2.1, Hct
30.4. ECG showed SR at 88, LBBB, NA, non-specific ST TW changes.
CXR: Increased left basilar opacity most likely represents
combination of pleural effusion and atelectasis. Mild pulmonary
edema. Patient was seen by cardiology who recommended ASA, beta
blocker, statin and lasix to net goal neg ___ ___s
admission to cardiology for CHF exacerbation in setting of viral
URI. Patient was given: Albuterol 0.083% Neb Soln 1 NEB,
Ipratropium Bromide Neb 1 NEB, PredniSONE 60 mg, Lasix ___ IV
before transfer to the floor.
Past Medical History:
CAD s/p recent CABG (___) x 4 (LIMA to LAD, SVG to Dl, OM,
SVG to OM, SVG to dRCA )
CVA x 3 with residual left hemiparesis
Type 2 diabetes mellitus
Hypertension
Chronic kidney disease
CLL
ORIF ___ for L hip fracture
Social History:
___
Family History:
No premature cardiovascular disease.
Physical Exam:
ADMISSION
VS: 98.3, 153/70, 88, 100% on RA
GENERAL: ___ speaking female with NAD
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple, unable to appreciate JVD
CARDIAC: well healing sternotomy scar, SEM at LUSB, RRR
LUNGS: crackles at bases, L>R, scattered inspiratory wheezes
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: trace pitting edema in ___
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas
DISCHARGE
VS: 97.8, 127-29/59-62, 95-99, 20, 94 2 l
Wt 63.9 kg (dry weight per pt: 65 kg or 143 lbs)
I/O: 620/incont (not recorded)
GENERAL: ___ speaking female, lying in bed
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple, no JVD
CARDIAC: well healing sternotomy scar, SEM at ___, RRR
LUNGS: scattered inspiratory wheezes, difficult to appreciate
crackles
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: no edema in ___
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
Pertinent Results:
___ 01:00PM BLOOD WBC-3.2*# RBC-3.41* Hgb-9.9* Hct-30.4*
MCV-89 MCH-29.1 MCHC-32.7 RDW-15.8* Plt Ct-87*
___ 06:15AM BLOOD WBC-4.4 RBC-3.09* Hgb-9.1* Hct-26.7*
MCV-87 MCH-29.3 MCHC-33.9 RDW-16.0* Plt ___
___ 01:00PM BLOOD Neuts-56.2 ___ Monos-1.7* Eos-1.1
Baso-0.3
___ 03:25AM BLOOD Neuts-67.9 ___ Monos-1.9* Eos-0.3
Baso-0.1
___ 01:00PM BLOOD ___ PTT-25.8 ___
___ 01:00PM BLOOD Plt Smr-VERY LOW Plt Ct-87*
___ 06:15AM BLOOD Plt ___
___ 01:00PM BLOOD Glucose-187* UreaN-36* Creat-2.1* Na-140
K-4.7 Cl-106 HCO3-23 AnGap-16
___ 06:15AM BLOOD Glucose-136* UreaN-34* Creat-2.1* Na-138
K-4.2 Cl-101 HCO3-25 AnGap-16
___ 01:00PM BLOOD CK(CPK)-95
___ 03:35PM BLOOD CK(CPK)-41
___ 01:00PM BLOOD CK-MB-4 cTropnT-0.20* proBNP-5434*
___ 06:10AM BLOOD proBNP-3373*
___ 03:25AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.2
___ 06:15AM BLOOD Calcium-8.5 Phos-3.9 Mg-2.1
___ 08:48AM BLOOD Lactate-1.1
2D ECHOCARDIOGRAM - ___:
The left atrium is dilated. No spontaneous echo contrast or
thrombus is seen in the body of the left atrium/left atrial
appendage or the body of the right atrium/right atrial
appendage. No atrial septal defect is seen by 2D or color
Doppler. Left ventricular wall thicknesses and cavity size are
normal. Overall left ventricular systolic function is mildly
depressed (LVEF= 45 %).
Right ventricular chamber size and free wall motion are normal.
There are focal calcifications in the aortic arch. There are
complex (>4mm) atheroma in the descending thoracic aorta. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. Mild to moderate (___) mitral
regurgitation is seen. There is no pericardial effusion.
PostBypas:
Intact thoracic aorta. Mild to Moderate MR. ___ improvement in
the LV systolic function. EF 45 to 50%. Normal RV systolic
function.
No other new valvular findings.
CARDIAC CATH ___:
1. Severe 3 vessel and moderate left main CAD
2. Consult CT surgery for CABG - disease poorly suitable for PCI
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with weakness and cough // r/o acute infectious
process
TECHNIQUE: Chest Frontal and Lateral
COMPARISON: ___
FINDINGS:
Left base opacity has increased, which most likely represents combination of
pleural effusion and atelectasis, although underlying consolidation is not
excluded. There are low lung volumes and increased perihilar interstitial
markings suggesting mild pulmonary edema. No right pleural effusion is seen.
There is no evidence of pneumothorax. The cardiac silhouette remains
top-normal to mildly enlarged with evidence of left atrial enlargement. The
patient is status post median sternotomy and CABG.
IMPRESSION:
Increased left basilar opacity most likely represents combination of pleural
effusion and atelectasis, although underlying consolidation not excluded.
Mild pulmonary edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with CHF, CAD s/p CABG influenza and worsening
respiratory status. CHF, ?ARDS
TECHNIQUE: Single portable AP view of the chest.
COMPARISON: Chest radiograph from ___, and ___.
FINDINGS:
Compared with the prior radiograph, lung volumes are still low with increased
interstitial perihilar markings, suggesting continued mild pulmonary edema.
Left basilar atelectasis and effusion are unchanged. No right pleural
effusion. No evidence of pneumothorax. Cardiomediastinal silhouette is
stable. Intact median sternotomy wires and mediastinal clips. No focal
consolidation concerning for pneumonia.
IMPRESSION:
Mild pulmonary edema and left basilar atelectasis and effusion are unchanged.
Gender: F
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: Cough, Weakness
Diagnosed with CONGESTIVE HEART FAILURE, UNSPEC
temperature: 98.5
heartrate: 78.0
resprate: 18.0
o2sat: 100.0
sbp: 166.0
dbp: 69.0
level of pain: 0
level of acuity: 3.0 | ___ with PMH of CAD s/p CABG (___), CHF (EF 40%), DM2, HTN,
CLL (stable), strokex3 and CKD (baseline Cr 2.0) with residual
hemiparesis who presented with productive cough and wheezing
over the past 5 days and found to have the flu and CHF
exacerbation.
# Cough and wheezing: Positive for the flu. Given tamaflu and
continued levofloxacin for possible superimposed bacterial
infection. Treated symptomatically with oxygen, DuoNebs,
Benzonatate, Guaifenesin, lozenges.
# CHF exacerbation: BNP on admission 5434. Slightly volume up on
exam and diuresed to dry weight on discharge.
#Tropinemia: Likely in setting of demand from mild CHF
exacerbation in setting of CKD. No chest pain or acute ST
changes concerning for ACS. Held heparin drip. Continued home
ASA. Not on ACE because of CKD.
# Pancytopenia: Patient has history of CLL which can lead to
pancytopenia since Autoimmune hemolytic anemia (AIHA), immune
thrombocytopenia (ITP), and pure red cell aplasia (PRCA) are
well-described complications associated with chronic lymphocytic
leukemia (CLL). Her hematocrit was around her baseline on this
admission, and her admission leukopenia (___ 1798) and
thrombocytopenia were likely exacerbated by infection; improved
on discharge.
CHRONIC MEDICAL ISSUES:
# Type 2 diabetes: poorly controlled. Daughter states pt has
very labile blood sugars at home. Continued home insulin regimen
and ISS, held standing humalog with meals given episodes of
hypoglycemia on recent hospital stay.
# Chronic kidney disease: Patient's creatinine 1.9-2.1
throughout admission which is at her baseline.
# Hypertension: Continued Metoprolol Tartrate 25 mg PO BID,
changed to metoprolol succ 50 mg daily on discharge.
# HL: Continued home statin. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine
Attending: ___
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male w/ a history of paraplegia (s/p work accident
in his teens), recurrent UTIs, migraines, who presents with
several days of lethargy and diaphoresis in the setting of
recently treated UTI.
Patient presented to PCP ___ ___ with similar symptoms, had
positive UA and was given prescription for cipro x 10d. Urine
culture was sent and grew gram positive cocci/rods, but no
sensitivities were performed.
ED course:
- VS: T 100, BP 132/70, HR 94, RR 18, O2 100% on RA
- Imaging: CTU - R perinephric stranding c/w pyelonephritis,
multiple non-obstructing renal stones bilaterally, CXR - no
acute process, but slight prominence of mediastinum potentially
requiring f/u imaging
- Labs: Notable for WBC 24.1, UA w/ +LEs, +nitrite, 86wbc, mod
bact, urine and blood cultures pending
- Meds: Ketorolac 30mg IV, vancomycin 1gm IV, ceftriaxone 1gm
IV, 2L NS
- Admitted to medicine for further management of pyelonephritis
Past Medical History:
Paraplegia (s/p work accident in his teens)
Recurrent UTIs
Migraine headaches
Social History:
___
Family History:
Mother: Healthy
Father: Died of likely MI
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: T 99.4, BP 97/54, HR 89, RR 18, O2 97% on RA
Gen: Well appearing, in no apparent distress, sitting upright in
bed
HEENT: NCAT, oropharynx clear
Lymph: no cervical lymphadenopathy
CV: No JVD present, regular rate and rhythm, no murmurs
appreciated
Resp: CTA bilaterally in anterior and posterior lung fields, no
increased work of breathing
GI: Mild diffuse tenderness, soft, non-distended. No
hepatosplenomegaly appreciated.
Extremities: Bilateral 2+ ___ edema (at baseline per patient,
usually wears compression stockings)
Neuro: ___ b/l ___ strength and sensation (at baseline),
otherwise no focal neurologic deficits.
Psych: Euthymic, speech non-tangential, appropriate
DISCHARGE EXAM:
VSS, afebrile
GEN: AO x 3, in NAD
HEENT: NC/AT
CV: RRR, no m/r/g
PULM: CTA B
BACK: no CVAT
GI: soft, NT/ND, NABS
EXT: 2+ pitting edema of the ___, no calf tenderness
SKIN: Warm, +small vesicular lesions on right fingers
NEURO: Baseline paraplegia
Pertinent Results:
CTU (___)
1. The striated nephrogram in the upper and lower pole of the
right kidney and mild asymmetric right perinephric stranding in
a patient with urosepsis is consistent with pyelonephritis.
There is no evidence of renal abscess or perinephric collection.
The kidneys are notable for multifocal bilateral cortical
scarring from prior injury. Multiple nonobstructing renal stones
are present bilaterally, largest in the right lower pole
measures 1.0 x 1.2 cm. The remaining are punctate and scattered.
No hydronephrosis.
2. Unusual lobulated morphology of the bladder is probably
postsurgical. Multiple bladder stones are noted measuring up to
7 mm. Bladder wall thickening may relate to underdistention or
represent cystitis.
3. Anastomotic sutures are noted in the region of the cecum. The
appendix is not visualized and may be surgically absent. There
are no inflammatory changes in the right lower quadrant.
CXR (___):
No focal consolidation to suggest pneumonia.
Slight prominence of the superior mediastinum which may be due
to AP technique and prominent vasculature. No prior for
comparison to assess chronicity. If clinical concern for acute
mediastinal or spinal process, CT is more sensitive and should
be considered.
ADMISSION LABS:
___ 06:15PM WBC-24.1* RBC-5.55 HGB-16.3 HCT-48.4 MCV-87
MCH-29.4 MCHC-33.7 RDW-12.9 RDWSD-40.4
___ 06:15PM NEUTS-86.6* LYMPHS-3.2* MONOS-8.3 EOS-0.3*
BASOS-0.4 IM ___ AbsNeut-20.85* AbsLymp-0.76* AbsMono-1.99*
AbsEos-0.07 AbsBaso-0.10*
___ 06:15PM GLUCOSE-103* UREA N-14 CREAT-1.1 SODIUM-137
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-21* ANION GAP-16
___ 07:24PM ___ PTT-32.9 ___
___ 06:24PM LACTATE-1.4
___ MICRO DATA:
Urine culture (___) - sensis not performed:
URINE CULTURE:
Gram Positive Cocci: 3 different colonies
>100,000 cfu/mL (A)
URINE CULTURE:
Gram Positive Rod
>100,000 cfu/ml
DISCHARGE DATA:
___ 07:20AM BLOOD WBC-7.1 RBC-4.58* Hgb-13.4* Hct-40.2
MCV-88 MCH-29.3 MCHC-33.3 RDW-12.9 RDWSD-41.6 Plt ___
___ 07:20AM BLOOD Glucose-99 UreaN-12 Creat-0.7 Na-141
K-3.8 Cl-108 HCO3-24 AnGap-13
___ 06:15PM BLOOD ALT-26 AST-25 AlkPhos-95 TotBili-1.0
___ 07:20AM BLOOD Calcium-8.3* Phos-2.5* Mg-2.0
___ 09:00AM BLOOD Vanco-14.2
___ 06:24PM BLOOD Lactate-1.4
URINE CX HERE CONTAMINATED
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID poison ___
right hand
RX *triamcinolone acetonide 0.1 % apply to skin three times a
day Disp #*30 Gram Gram Refills:*0
2. Acetaminophen 325-650 mg PO Q6H:PRN pain / fever
3. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
Last dose on the evening of ___
RX *amoxicillin-pot clavulanate [Augmentin] 875 mg-125 mg 1
tablet(s) by mouth twice a day Disp #*19 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Pyelonephritis
Poison ___ - right hand
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with hx recurrent UTIs, T10 paraplegia, referred in
for rigors // eval ? infx
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: None.
FINDINGS:
The lungs are relatively hyperinflated. No focal consolidation is seen. No
pleural effusion or pneumothorax is seen. The cardiac silhouette is top-normal
to mildly enlarged. The aorta is tortuous. There is slight prominence of the
superior mediastinum which may be due to AP technique and prominent
vasculature. If clinical concern for acute mediastinal or spinal process, CT
is more sensitive and should be considered.
IMPRESSION:
No focal consolidation to suggest pneumonia.
Slight prominence of the superior mediastinum which may be due to AP technique
and prominent vasculature. No prior for comparison to assess chronicity. If
clinical concern for acute mediastinal or spinal process, CT is more sensitive
and should be considered.
Radiology Report
INDICATION: History: ___ with sepsis, likely urinary source but notable
diffuse abd pain + suprapubic and RLQ, eval ? appendicitis, colitis
TECHNIQUE: CTU: Multidetector CT of the abdomen and pelvis were acquired
prior to and after intravenous contrast administration with the patient in
prone position. The non-contrast scan was done with low radiation dose
technique. The contrast scan was performed with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.8 s, 63.0 cm; CTDIvol = 16.5 mGy (Body) DLP =
1,040.9 mGy-cm.
2) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 31.3 mGy (Body) DLP =
15.6 mGy-cm.
3) Spiral Acquisition 5.9 s, 64.5 cm; CTDIvol = 16.5 mGy (Body) DLP =
1,064.9 mGy-cm.
Total DLP (Body) = 2,121 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: A nodular opacity at the right base posteriorly likely
represents rounded atelectasis. There is no evidence of pleural or
pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. An 8
mm ill-defined hypodense lesion in the right lobe of the liver is too small to
characterize (04:15, 605b:35). There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. The striated
nephrogram of the upper and lower poles of the right kidney may represent
pyelonephritis. The left kidney enhances homogeneously. Multiple
nonobstructing renal stones are present bilaterally. The largest stone is in
the right lower pole measuring 1.0 x 1.2 cm. Remaining scattered stones in
bilateral kidneys are punctate. There is no hydronephrosis. There is no
perinephric abnormality. Multiple hypodensities in bilateral kidneys are
either simple cysts or too small to characterize. There are multiple areas of
cortical scarring in bilateral kidneys. The ureters are within normal limits.
Unusual morphology of the bladder should be correlated with a prior history of
surgery. Multiple stones measuring up to 7 mm are seen layering dependently
in the bladder.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. Anastomotic
sutures are noted in the region of the cecum. The colon and rectum are
otherwise within normal limits. The appendix is not visualized and may be
surgically absent.
PELVIS: There is no free fluid in the pelvis.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: Note is made of heterotopic ossification in the soft tissues
along the left anterior superior thigh and the posterior right gluteal region
and along the right iliac crest extending inferiorly into the upper anterior
thigh.
IMPRESSION:
1. The striated nephrogram in the upper and lower pole of the right kidney and
mild asymmetric right perinephric stranding in a patient with urosepsis is
consistent with pyelonephritis. There is no evidence of renal abscess or
perinephric collection. The kidneys are notable for multifocal bilateral
cortical scarring from prior injury. Multiple nonobstructing renal stones are
present bilaterally, largest in the right lower pole measures 1.0 x 1.2 cm.
The remaining are punctate and scattered. No hydronephrosis.
2. Unusual lobulated morphology of the bladder is probably postsurgical.
Multiple bladder stones are noted measuring up to 7 mm. Bladder wall
thickening may relate to underdistention or represent cystitis.
3. Anastomotic sutures are noted in the region of the cecum. The appendix is
not visualized and may be surgically absent. There are no inflammatory
changes in the right lower quadrant.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Lethargy, Abd pain
Diagnosed with Acute pyelonephritis
temperature: 99.9
heartrate: 94.0
resprate: 18.0
o2sat: 100.0
sbp: 112.0
dbp: 98.0
level of pain: 5
level of acuity: 2.0 | ___ year old male w/ a history of paraplegia (s/p work accident
in his teens), recurrent UTIs, migraines, who presents with
several days of lethargy and diaphoresis in the setting of
recently treated UTI, now w/ likely inadequately treated UTI
leading to sepsis due to pyelonephritis.
# Sepsis secondary to
# Pyelonephritis:
CTU shows R perinephric stranding c/w pyelo. Multiple stones,
but non-obstructing. Urine cx shows GPC and GPR, likely not
treated by ___ as prescribed last week. Started on Vanc/CTX
here with marked improvement in symptoms, fever curve, and WBC
(24->7). Urine cx at ___ from ___ with 3 different GPC
isolate and one GPR isolate Urine culture here at ___
contaminated. Based on unrevealing culture data, ID was
consulted to help provide guidance re: optimal oral abx
treatment upon discharge. Based on prior culture data,
Augmentin was recommended to complete 14-day total course of
antibiotics Patient is strongly recommended to see Urology
given h/o stones and prior urologic procedures with now frequent
UTIs; he may also benefit from suppressive antibiotics in the
future.
# ___ - mild on the right hand after exposure prior to
admission. Treated with triamcinolone cream x 7 days. |
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
Colonic volvulus
Incarcerated ventral hernia
Small bowel perforation
Major Surgical or Invasive Procedure:
Subtotal colectomy
End ileostomy
History of Present Illness:
HPI: Mr. ___ is a ___ male with PMH most notable for
morbid obesity s/p Roux en Y gastric bypass in ___ who
presented
to an OSH with severe LLQ abdominal pain which began
approximately 12 hours prior. He also endorsed intermittent
nausea, one episode of non-bilious emesis yesterday, and being
febrile up to 101 at home. His last BM was on ___, and he
reports no flatus since that time. He reports no CP/SOB, no
dysphagia/BRBPR/melena. A CT scan done at the OSH was concerning
for perforated colon, therefore he was transfered emergently to
___ for further evaluation.
In the ___ ED, upon presentation he was noted to be slightly
hypotensive (SBP 80-90s) but not tachycardic (HR 90-100s),
mentating and endorsing persistent abdominal pain, distension,
and nausea. A central line was placed and aggressive IVF
resuscitation was started immediately, and the Bariatric and ACS
Surgical services were consulted.
Past Medical History:
Past Medical History: Morbid obesity, DM, ventral hernia, MRSA
leg infection, gout, OA
Past Surgical History: Subtotal colectomy, end ileostomy, Roux
en Y gastric bypass (___), L hip fracture repair (___), R
ulnar nerve release (___)
Social History:
___
Family History:
Noncontributory.
Physical Exam:
Discharge Day Physical Exam:
VS: Tm 99.7 Tc 99.0 P 80 BP 119/57 R 18 sO2 94% RA BS 187
Gen: Obese caucasian male sitting up in bed in NAD.
HEENT: PERRL, EOMI.
CV: RRR, no m/r/g.
Resp: CTAB, no w/r/r.
Abd: Midline abdominal incision with ___ in place,
C/D/I. End ileostomy site in RLQ with brown/green output, no e/o
infection.
Skin: no rashes or lesions.
Ext: 2+ peripheral pulses bilaterally. No c/c/e.
Neuro: CN II-XII intact. Sensation and motor strength grossly
intact.
Pertinent Results:
___ 04:45AM BLOOD WBC-32.0*# RBC-5.40 Hgb-13.6* Hct-42.2
MCV-78*# MCH-25.2* MCHC-32.2 RDW-15.7* Plt ___
___ 04:45AM BLOOD Neuts-92.1* Lymphs-5.4* Monos-2.2 Eos-0.1
Baso-0.2
___ 04:45AM BLOOD Neuts-92.1* Lymphs-5.4* Monos-2.2 Eos-0.1
Baso-0.2
___ 04:45AM BLOOD ___ PTT-34.2 ___
___ 04:45AM BLOOD Glucose-190* UreaN-43* Creat-2.5*# Na-134
K-4.5 Cl-98 HCO3-24 AnGap-17
___ 04:45AM BLOOD ALT-9 AST-13 AlkPhos-54 TotBili-0.6
___ 04:45AM BLOOD Lipase-9
___ 04:45AM BLOOD Albumin-3.4* Calcium-9.1 Phos-4.9*#
Mg-1.3*
___ 06:10AM BLOOD ___ pO2-41* pCO2-39 pH-7.36
calTCO2-23 Base XS--2 Intubat-NOT INTUBA Vent-SPONTANEOU
___ 05:21AM BLOOD Lactate-2.3*
___ 04:24AM BLOOD WBC-8.2 RBC-2.90* Hgb-7.5* Hct-23.5*
MCV-81* MCH-25.8* MCHC-31.8 RDW-15.8* Plt ___
___ 10:44PM BLOOD CK-MB-1 cTropnT-<0.01
___ 02:47AM BLOOD ___ PTT-29.9 ___
___ 04:24AM BLOOD Glucose-128* UreaN-8 Creat-0.4* Na-139
K-3.7 Cl-104 HCO3-27 AnGap-12
___ 04:24AM BLOOD Calcium-7.5* Phos-4.0 Mg-1.8
Medications on Admission:
Lasix 40 mg BID, ranitidine 300 mg daily, bupropion
SR 100 mg BID, citalopram 40 mg daily, abilify 15 mg daily, ASA
325 mg daily, lisinopril 20 mg daily, MVI, fentanyl 75 mcg/hr
patch, Klor-con 20 mEq daily, metformin ER ___ mg daily, Vit D,
MVI, PEG daily, percocet PRN
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Aripiprazole 15 mg PO DAILY
3. Aspirin 325 mg PO DAILY
4. BuPROPion (Sustained Release) 100 mg PO BID
5. Citalopram 40 mg PO DAILY
6. Fentanyl Patch 75 mcg/h TD Q72H
7. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
8. Ranitidine 300 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Small bowel perforation
Colonic volvulus
Incarcerated ventral hernia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH
INDICATION: Status post colonic perforation and colectomy, extubation,
evaluation for interval change.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the patient is rotated to
the left. In the interval, extubation has been performed. Internal jugular
vein catheter and the nasogastric tube are in unchanged position. The lung
volumes remain low, with areas of small atelectasis at the right lung base.
Borderline size of the cardiac silhouette without overt pulmonary edema. No
larger pleural effusions. No pneumonia.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Perforated colon, status post high volume fluid resuscitation,
evaluation for pulmonary edema.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the lung volumes remain
low. The heart is moderately enlarged and mild fluid overload is seen in
almost unchanged manner. However, there is no overt pulmonary edema. Minimal
atelectasis at the right lung bases. The right internal jugular vein catheter
is unchanged, the nasogastric tube has been removed in the interval.
Radiology Report
HISTORY: ___ male with hypoxia and bowel perforation. Evaluation for
pneumonia.
COMPARISON: Comparison is made with radiograph of the chest from ___, obtained at an outside hospital (___).
FINDINGS:
2 supine portable views of the chest demonstrate interval placement of a right
internal jugular central venous catheter, which terminates at the cavoatrial
junction. There is no pneumothorax. There is elevation of the right
hemidiaphragm, and relatively low lung volumes, and right basilar atelectasis.
The heart size is top normal and the mediastinum is likely within normal
limits, allowing for supine portable technique, although hilar prominence
suggests underlying fluid overload. Relatively asymmetric opacification in
the left apex compared to the right, is possibly due to non-cardiogenic edema.
No large pleural effusion is present and no consolidation concerning for
pneumonia is seen.
IMPRESSION:
Right internal jugular central venous catheter in appropriate position. No
pneumothorax or focal pneumonia. Left apical haziness could represent a
component of non-cardiogenic edema, in addition to underlying fluid overload
and right basilar atelectasis.
The above findings were communicated to Dr. ___ by Dr. ___
telephone at 9:14 am, after attending review.
Radiology Report
INDICATION: Subtotal colectomy, post-op chest x-ray.
COMPARISONS: ___.
FINDINGS: Single portable chest radiograph was provided. Endotracheal tube
is 6.2 cm above the carina. Nasogastric tube courses below the diaphragm into
the stomach. A right internal jugular central line terminates in the lower
SVC. There is no focal consolidation, pleural effusion or pneumothorax. The
cardiac silhouette is enlarged but unchanged.
IMPRESSION: Endotracheal tube may be advanced 2 cm for better positioning.
Radiology Report
HISTORY: Post-operative.
FINDINGS: In comparison with the study of ___, allowing for differences in
degree of rotation, there may be little change. Continued enlargement of the
cardiac silhouette. The right hemidiaphragm is not sharply seen. This raises
the possibility of layering effusion with compressive atelectasis at the base.
Various monitoring and support devices are in unchanged position.
Radiology Report
CLINICAL HISTORY: Nasogastric tube placed, check position.
CHEST AND UPPER ABDOMEN.
Nasogastric tube can be followed as far as the distal esophagus but how far
beyond this it goes cannot be determined.If a small amount of barium was
placed within the nasogastric tube, its exact position could be determined.
IMPRESSION: Exact position of tip of nasogastric tube cannot be determined.
Radiology Report
CLINICAL HISTORY: Nasogastric tube advanced 5 cm. Check position.
The upper abdomen is not shown on this film and the position of the
nasogastric tube cannot be determined. If it was advanced 5 cm, I would
suspect it is in a satisfactory position.
Radiology Report
PORTABLE CHEST RADIOGRAPH, ___
COMPARISON: Radiograph of one day earlier.
FINDINGS: Support and monitoring devices are in standard position. The
patient is severely rotated towards the right, limiting assessment of
cardiomediastinal contours. Apparent worsening opacity in the right lower
lobe with associated partial obscuration of right heart border favors
atelectasis, but coexisting infectious pneumonia is possible in the
appropriate clinical setting. Adjacent right pleural effusion is probably not
changed.
Gender: M
Race: WHITE
Arrive by UNKNOWN
Chief complaint: ABD PERF
Diagnosed with PERFORATION OF INTESTINE, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, BARIATRIC SURGERY STATUS
temperature: 97.9
heartrate: 106.0
resprate: 15.0
o2sat: 96.0
sbp: 129.0
dbp: 88.0
level of pain: 10
level of acuity: 2.0 | Mr. ___ was admitted to the General Surgery - Acute Care
Service (ACS) at ___ on ___ for surgical management of
colonic volvulus, an incarcerated ventral hernia and small bowel
perforation in the setting of past Roux-en-Y gastric bypass. The
patient was first evaluated at an outside hospital, but
transferred to ___ emergently upon discovery of the small
intestinal perforation. In the emergency department, the patient
was noted to become hemodynamically unstable and required
vasopressor support. He was taken urgently to the operating room
at which point he underwent a subtotal colectomy with
end-ileostomy. Two JP drains were placed, in the hernia sac and
paracolic gutter, respectively. Please see the operative note
for further details regarding this procedure. Post-operatively
he remained intubated due to the complexity of the procedure and
the patient's body habitus; he was transferred to the SICU for
further care.
While in the SICU, the patient's course was notable for a
continued early vasopressor requirement including phenylephrine
and norepinephrine. His lactate trended down appropriately. The
patient remained intubated on HD#2 - HD#3 due to agitation with
multiple attempts at weaning his sedation. He was extubated on
HD#4 without difficulty. The hernia sac JP was removed and his
NG tube was clamped with no residual. He was transferred to
floor care on HD#6 once tolerating a full diet and off pressor
requirement. The second JP drain was removed on HD#8. The
patient remained on a regular diet which he tolerated well. He
had adequate urine output via indwelling Foley catheter.
Electrolytes were monitored due to high ostomy output; this
trended down with addition of psyllium wafers to the patient's
diet. He was evaluated by Physical Therapy and underwent
multiple conditioning sessions with our ___ team. On day of
discharge the patient was able to be transferred from bed to
chair with assist and stand unsupported. He was discharged to a
___ rehabilitation facility in improved condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
pine smell
Attending: ___
Chief Complaint:
Heart failure
Major Surgical or Invasive Procedure:
___ 1. Mitral valve repair, radical reconstruction.
2. Autologous pericardial patch repair of perforation in the
anterior mitral leaflet.
3. Commissuroplasty A3 P3 section.
4. Repair with 28 ___ annuloplasty band.
History of Present Illness:
Mr. ___ is a ___ year old male with history of alcohol
dependence/alcohol withdrawal seizures, hypertension,
endocarditis treated medically at ___ about ___ years ago, and
diabetes mellitus type 2 on insulin who was found unresponsive
in bed and brought to ___ for hypoglycemia (BS 45) and
hypoxemia (SpO2 ___ requiring intubation, with course
complicated by seizures. He was transferred to ___ and
admitted to the ___ for further management. He was treated for
possible aspiration pneumonia and encephalomeningitis. ___
revealed severe mitral regurgitation secondary to an
aneurysmal/perforated anterior mitral leaflet. Cardiac surgery
consulted for mitral valve repair vs. replacement.
Past Medical History:
Alcohol Dependence/Withdrawal Seizures
Diabetes Mellitus, Type II (on Insulin)
Endocarditis - treated ___ years ago
Hypertension
Diabetes mellitus type 2 on Insulin
Hypomagnesemia
Social History:
___
Family History:
non-contributory
Physical Exam:
BP: 117/82 HR: 77 RR: 13 O2 sat: 97% RA
Height: 76 in Weight: 105 kg
Skin: Dry [] intact [x]
HEENT: PERRLA [x] EOMI [] ET tube secured, trachea midline [x]
Neck: Supple [x] Full ROM []
Chest: Lungs clear bilaterally [] transmitted mechanical breath
sounds [x]
Heart: RRR [] Irregular [] Holosystolic Murmur [x] grade 2
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+ []
Extremities: Warm [x], well-perfused [x] No edema [x]
Varicosities: None [x]
Neuro: Unable to assess, intubated/sedated [x]
Pulses:
Femoral Right: palp Left: palp
DP Right: palp Left: palp
___ Right: palp Left: palp
Radial Right: palp Left: palp
Carotid Bruit: absent
Discharge Exam:
98.0
PO 95 / 63
R Sitting 87 18 98 Ra
.
General: NAD [x] walking unit
Neurological: A/O x3 [x] Moves all extremities [x] Follows
commands [x]
Cardiovascular: RRR [x]
Respiratory: CTA [x] No resp distress [x]
GI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT [x]
Extremities:
Right Upper extremity Warm [x] Edema
Left Upper extremity Warm [x] Edema
Right Lower extremity Warm [x] Edema none
Left Lower extremity Warm [x] Edema none
Pulses:
DP Right: palp Left: palp
___ Right: palp Left: palp
Radial Right: palp Left: palp
Skin/Wounds: Dry [x] intact [x]
Sternal: CDI [x] no erythema or drainage [x]
Sternum stable [x]
Pertinent Results:
Transthoracic Echocardiogram ___
The left atrium is mildly dilated. There is no evidence for an
atrial septal defect by 2D/color Doppler. The right atrial
pressure could not be estimated. There is mild symmetric left
ventricular hypertrophy
with a moderately increased/dilated cavity. There is normal
regional left ventricular systolic function. Overall left
ventricular systolic function is low normal. The visually
estimated left ventricular
ejection fraction is 50-55%. Due to severity of mitral
regurgitation, intrinsic left ventricular systolic function is
likely lower. There is no resting left ventricular outflow tract
gradient. No ventricular septal defect is seen. Mildly dilated
right ventricular cavity with normal free wall motion. The
aortic sinus diameter is normal for gender with a normal
ascending aorta diameter for gender. The aortic arch
diameter is normal with a normal descending aorta diameter. The
aortic valve leaflets (3) appear structurally normal. No masses
or vegetations are seen on the aortic valve. There is no aortic
valve stenosis. There is no aortic regurgitation. The mitral
valve leaflets are mildly thickened with no mitral valve
prolapse. A LARGE (1.1 x 0.7 cm), mobile, irregular echodensity
is seen on the left atrial side of
the anterior mitral valve leaflet most c/w a VEGETATION. There
is a perforation in the anterior mitral valve leaflet. There is
an eccentric, inferolateral directed jet of SEVERE [4+] mitral
regurgitation. Due to the Coanda effect, the severity of mitral
regurgitation could be UNDERestimated. The pulmonic valve
leaflets are normal. No masses/vegetations are seen on the
pulmonic valve. The tricuspid valve leaflets are mildly
thickened. No mass/vegetation seen, but cannot exclude due to
suboptimal image quality. There is mild [1+] tricuspid
regurgitation. There is mild pulmonary artery systolic
hypertension. There is no pericardial effusion. A left pleural
effusion is present.
IMPRESSION: Large, mobile, irregular echodensity on the atrial
aspect of the anterior mitral valve leaflet most c/w a
vegetation. There is an associated perforation of the anterior
mitral valve leaflet and severe ___ = 1.8 cm2; regurgitant
volume = 217 mL) inferolaterally directed mitral regurgitation.
Mild left ventricular wall thickness with mild cavity dilation
and low-normal global systolic function. Mild right ventricular
cavity dilation with normal systolic function. Mild
tricuspid regurgitation (cannot exclude associated vegetation or
abscess). Mild pulmonary artery systolic hypertension.
.
Transesophageal Echocardiogram ___
There is no spontaneous echo contrast in the body of the left
atrium or left atrial appendage. No spontaneous echo contrast or
thrombus is seen in the body of the right atrium/right atrial
appendage. The right atrial appendage ejection velocity is
normal. There is no evidence for an atrial septal defect by
2D/color Doppler. There are no aortic arch atheroma with no
atheroma in the descending aorta. The aortic valve leaflets (3)
appear structurally normal. No masses or vegetations are seen on
the aortic valve. No abscess is seen. There is no aortic
regurgitation. The mitral valve leaflets are mildly thickened
and myxomatous with no mitral valve prolapse. The A2 segment of
the anterior leaflet is aneurysmal with a 0.3cm2 perforation.
There is 1.1cm of mobile material on the leaflet which mostly
comprises the aneurysmal leaflet, but a concurrent small
vegetation cannot be excluded. No abscess is seen. There is an
eccentric, inferolateral directed jet of SEVERE [4+] mitral
regurgitation through the perforated leaflet. The tricuspid
valve leaflets appear structurally normal. No mass/vegetation
are seen on the tricuspid valve. No abscess is seen. There is
mild [1+] tricuspid regurgitation. The pulmonary artery systolic
pressure could not be estimated.
IMPRESSION: Severe mitral regurgitation secondary to to an
ansurysmal/perforated anterior mitral leaflet; a small
concurrent vegetation cannot be excluded.
.
Cardiac Catheterization ___
Coronary arteries are angiographically normal
.
Transesophageal Echocardiogram ___
PRE-OPERATIVE STATE: Sinus rhythm.
Left Atrium (LA)/Pulmonary Veins: No ___
mass/thrombus. Abnormal left and right pulmonary vein flow with
systolic blunting Abnormal left and right pulmonary vein flow
with systolic blunting
Right Atrium (RA)/Interatrial Septum/Inferior Vena Cava (IVC):
Normal RA size. Normal interatrial septum, no PFO, bowing
towards RA No atrial septal defect by 2D/color flow Doppler.
Left Ventricle (LV): Moderately dilated cavity. Normal regional
& global systolic function No mass/thrombus. LVEDV 185 ml
Right Ventricle (RV): Normal free wall motion. No mass.
Aorta: Normal sinus diameter. Normal ascending diameter. Normal
arch diameter. Normal descending aorta diameter. No dissection.
PULMONARY ARTERY: Normal main diameter. PA catheter tip seen in
main PA
Aortic Valve: Thin/mobile (3) leaflets. Minimal leaflet
calcification. No stenosis. No regurgitation. No masses
Mitral Valve: Abnormal valve. A 0.4 x 0.3 cm perforation seen in
the A2 region of anterior leaflet with mod-severe MR through the
perforation. Minimal MR at leaflet coaptation site. Medial
commisure prolapse involving A3-P3 leaflets. MR ___ 0.36 cm2,
Regurgitant volume 68 ml Minimal leaflet calcification. No
stenosis. Moderate to severe [3+] regurgitation.
Tricuspid Valve: Normal leaflets. Mild [1+] regurgitation. No
mass visualized
Pericardium: No effusion.
POST-OP STATE: The TEE was performed at 12:30:00. Sinus rhythm.
Post-op Comments S/P MV PERFORATION REPAIR WITH PERICARDIAL
PATCH, MEDIAL COMMISUROPLASTY AND ANNULOPLASTY RING. Improved
pulmonary vein flow compared to preop
Support: Vasopressor(s): none.
Left Ventricle: Similar to preoperative findings. Global
ejection fraction is normal.
Aorta: Intact. No dissection.
Aortic Valve: No change in aortic valve morphology from
preoperative state. Post-bypass, the mean aortic valve gradient
is 2mmHg. No change in aortic regurgitation.
Mitral Valve: Annular ring. Well-seated annular ring. Trace MR,
mean gradient 2 mmHg. Repaired anterior leaflet perforation site
No change in valvular regurgitation from preoperative state.
Tricuspid Valve: No change in tricuspid valve morphology vs.
preoperative state.
Pericardium: No effusion.
.
Transthoracic echocardiogram: ___
The left atrial volume index is normal. There is mild symmetric
left ventricular hypertrophy with a normal cavity size. There is
normal regional and global left ventricular systolic function.
Overall left ventricular systolic function is mildly depressed.
The visually estimated left ventricular ejection fraction is
40-45%. Left ventricular cardiac index is normal (>2.5
L/min/m2). There is no resting left ventricular outflow tract
gradient. No ventricular septal defect is seen. The right
ventricle has uninterpretable free wall motion assessment.
There is post-thoracotomy interventricular septal motion. The
aortic sinus is mildly dilated with a normal ascending aorta
diameter for gender. The aortic arch diameter is normal with a
normal descending aorta
diameter. There is no evidence for an aortic arch coarctation.
The aortic valve leaflets (3) appear structurally normal. There
is no aortic valve stenosis. There is no aortic regurgitation.
There is a mitral annular ring. The annular ring is well seated
and high normal mean gradient. There is mild [1+] mitral
regurgitation. Due to acoustic shadowing, the severity of mitral
regurgitation could be UNDERestimated. The pulmonic valve
leaflets are normal. There is mild pulmonic regurgitation. The
tricuspid valve leaflets appear structurally normal. There is
mild to moderate [___] tricuspid regurgitation. There is
moderate pulmonary artery systolic hypertension. There is no
pericardial effusion.
IMPRESSION: Suboptimal image quality. Well-seated mitral
annular ring with mild mitral regurgitation and high-normal
gradient. Mild symmetric left ventricular hypertrophy with
normal cavity size and mild global systolic dysfunction in the
setting of visual dyssynchrony from
prominent post-operative septal motion. Cannot relaibly assess
right ventricular function due to poor windows. Mild-moderate
tricuspid regurgitation. Moderate pulmonary artery systolic
hypertension.
.
___ 05:32AM ___ WBC-7.4 RBC-2.74* Hgb-9.0* Hct-27.7*
MCV-101* MCH-32.8* MCHC-32.5 RDW-13.5 RDWSD-49.7* Plt ___
___ 12:50PM ___ WBC-19.3* RBC-3.59* Hgb-12.0* Hct-36.3*
MCV-101* MCH-33.4* MCHC-33.1 RDW-13.7 RDWSD-49.8* Plt ___
___ 01:50AM ___ ___ PTT-30.9 ___
___ 01:55AM ___ ___ PTT-32.9 ___
___ 05:32AM ___ Glucose-101* UreaN-12 Creat-0.7 Na-142
K-4.7 Cl-101 HCO3-27 AnGap-14
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Atorvastatin 20 mg PO QPM
2. Gabapentin 300 mg PO TID
3. Basaglar KwikPen U-100 Insulin (insulin glargine) 32 U
subcutaneous QAM
4. Basaglar KwikPen U-100 Insulin (insulin glargine) 10 U
subcutaneous QPM
5. Lisinopril 5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. Aspirin EC 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
3. Docusate Sodium 100 mg PO BID
hold for loose stool
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
5. Furosemide 20 mg PO DAILY Duration: 5 Days
RX *furosemide 20 mg 1 tablet(s) by mouth once a day Disp #*5
Tablet Refills:*0
6. Metoprolol Tartrate 50 mg PO TID
RX *metoprolol tartrate 50 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*1
7. Multivitamins W/minerals 1 TAB PO DAILY
RX *multivitamin,tx-minerals [Vitamins and Minerals] 1
tablet(s) by mouth once a day Disp #*30 Tablet Refills:*1
8. Omeprazole 20 mg PO DAILY Duration: 30 Days
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*30
Capsule Refills:*0
9. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
10. Potassium Chloride 20 mEq PO DAILY Duration: 5 Days
RX *potassium chloride 20 mEq 1 packet(s) by mouth once a day
Disp #*5 Tablet Refills:*0
11. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*1
12. Glargine 60 Units Breakfast
Glargine 44 Units Dinner
Humalog 12 Units Breakfast
Humalog 12 Units Lunch
Humalog 12 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
RX *insulin lispro 100 unit/mL AS DIR Up to 15 Units QID per
sliding scale 12 Units before LNCH; Units QID per sl scale 12
Units before DINR; Units QID per sliding scale Disp #*3 Vial
Refills:*3
RX *insulin syringe-needle U-100 [BD Insulin Syringe Ultra-Fine]
30 gauge X ___ 1 four times a day Disp #*100 Syringe Refills:*1
13. Atorvastatin 20 mg PO QPM
14. Gabapentin 300 mg PO TID:PRN Pain, insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Multifocal pneumonia, likely due to aspiration
Alcohol withdrawal
Hypoglycemia
Hypoxic respiratory failure
Severe mitral regurgitation
Secondary:
Hypertension
Diabetes mellitus type 2
ETOH dependence/Alcohol withdrawal seizures
Hypomagnesemia
Endocarditis
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema or drainage
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with sob tranfer +ett // intbuated transfer
TECHNIQUE: Single frontal view of the chest
COMPARISON: None
FINDINGS:
Enteric tube courses below the diaphragm, out of the field of view.
Endotracheal tube terminates approximately 5 cm above the carina. There are
extensive bilateral pulmonary opacities, with differential diagnosis including
massive aspiration, extensive pneumonia, severe pulmonary edema. Bilateral
pleural effusions are not excluded. No evidence of pneumothorax. Cardiac
silhouette is mildly enlarged. Mediastinal contours are unremarkable.
IMPRESSION:
Enteric tube courses below the diaphragm, out of the field of view.
Endotracheal tube terminates approximately 5 cm above the carina.
Extensive bilateral pulmonary opacities. Differential diagnosis includes
massive aspiration, extensive multifocal pneumonia, severe pulmonary edema.
Associated bilateral pleural effusions not excluded. No prior available for
comparison.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ETOH use, presenting after seizure and
intubation as well as likely aspiration event // eval ETT position,
progression of bilateral opacities
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Pulmonary edema is unchanged. Support lines and tubes are also unchanged.
Bilateral effusions are stable. Cardiomediastinal silhouette is unchanged.
No pneumothorax.
Radiology Report
EXAMINATION: Chest radiograph, portable AP upright.
INDICATION: Intubated patient with mild endotracheal tube displacement.
COMPARISON: Prior day.
FINDINGS:
Endotracheal tube terminates 6 cm above the carina. Orogastric tube can be
followed as far as the lower mediastinum but its course is difficult to follow
after that due to underpenetration. However there is no indication the
displacement is likely to have changed. Heterogeneous multifocal opacities
are very similar in each lung. Left costophrenic angle is partly excluded.
No definite pleural effusion. No visible pneumothorax.
IMPRESSION:
Endotracheal tube terminating about 6 cm above the carina. Poor visualization
of distal course of orogastric tube. Stable extensive pulmonary opacities
most suggestive of severe multifocal pneumonia.
Radiology Report
EXAMINATION: Chest radiograph, portable AP semi-upright.
INDICATION: Right internal jugular central venous catheter placement.
COMPARISON: Prior evening.
FINDINGS:
Right internal jugular catheter terminates in the upper superior vena cava.
There has been no definite change in multifocal pulmonary opacities. No
pneumothorax.
IMPRESSION:
Right internal jugular catheter is new, terminating in the upper superior vena
cava. No other significant change. No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with hypoxic respiratory failure intubated in
FICU with probable aspiration // eval for interval change, pulmonary edema,
effusions, consolidation
IMPRESSION:
In comparison with the study of ___, the monitoring and support devices
are stable. The extensive opacification in the right hemithorax has
decreased, with little overall change in the left hemithorax. In view of the
enlargement of the cardiac silhouette, this change could represent decreasing
pulmonary edema, with the remaining opacification reflecting bilateral areas
of pneumonia.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with RLL pneumonia, AMS, septic shock //
changes? Progress in resolution of pneumonia?
IMPRESSION:
In comparison with the study of ___, the monitoring and support devices
are stable. Cardiomediastinal silhouette is unchanged and the diffuse
bilateral pulmonary opacifications appear more prominent. Again, this most
likely represents combination of substantial pulmonary edema and underlying
areas of consolidation.
Radiology Report
INDICATION: ___ year old man with pneumonia, AMS, septic shock, intubated //
progression of pna?
COMPARISON: Prior radiographs dated ___
IMPRESSION:
Endotracheal tube tip projects 6.7 cm about the level of carina. Cardiac
monitoring leads overlying the chest wall. An enteric tube is projecting over
the distal esophagus. The heart size is unchanged. Right internal jugular
catheter terminates within the proximal superior vena cava. Mildly prominent
interstitial markings suggestive of pulmonary edema, unchanged from prior.
Multifocal consolidative changes with mild interval improvement from prior.
Mild interval improvement in aeration.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with MR, increased congestion at bases //
?worsening pulm edema
IMPRESSION:
It in comparison with the study of ___, the cardiac silhouette is less
prominent and the pulmonary edema has essentially cleared. Hemidiaphragms are
sharply seen consistent with resolved pleural effusion and basilar
atelectasis, though some of this could merely reflect a more upright position
of the patient.
Endotracheal and nasogastric tubes have been removed. Right IJ catheter tip
extends to the upper to mid SVC.
Radiology Report
EXAMINATION: CHEST (PRE-OP AP ONLY)
INDICATION: ___ with severe MR, pre-op // pre-op Surg: ___ (Mitral
valve replacement)
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior chest radiographs most recently ___
FINDINGS:
In comparison with the study of ___, the cardiac silhouette is similar,
mildly enlarged. There is no evidence of pulmonary edema. There is a new
opacity projecting over the left lower lung field, likely atelectasis. Right
internal jugular central line has been removed. There is a 7 mm calcified
granuloma in the left mid lung field.
IMPRESSION:
Right internal jugular central line has been removed. Interval increase in
left basilar atelectasis.
Radiology Report
EXAMINATION: CHEST (PRE-OP PA AND LAT)
INDICATION: ___ year old man with mitral regurg // chf Surg: ___ (MVR)
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
There is no focal consolidation, pleural effusion or pneumothorax. Bibasilar
atelectasis is present. A calcified granuloma in the left upper lung is
unchanged. The size of the cardiomediastinal silhouette is within normal
limits. The bony thorax is grossly intact.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with S/P MVR // fast track extubation, effusion,
pneumothx Contact name: Cardiac surgery PA/NP, Phone: 1
IMPRESSION:
In comparison with the study of ___, there has been a mitral valve
replacement performed with intact midline sternal wires. Endotracheal tube
tip lies approximately 3 cm above the carina. Right IJ Swan-Ganz catheter tip
is in the pulmonary outflow tract. Left chest tube is in place and there is
no evidence of pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p MVrepair // CT removal, eval PNX
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Lungs are low volume with bibasilar atelectasis. The ET tube, NG tube and
Swan-Ganz catheter has been removed. Left-sided chest tube is also been
removed. Trace pneumomediastinum is seen. There is bibasilar atelectasis.
Small bilateral effusions are stable.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man s/p MVR.
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior chest radiographs dating back to ___
with most recent prior study dated ___
FINDINGS:
The sternal cerclage wires are intact. However, the bottom 3 sternal wires
demonstrate leftward displacement, which appears minimally more pronounced
than prior study. Cardiomediastinal silhouette is stable. There is no acute
focal consolidation. No pneumothorax. There is a small left pleural
effusion, unchanged. No pneumothorax.
IMPRESSION:
1. Bottom 3 sternal cerclage wires demonstrate leftward displacement,
minimally more pronounced than prior study. If there is a clinical suspicion
for dehiscence or infection, this should be correlated for clinically.
2. Small left pleural effusion, unchanged.
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Intubated, Transfer
Diagnosed with Acute respiratory failure with hypoxia
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | SUMMARY:
==========
___ is a ___ y/o M w/ PMH of mitral valve endocarditis,
alcohol use disorder with history of alcohol withdrawal seizures
and IDDM2 that was found unresponsive in bed at his home on
___ and brought to ___ for hypoglycemia (BS 45) and
hypoxemia (SpO2 ___, had seizures, required ___
transferred to ___ and admitted to the ___ where he was
treated for septic shock and ARDS. He was extubated and
transferred to medical floor on ___. *** |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with hx of laparoscopic cholecystectomy ___ days (OSH) c/b
cystic duct stump leak s/p interval ERCP with stent placement 4
days ago now presenting with RUQ pain. Patient reports he has
had
symptoms of 'reflux' with epigastric pain for several months and
presented with acute on chronic epigastric/RUQ pain before his
cholecystectomy ___ days ago. He was discharged in the interim
but
developed acute onset of RUQ pain, found to have a 'leak' and
underwent ERCP/stenting 4 days ago. He recovered well from this
procedure and remained afebrile without much pain until today
when he developed return of his RUQ pain. He notes loss in
appetite but denies vomiting; denies jaundice but has noted some
pruritis of his right hemi-abdomen. Denies fevers or chills.
Past Medical History:
PMH:hyperlipidemia, GERD
PSH:laparoscopic cholecystectomy ___ (___), ERCP with stent
placement (___), left knee surgery
___, protonix
Social History:
___
Family History:
Fam Hx:notable for gallstone disease; denies hepatobiliary or GI
malignancy.
Physical Exam:
At admission:
PE: VS:97.8 92 138/83 18 97% 2L Nasal Cannula
___: in no acute distress, but appears tired
HEENT: sclera anicteric, mucus membranes moist, nares clear,
trachea at midline
CV: regular rate, rhythm. No appreciable murmurs, rubs, gallops
Pulm: clear to auscultation bilaterally
Abd: well-healing laparoscopic incisions, stapled. Mild-moderate
tenderness of RUQ/right flank. No overlying skin changes, no
rebound tenderness or guarding
MSK: warm, well perfused
Neuro: alert, oriented to person, place, time
At Discharge
VS: stable, afebrile
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: (-)LAD, mucous membranes moist, trachea midline, EOMI,
PERRL.
CHEST: Clear to auscultation bilaterally, (-) cyanosis.
ABDOMEN: (+/-) BS x 4 quadrants, soft, mildly tender to
palpation incisionally, non-distended. Incisions: clean, dry and
intact, dressed with steristrips s/p staple removal.
EXTREMITIES: Warm, well perfused, pulses palpable, (+/-) edema
Pertinent Results:
___ 01:45PM BLOOD WBC-10.0 RBC-4.91 Hgb-14.0 Hct-40.8
MCV-83 MCH-28.5 MCHC-34.3 RDW-13.5 Plt ___
___ 01:45PM BLOOD Neuts-85.2* Lymphs-8.1* Monos-5.3 Eos-0.9
Baso-0.3
___ 05:37AM BLOOD Lipase-143*
___ 01:45PM BLOOD ALT-163* AST-95* AlkPhos-98 TotBili-0.8
DirBili-0.3 IndBili-0.5
___ 05:37AM BLOOD ALT-105* AST-45* AlkPhos-88 TotBili-0.7
RUQ U/S ___:
1. Persistent mild pneumobilia and fluid collection in
gallbladder fossa, which could represent a biloma or seroma.
Further evaluation with a HIDA scan is recommended.
2. CBD measures 3.6 mm.
HIDA Scan ___:
Prior cholecystectomy, with biliary leak and biloma formation in
the gallbladder fossa. There is also evidence of bile reflux
into the stomach.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 40 mg PO Q12H
2. Simvastatin 40 mg PO QPM
3. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety
Discharge Medications:
1. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety
2. Pantoprazole 40 mg PO Q12H
3. Simvastatin 40 mg PO QPM
4. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*6 Tablet Refills:*0
5. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*9 Tablet Refills:*0
6. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone 2 mg ___ tablet(s) by mouth q4h:prn Disp #*2
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Biliary leak
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ man with billary leak status-post stent and POD10
status-post laparoscopic cholecystectomy; evaluate CBD diameter/intrahepatic
dilatation.
TECHNIQUE: Grey scale, color, and spectral Doppler ultrasound images of the
abdomen were obtained.
COMPARISON: CT abdomen and pelvis from an outside hospital dated earlier
today, ___ at 8:26 am.
FINDINGS:
The hepatic parenchyma is within normal limits without a focal hepatic mass.
The main portal vein is patent with hepatopetal flow. There is no ascites.
There is left pneumobilia, also noted on recent CT. The gallbladder is
surgically absent. A predominately anechoic fluid collection with mild central
echogenic debris is seen within the gallbladder fossa, stable in size from CT
performed earlier today. The CBD measures 3.6 mm. The imaged portion of the
pancreatic body is grossly unremarkable.
IMPRESSION:
1. Persistent mild pneumobilia and fluid collection in gallbladder fossa,
which could represent a biloma or seroma. Further evaluation with a HIDA scan
is recommended.
2. CBD measures 3.6 mm.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, Abd pain
Diagnosed with OTHER SPEC COMPL S/P SURGERY, ABN REACT-PROCEDURE NOS
temperature: 97.8
heartrate: 92.0
resprate: 18.0
o2sat: 97.0
sbp: 138.0
dbp: 83.0
level of pain: 3
level of acuity: 3.0 | ___ s/p open cholecystectmoy at ___ on ___ w/ subsequent
obstruction s/p ERCP with stent placed on ___, admitted here
with persistent biliary leak. Patient was admitted and had a
HIDA scan, which was consistent with a small biliary stump leak.
He was started on cipro/flagyl to complete 5 days of
antibiotics. Fluid collection in gall bladder fossa was stable
and did not require drainage. Patient's pain improved and diet
was advanced as tolerated. Patient as ambulating prior to
discharge. He will follow up with us in surgery clinic given his
desire to transfer care away from ___ and should follow up with
GI at ___ for stent removal. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Nickel / Bactrim
Attending: ___
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Cath on ___
History of Present Illness:
Mr. ___ is a ___ y/o male with CAD s/p stents x2, thoracic
aneurysm s/p grafting, HTN, bilateral RAS, MRSA UTI who presents
with dyspnea.
Patient reports that he first noticed feeling short of breath
about a week ago. He reports no cough, or fevers or chills.
Shortness of breath is worse with exertion, and resolves when he
sits down to rest. He reports no chest pain, neck pain, or arm
pain. However, around 2 days ago he started to have chest
pressure and tightness with his shortness of breath. This also
gets worse with exertion, and resolves with rest. It has lasted
up to a few hours, but most often will last for several minutes
until his shortness of breath is not worse with lying flat. He
does note also a sweating episode when he has a "moment of
panic"
when he was feeling unable to breathe.
Regarding his coronary artery disease, patient reports that he
continues on a statin. However he reports he is not on aspirin
at home due to issues he had with clotting in the past. He has
had 2 stents placed previously.
Regarding his history of incontinence, patient reports that he
has had somewhat increased urinary frequency, but no pain with
urination. Notes he had some bleeding in his urine a few weeks
ago, which is now resolved. He is followed by urology.
On review of records, patient was last hospitalized from ___
through ___ with abdominal pain, and labs concerning for
DIC.
He was seen by hematology and vascular surgery. Ultimately,
patient remained hemodynamically stable with no evidence of
bleeding. He was discharged with heme/onc follow-up. His
fibrinogen at discharge was 99.
He has been followed by vascular surgery for history of
abdominal
aortic aneurysm. He has undergone a TEVAR, open aortobi-iliac
repair with graft and reimplantation of ___ onto graft and also
a
left ___
bypass w GSV. He is followed by Dr. ___ as an outpatient.
Multiple notes also mention a 2.5 cm cerebral aneurysm.
However,
on review of ___ and ___ records, I am
unable to find details about this diagnosis or when it was made.
In the ED:
Initial vital signs were notable for: T 96.5, HR 116, BP
187/119,
RR 24, 88% RA
Exam notable for: Mild bibasilar crackles in lung bases
Labs were notable for:
- CBC: WBC 17.1, hgb 12.8, plt 113
- Lytes:
135 / 102 / 26 AGap=13
-------------- 337
7.4 \ 20 \ 2.1
- repeat K - 4.0
- ___: 12423
- trop 0.08 -> 0.1 -> 0.08
Studies performed include: CXR with opacities at the medial lung
bases are not able to be correlated given lack of lateral. In
the
correct clinical setting, these are concerning for underlying
infection.
Patient was given:
- Vancomycin, CefePIME and flagyll
- 1L NS
- insulin 10u SC
- hydralazine 50mg
- aspirin 81
- Lasix 20mg IV
- amlodipine 10mg
- insulin 2u SC
Vitals on transfer: T 98.8, HR 101, BP 148/89, RR 20, 98% RA
Upon arrival to the floor, patient states he is starting to feel
slightly more short of breath again. He otherwise recounts
history as above.
Past Medical History:
- CAD s/p 2 stents RCA ___
- DVT s/p IVC filter
- Thoracic aneurysm w/ h/o stent graft c/b post-op paresis
- L leg ischemia s/p L ___ graft
- HTN
- Bilat renal artery stenosis
- Urinary retention
- Incontinence
- PTSD
- Brain aneurysm (2.5cm)
- H. pylori
- Thoracic stent graft
- L ___ graft
- Laminectomy w/ fusion for spinal stenosis
Social History:
___
Family History:
Brother ___ - Type II; Hyperlipidemia;
Hypertension; Psych - Depression; Stroke
Father ___ CHF; Diabetes - Type II; Hypertension
Mother ___
Physical ___:
ADMISSION PHYSICAL EXAM
========================
VS: T 98.4F, BP 185/112, HR 94, RR 18, O2 sat 97% RA
GENERAL: Patient appears to be in no apparent distress.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: JVP 6.5 cm above the sternal angle.
CARDIAC: normal S1, S2 without murmurs, rubs, or gallops
LUNGS: clear to auscultation bilaterally
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. Trace pretibial edema
bilaterally.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAM
========================
VITALS: T 98.4, HR 74, BP 108/64, RR 16, 96% 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: Faint crackles at lower lung bases bilaterally
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. No peripheral edema
SKIN: No rashes or ulcerations noted
NEURO: NEURO: CN II-XII intact, ___ strength in all extremities,
sensation intact to light touch in all extremities.
PSYCH: pleasant, appropriate affect
Pertinent Results:
Admission Labs:
___ 03:14AM BLOOD WBC-17.1* RBC-4.58* Hgb-12.8* Hct-41.8
MCV-91 MCH-27.9 MCHC-30.6* RDW-16.6* RDWSD-54.3* Plt ___
___ 03:14AM BLOOD Neuts-88.2* Lymphs-5.6* Monos-5.3
Eos-0.2* Baso-0.3 Im ___ AbsNeut-15.07* AbsLymp-0.95*
AbsMono-0.90* AbsEos-0.04 AbsBaso-0.05
___ 03:14AM BLOOD ___ PTT-21.2* ___
___ 09:30PM BLOOD ___
___ 09:30PM BLOOD Ret Aut-2.4* Abs Ret-0.09
___ 03:14AM BLOOD Glucose-337* UreaN-26* Creat-2.1* Na-135
K-7.4* Cl-102 HCO3-20* AnGap-13
___ 08:48AM BLOOD ALT-85* AST-42* LD(___)-293* AlkPhos-235*
TotBili-0.7
___ 03:14AM BLOOD CK-MB-4 ___
Trop Trend:
___ 03:14AM BLOOD cTropnT-0.08*
___ 08:29AM BLOOD CK-MB-5
___ 08:29AM BLOOD cTropnT-0.10*
___ 02:42PM BLOOD CK-MB-5 cTropnT-0.08*
___ 12:12AM BLOOD CK-MB-3 cTropnT-0.07*
Discharge Labs:
===============
___ 07:43AM BLOOD WBC-10.7* RBC-3.69* Hgb-10.3* Hct-33.2*
MCV-90 MCH-27.9 MCHC-31.0* RDW-16.6* RDWSD-55.1* Plt ___
___ 07:43AM BLOOD Glucose-180* UreaN-36* Creat-2.4* Na-141
K-4.6 Cl-101 HCO3-25 AnGap-15
___ 07:43AM BLOOD Calcium-9.0 Phos-4.6* Mg-2.4
PERINENT MICROBIOLOGY:
___ 8:40 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPH AUREUS COAG +. >100,000 CFU/mL.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- 2 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S
IMAGING:
========
EKG ___:
Rate 69 bpm, PR 202 ms, QRS 122 ms, QTc 540 ms
___ rhythm with sinus arrhythmia
left atrial abnormality
Left axis deviation
Cannot rule out Anteroseptal infarct (cited on or before
___
ST & Marked T wave abnormality, consider inferolateral ischemia
When compared with ECG of ___ 07:44,the HR is slower and
the lateral
___ CXR:
No pulmonary edema. Small bilateral pleural effusions, right
greater than
left have increased since ___. No pneumothorax. Heart
size normal.
Thoracic aorta is extremely tortuous, somewhat dilated,
containing a long
Endograft, and all entirely unchanged since ___.
CTA ___:
1. No evidence of pulmonary embolism.
2. Status post endovascular repair of a descending thoracic
aortic aneurysm
with thoracic stent graft seen in situ. However evaluation of
the descending
thoracic aorta and the abdominal aorta is severely limited as
contrast has not
reached these levels. Further imaging with dedicated CTA of the
thoracic
aorta can be performed if clinically indicated.
3. Small bilateral pleural effusions new since ___.
There is mild
bilateral pulmonary edema.
4. Mediastinal and hilar lymphadenopathy are likely reactive.
Cardiac Cath ___
LM: The Left Main, arising from the left cusp, is a large
caliber vessel. This vessel bifurcates into the
Left Anterior Descending and Left Circumflex systems. There is a
20% stenosis in the proximal and mid
segments.
LAD: The Left Anterior Descending artery, which arises from the
LM, is a large caliber vessel. There is
a 40% stenosis in the proximal/mid segment.
The Septal Perforator, arising from the proximal segment, is a
small caliber vessel.
The Diagonal, arising from the proximal segment, is a medium
caliber vessel. There is a 70% stenosis in
the proximal segment.
The Superior lateral of the Diag, arising from the proximal
segment, is a medium caliber vessel.
Cx: The Circumflex artery, which arises from the LM, is a large
caliber vessel. There is a 30% stenosis
in the proximal and mid segments.
The ___ Obtuse Marginal, arising from the proximal segment, is a
medium caliber vessel.
The ___ Obtuse Marginal, arising from the mid segment, is a
medium caliber vessel.
RCA: The Right Coronary Artery, arising from the right cusp, is
a large caliber vessel. There is a stent
in the ostium and proximal segment. There is a 100% in-stent
restenosis in the ostium. Collaterals from
the distal segment of the SP connect to the distal segment.
The Acute Marginal, arising from the proximal segment, is a
small caliber vessel.
The Right Posterior Descending Artery, arising from the distal
segment, is a medium caliber vessel.
The Right Posterolateral Artery, arising from the distal
segment, is a medium caliber vessel.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. HydrALAZINE 50 mg PO TID
2. MetFORMIN (Glucophage) 500 mg PO BID
3. Atorvastatin 80 mg PO QPM
4. amLODIPine 10 mg PO DAILY
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. CARVedilol 12.5 mg PO BID
3. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
4. Spironolactone 12.5 mg PO DAILY
5. Torsemide 80 mg PO DAILY
6. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of breath
7. amLODIPine 10 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. HydrALAZINE 50 mg PO TID
10. MetFORMIN (Glucophage) 500 mg PO BID
11.Outpatient Lab Work
N17: Acute kidney injury
Please obtain chem-7, calcium, magnesium, phosphorus on ___.
Please fax results to Pt's cardiologist, ___
(___).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
# Acute-on-chronic Heart failure with preserved ejection
fraction exacerbation
# Unstable angina
Secondary:
# Thoracic aneurysm
# Abdominal aortic aneurysm
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 dyspnea// pna
TECHNIQUE: AP portable upright radiograph the chest
COMPARISON: Multiple prior examinations, most recent CTA torso from ___ and most recent chest radiograph from ___
FINDINGS:
There is is increased opacity at the bilateral medial lung bases, which cannot
be correlated given lack of lateral. Overall, these findings are concerning
for possible underlying infection in either lung base. Right pleural spaces
are normal. Left costophrenic angle is obscured, which may represent a small
underlying effusion.
Appearance of the cardiomediastinal silhouette is unchanged compared to
multiple priors with thoracic aortic stent in place.
IMPRESSION:
1. Opacities at the medial lung bases are not able to be correlated given lack
of lateral. In the correct clinical setting, these are concerning for
underlying infection. Obscuration of the left costophrenic angle likely
represents a small effusion. No pneumothorax.
2. Unchanged appearance of the cardiomediastinal silhouette and thoracic
aortic stent.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with dyspnea, tachycardia, chest pressure,
concerning for PE. Unable to do CTA given ___// eval for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is a segment of right common femoral vein which contains echogenic
material and is noncompressible with no residual flow seen, consistent with
occlusive thrombosis. There is normal compressibility, color flow, and
spectral doppler of the right femoral, and popliteal veins. Normal color flow
and compressibility are demonstrated in the posterior tibial and peroneal
veins.
There is normal compressibility, color flow, and spectral doppler of the left
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1. Deep vein thrombosis in the right common femoral vein.
2. No evidence of deep venous thrombosis in the leftlower extremity veins.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
on the telephone on ___ at 1:33 am, within 30 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ year old man with Chest pain, DVT on ___, please eval for
PE// Eval for 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) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.2 mGy (Body) DLP = 1.8
mGy-cm.
2) Stationary Acquisition 10.7 s, 0.2 cm; CTDIvol = 180.5 mGy (Body) DLP =
36.1 mGy-cm.
3) Spiral Acquisition 6.3 s, 40.9 cm; CTDIvol = 5.8 mGy (Body) DLP = 234.7
mGy-cm.
Total DLP (Body) = 273 mGy-cm.
COMPARISON: CTA torso ___.
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus.
Patient is status post endovascular repair of a descending thoracic aortic
aneurysm with thoracic stent graft in situ. However, evaluation is limited as
contrast has not reached the descending aorta. The heart is mildly enlarged.
The pericardium, and great vessels are within normal limits. No pericardial
effusion is seen. Moderate coronary artery calcifications are seen. There is
reflux of contrast into the IVC and hepatic veins.
AXILLA, HILA, AND MEDIASTINUM: No axillary lymphadenopathy is seen. Prominent
AP window lymph node measuring 1.2 cm in short access is similar to prior (6;
123). There are bilateral hilar lymphadenopathy, measuring up to 1.5 cm in
short axis on the left and measuring up to 1.4 cm on the right, increased in
size compared to prior and likely reactive.
PLEURAL SPACES: There are small bilateral pleural effusions. No pneumothorax.
There is loculated fluid within the left major fissure.
LUNGS/AIRWAYS: Interlobular septal thickening with bilateral ground-glass
opacities suggest mild bilateral pulmonary edema. There is bilateral mild
compressive atelectasis of the lower lobes. Mild bilateral bronchial wall
thickening may represent inflammation of the small airways or edema. The
airways are patent to the level of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen demonstrates partially
visualized intra-abdominal aortic aneurysm measuring 5.2 x 6.4 cm at the level
of the celiac axis and measuring 5.2 x 6.3 cm at the level of the renal
arteries, similar to prior no a valuation is limited without contrast
opacification reaching the distal aorta.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Status post endovascular repair of a descending thoracic aortic aneurysm
with thoracic stent graft seen in situ. However evaluation of the descending
thoracic aorta and the abdominal aorta is severely limited as contrast has not
reached these levels. Further imaging with dedicated CTA of the thoracic
aorta can be performed if clinically indicated.
3. Small bilateral pleural effusions new since ___. There is mild
bilateral pulmonary edema.
4. Mediastinal and hilar lymphadenopathy are likely reactive.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with shortness of breath// asses pulmonary edema
TECHNIQUE: AP portable chest radiograph
COMPARISON: CT chest from earlier today
FINDINGS:
A thoracic aortic stent graft is present, unchanged in appearance. The size
of the cardiomediastinal silhouette is unchanged. There is mild pulmonary
edema. Hazy opacities at the right lung base likely reflect layering pleural
fluid. A small left pleural effusion is also present. No pneumothorax.
IMPRESSION:
Mild pulmonary edema as well as small bilateral pleural effusions.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with sudden dyspnea// Flash? Flash?
IMPRESSION:
Compared to chest radiographs ___.
No pulmonary edema. Small bilateral pleural effusions, right greater than
left have increased since ___. No pneumothorax. Heart size normal.
Thoracic aorta is extremely tortuous, somewhat dilated, containing a long
Endograft, and all entirely unchanged since ___.
Gender: M
Race: HISPANIC/LATINO - CUBAN
Arrive by WALK IN
Chief complaint: Dyspnea, Hypoxia
Diagnosed with Pneumonia, unspecified organism
temperature: 96.5
heartrate: 116.0
resprate: 24.0
o2sat: 88.0
sbp: 187.0
dbp: 119.0
level of pain: 4
level of acuity: 1.0 | ___ y/o male with CAD s/p DES x2 to RCA in ___ (___), thoracic
aneurysm s/p grafting TEVAR, s/p infrarenal aorta repair with
aorto right iliac graft, HTN, bilateral RAS, DVT s/p IVC filter,
PVD, CKD, who presented with shortness of breath, transferred to
Cardiology for management of unstable angina and HFpEF
exacerbation.
CORONARIES: 100% in-stent restenosis of RCA, R-L collaterals,
20%
stenosis of pLM, dLM, 40% pLAD, 40% mLAD, 70% pDiag
PUMP: EF 36% (___)
RHYTHM: Sinus tachycardia.
==================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / adhesive tape
Attending: ___.
Chief Complaint:
Chronic abdominal pain
Major Surgical or Invasive Procedure:
___: Ultrasound guided drainage of a 9.4 cm left hepatic
cyst
History of Present Illness:
___ year old female with history of afib on Coumadin, SSS s/p
PPM, COPD/emphysema/interstitial pulmonary fibrosis on O2 at
night, and HTN presents as transfer from ___ with LUQ and
epigastric abdominal pain in the setting of known hepatic cysts.
The patient has had LUQ abdominal pain for about 5 weeks now
which has gotten worse over the past couple of days. She has a
difficult time explaining her pain and when it began. She has
been constipated recently and straining to have a BM. She felt
that left sided abdominal pain worsened when she was straining
to have a BM. She denies any vomiting, has +flatus, and last BM
yesterday. She does have chronic nausea and was scheduled to
have HIDA as an outpatient. She was also scheduled for rib films
due to ongoing RUQ/flank pain. No recent trauma.
She has known liver cysts and had one drained years ago. She
does not recall the situation surrounding that cyst and whether
or not she had any symptoms.
In the ED, initial vitals were: 98.7 84 181/76 18 98% RA
PE: bibasilar crackles, tender to palpation of the epigastrium
and LUQ. otherwise normal except for chronic ___ venous stasis
skin changes and dry MM.
Hepatology was consulted and recommended:
-have images uploaded and formally read by our radiologist to
better characterize cysts and other potential etiologies for
abdominal pain.
-DO NOT ASPIRATE these hepatic cysts yet. Her case will need to
be formally reviewed by hepatology, radiology, and liver surgery
for diagnosis and intervention.
-it is unlikely that she would be an appropriate surgical
candidate given her comorbidities.
-obtain outside medical records
-can admit to medicine, hepatology consult if needed.
Labs at OS___ were normal (Cr 1.0 and GFR 52, INR 2.6). She
destatted and was placed on 2 NC. Labs were significant for trop
<0.01. She received ___nd a ___ to he upper
ebdeoment.
At OSH, CT scan showed:
1. multiple hypodense liver lesions ranging from a few mm to
the largest cyst 10x9x7 cm in the lateral segment of the left
lobe previously measured at 10x8x6. It exerts mass effect in
conjunction with an adjacent splenic cyst upon the stomach,
somewhat increased from prior.
2. CBD distention to 8mm w/o etiology similar to prior
3. main pancreatic duct mildly prominent at 3-4mm in diameter
with elongated tubular cysts in the head and uncitate process of
the pancreas measuring up to 16mm in diameter, unchanged from
prior. Possibly IPMN. 4mm cystic lesion in posterior tail of
pancreas.
4. subtle induration of fat LUQ anterior to spleen, stomach and
Left upper lobe of liver. Trace fluid is seen adjacent to the
anterior periohery of LUL of liver not presents on earlier
study, no surrounding inflammatory changes.
5.normal spleen and bowel with diverticulosis no
diverticulitis.
6.hiatal hernia
On the floor, patient is sleeping comfortably. When awake she
complains of abdominal pain and slight nausea. Had normal BM
yesterday.
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. No recent change in bowel or bladder
habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
Chronic, multi-oragan cystic process of liver, spleen,
pancreas, kidney
Atrial fibrillation on Coumadin
Emphysemia
Hypertension
Sinoatrial node dysfunction
Cardiomyopathy
Macular degeneration
Interstitial lung disease/pulmonary fibrosis of the lung bases
Hearing loss
Social History:
___
Family History:
noncontributory
Physical Exam:
============================
ADMISSION PHYSICAL
============================
Vital Signs: 97.9 194/96 R Lying, repeat 188/76 97 18 94 2L
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
============================
DISCHARGE PHYSICAL
============================
Vital Signs: 97.4 149/77 75 95%RA
General: Alert, oriented, no acute distress, wearing glasses
HEENT: Sclerae anicteric, hearing aids in place
Neck: JVP not elevated
CV: irregular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Velcro-like crackles at the bases bilaterally
Abdomen: +BS, soft, discomfort in LUQ, epigastric area, no
rebound or guarding. small bandage in place at drainage site
which is c/d/i with no surrounding inflammation of the skin
Ext: Warm, discolored with stasis changes in lower ext, no edema
Skin: extensive plaques with thick scale on scalp.
Pertinent Results:
============================
ADMISSION LABS
============================
___ 11:00PM URINE RBC-3* WBC-<1 Bacteri-FEW Yeast-NONE
Epi-<1
___ 11:00PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-40 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 11:00PM URINE Color-Straw Appear-Clear Sp ___
___ 07:12AM BLOOD WBC-10.3* RBC-4.49 Hgb-13.1 Hct-41.2
MCV-92 MCH-29.2 MCHC-31.8* RDW-12.8 RDWSD-43.0 Plt ___
___ 07:12AM BLOOD ___ PTT-68.3* ___
___ 07:12AM BLOOD Glucose-75 UreaN-19 Creat-0.9 Na-138
K-4.5 Cl-98 HCO3-25 AnGap-20
___ 07:12AM BLOOD ALT-16 AST-25 LD(LDH)-222 AlkPhos-110*
TotBili-0.6
___ 07:12AM BLOOD Albumin-3.2* Calcium-8.6 Phos-4.4 Mg-2.0
============================
DISCHARGE LABS
============================
___ 06:25AM BLOOD ___
============================
INTERVAL LABS
============================
___ 07:15AM BLOOD Digoxin-1.5
============================
PROCEDURES
============================
___ Ultrasound guided aspiration of hepatic cyst
Corresponding to the large left hepatic cyst seen on prior CT,
there is a 9.4 cm anechoic structure within the left hepatic
lobe with internal nonvascular septations. Post aspiration
imaging demonstrates collapse of the cavity.
IMPRESSION:
Successful ultrasound-guided aspiration of a 9.4 cm left hepatic
cyst with
collapse of the cavity on post aspiration imaging. 350 cc of
dark non
purulent fluid was aspirated with a sample sent for microbiology
and cytology evaluation.
============================
CYTOLOGY
============================
Hepatic cyst fluid:
NEGATIVE FOR MALIGNANT CELLS.
-Blood and macrophages consistent with cyst contents.
-No cyst lining is present.
============================
MICRO
============================
__________________________________________________________
___ 3:26 pm FLUID,OTHER Source: Hepatic Cyst.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
__________________________________________________________
___ 7:12 am BLOOD CULTURE
Blood Culture, Routine (Pending): no growth at discharge
__________________________________________________________
___ 11:00 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Taztia XT (dilTIAZem HCl) 360 mg oral DAILY
2. bumetanide 1 mg oral DAILY
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. ALPRAZolam 0.25 mg PO TID:PRN anxiety
6. Lunesta (eszopiclone) 2 mg oral QHS:PRN
7. Warfarin 2 mg PO DAILY16
8. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
9. Livalo (pitavastatin) 2 mg oral QHS
10. digoxin 125 mcg oral DAILY
11. Ondansetron Dose is Unknown PO Q8H:PRN dyspepsia, nausea
12. Fexofenadine 180 mg PO DAILY
13. Sotalol 40 mg PO BID
14. lutein 20 mg oral DAILY
15. Bevacizumab (Avastin) unknown IV Q 8 WEEKS to left eye
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
RX *acetaminophen 500 mg ___ tablet(s) by mouth every 8 hours
Disp #*30 Tablet Refills:*0
2. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Please take only if becoming constipation.
RX *polyethylene glycol 3350 [Gavilax] 17 gram/dose 17g
powder(s) by mouth every day Refills:*0
3. Psyllium Powder 1 PKT PO TID constipation
RX *psyllium husk (aspartame) [___] 3.4 gram/5.8 gram 1
powder(s) by mouth three times daily with 8oz of water
Refills:*0
4. ALPRAZolam 0.25 mg PO TID:PRN anxiety
5. Bevacizumab (Avastin) unknown IV Q 8 WEEKS to left eye
6. bumetanide 1 mg oral DAILY
7. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
8. Digoxin 125 mcg oral DAILY
9. Fexofenadine 180 mg PO DAILY
10. Levothyroxine Sodium 50 mcg PO DAILY
11. Livalo (pitavastatin) 2 mg oral QHS
12. Lunesta (eszopiclone) 2 mg oral QHS:PRN
13. lutein 20 mg oral DAILY
14. Omeprazole 20 mg PO DAILY
15. Sotalol 40 mg PO BID
16. Taztia XT (dilTIAZem HCl) 360 mg oral DAILY
17. Warfarin 2 mg PO DAILY16
18.Outpatient Lab Work
INR
ICD10: ___
___
Fax results: Dr. ___ ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: Chronic, multi-organ polycystic process of
unclear etiology.
Secondary diagnosis: atrial fibrillation, fibrotic lung disease,
psoriasis, cardiomyopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Ultrasound-guided aspiration
INDICATION: ___ year old woman with ILD who presents with LUQ pain and is
found to have a large hepatic cyst compressing the stomach. // please drain
hepatic cyst compressing stomach
COMPARISON: Send reference was made to a CT of the abdomen and pelvis
performed on ___ at an outside hospital.
PROCEDURE: Ultrasound-guided aspiration of a large left hepatic cyst.
OPERATORS: Dr. ___, radiology fellow and Dr. ___ , attending
radiologist. Dr. ___ personally supervised the trainee during the
key components of the procedure and reviewed and agree with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the US scan table. Limited
preprocedure ultrasound was performed to localize the collection. Based on
the ultrasound findings an appropriate skin entry site for the aspiration was
chosen. The site was marked. Local anesthesia was administered with 1%
Lidocaine solution.
Using continuous sonographic guidance, 5 ___ catheter was inserted
into the collection. A sample of fluid was aspirated, confirming needle
position within the collection. Approximately 350 cc of dark non purulent
fluid was drained with a sample sent for microbiology and cytology evaluation.
Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
SEDATION: Moderate sedation was not administered. The patient received
intravenous fentanyl.
FINDINGS:
Corresponding to the large left hepatic cyst seen on prior CT, there is a 9.4
cm anechoic structure within the left hepatic lobe with internal nonvascular
septations. Post aspiration imaging demonstrates collapse of the cavity.
IMPRESSION:
Successful ultrasound-guided aspiration of a 9.4 cm left hepatic cyst with
collapse of the cavity on post aspiration imaging. 350 cc of dark non
purulent fluid was aspirated with a sample sent for microbiology and cytology
evaluation.
Gender: F
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: Abd pain, Abnormal CT, Transfer
Diagnosed with Hepatomegaly, not elsewhere classified
temperature: 98.7
heartrate: 84.0
resprate: 18.0
o2sat: 98.0
sbp: 181.0
dbp: 76.0
level of pain: 7
level of acuity: 2.0 | ***TRANSITIONAL ISSUES***
#Patient has a chronic, polycystic process affecting her liver,
spleen, pancreas, and spleen of unclear etiology. ___ need
further workup and drainage procedures depending on her pain
level, goals of care.
#Please assist for follow up with Dr. ___, her GI
doctor in ___. Patient's nephew aware and will reach out
for a follow up appointment.
#CT A/P showing extensive bilateral fibrosis with honeycombing
of the lung bases. Diagnosis may need clarification.
#Patient noted to desat to 88% with ambulation, quickly
recovered with rest, may need to wear oxygen more than just at
night
#Patient is troubled by her psoriasis, consider starting
treatment
#Warfarin follow by Dr. ___ ___, currently 2mg
daily
#Digoxin level 1.5, monitor closely as outpatient may need dose
reduction
#Discharge weight: 44.32kg (euvolemic exam)
#CODE STATUS: DNR/DNI (confirmed ___ with patient)
#CONTACT: ___, nephew ___, ___
___ year old female with history of a chronic, polycystic process
affecting her liver, spleen, pancreas, and spleen of unclear
etiology, afib/SSS s/p PPM on warfarin, fibrosis/honeycombing of
the lung bases on O2 at night who presents as transfer from
___ with chronic, worsening LUQ and epigastric abdominal
pain. Abdominal imaging showed mass effect from these cysts, and
our team believed this explained her chronic abdominal pain.
On ___ she had an uncomplicated ultrasound-guided
aspiration of a 9.4 cm left hepatic cyst with collapse of the
cavity on post aspiration imaging. 350 cc of dark non purulent
fluid. Cytologic evaluation was negative for malignant cells
and no microorganisms were seen on gram stain or culture.
After the procedure her pain had improved, though not
completely. Our team believed this was most likely due to the
multiple cysts that were not drained. We spoke extensively with
the patient regarding the utility of further aspiration
procedures. We noted that is very difficult to determine which
cysts are generating her pain and that the cysts can
re-accumulate fluid. Also explained the risk of infection and
bleeding with each additional procedure. Given that her pain
was "tolerable", she elected to defer any additional procedures
at this time. We told her this can be readdressed as an
outpatient if her pain level changes.
Additionally, patient had diarrhea for ___ days after her
procedure. This was likely related to an overly aggressive
bowel regimen which was started given her presenting complaint
of constipation. She was sent home with a bowel regimen to use
as needed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Lumbar back pain, sciatica
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with HTN, GERD, who s/p L5-S1 hemilaminectomy,
microdiscectomy in ___, who presents with low back pain x 1
day.
Yesterday morning was saudering at work while on hands and knees
and when he went to get on his feet, felt excruciating pain in
his left lower back that radiated all the way down to his calf.
Was barely able to continue working that day, as any movement
and walking exacerbated the pain. Also noticed that his left
foot was numb (since resolved) and that his left leg was weak
and he was limping due to this. Took 15 200mg ibuprofen and 4
tylenol PMs over the course of the day. Eventually went to OSH
ED and was transeferred here since his prior surgery had been
done here.
He sustained a work-related injury ___, with a L5-S1
disk rupture with central annular tear and protrusion of the
nucleus pulposus. He underwent conservative therapy for a number
of years with epidural steroid injections that temporarily
relieved his pain. He underwent a L5-S1 hemilaminectomy,
microdiscectomy by Dr. ___ on ___ without complications.
His pain had completely resolved and was able to go back to work
in ___ and had not been using any pain medication.
In the ED, initial vitals were: 97 62 142/88 16 98% 2L na
MRI spine showed status post left L5-S1 hemilaminectomy and
microdiskectomy with small persistent disc bulge with associated
left greater than right neural foraminal narrowing. No evidence
of spinal canal stenosis or epidural collection.
- The patient was given 1mg IV dilaudid x 3 and 5mg IV Morphine.
Spine consulted in ED. Recommended admission to medicine for
pain control and evaluation in AM by original surgeon Dr. ___.
Vitals prior to transfer were: 8 98.5 86 141/79 18 93% RA
Upon arrival to the floor, He states that the pain is tolerable
when he does not move but any movement is excruciating. Felt
that the morphine in the ED was more effective than the
dilaudid. Also complains of a headache over the course of the
day. Denies urinary or fecal incontinence.
Past Medical History:
___ esophagus
Hypertension
PSH:
Left L5-S1 hemilaminectomy, microdiscectomy ___ by Dr.
___
___
Right wrist surgery for ligamentous repair
Social History:
___
Family History:
Mother with CHF
Physical Exam:
ADMISSION PE:
PHYSICAL EXAM:
Vitals: 97.5 130/80 74 20 98
General: Alert, oriented, uncomfortable appearing
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
GU: No foley
Back: Unable to sit upright due to pain, TTP in paraspinal area
superior to iliac crest
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Sensory deficit along left lateral foot, other wise
intact along rest of left leg and all of right leg. Left leg and
right leg raise causes severe left sciatic pain. Unable to test
___ muscle strength due to pain. CN ___ intact.
DISCHARGE PE:
Vitals: T 97.4, HR 71, RR 20, BP 140/71, 95% RA
General: Alert, oriented, comfortable appearing
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound or guarding
GU: No foley
Back: Unable to sit upright due to pain, TTP in paraspinal area
superior to iliac crest
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Sensory deficit along left lateral foot, other wise
intact along rest of left leg and all of right leg. Left leg and
right leg raise causes severe left sciatic pain. CN ___ intact.
Antalgic gait
Pertinent Results:
Admission Labs:
=================
___ 11:58AM GLUCOSE-110* UREA N-18 CREAT-1.0 SODIUM-140
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-26 ANION GAP-15
___ 11:58AM estGFR-Using this
___ 11:58AM WBC-10.0 RBC-4.64 HGB-14.7 HCT-42.4 MCV-91
MCH-31.7 MCHC-34.7 RDW-11.7 RDWSD-38.9
___ 11:58AM NEUTS-58.4 ___ MONOS-9.7 EOS-3.8
BASOS-0.5 IM ___ AbsNeut-5.82 AbsLymp-2.64 AbsMono-0.97*
AbsEos-0.38 AbsBaso-0.05
___ 11:58AM PLT COUNT-207
Imaging:
MRI
1. Postoperative changes related to interval left L5-S1
microdiscectomy and hemilaminectomy as described. Small fluid
within surgical bed may be
postoperative in nature. No definite enhancing collection
identified.
Recommend clinical correlation and attention on followup
imaging.
2. Suggestion of small granulation tissue at L5-S1 discs midline
dorsal
margin, without spinal canal stenosis, and stable mild to
moderate left neural foraminal stenosis.
3. No definite evidence of cord or cauda equina compression.
4. Stable degenerative changes at L5-S1 levels described.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Quinapril 40 mg PO DAILY
2. Pantoprazole 40 mg PO Q24H
Discharge Medications:
1. Rolling walker
Prog:good. Length of need 13 months
724.3 diagnosis sciatica
2. Pantoprazole 40 mg PO Q24H
3. Quinapril 40 mg PO DAILY
4. Acetaminophen 650 mg PO Q6H:PRN headache
RX *acetaminophen 325 mg 2 tablet(s) by mouth every 6 hours Disp
#*30 Tablet Refills:*0
5. Diazepam 10 mg PO Q6H:PRN back pain
RX *diazepam 10 mg 1 tablet by mouth every 6 hours Disp #*20
Tablet Refills:*0
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*15 Capsule Refills:*0
7. Ibuprofen 600 mg PO Q6H:PRN back pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every 6 hours Disp
#*20 Tablet Refills:*0
8. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN severe pain
if NSAIDS not working
RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours Disp #*20
Tablet Refills:*0
9. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 capsule by mouth twice daily
Disp #*14 Capsule Refills:*0
10. Outpatient Physical Therapy
Diagnosis: Sciatica
ICD-9: 724.3
Discharge Disposition:
Home
Discharge Diagnosis:
L5/S1 radiculopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: MR ___ AND W/O CONTRAST ___ MR SPINE
INDICATION: ___ male status for microdiscectomy on ___, now
with atraumatic lower back pain. Evaluate for spinal cord or nerve root
compression.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging. After the uneventful intravenous administration
of 14 mL of Gadavist contrast agent, sagittal and axial T1 images were then
obtain.
COMPARISON: ___ outside noncontrast lumbar spine MRI.
___ lumbar spine x-ray.
FINDINGS:
For the purposes of numbering, the lowest rib bearing vertebral body was
designated the T12 level.Please note that this method is inappropriate for
surgical planning and that prior to any intervention appropriate levels must
be established.
There is been interval postsurgical change related to patient's noted left
L5-S1 microdiscectomy and hemilaminectomy. Small nonspecific fluid is noted
within the surgical bed without definite enhancing collection.
Vertebral body alignment is preserved. Vertebral body heights are preserved.
A T11 vertebral body hemangioma is noted. There is no marrow signal
abnormality. The visualized portion of the spinal cord is preserved in signal
and caliber. There is stable loss of intervertebral disc height and signal at
L5-S1. There is no paravertebral or paraspinal mass identified and there is
no evidence of infection or neoplasm. The visualized portion of the sacroiliac
joints are preserved.
At T12-L1, L1-2 there is no spinal canal or neural foraminal stenosis.
At L2-3 there is no spinal canal or neural foraminal stenosis.
At L3-4 there is no spinal canal or neural foraminal stenosis.
At L4-5 there is no spinal canal or neural foraminal stenosis.
At L5-S1 there is new small central enhancing soft tissue resulting in minimal
deformation of the ventral thecal sac. Additionally, there is stable small
left paracentral disc bulge. These findings result in stable mild to moderate
left neural foraminal stenosis withno spinal canal stenosis.
IMPRESSION:
1. Postoperative changes related to interval left L5-S1 microdiscectomy and
hemilaminectomy as described. Small fluid within surgical bed may be
postoperative in nature. No definite enhancing collection identified.
Recommend clinical correlation and attention on followup imaging.
2. Suggestion of small granulation tissue at L5-S1 discs midline dorsal
margin, without spinal canal stenosis, and stable mild to moderate left neural
foraminal stenosis.
3. No definite evidence of cord or cauda equina compression.
4. Stable degenerative changes at L5-S1 levels described.
RECOMMENDATION(S): Postoperative changes related to interval left L5-S1
microdiscectomy and hemilaminectomy as described. Small fluid within surgical
bed may be postoperative in nature. No definite enhancing collection
identified. Recommend clinical correlation and attention on followup imaging.
Gender: M
Race: UNKNOWN
Arrive by AMBULANCE
Chief complaint: Back pain, Numbness, Transfer
Diagnosed with LUMBAGO, HYPERTENSION NOS
temperature: 97.0
heartrate: 62.0
resprate: 16.0
o2sat: 98.0
sbp: 142.0
dbp: 88.0
level of pain: 10
level of acuity: 2.0 | ___ s/p L5-S1 hemilaminectomy, microdiscectomy in ___
presenting with acute back pain with positive straight leg raise
with sciatica.
#L5-S1 radiculopathy:
Patient presented with lumbar back pain, radiating down the leg,
MRI findings of herniated nucleus pulposus causing foraminal
narrowing L>R, suggesting that his pain is most likely due to
radiculopathy without evidence of cord compression. Also had
paraspinal muscle tenderness which suggests presence of
concommitant muscle spasm as well. Patient evaluated by spinal
surgery team without recommendation for surgical intervention.
Pain was controlled with IV/PO medication and transitioned
primarily to PO ibuprofen with oxycodone for breakthrough pain.
Valium also used for muscle spasm. Patient evaluated by ___ who
recommended outpatient ___ and rolling walker that were provided.
Patient was discharged with plan for close follow up with PCP
and ___ to evaluate renal function in setting of hypertension
and ibuprofen use. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Penicillins / bee venom (honey bee) / Imitrex
Attending: ___
Chief Complaint:
generalized weakness, malaise
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
The patient is a ___ with hx of depression, PTSD with multiple
suicide attempts in the past, migraines, hypothyroidism, pelvic
floor dysfunction, possible MS here with several weeks of
nonspecific symptoms involving feeling unwell, several days of
intermittently worsened b/l legs more than arm weakness leading
to one fall, and increased b/l arm more than leg weakness today
after ___ exercise stress test.
Patient is not a good historian - She has trouble describing the
timeline and the nature of ___ symptoms, citing ___ poor memory
as the reason for this.
She was first admitted to neurology in ___ with behavioral
changes and impulsive behavior - she was found to have abnormal
appearing FLAIR hyperintensities in anterior right temporal
lobe, left parietal centrum semiovale, left occipital
periventricular white matter. These were of unclear etiology and
she underwent LP with WBC 4, 5; lymphocytic ___, ; RBC 100s
to 4, Protein 64, Glu wnl. Infectious studies were negative,
oligoclonal bands were positive, CSF SPEP was positive. She has
been followed by ___ since that time who is unsure if
she truly has MS. ___ has considered ___ as a diagnosis and
would like to send genetic testing for this before attempting a
trial of treatment with Copaxone.
___ and his fellow mention through the months that - ___
symptoms of gait difficulty and bilateral lower extremity
weakness in the setting of UTI are likely a pseudoflare." or
that these worsened symptoms are "likely attributable to the UTI
and sequellae to this".
Today she reports that she has not felt well since before she
tried ODing on Valium on ___ requiring ___ and psych
admission to ___. There, ___ daily Ativan dose
was decreased, she was taken off valium.
She has continued to feel generalized fatigue, generalized
weakness, intermittent nausea, daily intermittent headaches
since then.
Around ___ days ago, she started having blurry vision in both
eyes (which she has also described intermittently in the past),
b/l leg more than arm weakness that fluctuates throughout the
day leading to one fall 2 days ago. She has baseline back pain
and difficulty with gait right legs more than left. 2 days ago,
she got up at night when she couldn't sleep and ended up falling
due to right more than left leg weakness (she cannot remember
the specifics of ___ fall). She was able to be functional
throughout these last few days, sleeping more than usual, but
driving to, walking to, and attending appointments. She went to
see ___ pain physician today as well as a treadmill stress test.
She was able to walk for the stress test but reports that she
became hot, nauseous, lightheaded while exercising. She had to
stop and take a rest but after she rested, she felt increased
weakness in ___ legs more than arms. She tried to walk to the
bathroom as well as walk back home to ___ car and by report of
echo staff, she had trouble doing this and almost fell twice.
Otherwise, on ROS, she endorses dysuria yesterday.
No fever, chills, myalgias, sore throat, cough, shortness of
breath, abd pain, nausea/vomiting, diarrhea.
On neurologic review of systems, the patient endorses pressure
headache daily headache, numb sensation from mid thigh and down
in bilateral legs, chronic issues with urinary
retention/incontinence from pelvic floor dysfunction.
Denies difficulty with producing or comprehending speech. Denies
loss of vision, diplopia, vertigo, hearing difficulty,
dysarthria, or dysphagia.
Past Medical History:
recurrent UTI-pelvic distress syndrome
hypothyroidism
migraines
allergic rhinitis
Social History:
___
Family History:
MS in ___ Aunt and Father's cousin.
Per ___ - ___ aunt and paternal cousin with muscular
dystrophy. Paternal uncle with parkinsons disease.
Physical Exam:
ADMISSION:
Vitals: 98.3F, HR 87, 122/82, RR 18, 97% on RA
Orthostatic VS
supine
HR 85
123/66
18
97% RA
sitting
HR 89
129/61
18
97% RA
standing
HR 101
114/65
18
97% RA
General: Awake, cooperative, NAD
HEENT: Dry mucous membraines, NC/AT, no scleral icterus noted,
no lesions noted in oropharynx
Neck: Supple, No nuchal rigidity
Abdomen: soft, NT/ND
Extremities: Mild b/l ankle edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history with
some difficulty for detail. Attentive, able to name ___ backward
without difficulty. Language is fluent with intact repetition
and
comprehension. Normal prosody. There were no paraphasic errors.
Pt was able to name both high and low frequency objects. Able
to
read without difficulty. Speech was not dysarthric. Able to
follow both midline and appendicular commands. Pt was able to
register 3 objects and recall ___ at 5 minutes spontaneously,
___
with category cue, ___ with multiple choice. There was no
evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 3 to 2mm and brisk. EOMI without
nystagmus. VFF to confrontation. Visual acuity ___ b/l but she
is not wearing corrective lenses today.
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 bilateral SCM with give way.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, possible slightly increased tone in right
leg. No pronator drift bilaterally - she has a postural
tremulousness in bilateral arms with testing of pronator drift
which appears irregular, fluctuating in intensity, I am unsure
if
this represents physiologic or non-organic tremor.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 4-* 5 5* 5* 5 5-* 5
R 5 ___ ___ 3 5 4+* 5* 5 5-* 5
Thigh ABduction b/l 5*, Thigh ADduction b/l 4*
*She has give way weakness in these muscles - the number
represents the highest degree of strength she provides before
giving way.
-Sensory: Poor sensory witness.
She has patchy decreased light touch in the upper extremities
not
following any particular dermatomal or peripheral nerve
distribution - Decreased light touch and pinprick over:
RUE - dorsum right hand and fingers, circumferential wrist and
forearm, anterior chest.
LUE - dorsum hand and fingers, palm and thumb, circumferential
wrist, anterior chest.
LT and PP intact over lower torso
Decreased LT and PP circumferentially from mid thigh down
involving entirety of both legs.
Cold sensation intact everywhere. Joint proprioception intact to
large and small movements bilaterally. Vibration sense ___
seconds in bilateral big toes.
No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 2
R 2 2 2 3 2
Plantar response was flexor bilaterally.
L ankle jerk slightly brisker than right. +trace crossed
adductor, suprapatellars.
-Coordination: She performs HKS and FNF very slowly but
accurately.
-Gait: Good initiation. She can stand independently but very
slowly with negative Romberg and is able to take around ___
steps
extremely slowly but symmetrically with a normal base. + some
estasia/abasia and leaning/grabbing on bed but no fall. After
standing and walking she feels lightheaded and nauseous.
DISCHARGE
General: Awake, cooperative, NAD
HEENT: moist mucous membranes, NC/AT, no scleral icterus noted
Neck: Supple, No nuchal rigidity
Abdomen: soft, NT/ND
Extremities: Mild b/l ankle edema.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history with
some difficulty for detail. Attentive, able to name ___ backward
without difficulty. Language is fluent with intact repetition
and comprehension. Normal prosody. There were no paraphasic
errors. 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. VFF to confrontation. Repeat visual acuity exam
deferred as she did not bring ___ reading glasses.
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 bilateral SCM with give way.
XII: Tongue protrudes in midline.
-Motor: Normal bulk and tone. No pronator drift bilaterally.
Mild postural
tremor in bilateral arms, fluctuating in intensity, which is
distractible.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 4-* 5 5 4* 5 5-*
5
R 5 ___ ___ 4-* 5 5 5* 5 5-*
5
*with give way weakness in these muscles
-Sensory: patchy decreased light touch in the upper extremities
not following any particular dermatomal or peripheral nerve
distribution.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 2
R 2 2 2 3 2
Plantar response was flexor bilaterally.
L ankle jerk slightly brisker than right. +trace crossed
adductor, suprapatellars.
-Coordination: She performs HKS and FNF without ataxia out of
proportion to exam
-Gait: Good initiation. Can stand independently. Deferred
further evaluation given inpending ___ assessment.
Pertinent Results:
___ 11:04PM BLOOD WBC-6.4 RBC-5.14 Hgb-13.2 Hct-41.2
MCV-80* MCH-25.7* MCHC-32.0 RDW-14.0 RDWSD-40.7 Plt ___
___ 11:04PM BLOOD Neuts-62.4 ___ Monos-7.2 Eos-2.2
Baso-0.9 Im ___ AbsNeut-3.98 AbsLymp-1.71 AbsMono-0.46
AbsEos-0.14 AbsBaso-0.06
___ 11:04PM BLOOD Glucose-96 UreaN-17 Creat-1.0 Na-138
K-3.1* Cl-102 HCO3-22 AnGap-17
___ 12:16PM BLOOD ALT-14 AST-15 AlkPhos-74 TotBili-0.3
___ 11:04PM BLOOD Calcium-9.2 Phos-2.6* Mg-2.1
___ 12:16PM BLOOD FSH-14* LH-13 Prolact-8.3
___ 12:16PM BLOOD Free T4-1.1
___ 12:16PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-POS*
Barbitr-NEG Tricycl-NEG
___ 01:13PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:13PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:13PM URINE COLOR-Straw APPEAR-Clear SP ___
Urine culture pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Cyclobenzaprine 5 mg PO DAILY:PRN back pain
2. Furosemide ___ mg PO DAILY
3. LamoTRIgine 100 mg PO QHS
4. Levothyroxine Sodium 150 mcg PO DAILY
5. LORazepam 1 mg PO QHS
6. LORazepam 0.5 mg PO BID:PRN anxiety
7. Potassium Chloride 20 mEq PO DAILY
8. rizatriptan 10 mg oral DAILY:PRN
9. Sertraline 200 mg PO DAILY
10. Topiramate (Topamax) 75 mg PO DAILY
Discharge Medications:
1. Cefpodoxime Proxetil 100 mg PO Q12H Duration: 4 Days
RX *cefpodoxime 100 mg 1 tablet(s) by mouth twice daily Disp #*8
Tablet Refills:*0
2. Cyclobenzaprine 5 mg PO DAILY:PRN back pain
3. Furosemide ___ mg PO DAILY
4. LamoTRIgine 100 mg PO QHS
5. Levothyroxine Sodium 150 mcg PO DAILY
6. LORazepam 1 mg PO QHS
7. LORazepam 0.5 mg PO BID:PRN anxiety
8. Potassium Chloride 20 mEq PO DAILY
9. rizatriptan 10 mg oral DAILY:PRN
10. Sertraline 200 mg PO DAILY
11. Topiramate (Topamax) 75 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Generalized weakness
Urinary tract infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with possible RRMS here with b/l leg weakness
and sensory change with functional overlay on exam. Evaluate for new lesions
with bilateral right more than left leg weakness.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 12 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: Multiple prior Brain MRI, most recent ___ and most
remotely ___
FINDINGS:
Previously noted confluent FLAIR signal hyperintensity in the left parietal
central semiovale extending inferiorly along the periventricular white matter
has slightly decreased in size. Previously noted hyperintense FLAIR signal.
Periventricular and subcortical white matter of the right anterior temporal
lobe is stable. These areas do not show slow diffusion or enhancement. There
is no new region of abnormal T2/FLAIR signal. A small enhancing mildly
T2/FLAIR hyperintense lesion in the central pons is unchanged dating back to
at least ___ (102:40). There is no new enhancing mass or mass
effect. The ventricles are stable and age-appropriate. There is no evidence
of hemorrhage, edema, midline shift or infarction. A possible sub cm
hypointense lesion in the pituitary is unchanged (100:87). Major intracranial
vascular flow voids are preserved.
IMPRESSION:
1. Previously seen confluent FLAIR signal hyperintensity in the left parietal
central semiovale extending inferiorly along the periventricular white matter
is slightly less conspicuous and does not show enhancement or slow diffusion.
2. Stable appearance of white matter FLAIR hyperintensity in the right
anterior temporal lobe without enhancement or slow diffusion.
3. No new enhancing lesions or areas of T2/FLAIR signal abnormality. No
hemorrhage or acute infarction.
4. A small enhancing lesion in the central pons is unchanged dating back to
at least ___.
5. Possible sub cm hypointense lesion in the pituitary gland is unchanged.
Radiology Report
EXAMINATION: MRI CERVICAL, THORACIC, AND LUMBAR PT22 MR SPINE
INDICATION: ___ year old woman with possible RRMS here with b/l leg weakness
and sensory change with functional overlay on exam. evaluate fornew lesions
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 imaging was performed. Axial GRE images of the cervical spine were
performed. After the uneventful administration of 12 mL of Gadavist contrast
agent, additional axial and sagittal T1 images were obtained.
COMPARISON: Thoracolumbar spine MRI dated ___ and cervical spine MRI
dated ___
FINDINGS:
CERVICAL:
Vertebral body heights and alignment are preserved.There is no bone marrow
signal abnormality. The spinal cord appears normal in caliber and
configuration. Multilevel degenerative changes in the cervical spine are mild
and worst at C5-6 and C6-7 where mild disc bulges result in minimal spinal
canal narrowing. There is also up to moderate neural foraminal narrowing on
the right at these levels. There is no abnormal enhancement.
THORACIC:
Vertebral body heights and alignment are preserved. There is no bone marrow
signal abnormality. The spinal cord appears normal in caliber and
configuration. Conus medullaris terminates at L1-2. Degenerative changes are
mild and there is no evidence of spinal canal or neural foraminal narrowing.
There is no evidence of infection or neoplasm. There is no abnormal
enhancement after contrast administration.
OTHER: Partially imaged lobulated enhancing T2 hyperintense lesion in the
right lobe of the liver is incompletely characterized on the current study,
but likely corresponds to the circumscribed hyperechoic mass seen on the
abdominal ultrasound of ___ and likely represents a hemangioma
(13:16).
IMPRESSION:
1. No abnormal T2 signal or enhancement in the cervical and thoracic spinal
cord or evidence of cord compression.
2. Mild multilevel degenerative changes in the cervical and thoracic spine as
described above without high-grade spinal canal or neural foraminal narrowing.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: B Leg weakness
Diagnosed with Urinary tract infection, site not specified
temperature: 98.3
heartrate: 87.0
resprate: 18.0
o2sat: 97.0
sbp: 122.0
dbp: 82.0
level of pain: 0
level of acuity: 3.0 | Patient presented with somewhat unclear, vague complaints of
generalized, symmetric weakness, with the legs more prominent
than the arms. For further evaluation, she had a metabolic and
infectious workup that revealed grossly positive UA, in the
context of dysuria and recent treatment courses for UTI with
CIprofloxacin. She was started on Ceftriaxone and discharged to
complete 5 day course with Cefpodoxime, given the recent Cipro
course with persistent symptoms. Repeat urine culture was
pending at the time of discharge. Given ___ increasing
disability and exacerbation of symptoms, it is possible that
this could represent a mild flare of MS. ___ pan-spine and
brain MRI did not reveal any new lesions. ___ examination
slightly improved on the morning following admission. She was
able to stand and walk without assistance. On day of discharge,
she also had ___ evaluation who determined patient was safe for
discharge home, with plans to resume ___ baseline ___ services.
She was also given a prescription for walker per ___
recommendations. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Phenothiazines / Lithium / Betadine Viscous Gauze / Morphine /
Dilaudid / Depakote / ketorolac / Ludiomil / Maprotiline /
trazodone / red and green dye / Ergotamine / Mylan brand patches
/ NSAIDS (Non-Steroidal Anti-Inflammatory Drug) /
povidone-iodine
Attending: ___.
Chief Complaint:
Post-op fevers, s/p fall
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
The patient is a ___ woman with PMHx notable for
anxiety, depression, chronic neck pain s/p C4-C5 laminectomy and
C2-C6 fusion on ___ who presented from rehab s/p falling and
hitting her head at ___. She had been having fevers.
It was assumed secondary to UTI, even though negative U/A and
negative urine culture, and was started on cipro. Her only other
new symtom was been abd pain, though she had been moving her
bowels. According to ___, the patient was febrile to
100.3 on admission, and reached 100.6 on the evening of ___,
for which she was sent to the ED.
In the ED initial vitals were: 99.6, 90, 121/72, 16, 99%RA. Labs
were unremarkable. Imaging was notable for CXR with post
operative ileus, CT head anc C-spine without acute change. The
patient was not given any medications and was admitted to
medicine for fever workup.
Past Medical History:
Depression/anxiety
Chronic neck and low back pain
s/p Iliotibial band release
Social History:
___
Family History:
Mother with ALS.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals - T: 99.8 BP:120/70 HR:94 RR:18 02 sat:99%RA
GENERAL: NAD, laying in bed with c-collar in place.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: nontender supple neck, no LAD
CARDIAC: RRR, S1/S2, no murmurs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
=======================
VS: Tm: 99.0, Tc 98.0, BP: 104-136/64-95, P: 79-105, R: 18, O2:
96-100% RA, bladder scan revealed >1L -> straight cathed for
800cc.
GENERAL: NAD, laying in bed with c-collar in place.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: nontender, supple neck, no LAD, stapled wound on back of
neck without overt signs of infection.
CARDIAC: RRR, S1/S2, no murmurs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: Alert and oriented, CN II-XII intact, no gross motor or
sensory deficits.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
==============
___ 11:00PM BLOOD WBC-6.3# RBC-3.26* Hgb-10.4* Hct-31.8*
MCV-98 MCH-31.9 MCHC-32.7 RDW-14.8 Plt ___
___ 11:00PM BLOOD Neuts-64.0 ___ Monos-8.8 Eos-1.7
Baso-0.3
___ 11:00PM BLOOD Glucose-108* UreaN-7 Creat-0.4 Na-139
K-3.9 Cl-105 HCO3-23 AnGap-15
___ 11:00PM BLOOD Calcium-8.8 Phos-3.6# Mg-2.0
NOTABLE LABS
============
___ 04:19AM URINE Color-Yellow Appear-Clear Sp ___
___ 04:19AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 04:19AM URINE RBC-2 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
___ 04:19AM URINE Mucous-OCC
___ 07:25AM BLOOD TSH-PND
___ 07:25AM BLOOD T4-PND
DISCHARGE LABS
==============
___ 08:34AM BLOOD WBC-4.4 RBC-3.41* Hgb-10.8* Hct-33.5*
MCV-98 MCH-31.8 MCHC-32.4 RDW-15.0 Plt ___
___ 08:34AM BLOOD Glucose-104* UreaN-7 Creat-0.5 Na-137
K-3.5 Cl-102 HCO3-26 AnGap-13
___ 08:34AM BLOOD Calcium-9.5 Phos-4.6* Mg-2.0
___ 08:34AM BLOOD ___
MICRO
=====
URINE CULTURE (Final ___: NO GROWTH.
Blood cultures pending.
STUDIES
=======
CXR ___
No acute cardiopulmonary process. Dilated bowel loops likely
related to ileus.
CT Head without contrast ___
No evidence of acute intracranial abnormalities.
CT C-spine without contrast ___
1. No fracture.
2. Unchanged mild retrolisthesis at C4-5 and C5-6.
3. Status post recent laminectomies at C4 and C5 and
instrumented posterior fusion of C2 through C6 without evidence
for hardware-related complications. Hyperdensity in the
laminectomy beds may represent streak artifact from hardware,
but postsurgical hematoma is not excluded. The spinal canal at
postsurgical levels is obscured by hardware-related artifacts,
but could be assessed by MRI if clinically warranted.
4. Mild prevertebral soft tissue edema could be related to
recent surgery, but MRI would be more sensitive for ligamentous
or other soft tissue injury, if clinically warranted.
5. Nonspecific ground-glass opacities at the visualized lung
apices,
compatible with atelectasis but not fully assessed.
ECG: Sinus rhythm. Small Q waves in leads II, III, and aVF of
unknown significance. Otherwise, no significant change compared
to the previous tracing of ___.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ? PNA
TECHNIQUE: Chest AP and Lateral
FINDINGS:
AP and lateral views of the chest are provided. They demonstrate lungs that
are clear. There is no pneumothorax. There is no evidence of pneumonia.
Trachea is midline. Cardiac silhouette is within normal limits. No pleural
effusion. Below the abdomen several distended loops of bowel are noted,
perhaps related to an ileus given that the patient is status post orthopedic
neck surgery.
IMPRESSION:
No acute cardiopulmonary process. Dilated bowel loops likely related to ileus.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with PARALYTIC ILEUS, ABN REACT-PROCEDURE NOS, FEVER, UNSPECIFIED
temperature: 99.6
heartrate: 90.0
resprate: 16.0
o2sat: 99.0
sbp: 121.0
dbp: 72.0
level of pain: 7
level of acuity: 3.0 | ___ year old woman with PMHx notable for anxiety, depression,
chronic neck pain s/p C4-C5 laminectomy and C2-C6 fusion on
___ who presented from rehab s/p falling and hitting her
head at ___ today and was admitted for work up of
post-op fevers.
ACUTE ISSUES
============
# Post Op Fevers: The patient is s/p C4-C5 laminectomy and C2-C6
fusion on ___ with fevers that were present post op
according to the patient. Pt was placed on PO cipro prior to
discharge despite having a negative U/A and urine culture with
no growth. She presented to Rehab where she continued to be
febrile with the highest documented fever of 100.6. In the ED,
she had a mild temperature of 99.8. She had no signs of
infection on exam and no WBC count. On the floor, the patient
reported feeling well other than pain in her neck. She denied
any shortness of breath, pain with breathing, dysuria or
increased urinary frequency, pain or swelling in her legs. The
ciprofloxicin was stopped, and Tylenol was discontinued to
monitor the fever curve. No fevers occurred. A UA and urine
culture was negative. Neurosurgery inspected the wound and
reported that the wound was not infected. As no source of
infection could be identified and the patient had no shortness
of breath/chest pain, the most likely cause of the
post-operative fever is atelectasis. The patient was given
incentive spirometry and had no recurrence of fevers since
admission. She will be discharged to ___, where she
will continue to receive physical therapy and pain management.
# Urinary retention: Likely related to opiate and other
medications including cyclobenzaprine and amitriptyline. She was
bladder scanned for >1000cc on two different occasions and was
emptied with a straight catheter. Given the failure of the
urinary retention to resolve, a Foley catheter was placed, which
should remain in place for ___ days.
# C4-C5 laminectomy and C2-C6 fusion: She achieved adequate pain
relief from morphine ___ q6h prn. Neurosurgery recommended
that the patient stay in a hard c-collar for 6 weeks or until
cleared at her appointment with Dr. ___.
# Post-op ileus: The patient was discharged with post-op ileus,
and she has been taking a large number of bowel meds at rehab
(8x daily miralax). She has been passing gas, having bowel
movements, and is eating. As she returns to rehab, the goal
should be to decrease pain medications as tolerated and to
continue the aggressive bowel regimen.
#s/p fall: per patient report, her "legs gave out" while
walking. The cause of her fall is likely multifactorial, but
medication effect may play a significant role. Would benefit
from medication reduction in the future.
CHRONIC ISSUES
==============
# Depression: continued home antidepressants
# Anxiety: Continued home medications
TRANSITIONAL ISSUES
===================
# Neurosurgery noted that the patient should remain in a hard
c-collar for 6 weeks after the procedure or until her Dr.
___ her.
# A Foley catheter was placed ___ due to urinary retention >1L.
The Foley should stay in for 3 days and then a voiding trial
should be conducted.
# Please consider decreasing pain medications as tolerated in
the setting of postoperative ileus. Presently, the patient
requires a very aggressive bowel regmen to have bowel movements.
# The patient and her PCP should review her medication list in
detail. In particular, she remains on two benzodiazepines, and
she is also on cyclobenzaprine and amitriptyline, which can
cause urinary retention. She may benefit from a reduction in the
number of medications she is taking.
# Code: confrimed full
# Emergency Contact: ___ (son), phone number:
___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Nifedipine / Verapamil Hcl / Morphine / Codeine / Percocet /
Dilaudid (PF) / Optiray 350 / Nsaids / Iodine-Iodine Containing
/ Fish Product Derivatives / Bactrim / doxycycline /
ciprofloxacin
Attending: ___
Chief Complaint:
Abdominal Pain, Nausea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old woman with secondary sclerosing
cholangitis due to biliary strictures, recurrent mpancreatitis,
whipple surgery, surgical revision, redo Roux-En-Y
hepaticojejunostomy in ___ and suppressive antibiotics who is
being admitted for acute on chronic cholangitis.
Ms. ___ has been on suppressive abx for chronic cholangitis
until about a month ago when she presented to outpatient clinic
with LUQ pain and her suppressive augmentin was increased from
500mg BID to ___ BID while awaiting MRCP. She experienced
minor
improvement in her symptoms, and a subsequent MRCP on ___
demonstrated acute on chronic cholangitis. On presentation to ___
clinic today, her pain had significant worsened and she had
progressed to being intolerant of all solid foods and now
liquids. She has significant experience with her disease and
knew
that this was out of the normal range of symptoms that she
experiences.
ROS positive for chills, looser bowel movements but no fevers,
no
chest pain, dyspnea, hematochezia.
EMERGENCY DEPARTMENT COURSE
Exam notable for:
- General: pleasant, leaning-over in pain
- Cardiac: RRR
- Pulm: CTAB
- Abd: soft, LUQ TTP to palpation with voluntary guarding
- Extremities: WWP, 2+ pulses
Labs were notable for:
- LFTs, WBC normal
Patient was given:
- Pip-Tazo 4.5g
- Hydrocodone-acetaminophen
- LR 1L
- Ondansetron 4mg
Consults:
- Hepatology
Vital signs prior to transfer:
- T 97.8, HR 82, BP 175/93, RR 18, O2 98% RA
Upon arrival to the floor:
- She reports feel significant improvement in pain after Vicodin
and Zofran.
=================
REVIEW OF SYSTEMS
=================
Complete ROS obtained and is otherwise negative.
Past Medical History:
- Secondary sclerosing cholangitis due to biliary strictures
- Recurrent pancreatitis
- Cholecystectomy
- ___ Whipple operation for recurrent pancreatitis, c/b biliary
stricutres
- ___ surgical revision
- ___ Redo Roux-En-Y hepaticojejunostomy
- Grade I varices on EGD (___)
Social History:
___
Family History:
- Mother with HTN, COPD, lung CA, bladder CA
- Father with alcohol use disorder
- Brother has pancreas disease
Physical Exam:
=======================
ADMISSION PHYSICAL EXAM
=======================
VITALS: T:97.7, BP:160/85, HR:57, RR:18, O2:98RA
GENERAL: Tired but well appearing, lying in bed
HEENT: Pupils equal and reactive, no scleral icterus, moist
mucous membranes
CARDIAC: S1/S2 regular with no murmurs, rubs or S3/S4
LUNGS: Clear bilaterally, somewhat diminished at R lung base
BACK: No CVA tenderness
ABDOMEN: Multiple healed abdominal scars. Non-distended. Bowel
sounds present. Tenderness to palpation diffusely, most in LUQ.
No rebound tenderness. No guarding.
EXTREMITIES: No lower extremity edema. Warm extremities.
SKIN: Warm and dry.
NEUROLOGIC: A+Ox3.
=======================
DISCHARGE PHYSICAL EXAM
=======================
Pertinent Results:
ADMISSION LABS
===============
___ 04:54PM BLOOD WBC-6.0 RBC-4.35 Hgb-12.8 Hct-40.8 MCV-94
MCH-29.4 MCHC-31.4* RDW-12.5 RDWSD-42.9 Plt ___
___ 04:54PM BLOOD Glucose-105* UreaN-6 Creat-0.8 Na-142
K-4.5 Cl-104 HCO3-26 AnGap-12
___ 04:54PM BLOOD ALT-23 AST-27 AlkPhos-91 TotBili-0.3
___ 04:54PM BLOOD Lipase-13
___ 12:03AM BLOOD hsCRP-1.5
___ 06:04AM BLOOD Calcium-9.1 Phos-3.4 Mg-1.9
___ 06:04AM BLOOD CRP-1.5
DISCHARGE LABS
===============
___ 06:11AM BLOOD WBC-4.3 RBC-3.90 Hgb-11.4 Hct-35.9 MCV-92
MCH-29.2 MCHC-31.8* RDW-12.8 RDWSD-42.9 Plt ___
___ 06:11AM BLOOD Glucose-98 UreaN-5* Creat-0.7 Na-146
K-4.0 Cl-108 HCO3-25 AnGap-13
___ 06:02AM BLOOD ALT-19 AST-25 AlkPhos-73 TotBili-0.2
___ 06:11AM BLOOD Calcium-8.8 Phos-3.2 Mg-2.0
IMAGING/STUDIES
================
___ RUQUS
IMPRESSION:
1. Coarsened nodular hepatic parenchyma in keeping with history
of secondary sclerosing cholangitis.
2. No evidence of an intrahepatic abscess.
3. Mild pneumobilia, similar to prior.
4. Patent hepatic vasculature.
___ MRCP
IMPRESSION:
Stable examination when compared with the recent prior study
with very mild acute on chronic cholangitis involving posterior
aspect of segment VI and mild chronic cholangitis involving
anterior aspect of segment II. No hepatic abscess or
microabscess.
___ CXR
IMPRESSION:
Interval placement of right chest PICC line terminates at the
upper SVC.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
2. estradiol 0.01 % (0.1 mg/gram) vaginal DAILY:PRN
3. Estring (estradiol) 10 mcg vaginal 2X
4. HYDROcodone-Acetaminophen (5mg-325mg) 2 TAB PO Q8H:PRN Pain -
Moderate
5. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
6. metaxalone 800 mg oral BID:PRN Neck pain
7. Ranitidine 150 mg PO BID
8. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
9. Cal-Citrate (calcium citrate-vitamin D2) 250-200 mg oral BID
10. Vitamin D 1000 UNIT PO DAILY
11. Lactobacillus acidophilus oral DAILY
12. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Medications:
1. CefTRIAXone 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 g IV once a
day Disp #*11 Intravenous Bag Refills:*0
2. MetroNIDAZOLE 500 mg IV Q8H
RX *metronidazole in NaCl (iso-os) [Metro I.V.] 500 mg/100 mL
500 mg IV every eight (8) hours Disp #*11 Intravenous Bag
Refills:*0
3. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
4. Cal-Citrate (calcium citrate-vitamin D2) 250-200 mg oral BID
5. estradiol 0.01 % (0.1 mg/gram) vaginal DAILY:PRN
6. Estring (estradiol) 10 mcg vaginal 2X
7. HYDROcodone-Acetaminophen (5mg-325mg) 2 TAB PO Q8H:PRN Pain
- Moderate
8. Lactobacillus acidophilus 1 tab oral DAILY
9. Lansoprazole Oral Disintegrating Tab 30 mg PO BID
10. metaxalone 800 mg oral BID:PRN Neck pain
11. Multivitamins W/minerals 1 TAB PO DAILY
12. Ranitidine 150 mg PO BID
13. Vitamin D 1000 UNIT PO DAILY
14. HELD- Amoxicillin-Clavulanic Acid ___ mg PO Q12H This
medication was held. Do not restart Amoxicillin-Clavulanic Acid
until Dr. ___ you to
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
==================
Secondary sclerosing cholangitis due to biliary strictures
SECONDARY DIAGNOSES
=====================
Recurrent pancreatitis
Chronic suppressive antibiotic therapy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old woman with secondary sclerosing cholangitis due to
biliary strictures, recurrent pancreatitis, whipple surgery, surgical
revision, redo Roux-En-Y hepaticojejunostomy in ___ on suppressive
antibiotics whopresents with worsening abdominal pain, inability to tolerate
PO consistent with acute on chronic cholangitis. Has hx of microabscess, on
chronic antibiotic suppression.// eval for microabscesses, acute cholangitis
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 7 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: MRCPs dated ___ and ___.
FINDINGS:
Lower Thorax: There is no pleural or pericardial effusion.
Liver: Slightly nodular contour to the liver without underlying steatosis is
unchanged. Scattered hepatic cysts, the largest in segment VII adjacent to
the diaphragm, are unchanged. There is no suspicious liver lesion. There is
no hepatic abscess. The portal and hepatic veins are patent.
Biliary: Patient is status post Whipple procedure with hepaticojejunostomy,
similar to the prior study, there is mild irregularity of the intrahepatic
biliary ducts with subtle heterogeneous peribiliary hepatic parenchymal
enhancement involving segment VI, where there is an unchanged mildly dilated
bile duct (___), and segment II, where there is an unchanged mildly
dilated bile duct (___). Findings are unchanged from the prior study
without evidence of new or worsening inflammatory changes.
Pancreas: Patient is status post Whipple procedure. The remaining pancreas is
normal in signal intensity in morphology. Millimetric cystic lesions are
unchanged and can be followed on subsequent surveillance imaging. Small fluid
collection adjacent to the pancreatic anastomosis is unchanged from multiple
prior studies.
Spleen: Normal in size without focal lesion.
Adrenal Glands: Unremarkable.
Kidneys: No suspicious lesion or hydronephrosis.
Gastrointestinal Tract: Visualized loops of large and small bowel are
unremarkable.
Lymph Nodes: There is no suspicious adenopathy.
Vasculature: Unremarkable.
Osseous and Soft Tissue Structures: Suspicious osseous lesion.
IMPRESSION:
Stable examination when compared with the recent prior study with very mild
acute on chronic cholangitis involving posterior aspect of segment VI and mild
chronic cholangitis involving anterior aspect of segment II. No hepatic
abscess or microabscess.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with new PICC needs tip confirmation// New Rt.
Brachial Dl ___. 33 cm. Power PICC ___ ___ Contact name: ___: ___
TECHNIQUE: Portable chest AP upright
COMPARISON: Chest radiograph from ___.
FINDINGS:
Interval placement of right chest PICC line terminates in the upper SVC.
There is no evidence of focal consolidation or pulmonary edema. No pleural
abnormality. Cardiac silhouette is normal.
IMPRESSION:
Interval placement of right chest PICC line terminates in the upper SVC.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Nausea
Diagnosed with Other cholangitis, Left upper quadrant pain
temperature: 98.0
heartrate: 67.0
resprate: 18.0
o2sat: 96.0
sbp: 151.0
dbp: 79.0
level of pain: 8
level of acuity: 3.0 | Ms. ___ is a ___ year old woman with secondary sclerosing
cholangitis due to biliary strictures, recurrent pancreatitis,
whipple surgery, surgical revision, redo Roux-En-Y
hepaticojejunostomy in ___ and suppressive antibiotics who
presented with worsening abdominal pain, inability to tolerate
PO consistent with acute on chronic cholangitis. Patient was
started on IV antibiotics (D1: ___- planned end ___
TRANSITIONAL ISSUES
===================
[] Should complete 2 weeks of IV antibiotics (D14: ___-
subsequent supporession choice/course will be determined by
patient's outpatient ID doctor (___).
ACUTE ISSUES
============
#Acute on chronic cholangitis
Patient has a history of chronic cholangitis and recurrent
pancreatitis managed on suppressive augmentin. She has recently
experienced worsening symptoms of abdominal pain, nausea, and
inability to tolerate PO. She was initially managed outpatient
with increased doses of her chronic augmentin but her symptoms
did not resolve. She was referred to the ED where she underwent
RUQ U/S without abscess. She was started on Zosyn and then
transitioned to CTX/flagyl (D1: ___. She underwent MRCP ___
which showed stable mild acute on chronic cholangitis without
evidence of abscess. Plan for 2 weeks of ceftriaxone 2 gm q24H +
metronidazole 500 mg q8H ending ___ she will have ID follow up
at that time to determine further course.
==============
CHRONIC ISSUES
==============
#Roux-En-Y Bypass
Continued home Lansoprazole 30mg ___ ___ 150mg BID,
Calcium citrate-Vit D (250-200) BID, Cholecalciferol 1000u
daily, Lactobacillus, and Multivitamin-minerals-lutein
CORE MEASURES
=============
#CODE: Full, confirmed
#CONTACT: ___, husband, ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
sore throat
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a recent diagnosis of mono p/w worsening sore throat
and difficulty swallowing. In ___ to ___ she
developed sore throat with low grade fevers and night sweats.
She was tested for strep and mono and was told that testing (at
her college) was negative for both. She was given clindamycin
and her sore throat and fevers resolved from this acute episode.
She maybe had 5 episodes of sore throats lasting two days each
up until recently. Her night sweats have continued since that
time although have not been accompanied by weight loss.
Two weeks ago she developed fevers > 101 associated with throat
swelling before her school semester ended. She came home and
was seen in primary care on ___ where she had a positive
monospot test and negative rapid strep and strep culture. She
was given motrin and tylenol symptomatically and her sore throat
has significantly worsened since that time and she developed a
cough occasionally productive of sputum. She noted that it is
now painful to swallow solids and liquids with the pain in the
upper throat immediately upon swallowing. She returned to
clinic on ___ for these worsening symptoms
A repeat strep culture was sent showing light growth of beta
hemolytic strep. She was written for oral PCN but did only took
one dose because she did not believe the diagnosis. She also
received pain medications to help with her throat discomfort.
She has tried percocet which she felt was not effective for a
significant amount of time after she took it as well as vicodin
which had a similar lack of efficacy. She was given plain
oxycodone which she felt made her too sleepy to take. She has
decreased her PO intake eating only a pancake yesterday. The
night prior to presentation her mother heard a ___ breathing
noise that would occur overnight and the patient reported she
was in severe pain and very anxious so she was brought to the
emergency room. Her family had reported to the ED that her
voice was softer but the patient states her voice was normal
during my interview.
In the ED, initial vitals were: 103.2 119 132/79 20 99% RA. She
was given tylenol, ketoralac, and dexamethasone in the ED. She
was observed and found to have a normal voice with patent airway
and significantly enlarged tonsils. She was reported to have a
significant snoring overnight but no stridor reported. She was
admitted for hydration, ongoing steroids, and monitoring.
Past Medical History:
Eating disorder NOS
Adjustment disorder with mixed anxiety and depressed mood
Irregular menses which have largely resolved
H/o lyme disease ___ treated with doxycycline
Low VitD levels
Social History:
___
Family History:
Father - ASD, anxiety
Brother - HTN
Physical ___:
ADMISSION EXAM:
VS: T: 97.5 BP: 110/68 P: 83 R: 18 O2: 98% RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, enlarged tonsils with white
exudates and 2cm between tonsils. Uvula midline.
NECK: supple, JVP not elevated. Soft tissue swelling, tender
anterior cervical lymphadenopathy. Trachea midline, no stridor
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi, good air movement, no increased work of breathing.
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, liver palpable just under costal
margin, no palpable splenomegaly.
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. No axillary or inguinal lymphadenopathy.
SKIN: No rashes or lesions
NEURO: AAOx3, attentive, motor strength full throughout
DISCHARGE EXAM:
VS: T 98.3 BP 114/64 P 56 RR 18 SO2 100%RA BMx2
GENERAL: Young woman in NAD
HEENT: Sclera anicteric, tender anterior cervical
lymphadenopathy bilaterally, no sinus or pre-auricular
tenderness, MMM unvula and trachea midline. Enlarged tonsils
with white exudates and 2cm between tonsils. No stridor.
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi, good air movement, no increased work of breathing.
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: Soft, non-tender, non-distended
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
SKIN: No rashes or lesions
NEURO: AAOx3, attentive
Pertinent Results:
ADMISSION LABS:
___ 02:20PM WBC-10.3 RBC-4.28 HGB-12.5 HCT-38.7 MCV-91
MCH-29.2 MCHC-32.3 RDW-12.8
___ 02:20PM NEUTS-58 BANDS-0 ___ MONOS-6 EOS-0
BASOS-0 ATYPS-2* ___ MYELOS-0
___ 02:20PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 02:20PM GLUCOSE-82 UREA N-9 CREAT-0.8 SODIUM-137
POTASSIUM-4.2 CHLORIDE-103 TOTAL CO2-22 ANION GAP-16
___ 02:20PM ALT(SGPT)-184* AST(SGOT)-83* ALK PHOS-345*
TOT BILI-0.5
___ 02:20PM ALBUMIN-3.9
___ 02:35PM LACTATE-0.9
IMAGING:
CXR
FINDINGS: Low lung volumes accentuate the cardiac silhouette
and
bronchovascular structures. With this limitation in mind, heart
size,
mediastinal and hilar contours are normal. No focal areas of
consolidation
are identified within the lungs. If clinical suspicion for
acute infection
persists, standard PA and lateral chest radiographs with
improved inspiratory
effort may be helpful to more fully evaluate the lung bases.
Radiology Report
PORTABLE CHEST, ___
No prior studies for comparison.
FINDINGS: Low lung volumes accentuate the cardiac silhouette and
bronchovascular structures. With this limitation in mind, heart size,
mediastinal and hilar contours are normal. No focal areas of consolidation
are identified within the lungs. If clinical suspicion for acute infection
persists, standard PA and lateral chest radiographs with improved inspiratory
effort may be helpful to more fully evaluate the lung bases.
Gender: F
Race: WHITE
Arrive by WALK IN
WALK IN
Chief complaint: Sore throat
Sore throat
Diagnosed with INFECTIOUS MONONUCLEOSIS
PERITONSILLAR ABCESS, ACUTE PHARYNGITIS
temperature: 97.8
103.2
heartrate: 117.0
149.0
resprate: 18.0
16.0
o2sat: 99.0
99.0
sbp: 95.0
96.0
dbp: 70.0
77.0
level of pain: 7-8
9
level of acuity: 3.0
1.0 | ___ with tonsilar swelling and exudates with tender cervical
lymphadenopathy and positive monospot test with mild hepatitis
overall consistent with a mono-like illness with decreased PO
intake and reported dyspnea at night prior to admission.
# Mono-like illness: Patient has a mono-like illness with some
atypical features. However, her overall clinic presentation
with abnormal LFTs, atypical lymphocytosis, tender cervical
adenopathy, and tonsilar exudates and swelling with positive
heterophile antibody are very suggestive of infectious
mononucleosis. Acute HIV was ruled out with undetectable viral
load. The differential would include autoimmune or malignant
(lymphomatous) processes but these appear to be less likely
based on history, exam, and LDH. They can be considered for
further workup if symptoms persist unexpectedly.
# Concern for airway obstruction: patient brought in with
concern for night time obstructive symptoms related to her
lymphadenopathy and tonsilar enlargement. Currently not at risk
for pending airway obstruction. She was monitored overnight on
telemetry with continuous O2 sat monitoring. She did not
desaturate overnight on room air. She was given Prednisone 40mg
daily for a planned 5 day course.
# Odynophagia with decreased PO intake: Likely related to her
mono-like illness with inflamed tonsils. She has been able to
drink >1L of a liquid diet prior to discharge. Pain was
initially controlled with roxicet elixir and ketoralac IV. Once
her pain was under control and she could take pills without
difficulty her regimen was changed to standing tylenol and
ibuprofen pills with oxycodone ___ Q4H PRN.
# Abnormal LFTs: Likely ___ suspected mono as above, was they
were previously normal in ___. Potential related to weight and
NASH vs. tylenol use but these were felt to be less likely. Her
LFTs should be rechecked as an outpatient when she is
recovering. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS
==============
___ 10:00AM BLOOD WBC-8.0 RBC-4.58 Hgb-14.1 Hct-42.2 MCV-92
MCH-30.8 MCHC-33.4 RDW-12.1 RDWSD-40.7 Plt ___
___ 10:00AM BLOOD Neuts-63.8 ___ Monos-5.5 Eos-0.5*
Baso-0.5 Im ___ AbsNeut-5.11 AbsLymp-2.35 AbsMono-0.44
AbsEos-0.04 AbsBaso-0.04
___ 10:00AM BLOOD Glucose-86 UreaN-12 Creat-0.7 Na-141
K-4.0 Cl-106 HCO3-24 AnGap-11
___ 10:00AM BLOOD HCG-<5
MICRO
=====
___ 01:00PM URINE Color-Straw Appear-Hazy* Sp ___
___ 01:00PM URINE RBC-2 WBC-21* Bacteri-FEW* Yeast-NONE
Epi-6
IMAGING
=======
___ CXR
No comparison. The lung volumes are normal. Normal size of the
cardiac
silhouette. Normal hilar and mediastinal contours. No
pneumonia, no
pulmonary edema. No pleural effusions. No pneumothorax.
___ CT Head
There is no evidence of intracranial hemorrhage. No mass
effect,
hydrocephalus or shift of normally midline structures.
Ventricles, cisterns and sulci appear within normal limits.
Gray-white matter distinction appears preserved in with.
Surrounding soft tissue structures appear normal. There is no
evidence of fracture or bone destruction. Visualized paranasal
sinuses and mastoid air cells appear clear.
___ EKG
Sinus bradycardia.
___ EKG
Normal sinus rhythm
Normal ECG
DISCHARGE LABS
==============
___ 05:50AM BLOOD WBC-7.9 RBC-4.52 Hgb-13.9 Hct-42.5 MCV-94
MCH-30.8 MCHC-32.7 RDW-12.0 RDWSD-41.7 Plt ___
___ 05:50AM BLOOD Glucose-85 UreaN-13 Creat-0.7 Na-142
K-4.2 Cl-106 HCO3-24 AnGap-12
___ 05:50AM BLOOD Calcium-9.5 Phos-4.2 Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sertraline 100 mg PO DAILY
2. ValACYclovir 500 mg PO Q24H
3. Loestrin ___ (21) (norethindrone ac-eth estradiol) 1.5-30
mg-mcg oral daily
Discharge Medications:
1. Loestrin ___ (21) (norethindrone ac-eth estradiol) 1.5-30
mg-mcg oral daily
2. Sertraline 100 mg PO DAILY
3. ValACYclovir 500 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Syncope
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 3 episodes of syncope, ?seizure in past 3 days,
also w/ rsr' on EKG // eval for underlying cause of syncope/?seizure eval
for underlying cause of syncope/?seizure
IMPRESSION:
No comparison. The lung volumes are normal. Normal size of the cardiac
silhouette. Normal hilar and mediastinal contours. No pneumonia, no
pulmonary edema. No pleural effusions. No pneumothorax.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111
INDICATION: History: ___ with 3 episodes of syncope, ?seizure in past 3 days,
also w/ rsr' on EKG // eval for underlying cause of syncope/?seizure
TECHNIQUE: Multidetector CT images of the head were obtained without
intravenous contrast. Sagittal and coronal reformations were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.1 cm; CTDIvol = 50.0 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None available.
FINDINGS:
There is no evidence of intracranial hemorrhage. No mass effect,
hydrocephalus or shift of normally midline structures. Ventricles, cisterns
and sulci appear within normal limits. Gray-white matter distinction appears
preserved in with. Surrounding soft tissue structures appear normal. There
is no evidence of fracture or bone destruction. Visualized paranasal sinuses
and mastoid air cells appear clear.
IMPRESSION:
No evidence of acute intracranial process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Syncope
Diagnosed with Syncope and collapse
temperature: 98.0
heartrate: 65.0
resprate: 14.0
o2sat: 98.0
sbp: 108.0
dbp: 70.0
level of pain: 0
level of acuity: 3.0 | TRANSITIONAL ISSUES
===================
[ ] Patient to get outpatient TTE in the next week. The order
has been placed in OMR for this to be performed at ___.
[ ] Patient to get outpatient event ___ of Hearts) monitor for
2 weeks. The order has been placed in OMR for this to be
scheduled by ___.
[ ] Patient to follow-up with Dr. ___ at ___
Cardiology in ___ weeks to follow up on the results of the above
studies. Patient to call office at ___ to make the
appointment. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Percocet
Attending: ___.
Chief Complaint:
R hip pain
R infected revised THA
Major Surgical or Invasive Procedure:
Right hip flap exposure
Right THA revision with endoprosthesis
Right hip irrigation & debridement
Right hip Prosthesis retrieve
Right hip I&D, VAC
Right hip wound closure/tissue rearrangement
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
This is a ___ year old male with PMHx afib on coumadin, breast
cancer s/p chemo/XRT/mastectomy, prostate cancer s/p
prostatectomy, total right hip replacement ___, revision in
___, chronic right hip ulceration complicated by klebsiella
bacteremia and septic joint, s/p total bursectomy and quadricep
flap, presenting with right thigh and hip pain.
Of note, the patient initially presented to ___ on
___ with fever and hypotension, found to have Klebsiella
septicemia and right septic hip, thought to be originating from
his right hip wound. He was transferred to ___ where he
underwent ___ guided joint aspiration (which ultimately grew
enterococcus and klebsiella) and OR joint washout. His ulcer was
excised and later underwent total complete bursectomy and
anterolateral flap reconstruction, as his hip capsule was found
to be infection. He was discharged on Ceftriaxone and Daptomycin
to complete a total of 6 weeks of IV antibiotics. He was
readmitted with nausea, vomiting, and diarrhea on ___ which
resolved on their own. Since he had completed a 6 week course of
IV antibiotic at this time, he was discharged on Amoxicillin and
Ciprofloxacin which he is still taking at this time.
He is now presenting with two days of right thigh and hip pain.
He reports that he has been able to work with physical therapy
and walk with a walker until two days ago. He is unable to
ambulate due to pain and reports pain to touch and with any
movement. He originally presented to an OSH where initial lab
work up was unrevealing other than an elevated sedimentation
rate at 60.
In the ED, initial vitals were: 98.0 87 129/81 18 95%
- Labs were significant for:
- BMP wnl, WBC 8.2, N:69.0 L:16.1 M:7.9 E:5.7 Bas:0.8
- ___: 29.3 PTT: 37.9 INR: 2.6
- CRP 38
- Lactate 2.6
- Imaging revealed:
- Knee X ray: Right total knee arthroplasty changes are noted.
There is no fracture. Enthesophytes seen at the quadriceps
insertion on the patella. Scattered surgical clips are
visualized in the right thigh. Intra medullary rod partially
visualized involving the proximal right femur.
- Patient was seen by ortho and plastics while in the ED and are
recommended aspiration of joint
- The patient was given: IV Dilaudid x 3
- Vitals prior to transfer were: 98.5 96 150/80 18 96% RA
Upon arrival to the floor, the patient still reports
excruciating right hip pain with any touch or movement. He
reports that he has not had a bowel movement in two days because
he is not able to sit on the toilet without having pain.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies cough, shortness of breath. Denies chest pain or
tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No dysuria.
Past Medical History:
-R breast ca dx ___ s/p mastectomy, chemo and XRT fall to
winter. No mets per pt
-Right hip replacement complicated by klebsiella bacteremia and
septic joint treated with ceftriaxone and daptomycin (ongoing
treatment)
-AFib on warfarin, onset ___ after radical prostatectomy
-Diverticulosis
-Depression
-Hepatic cyst
-Fatty liver
-Urinary incontinence s/p urethral sling
-Prostate cancer s/p prostatectomy
Social History:
___
Family History:
Denies significant FHx
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: 98.2 153/90 66 20 95% RA
General: Alert, oriented, appears to be in severe pain with any
movement
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI
CV: Regular rate and irregular rhythm, normal S1 + S2, no
murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley, some erythema of testicles
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema. Right hip with erythema and warmth, tender to palpation,
sever pain with any ROM
Neuro: ___ strength left lower extremity, unable to move right
leg ___ pain
Exam on Discharge:
AVSS
NAD, A&Ox3
RLE: Incision well approximated. Fires
___. SITLT s/s/dp/sp/tibial
distributions. 1+ DP pulse, wwp distally. no ROM at Hip
(Prosthesis was taken out due to infection)
Pertinent Results:
ADMISSION LABS
___ 09:30AM WBC-8.2 RBC-4.19* HGB-12.2* HCT-39.4* MCV-94
MCH-29.1 MCHC-31.0* RDW-14.6 RDWSD-50.1*
___ 09:30AM NEUTS-69.0 LYMPHS-16.1* MONOS-7.9 EOS-5.7
BASOS-0.8 IM ___ AbsNeut-5.68 AbsLymp-1.33 AbsMono-0.65
AbsEos-0.47 AbsBaso-0.07
___ 09:30AM PLT COUNT-291
___ 09:39AM LACTATE-2.6*
DISCHARGE LABS
___ 04:56AM BLOOD WBC-8.2 RBC-2.67* Hgb-7.7* Hct-24.8*
MCV-93 MCH-28.8 MCHC-31.0* RDW-16.3* RDWSD-54.4* Plt ___
MICRO
___ RIGHT HIP TISSUE:
GRAM STAIN (Final ___: 1+ (<1 per 1000X FIELD):
POLYMORPHONUCLEAR LEUKOCYTES. NO MICROORGANISMS SEEN.
TISSUE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
ACID FAST SMEAR (Final ___: NO ACID FAST BACILLI SEEN ON
DIRECT SMEAR.
ACID FAST CULTURE (Preliminary):
POTASSIUM HYDROXIDE PREPARATION (Final ___: NO FUNGAL
ELEMENTS SEEN.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Right HIP aspiration: FLUID CULTURE (Final ___: NO
GROWTH
- Deep R hip wound swab: Enterococcus
- Acetablum R hip tissue: MRSA, rare growth
- Femur tissue: No growth
- SKIN SINUS TRACT #2 RIGHT HIP: No growth
- RIGHT PERIACETUBULAR -BONE: No growth
STUDIES
Before retrial of Hip Prosthesis:
R Hip Xray
Superolateral migration of the acetabular prosthesis from the
native
acetabulum. There is also some lucency about the distal tip of
the femoral stem which also suggests loosening.
R Knee Xray
Right total knee arthroplasty changes are noted. There is no
fracture.
Enthesophytes seen at the quadriceps insertion on the patella.
Scattered
surgical clips are visualized in the right thigh. Intra
medullary rod
partially visualized involving the proximal right femur.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fludrocortisone Acetate 0.1 mg PO TID
2. Midodrine 10 mg PO BID
3. Midodrine 5 mg PO QPM
4. Amoxicillin 875 mg PO Q12H
5. BuPROPion (Sustained Release) 300 mg PO QAM
6. Metoprolol Tartrate 12.5 mg PO BID
7. Digoxin 0.25 mg PO DAILY
8. Warfarin 6 mg PO DAILY16
9. Ciprofloxacin HCl 500 mg PO Q12H
10. Potassium Chloride 10 mEq PO DAILY
Discharge Medications:
1. BuPROPion (Sustained Release) 300 mg PO QAM
2. Digoxin 0.25 mg PO DAILY
3. Fludrocortisone Acetate 0.1 mg PO TID
4. Metoprolol Tartrate 12.5 mg PO BID
5. Midodrine 10 mg PO BID
6. Midodrine 5 mg PO QPM
7. Acetaminophen 650 mg PO TID
RX *acetaminophen 650 mg 1 tablet(s) by mouth three times a day
Disp #*60 Tablet Refills:*0
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*40 Capsule Refills:*0
9. Senna 17.2 mg PO HS
RX *sennosides [senna] 8.6 mg 1 softgel by mouth at bedtime Disp
#*30 Capsule Refills:*0
10. TraZODone 25 mg PO HS:PRN insomnia
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth at bedtime
Disp #*20 Tablet Refills:*0
11. Warfarin 6 mg PO DAILY16
12. Potassium Chloride 10 mEq PO DAILY
13. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg sc once a day Disp #*20
Syringe Refills:*0
14. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 GM IV once a
day Disp #*20 Intravenous Bag Refills:*0
15. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
16. HYDROmorphone (Dilaudid) ___ mg PO Q6H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg 1 tablet(s) by mouth every six
(6) hours Disp #*70 Tablet Refills:*0
17. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
18. Vancomycin 1000 mg IV Q 12H
RX *vancomycin 500 mg 2 Vial IV once a day Disp #*20 Vial
Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
Infected right revised THA
Secondary Diagnosis
Urinary Incontinence
Atrial Fibrillaiton
Orthostatic Hypotension
Chronic Systolic Heart Failure
Depression
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: ___ with R thigh pain during ___ ___ days prior, hx R hip total
hip ___ c/b chronic infx, recent flap // eval ? femur fx
TECHNIQUE: AP and lateral views of the right knee.
COMPARISON: None.
FINDINGS:
Right total knee arthroplasty changes are noted. There is no fracture.
Enthesophytes seen at the quadriceps insertion on the patella. Scattered
surgical clips are visualized in the right thigh. Intra medullary rod
partially visualized involving the proximal right femur.
IMPRESSION:
No acute fracture.
Radiology Report
EXAMINATION: INJ/ASP MAJOR JT W/FLUORO
INDICATION: ___ year old man with complicated right hip history, h/o hip
replacement c/b septic joint, now with recurrent hip pain // eval for right
hip infection
COMPARISON: MOST RECENT PRIOR RIGHT HIP RADIOGRAPH ___.
Fluoroscopy time 4 min 5 sec
DAP 355.0 mGy
PROCEDURE: The procedure was supervised by Dr. ___ attending
radiologist, who was present for the critical portions of the procedure.
The risks, benefits, and alternatives were explained to the patient and
written informed consent obtained.
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.
5 cc 1% Lidocaine was used to achieve local anesthesia. Under intermittent
fluoroscopic guidance, an 18-gauge spinal needle was advanced into the right
hip joint and aspiration was attempted. No fluid was aspirated. Subsequently
a 20 gauge spinal needle was advanced into the right hip joint, along the
prosthesis under fluoroscopic guidance and aspiration as attempted. No fluid
was aspirated and a small amount of Optiray was injected to confirm intra
articular position. After confirmation of placement, re-aspiration was
attempted and a few drops (<1 cc) of serosanguinous fluid was aspirated.
Fluid was sent to pathology for gram stain, culture, and sensitivity.
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:
There has been interval dislocation of the right acetabular prosthesis
component, which now is now oriented more lateral and cranial than prior
study.
IMPRESSION:
1. Imaging Findings - Interval dislocation of the acetabular prosthesis.
2. Procedure - Technically successful right hip joint aspiration, with a few
drops of serosanguinous fluid re-aspirated.
I, Dr. ___ supervised the Resident/Fellow during the key
components of the above procedure and I have reviewed and agree with the
Resident/Fellow findings/dictation.
NOTIFICATION: Findings were communicated to Dr. ___ via phone by
Dr. ___ on ___ at 1045am
Radiology Report
EXAMINATION: HIP UNILAT MIN 2 VIEWS RIGHT
INDICATION: ___ year old man with right THA now with R hip pain // Need
AP/Lateral/Judet views of R hip NEED AP LATERAL VIEWS OF RIGHT HIP
TECHNIQUE: AP view of the pelvis and two views of the right hip.
COMPARISON: Images from aspiration under fluoroscopy same day, and outside
hospital radiographs ___.
FINDINGS:
The acetabular prosthesis has migrated out of the native acetabulum,
positioned proximally, laterally and with abnormal rotation. Postsurgical
change is seen in the lumbar spine. There is mild left hip degenerative
change. There are surgical clips in the pelvis. There is relative asymmetric
demineralization in the right hemipelvis. There is also some abnormal lucency
on about the distal tip of the femoral stem, measuring 7 mm.
IMPRESSION:
Superolateral migration of the acetabular prosthesis from the native
acetabulum. There is also some lucency about the distal tip of the femoral
stem which also suggests loosening.
Radiology Report
EXAMINATION: PELVIS (AP ONLY)
INDICATION: ___ year old man with s/p R revision THA // please obtain AP
pelvis stat, thank you. please obtain AP pelvis stat, thank you.
TECHNIQUE: AP pelvis, supine portable.
COMPARISON: ___
FINDINGS:
Interval revision right hip arthroplasty in satisfactory position. Expected
postoperative soft tissue changes, with skin staples, and surgical drain.
Multiple staples are seen in the pelvis. Degenerative and postsurgical
changes lower lumbar spine. Moderate left hip osteoarthritis.
Note that the inferior portion of the femoral prosthesis is not included in
the field of view.
IMPRESSION:
Satisfactory alignment of visualized right hip arthroplasty.
Radiology Report
EXAMINATION: BLADDER US
INDICATION: Bladder US to be performed immediately ___ emptying bladder //
Bladder US to be performed immediately ___ emptying bladder to eval post void
residual and placement of bladder device
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the bladder.
COMPARISON: None.
FINDINGS:
Grayscale and color Doppler ultrasound images of the bladder were obtained and
reviewed. The bladder is unremarkable without evidence of focal mass or other
abnormality. Prevoid the bladder volume is 239.4 cc. Postvoid bladder volume
is 202.8 cc.
IMPRESSION:
Postvoid residual bladder volume of 202.8 cc. Otherwise, unremarkable
appearance of the bladder.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with new L PICC // 49 cm L basilic SL PICC -
___ ___ Contact name: ___: ___
TECHNIQUE: Portable semi-upright chest radiograph.
COMPARISON: Chest radiograph dated ___.
Chest radiograph dated ___
FINDINGS:
The left PICC is malpositioned and appears to be curled within the basilic
vein with tip in the left mid subclavian.
There is chronic elevation of the right hemidiaphragm since ___.
Stable cardiac silhouette. The mediastinal and hilar contours are normal. The
pulmonary vasculature is normal. Lungs are clear. No pleural effusion or
pneumothorax is seen. There are no acute osseous abnormalities.
IMPRESSION:
1. Left PICC malpositioned coils in left axilla before terminating in left
subclavian vein.
2. Chronic elevation of the right hemidiaphragm.
NOTIFICATION: The findings were discussed by Dr. ___ with ___ nurse
___ on the telephone on ___ at 11:50 ___, 3 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: PELVIS (AP ONLY)
INDICATION: ___ year old man with R endoprosthesis // eval for ? atraumatic
dislocation eval for ? atraumatic dislocation
TECHNIQUE: AP view of the pelvis.
COMPARISON: ___.
FINDINGS:
Patient is status post right hip arthroplasty. There has been interval
superior dislocation of the right hip prosthesis. No fracture is identified.
There is diffusely decreased bone mineralization. Multiple radiopaque clips
are seen overlying the pelvis.
IMPRESSION:
Superior dislocation of the right hip prosthesis.
NOTIFICATION: The findings were discussed by Dr. ___ with ___ on
the telephone on ___ at 11:34 AM, 5 minutes after discovery of the
findings.
Radiology Report
INDICATION: ___ year old man with malpositioned L basilic PICC // Please
replace bedside placed malposition PICC, 49cm pulled back 30cm
COMPARISON: Chest radiograph ___.
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: 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site.
MEDICATIONS: 1% lidocaine.
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 2:43 min, 160 cGy.cm2
PROCEDURE: PROCEDURE DETAILS: Following the explanation of the risks,
benefits and alternatives to the procedure, written informed consent was
obtained from the patient. The patient was then brought to the angiography
suite and placed supine on the exam table. A pre-procedure time-out was
performed per ___ protocol. The left arm was prepped and draped in the usual
sterile fashion.
The existing PICC has been withdrawn, with the tip in the left axillary vein.
That PICC was removed over a wire, which was used for measurement purposes. A
new PICC was cut to length and advanced over the wire, with the tip positioned
near the cavoatrial junction. The catheter length was measured at 54 cm, with
0 cm exposed.
Final spot fluoroscopic image demonstrates good alignment of the catheter and
no kinking. The catheter was flushed and capped. Sterile dressings were
applied. The patient tolerated the procedure well.
FINDINGS:
Successful PICC exchange. Final fluoroscopic image showing PICC catheter with
tip terminating near the cavoatrial junction.
IMPRESSION:
Successful placement of a 54 cm PICC, 0 cm exposed. The tip of the catheter
terminates near the cavoatrial junction. The catheter is ready for use.
Radiology Report
EXAMINATION: PELVIS PORTABLE
INDICATION: PRE SURGICAL PLANNING FOR PELVIC SURGERY
IMPRESSION:
In comparison with the study of ___, there has been removal of the total
hip arthroplasty on the right. Otherwise little change.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, R Hip pain
Diagnosed with JOINT PAIN-PELVIS
temperature: 98.0
heartrate: 87.0
resprate: 18.0
o2sat: 95.0
sbp: 129.0
dbp: 81.0
level of pain: 0
level of acuity: 3.0 | ___ with h/o afib on coumadin, prostate cancer s/p
prostatectomy, breast cancer s/p chemo/XRT/mastectomy, total
right hip replacement, revision in ___, chronic right hip
ulceration, p/w right thigh pain
ACTIVE ISSUES
# Right Hip Prosthesis Dislocation: ___ and Hip X ray on
admission showed interval dislocation of acetabular prosthesis.
Joint aspiration was negative on ___ and fluid culture. He was
continued on PO Amoxicillin and Ciprofloxacin which he was
taking after completing a 6 week course of IV Ceftriaxone and
Daptomycin for prior enterococcous/Enterococcus/Klebsiella
septic R hip. He was evaluated by orthopedics and plastic
surgery and underwent flap preservation and I/D with synovectomy
of chronically infected right revision total knee replacement,
removal of acetabulum cup insert and femoral head and insertion
of endoprosthetic unipolar head on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Plasma-Lyte 148 / Mexiletine / Amiodarone
Attending: ___.
Chief Complaint:
Epistaxis
Major Surgical or Invasive Procedure:
- None.
History of Present Illness:
___ with M h/o of CAD, s/p CABG ___ and PCI to RCA ___,
stable angina, CHF (EF = 30%), LV thrombus on coumadine, pacer +
ICD, HTN, HLD who is admitted for epistaxis and chest pain.
.
Patient initially presented to the ED at 9PM with spontaneous
epistaxis which started at 7pm, by the time he got to the ED, it
stopped. MD removed gauze; there was no rebleeding. Patient was
discharged from the ED but then spontanously restarted bleeding.
Bleeding site in anterior right nostril; cauterized in ED.
Patient then developed chest pain, that was typical of his chest
pain at home. It resolved with ASA, and a SL NTG. Chest pain
free at the time of admission.
.
Patient had recent admission ___ for hematuria which was
attributed to coumadin treatment and cleared. Discharge summary
not available.
.
Per chart, the patient saw his cardiologist ___ for slowly
progressing exertional dyspnea (he can only walk a few ___ yards
before experiencing chest pain, DOE. The rest of his cardiac ROS
was ath the time negative. Most recent (date?) myocardial
perfusion imaging is reported to have demonstrated only fixed
myocardial perfusion defects without any evidence of reversible
perfusion abnormalities. Known to have LVEF ___ with only
mild mitral regurgitation as well as PHTN and right ventricular
contractile dysfunction but without clinical signs of right
heart failure (no peripheral edema). On that appointment the
plan was treat angina medically: metoprolol dose was increased
from 25 mg daily to 50 mg daily and to consider coronary
angiography only if patient's symptoms became debilitating.
Past Medical History:
- CAD status post CABG x 4 in ___
----> SVG Y graft to D1 and OM1
----> SVG to RPDA
----> SVG to LAD
----> PCI to RCA in ___.
- V tach s/p ablation ___ (last episode ___
- CHF (EF 30%)
----> Biventricular PPM with ICD
- PVD s/p multiple PCIs
- HTN
- HLD
- LV thrombus, on chronic warfarin
- CVA in ___.
- GI bleed in the past.
- BPH with laser surgery & intermittent hematuria.
Social History:
___
Family History:
- Mother: CVA at ___
- Father: CVA at ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
Temp 96.4 F, 134/76BP , HR 92 , R ,18 97 O2-sat % RA
GENERAL - well-appearing in NAD, comfortable, appropriate
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 - sternotomy scar, RRR, fixed split S2, no MRG
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 1+ radials, faint DPs
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, bil symetric eyelid droop, CNs II-XII
grossly intact, muscle strength ___ throughout, sensation
grossly intact throughout, DTRs 2+ and symmetric.
DISCHARGE PHYSICAL EXAM:
97.6 129/80(120-130/70-80) 95(90) 18 98/RA
GEN: Well-appearing, NAD
HEENT: NCAT, MMM
NECK: No JVD.
COR: +S1S2, regular. Pacer noted in L chest, no swelling,
erythema.
PULM: CTAB, no c/w/r.
___: +NABS in 4Q. Soft, NTND.
EXT: WWP. No c/c/e.
NEURO: MAEE.
Pertinent Results:
ADMISSION LABS:
___ 09:50PM BLOOD WBC-5.5 RBC-3.79* Hgb-12.2* Hct-35.4*
MCV-94 MCH-32.2* MCHC-34.4 RDW-14.6 Plt ___
___ 09:50PM BLOOD Neuts-61.3 ___ Monos-8.3 Eos-5.9*
Baso-1.2
___ 09:50PM BLOOD ___ PTT-40.2* ___
___ 09:50PM BLOOD cTropnT-<0.01
DISCHARGE LABS:
___ 07:45AM BLOOD WBC-4.2 RBC-3.54* Hgb-11.6* Hct-33.5*
MCV-95 MCH-32.7* MCHC-34.6 RDW-14.5 Plt ___
___ 07:45AM BLOOD Glucose-102* UreaN-25* Creat-1.0 Na-143
K-4.2 Cl-109* HCO3-24 AnGap-14
___ 07:45AM BLOOD CK-MB-4 cTropnT-<0.01
___ 07:45AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.2
STUDIES:
CXR (___):
IMPRESSION: Stable cardiomegaly with mild edema - may represent
early heart failure.
Medications on Admission:
- Plavix 75 mg QD
- Finasteride 5 mg QD
- Furosemide 20 mg QD
- Lisinopril 2.5 mg QD
- Lorazepam 0.25 mg QHS PRN insomnia
- Metoprolol succinate 50 mg QD
- Nitroglycerin PRN
- Pravastatin 20 mg QD
- Ranitidine 150 mg QPM
- Tamsulosin 0.4 mg ER QD
- Warfarin 5 mg tablet alternating with 7 mg
- Aspirin 81 mg QD
- Docusate 100 mg TID
- Senna 1 capsule QD PRN
Discharge Medications:
1. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO three
times a day as needed for constipation.
2. senna 8.6 mg Tablet Sig: One (1) Tablet PO DAILY (Daily) as
needed for constipation.
3. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
4. tamsulosin 0.4 mg Capsule, Ext Release 24 hr Sig: One (1)
Capsule, Ext Release 24 hr PO HS (at bedtime).
5. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
7. furosemide 20 mg Tablet Sig: One (1) Tablet PO ONCE (Once)
for 1 doses.
8. lisinopril 5 mg Tablet Sig: 0.5 Tablet PO DAILY (Daily).
9. lorazepam 0.5 mg Tablet Sig: ___ Tablet PO HS (at bedtime) as
needed for sleep.
10. metoprolol succinate 50 mg Tablet Extended Release 24 hr
Sig: One (1) Tablet Extended Release 24 hr PO DAILY (Daily).
11. nitroglycerin 0.3 mg Tablet, Sublingual Sig: One (1) Tablet,
Sublingual Sublingual PRN (as needed) as needed for chest pain:
Up to 3 doses 5 minutes apart. If pain dose not resolve, call
___.
12. pravastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
13. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
14. warfarin 5 mg Tablet Sig: One (1) Tablet PO Once Daily at 4
___.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
- Epistaxis (nose bleed)
SECONDARY DIAGNOSIS:
- Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with chest pain.
STUDY: AP and lateral chest radiograph.
COMPARISON: ___ and ___.
FINDINGS: Sternotomy wires are unchanged as are mediastinal clips. A pacer
defibrillator unit projects over the left chest with leads in the right atrium
and right ventricle as well as a set of abandoned leads, all similar to prior
exam. The heart continues to be enlarged but not changed from prior exam.
The mediastinal contours are not widened. The lungs demonstrate prominent
pulmonary vasculature and mild edema. There is no large pleural effusion or
pneumothorax.
IMPRESSION: Stable cardiomegaly with mild edema - may represent early heart
failure.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: EPISTAXIS
Diagnosed with EPISTAXIS, CHEST PAIN NOS, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 97.9
heartrate: 92.0
resprate: 16.0
o2sat: 98.0
sbp: 145.0
dbp: 79.0
level of pain: 0
level of acuity: 3.0 | REASON FOR HOSPITALIZATION:
___ with M h/o of CAD, s/p CABG ___ and PCI to RCA ___,
stable angina, CHF (EF = 30%), LV thrombus on coumadine, pacer +
ICD, HTN, HLD who is admitted for epistaxis and chest pain. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: ___
Service: MEDICINE
Allergies:
Cipro / Sulfa(Sulfonamide Antibiotics) / codiene / tamazepam /
Plavix
Attending: ___.
Chief Complaint:
Encephalopathy
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ MEDICINE ATTENDING ADMISSION NOTE .
___
Time: ___
_
________________________________________________________________
PCP:Name: ___.
Location: ___
Address: ___
Phone: ___
Fax: ___
.
_
________________________________________________________________
HPI:
The patient is an unfortunate ___ year old female with h/o CVA x
___ s/p unwitnessed fall during which she sustained a sub-dural
hematoma and L hip fracture s/p repair (admitted from ___ -
___. She was noted to have seizures with b/l UE shaking for
which she was started on keppra and dilantin with an improvement
in her EEG. She was d/c'ed to ___ RSU on ___. Upon discharge
she was intermittently disoriented but did not have agressive or
combative behavior. She was then admitted from ___ to ___ from
___ to ___ with encephalopathy after hitting an RN and
causing bleeding. Her EEG was negative for seizures and her CT
scan was unchanged. Her phenytonin level was elevated at 22.3
and thus was held returning to 17.5 at the time of discharge.
She is now admitted to ___ from ___ for agressive combative
behaviour posing a danger to herself and others. Per her dtr she
still as periods of lucency where she is able to recognize that
her behavior is unacceptable- this occured the night prior to
admission.
In ER: (Triage Vitals: 0 97.9 58 155/65 16 98% )
Meds Given: seroquel and zyprexa
Fluids given: None
Radiology Studies: head cT no acute change
consults called: neurology
.
Upon arrival to the floor she denies pain, sob,n/v/d. She is
continuously trying to get out of bed. She throws her pills on
the floor. She states that her dtr is trying to kill her. She is
fixated on paper tape that is securing her IV. She tells me
about men that are taking away a car or a club. Her daughter is
most concerned that she could be having strokes that could be
causing her behavorial distubances.
[X]all other systems negative except as noted above
________________________________________________________________
Past Medical History:
- Right subdural hemorrhage (___)
- left hip fracture s/p fixation (___)
- Atrial fibrillation on coumadin
- prior stroke ___ and ___ leading to loss of vision
- Suicide attempt in ___ in ___ because she was blind
with xanax
- she went home with hospice in ___ and dramatically
improved and wanted to live again
- HLD
- Depression
- peripheral neuropathy
- hypothyroidism
- IBS
- insomnia
Social History:
___
Family History:
Brother died due to cardiac disease. Mother with multiple
strokes. Father died of bowel obstruction.
Physical Exam:
PHYSICAL EXAM: I3 - PE >8
1. VS P = 96 BP = 165/75 RR = 22 O2Sat on __97% RA
GENERAL:Emaciated elderly female. She is sitting up in bed. She
keeps standing up.
Nourishment: greatly at risk
Grooming: OK
Mentation: alert, hypervigilant, suspcious.
2. Eyes: [] WNL
EOMI without nystagmus, Conjunctiva: clear
3. ENT [] WNL
[] Moist [] Endentulous [] Ulcers [] Erythema [] JVD ____ cm
[x] Dry [] Poor dentition [] Thrush [] Swelling [] Exudate
4. Cardiovascular [] WNL
[X] Regular [] Tachy [X] S1 [X] S2 [-] Systolic Murmur /6,
Location:
[] Irregular []Brady []S3 [] S4 [] Diastolic Murmur /6,
Location:
[X] Edema RLE None
[x] Edema LLE None
[] Vascular access [X] Peripheral [] Central site:
5. Respiratory [ ]
[X] CTA bilaterally- but distant breath sounds [ ] Rales [ ]
Diminshed
[] Comfortable [ ] Rhonchi [ ] Dullness
[ ] Percussion WNL [ ] Wheeze [] Egophony
6. Gastrointestinal [ ] WNL
Scaphoid abdomen but non-tender
7. Musculoskeletal-Extremities [X] WNL
She is able to stand but is unable to take a few steps.
8. Neurological [] WNL
[X ] Alert and Oriented x 3 [ ] Romberg: Positive/Negative [ ]
CN II-XII intact [ X] Normal attention [ ] FNF/HTS WNL []
Sensation WNL [ +] Delirious/confused [ ] Asterixis
Present/Absent [ ] Position sense WNL
9. Integument [] WNL
[] Warm [X] Dry [] Cyanotic [] Rash:
none/diffuse/face/trunk/back/limbs
[ ] Cool [] Moist [] Mottled [] Ulcer:
None/decubitus/sacral/heel: Right/Left
10. Psychiatric [] WNL
[] Appropriate [] Flat affect [] Anxious [] Manic [] Intoxicated
[] Pleasant [] Depressed [X] Agitated [X] Psychotic
Pertinent Results:
___ 07:15AM BLOOD WBC-4.3 RBC-3.84* Hgb-11.9* Hct-36.1
MCV-94 MCH-31.0 MCHC-33.0 RDW-15.7* Plt ___
___ 05:35AM BLOOD WBC-4.1 RBC-3.81* Hgb-11.6* Hct-36.0
MCV-95 MCH-30.4 MCHC-32.1 RDW-15.5 Plt ___
___ 06:35AM BLOOD WBC-4.8 RBC-3.72* Hgb-11.5* Hct-34.8*
MCV-94 MCH-30.8 MCHC-32.9 RDW-15.9* Plt ___
___ 06:35AM BLOOD WBC-5.7 RBC-4.02* Hgb-12.1 Hct-38.0
MCV-95 MCH-30.1 MCHC-31.9 RDW-15.7* Plt ___
___ 11:45AM BLOOD WBC-4.5 RBC-3.43* Hgb-10.5* Hct-32.3*
MCV-94 MCH-30.6 MCHC-32.5 RDW-15.2 Plt ___
___ 06:35AM BLOOD Neuts-68.8 ___ Monos-6.5 Eos-2.2
Baso-0.5
___ 11:45AM BLOOD Neuts-67.1 ___ Monos-6.6 Eos-1.4
Baso-0.5
___ 07:15AM BLOOD Plt ___
___ 07:15AM BLOOD ___ PTT-28.0 ___
___ 05:35AM BLOOD Plt ___
___ 05:35AM BLOOD ___ PTT-27.7 ___
___ 12:45PM BLOOD ___ PTT-28.3 ___
___ 06:35AM BLOOD ___ PTT-29.4 ___
___ 11:45AM BLOOD ___ PTT-27.5 ___
___ 05:35AM BLOOD Creat-0.7
___ 06:35AM BLOOD Glucose-101* UreaN-12 Creat-0.7 Na-137
K-4.5 Cl-101 HCO3-28 AnGap-13
___ 06:35AM BLOOD Glucose-99 UreaN-12 Creat-0.6 Na-142
K-4.3 Cl-104 HCO3-29 AnGap-13
___ 11:45AM BLOOD Glucose-131* UreaN-14 Creat-0.7 Na-137
K-4.4 Cl-100 HCO3-25 AnGap-16
___ 11:45AM BLOOD ALT-26 AST-35 AlkPhos-126* TotBili-0.2
___ 06:35AM BLOOD Calcium-9.4 Phos-3.9 Mg-2.2
___ 11:45AM BLOOD Albumin-3.7 Calcium-8.8 Phos-3.9 Mg-2.2
___ 06:35AM BLOOD VitB12-480
___ 06:35AM BLOOD Free T4-0.88*
___ 07:40PM BLOOD Phenyto-13.8
___ 11:45AM BLOOD Phenyto-14.4
___ 11:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:52AM BLOOD Lactate-1.6 K-4.4
.
___ EKG:
Ectopic atrial rhythm with bradycardia. Low voltage in the limb
leads.
Compared to the previous tracing of ___ the rhythm has
changed.
Read by: ___.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
47 0 ___ 0 75 49
.
CXR:
IMPRESSION:
No acute cardiopulmonary process.
.
CT head ___:
IMPRESSION:
Expected continued evolution of the right posterior subdural
hematoma with stable right occipital and left temporal lobe
encephalomalacia. No new hemorrhage or other acute change.
.
___ 02:38PM URINE Color-Yellow Appear-Clear Sp ___
___ 02:38PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-TR
___ 02:38PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1 TransE-<1
___ 02:38PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
.
___ BLOOD CULTURE Blood Culture, Routine-PENDING
INPATIENT
___ SEROLOGY/BLOOD RAPID PLASMA REAGIN
TEST-FINAL INPATIENT negative.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D 50,000 UNIT PO DAILY
2. Pravastatin 10 mg PO DAILY
3. Vitamin B Complex 1 CAP PO DAILY
4. Levothyroxine Sodium 25 mcg PO QHS
5. Metoprolol Tartrate 12.5 mg PO DAILY
6. Gabapentin 400 mg PO TID
7. Acetaminophen 650 mg PO Q6H:PRN pain/fever
8. Lorazepam 1 mg PO Q 8 AM, Q 12 NOON, Q 1700, Q ___
9. Lorazepam 1 mg PO BID:PRN anxiety
10. Senna 1 TAB PO HS
11. LeVETiracetam 1000 mg PO BID
12. Phenytoin Infatab 100 mg PO TID
13. traZODONE 25 mg PO HS:PRN insomnia
14. Thiamine 100 mg PO DAILY
15. Warfarin 2.5 mg PO DAYS (___)
16. Quetiapine Fumarate 50 mg PO QHS
17. Quetiapine Fumarate 25 mg PO QAM
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain/fever
2. Vitamin D 50,000 UNIT PO DAILY
3. Pravastatin 10 mg PO DAILY
4. Levothyroxine Sodium 25 mcg PO QHS
5. Metoprolol Tartrate 12.5 mg PO DAILY
6. Gabapentin 300 mg PO Q12H
7. Lorazepam 1 mg PO TID anxiety
8. Senna 1 TAB PO HS
9. Vitamin B Complex 1 CAP PO DAILY
10. Phenytoin Infatab 100 mg PO TID
11. Warfarin 3 mg PO DAILY16
12. Thiamine 100 mg PO DAILY
13. Quetiapine Fumarate 50 mg PO QHS
please monitor QTC
14. Quetiapine Fumarate 25 mg PO QAM
Please monitor QTC
15. Quetiapine Fumarate 12.5 mg PO QID:PRN severe agitation
use only if necessary. MOnitor QTC
16. LeVETiracetam 500 mg PO BID Duration: 2 Days
for ___ and ___. LeVETiracetam 250 mg PO BID Duration: 3 Days
x3 days. For ___
18. LeVETiracetam 250 mg PO HS Duration: 3 Days
x3 days. For ___ and then STOP.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
delerium/agitation due to medication (keppra)
.
H.o SDH and TBI
afib
CVA
hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Altered mental status.
TECHNIQUE: Portable AP view of the chest.
COMPARISON: ___.
FINDINGS:
The cardiac silhouette size is normal. Mediastinal and hilar contours are
unchanged. Pulmonary vascularity is normal. No focal consolidation, pleural
effusion or pneumothorax is identified. Minimal atelectasis is seen in both
lung bases. No pulmonary edema is seen. There are no acute osseous
abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
HISTORY: Recent posterior parafalcine subdural hematoma presenting with
mental status change.
TECHNIQUE: Contiguous axial MDCT images of the head were obtained without IV
contrast. Multiplanar reformatted images were generated in the coronal and
sagittal planes as well as thin section bone algorithm images.
DLP: 1538.57 mGy-cm.
COMPARISON: Multiple nonenhanced CT head studies dating back to ___.
FINDINGS:
Again appreciated is hypodense material layering along the posterior right
cerebral convexity and the right posterior aspect of the falx consistent with
expected continued evolution of the previously appreciated subdural hematoma
without increase in amount of fluid. Adjacent right occipital lobe
encephalomalacia is unchanged. There is unchanged left temporal
encephalomalacia. Gray-white matter differentiation is preserved in the
remainder of the brain. There is no new hemorrhage, edema, mass effect or
acute large territory infarct. Mild prominence of the ventricles and sulci is
suggestive of age-related involutional change. The basal cisterns appear
patent. No fracture is identified. A mucosal retention cyst is visualized in
the right sphenoid air cell. The remainder of the visualized paranasal
sinuses, mastoid air cells and middle ear cavity is clear. The globes are
unremarkable.
IMPRESSION:
Expected continued evolution of the right posterior subdural hematoma with
stable right occipital and left temporal lobe encephalomalacia. No new
hemorrhage or other acute change.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: BEHAVIOR CHANGES
Diagnosed with PSYCHOSIS NOS, HYPOTHYROIDISM NOS, HYPERLIPIDEMIA NEC/NOS, LONG TERM USE ANTIGOAGULANT
temperature: 97.9
heartrate: 58.0
resprate: 16.0
o2sat: 98.0
sbp: 155.0
dbp: 65.0
level of pain: 0
level of acuity: 1.0 | Assessment/Plan:
___ is an ___ y.o female with h.o AFib, CVA, s/p fall with hip fx
and SDH, ?seizures, depression who was admitted for evaluation
of encephalopathy and agitation.
.
#metabolic encephalopathy with agitation/aggression-EKG, EEG,
head CT and laboratory testing were unrevealing. Considered
possibility of CVA and behavioral changes related to SDH and TBI
as well as possible seizure. However, her symptoms were felt to
be likely due to medication effect from keppra. The geriatrics,
neurology, and psychiatry teams were all consulted and
recommended a keppra taper (750mg BID x3 days-complete, 500mg
BID x3 days (Started ___, then 250mg BID x3 days, then 250mg
QHS x3 days then off. These teams also recommended considering
an ativan taper to off as well. However, she is currently on 1mg
TID and doing very well with this regimen. Trazodone was also
discontinued her her gabapentin dosing was changed to be renally
dosed at 300mg BID. As the keppra taper was started, pt's
symptoms markedly improved. She was calm, cooperative, and did
not exhibit confusion from ___. There was
never any evidence of seizure or CVA noted during admission.
B12, rpr were unrevealing and dilantin level appeared to be
apppropriate. The patient will need to follow up with the
Traumatic Brain Injury clinic with Dr. ___ (___)
as well as Drs. ___ in the General Neurology clinic
(___) as planned during her prior admission. She should
followup with Dr. ___ in the ___ clinic
(___) at the beginning of ___ as previously planned
planned.
++ Of note, after discussion with neurology, it was decided that
pt should be therapeutic with an INR of 2.0 on her coumadin. Her
coumadin dosing was increased to 3mg on ___. This should be
continually uptitrated to reach an INR goal of about 2.
++Of note, her Free t4 was mildly decreased. Her levothyroxine
can be further titrated in the outpatient setting.
.
#afib-continued coumadin. Increased dosing to 3mg daily as she
was subtherapeutic. She should continue her coumadin with
increasing uptitration to a goal INR of about 2.0 given her
prior CVAs. She was not bridged with heparin or lovenox given
her prior history of intracranial bleeding. Neurology agreed
with this plan.
-follow daily INR and continue to uptitrate coumadin carefully
to INR of 2
.
#h.o sub dural hematoma/h.o seizures?-Neurology was consulted.
Pt's dilantin was continued a current dosing for seizure
propylaxis. Dilantin levels were appropriate. Keppra titration
to off was started. See above given pt's delerium and mood
swings. Please see above for keppra instructions. Pt will need
to follow up with neurology, TBI, and ___ clinic.
.
#HTN benign-continued metoprolol
.
#s/p CVA-continued coumadin (see dosing changes above under
afib), statin
.
#Hyperlipidemia- continued statin
.
#neuropathy-gabapentin decreased to appropriate renal dosing at
300mg BID
.
#hypothyroidism-continued levothyroxine at current dosing.
However, given slighly low free t4 (see results section above),
may want to uptitrate.
.
FEN: regular
.
DVT PPx: hep SC TID while INR suptherapeutic while admitted.
.
CODE: DNR/DNI
.
Transitional care
1.continue keppra taper as outlined above
2.consider downtitration of ativan
3.pt will need f/u with neurology, ___ clinic, an
neurosurgery
4.INR monitoring and uptitration of coumadin to INR goal of 2
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Bactrim / Lisinopril
Attending: ___.
Chief Complaint:
lower extremity edema
Major Surgical or Invasive Procedure:
2 units PRBC transfusion on this hospitalization ___,
___
History of Present Illness:
Ms. ___ is a ___ woman with history of gout, OSA on CPAP,
psoriasis, recently diagnosed hyperthyroidism (treated with
metoprolol with improvemen in symptoms, no antithyroid
medications given), and myelodysplastic syndrome (followed by
hematology for ___ years) for which she was recently started on
treatment with azacitidine (finished first course 3 days prior
to admission); who presented with ___ edema, SOB, ab fullness,
and low grade temp 100.1.
In the ED, HCT was 18 and she was transfused 1 unit RBCs with
appropriate response to HCT 20.8.
She states that her ___ swelling started on the ___ prior to
presentation. Feels like her legs and abdomen are fluid filled.
Shorntess of breath also progressed since ___ and is worse
with exertion. She states that she experiences a similar DOE
when she is anemic however the lower extremity edema is
definitely new. Denies chest pain.
She recently had a flare of gout involving her R great toe for
which he was prescribed prednisone which she started on ___
at a dose of 60 mg daily tapered thereafter by 10 mg decrements
every 2 days.
At her PCPs office in ___, she was noticed to be anxious,
tremulous, and with a rapid heart rate even at rest. Evaluation
by her PCP found she was hyperthyroid (TSH 0.25 on ___ and
0.024 on ___. She was referred to a local endocrinologist
who placed her on metoprolol to control her symptoms, but held
off on any treatment. Palpitations had reportedly improved as
well as her tremulousness. She has follow up with Endocrinology
scheduled in early ___.
Ms. ___ was diagnosed with a multifocal pneumonia diagnosed
in ___. She subsequently had a follow up CXR done
locally by her PCP in late ___ to document resolution of a
previous pneumonia which did show resolution of the opacity but
revealed a new nodule for which she subsequently had a chest CT
which according to her local pulmonologist, Dr. ___ in
___, which did not show a nodule, but reported
"infiltrations" at the bases of her lungs. She was placed on a
course of clindamycin and 5 day course of prednisone 30 mg
daily, which she completed at the end of ___.
ROS:
(+)SOB, onset ___. ab fullness. Noted soft stools yesterday.
Bilateral swelling noted in legs. 8 lb weight gain since last
week.
(-)denies cp. No black or bloody stool, no dysuria. No recent
periods of extended immobilization.
Remainder of comprehensive 10 point ROS it otherwise negative.
No history of blood clot.
Past Medical History:
1. Superficial perivascular lymphocytic infiltrate with
scattered eosinophils attributed to lisinopril plus or minus
hydrochlorothiazide.
2. Hypertension.
3. Sleep apnea
4. Gout
5. s/p bilateral wrist fracture
6. Hyperthyroidism
7. psoriasis
PAST HEMATOLOGIC HISTORY:
PER OMR:
Summary of Hematologic and Treatment History:
1. Procrit therapy in ___ yielded reconstitution of her red
cell mass based on improved hemoglobin and hematocrit levels.
However, she developed hypertension and headaches. Procrit was
stopped.
2. On ___, she began Aranesp for acute on chronic
symptomatic anemia. RBC mass grew slowly in response, with
improved sense of well-being.
3. Last bone marrow biopsy was performed on ___ which
continued to show findings consistent with RARS without
increased blasts. Cytogenetics showed no chromosomal
abnormalities; MDS-FISH panel was normal.
4. Her hemoglobin level declined transiently in ___ due to
not getting Aranesp while awaiting insurance approval.
Social History:
___
Family History:
Significant for colon cancer which took the life of her mother
at age ___, and colon cancer in her paternal grandfather. Her
father also has prostate cancer and interestingly she was
recently told that he also has an anemia with large red cells.
The other status of his workup at this time is unknown. No
family history of CHF.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 100.1 P88 R18 137/45 100% on RA
Admit Weight: 156 pounds
GEN: Alert, lying in bed, no acute distress
HEENT: MMM, anicteric sclera, no conjunctival pallor
NECK: Supple without LAD
PULM: scant crackles at bases bilaterally
COR: RRR, normal S1/S2, no murmurs, 3+ pitting lower extremity
edema up to knees bilaterally, R is slightly worse than L
ABD: slightly distended, Soft, NT, normal BS
EXTREM: warm well perfused
SKIN: bruising noted on the anterior shins bilaterally,
psoriasis
NEURO: CN II-XII grossly intact, motor function grossly ___
DISCHARGE PHYSICAL EXAM:
VS: 98.6, 130/70, 75, 18, 94%RA
Weight: 149 pounds
UOP 2275/24
Pain: zero out of 10.
Gen: NAD, sitting in chair, comfortable
HEENT: anicteric, MMM
CV: RRR, no murmur
Pulm: good air movement. No crackles or wheeze
Abd: soft, NT, ND, NABS
Ext: warm, resolved edema
Skin: dry
Neuro: AAOx3, fluent speech
Psych: stable, appropriatel
Pertinent Results:
PERTINENT LABS:
___ 11:30PM BLOOD WBC-7.5# RBC-1.96*# Hgb-6.0*# Hct-18.7*#
MCV-95 MCH-30.6 MCHC-32.1 RDW-19.1* RDWSD-63.0* Plt ___
___ 11:30PM BLOOD ___ PTT-31.2 ___
___ 11:30PM BLOOD Glucose-101* UreaN-26* Creat-1.2* Na-142
K-3.7 Cl-104 HCO3-27 AnGap-15
___ 11:30PM BLOOD Lipase-63*
___ 11:30PM BLOOD cTropnT-<0.01
___ 07:35AM BLOOD proBNP-1794*
___ 11:30PM BLOOD Albumin-4.0
___ 06:45AM BLOOD Calcium-8.8 Phos-3.4 Mg-1.8
___ 06:45AM BLOOD TSH-0.041*
___ 06:45AM BLOOD T4-10.1 T3-146 Free T4-1.8*
___ 12:30AM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
IMAGING:
___ PA/LAT CXR
IMPRESSION:
Cardiomegaly and mild pulmonary vascular congestion. Right
infrahilar opacity could potentially represent pneumonia the
appropriate clinical setting.
RECOMMENDATION(S): Short term followup chest radiograph is
advised to ensure
resolution.
___ ___ Ultrasound
IMPRESSION:
No evidence of deep venous thrombosis in the bilaterallower
extremity veins.
___ Echocardiogram
The left atrium is elongated. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF =
65%). Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). The right
ventricular free wall is hypertrophied. The right ventricular
cavity is mildly dilated with normal free wall contractility.
There is abnormal septal motion/position consistent with right
ventricular pressure/volume overload. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve is not well seen. There is mild aortic valve stenosis
(valve area 1.2-1.9cm2). No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The tricuspid valve leaflets are mildly
thickened. Moderate to severe [3+] tricuspid regurgitation is
seen. There is moderate pulmonary artery systolic hypertension.
[In the setting of at least moderate to severe tricuspid
regurgitation, the estimated pulmonary artery systolic pressure
may be underestimated due to a very high right atrial pressure.]
There is no pericardial effusion.
___ PA/LAT CXR
IMPRESSION:
Compared to chest radiographs since ___, most recently
___.
Previous mild basal pulmonary edema has resolved. Mild
cardiomegaly stable. No pleural abnormality. Upper lungs clear.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 2.5 mg PO DAILY
3. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
4. FoLIC Acid 1 mg PO DAILY
5. Minocycline 100 mg PO Q12H
6. Sertraline 100 mg PO DAILY
7. Cyanocobalamin 50 mcg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Pyridoxine 100 mg PO DAILY
10. Metoprolol Tartrate 50 mg PO BID
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Amlodipine 2.5 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Metoprolol Tartrate 50 mg PO BID
5. Omeprazole 20 mg PO DAILY
6. Sertraline 100 mg PO DAILY
7. Clobetasol Propionate 0.05% Ointment 1 Appl TP BID
8. Cyanocobalamin 50 mcg PO DAILY
9. Minocycline 100 mg PO Q12H
10. Pyridoxine 100 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Volume overload, peripheral edema
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with MDS presenting with new ___ edema // 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 compressibility is
demonstrated in the bilateral 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 bilaterallower extremity veins.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with symptoms of CHF, repeat after diuresis.
// ?persistent evidence of volume overload. ?persistent evidence of
volume overload.
IMPRESSION:
Compared to chest radiographs since ___, most recently ___.
Previous mild basal pulmonary edema has resolved. Mild cardiomegaly stable.
No pleural abnormality. Upper lungs clear.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Shortness of breath
temperature: 100.1
heartrate: 88.0
resprate: 18.0
o2sat: 100.0
sbp: 137.0
dbp: 45.0
level of pain: 0
level of acuity: 2.0 | ___ yo M with history of gout, recently diagnosed hyperthyroidism
(treated with metoprolol with improvement in symptoms, no
antithyroid medications given), and MDS ___ by hematology
for ___ years) for which she was recently started on treatment
with azacitidine (finished first course 3 days prior to
admission); who presented with ___ edema, SOB, weight gain, and
anemia.
Her symptoms may be attributable to azacitadine (based on
reading, ___ swelling may be seen in up to 19% of patients and
SOB in up to 29%) however more concerning is that this may be
new
diastolic heart failure stemming from iron overload given her
long history of multiple transfusions (ferritin recently
>1,000). She may be a candidate for chelation therapy and/or
consideration
for bone marrow transplant. Will trial Lasix and check echo/BNP
to confirm dx.
Low grade temperature and ? infrahilar opacity raise the
possibility of pneumonia however given clinical stability, lack
of other respiratory symptoms of infection despite multiple
recent courses of antibiotics, will observe and hold antibiotics
for now and see for improvement with trial of diuresis as below.
___ edema/?New onset CHF: given history of iron overload,
SOB, ___ edema, 8lb weight gain, with vascular congestion on CXR.
Possible contributing factors of hyperthyroidism and recent
steroid taper. Side effect of recent Vidaza may be
contributing. PE is less likely given evidence of volume
overload, negative ___ and positive CXR findings. Troponin
was negative in the ED. Flu swab negative. Clinically and
radiographically responded well to diuresis. TTE with normal
LVEF, but does have mild elevated LV filling pressure. Has
known moderate pulm HTN, which is confirmed on TTE. Responded
well to 2 doses of IV Lasix (20mg x 1, 40mg x 1), with
improvement in ___ edema, decrease in weight of 7 pounds and
improvement on CXR. Per d/w ___ team, current ferritin level
unlikely to be causing iron deposition related cardiomyopathy.
Ultimately, her symptoms felt to represent volume overload due
to multiple factors - prednisone course, hyperthyroidism,
pulmonary HTN due to OSA and possible side effect of
azacitadine.
#Hyperthyroidism: At her PCPs office in ___, she was noticed
to be anxious, tremulous, and with a rapid heart rate even at
rest. Evaluation by her PCP found she was hyperthyroid (TSH 0.25
on ___ and 0.024 on ___, Free T4 elevated). She was
referred to a local endocrinologist who placed her on metoprolol
to control her symptoms, but held off on any treatment. She
states she had a thyroid u/s at ___ which was
reportedly normal but she has not had a RAI uptake scan per the
patient. Palpitations had reportedly improved as well as her
tremulousness. She was continued on metoprolol. TFT's were
checked, with persistent low TSH but T4 only minimally elevated.
She should follow-up with Endocrinology as previously scheduled.
#MDS:
-per outpatient notes, she learned recently that her sister is a
match for allogeneic bone marrow transplant. "Ms. ___ is not
ready to embark down that path." Hematologist is Dr. ___
___ NP.
#Anemia: sideroblastic anemia unresponsive to Epo per outpt
notes. Consistent with known MDS +/- anemia of chronic disease
(recent iron studies from ___ showed Fe 182 and ferritin >1000).
Also note that EGD was performed on ___ which noted a small
hiatal hernia but was otherwise normal in appearance. No
evidence of bleeding was noted. Biopsies of the antrum and body
were
normal with negative stains for H. pylori. Duodenal biopsy was
within normal limits. s/p 2 units PRBC during this admission.
#CXR Abnormality: Ms. ___ was diagnosed with a multifocal
pneumonia diagnosed in ___. She subsequently had a
follow up CXR done locally by her PCP in late ___ to
document
resolution of a previous pneumonia which did show resolution of
the opacity but revealed a new nodule for which she subsequently
had a chest CT which according to her local pulmonologist, Dr.
___ in ___, which did not show a nodule, but
reported "infiltrations" at the bases of her lungs. She was
placed on a course of clindamycin and 5 day course of prednisone
30 mg daily, which she completed at the end of ___. She
will need follow up imaging for abnormality seen on CXR this
admission but would defer to her outpatient pulmonologist or
PCP. This was discussed with patient and letter also sent to
PCP.
#Gout: continue allopurinol, will need to renally dose if Cr
worsens. Currently asymptomatic.
#HTN: continue home amlodipine/metoprolol
#OSA: pt has her own variable pressure CPAP which she has
brought
#Transitional:
-CXR abnormality: Note region over left lung requires short term
follow up. Can be monitored by PCP or outpatient pulmonary MD
-___ f/u to discuss chelation therapy and BMT
-She has follow up with Endocrinology scheduled in early ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Gastric tube placement
History of Present Illness:
___ with metastatic pancreatic CA discharged yesterday after a
hospitalization for a partial SBO presents again with abdominal
discomfort, distension and nausea earlier today after eating a
egg salad. He had been on a pureed diet prior to discharge and
reports that he chewed the egg salad well. No vomiting. No
other new symptoms. He was seen in clinic today for Neulasta.
He has felt very fatigued since receiving chemo during his last
hospitalization but feels his energy is mildly improved now.
In the ER, he had an NGT placed with approximately 1200 cc
output and resolution of symptoms. He initially had ___
"discomfort" and ___ 'pain' which is now resolved.
All ROS is otherwise unremarkable.
Past Medical History:
pancreatic cancer
Sarcoid
PMR
Atrial fibrillation/flutter with slow ventricular response.
Bradycardia.
Spinal stenosis.
Esophageal achalasia.
Status post vasectomy.
More detailed Onc History per prior notes: Mr. ___ initially
p/w painless jaundice, diarrhea, acholic stools & 15lb weight
loss in ___. MRCP performed ___ showed a 4.2 x 4.8
cm pancreatic head mass. He was taken to the OR by Dr. ___
___ for planned pancreaticoduodenectomy.
Intraoperatively, the tumor was deemed unresectable, & he
underwent palliative choledochojejunostomy & gastroenterostomy.
He began gemcitabine ___. This was dose reduced to
750mg/m2 for elevated bilirubin. He continued w/ dose reductions
due to cytopenias: 800mg/m2 D1,8,15. He was treated w/
CyberKnife ___ - ___. He required dose hold C7D15
(___) due to worsening fatigue, low grade temps and
thrombocytopenia. He returned ___ w/ resolution of fevers,
but had ongoing fatigue, SOB/dry cough, increased leg swelling,
& abdominal fullness. He received Cycle 7, Day 15 gemcitabine.
He returned ___ for Cycle #8 w/ resolution of his low grade
temps, dry cough, & myalgias. He continued to have mild fatigue,
his GI symptoms improved with use of Zantac. He received Cycle
#8 w/o issues. He was seen ___ for Cycle #9. At that time he
was feeling well apart from mild fatigue, his CA ___ showed
continued decline at 37. He received Cycle 9 without problems.
Cycle 10 was postponed 1 week due to URI symptoms, he then
received Cycle 10 without issue. He returned to clinic ___
for Cycle #11. CA ___ was down further to 24. He started Cycle
#12 on ___, and had improved GI symptoms with switch from H2
blocker to PPI. Day 8 counts were notable for low WBC with ANC
around 1000, his platelets were originally read as quite low,
but found to have clumping and repeat counts were stable in the
200's. Day 8 treatment was held, he returned for Day 15. He last
received gemcitabine in ___. He underwent Cyberknife x 5
sessions to pancreas/lymph nodes ___.
Social History:
___
Family History:
brother - GBM
brother - t-cell lymphoma
father - COPD
mother - CVA, UC
granddaughter - ___
paternal grandfather - unknown cancer
Physical Exam:
On Admission:
98.6 141/83 62 12 93% on RA
GEN: NAD, fatigued, pale
HEENT: EOMI, oropharynx clear
CV: RRR no m/r/g
PULM: CTAB
ABD: hypoactive bowel sounds, soft, NTND
EXT: no edema
MS: thin, normal tone
PSYCH: normal affect
DERM: no rashes
On discharge:
Stable vitals
GEN: NAD, fatigued, pale
HEENT: EOMI, oropharynx clear
CV: RRR no m/r/g
PULM: CTAB
ABD: hypoactive bowel sounds, soft, ND, G tube in place
EXT: no edema
MS: thin, normal tone
Pertinent Results:
___ 08:10PM GLUCOSE-126* UREA N-20 CREAT-0.6 SODIUM-135
POTASSIUM-3.7 CHLORIDE-102 TOTAL CO2-20* ANION GAP-17
___ 08:10PM WBC-17.2*# RBC-3.72* HGB-11.3* HCT-33.0*
MCV-89 MCH-30.3 MCHC-34.2 RDW-14.8
___ 08:10PM NEUTS-93.8* LYMPHS-5.5* MONOS-0.4* EOS-0.2
BASOS-0.1
___ 08:10PM PLT COUNT-122*
___ 06:00AM GLUCOSE-131* UREA N-14 CREAT-0.7 SODIUM-136
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-29 ANION GAP-10
___ 06:00AM CALCIUM-9.2 PHOSPHATE-3.3 MAGNESIUM-2.1
CXR ___
PA AND LATERAL VIEWS OF THE CHEST: Lungs are clear.
Cardiomediastinal
silhouette is unremarkable. NG tube is seen coursing below the
level of the diaphragm, distal tip not included on the images.
Right-sided Port-A-Cath is in unchanged position, tip in the
distal SVC. There is no pleural effusion or pneumothorax.
IMPRESSION: No acute intrathoracic process.
___
FINDINGS: Two portable views of the abdomen are provided. NG
tube is seen
coursing into the expected location of the stomach with its last
port past the GE junction. Air-fluid level in the stomach is
noted. There is gaseous
distention of the stomach. Gastroduodenal stent is in unchanged
position. Air is seen to the level of the rectum. There is an
air-distended loop of bowel in the left upper quadrant,
measuring at least 4 cm, difficult to truly discern if large or
small bowel. If small bowel, would be dilated. No evidence of
free air.
CT AB/PELVIS w/ contrast
ABDOMEN: There is persistent pneumobilia within the intrahepatic
biliary
ductal system, consistent choledochoduodenostomy. Otherwise, the
liver
enhances homogeneously, without focal abnormality. The patient
is status post cholecystectomy. There is a poorly delineated
hypodense pancreatic head mass with evidence of local invasion,
which is not particularly well visualized on this study. The
appearance is largely similar to the previous study. The spleen,
adrenal glands and kidneys appear normal.
The stomach is dilated and contrast can be seen filling the
lumen and
progressing through the patent duodenal stent and across midline
within the duodenum until it curves anteriorly and abruptly
tapers (2H:27). No contrast has progressed beyond this point.
The stomach and duodenum up to this transition point are mildly
dilated and an appearance similar to prior
studies. Distal to this, there are multiple loops of
decompressed small bowel as well as fluid-filled, nondilated
colon. There is no ascites, fluid collection, or
pneumoperitoneum.
The portal and splenic veins appear patent. The superior
mesenteric vein
appears to be invaded by the pancreatic mass and no contrast can
be seen
within it. This is stable from the prior examinations. The
abdominal aorta
is tortuous with extensive atherosclerotic calcifications, with
stable
stenosis at the origin of the SMA. Several prominent lymph nodes
within the celiac chain, all of which are unchanged from the
prior study.
PELVIS: There is air and fluid within the rectum and sigmoid
colon. There is no mass or focal wall thickening. The prostate
is stably enlarged. The
bladder and seminal vesicles appear normal. There is no pelvic
or inguinal
lymphadenopathy.
MUSCULOSKELETAL: There are extensive stable degenerative changes
of the
lumbosacral spine. There are no aggressive-appearing osseous
lesions
concerning for malignancy.
IMPRESSION:
Gastric and duodenal dilation up to an abrupt transition point
in the distal duodenum, which may indicate early or partial
small bowel obstruction. The duodenal stent is patent. The
findings may also be due to insufficient transit time of
contrast.
Otherwise, stable examination from prior study, including a
large pancreatic head mass with probable involvement of the SMV
and other incidental findings as outlined above.
Medications on Admission:
1. Creon 24,000-76,000 -120,000 unit Capsule, Delayed
Release(E.C.) Sig: ___ Caps PO ASDIR (AS DIRECTED).
2. Reglan 10 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for nausea.
3. pantoprazole 40 mg Tablet, Delayed Release (E.C.) Sig: One
(1) Tablet, Delayed Release (E.C.) PO Q12H (every 12 hours).
4. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO ASDIR. - pt not currently taking
5. prochlorperazine maleate 10 mg Tablet Sig: One (1) Tablet PO
twice a day as needed for nausea. - pt not taking currently
6. Zofran 4 mg Tablet Sig: ___ Tablets PO three times a day as
needed for nausea. - pt not taking currently
Discharge Medications:
1. lipase-protease-amylase 12,000-38,000 -60,000 unit Capsule,
Delayed Release(E.C.) Sig: One (1) Capsule, Delayed
Release(E.C.) PO ASDIR.
Disp:*90 Capsule, Delayed Release(E.C.)(s)* Refills:*0*
2. Protonix 40 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO twice a day.
Disp:*60 Tablet, Delayed Release (E.C.)(s)* Refills:*0*
3. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO three times a day.
4. morphine concentrate 100 mg/5 mL (20 mg/mL) Solution Sig:
___ mg PO Q1H (every hour) as needed for pain: Hold in mouth
for 20seconds and then swallow.
Disp:*20 ml* Refills:*0*
5. ZOFRAN ODT 4 mg Tablet, Rapid Dissolve Sig: ___ Tablet, Rapid
Dissolves PO every four (4) hours as needed for nausea.
Disp:*90 Tablet, Rapid Dissolve(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
pancreatic cancer
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 small bowel obstruction,
here with NG tube placement. Confirm NG tube placement.
COMPARISON: ___.
PA AND LATERAL VIEWS OF THE CHEST: Lungs are clear. Cardiomediastinal
silhouette is unremarkable. NG tube is seen coursing below the level of the
diaphragm, distal tip not included on the images. Right-sided Port-A-Cath is
in unchanged position, tip in the distal SVC. There is no pleural effusion or
pneumothorax.
IMPRESSION: No acute intrathoracic process.
Radiology Report
CLINICAL HISTORY: ___ man with small bowel obstruction. Status post
NG tube placement.
COMPARISON: ___.
FINDINGS: Two portable views of the abdomen are provided. NG tube is seen
coursing into the expected location of the stomach with its last port past the
GE junction. Air-fluid level in the stomach is noted. There is gaseous
distention of the stomach. Gastroduodenal stent is in unchanged position. Air
is seen to the level of the rectum. There is an air-distended loop of bowel
in the left upper quadrant, measuring at least 4 cm, difficult to truly
discern if large or small bowel. If small bowel, would be dilated. No
evidence of free air.
Radiology Report
INDICATION: Patient with unresectable pancreatic cancer with duodenal stent
and symptoms consistent with SBO. Evaluate for obstruction prior to G-tube
versus GJ tube placement.
COMPARISONS: CTs from ___ and ___.
TECHNIQUE: MDCT-acquired axial images from the lung bases through the pubic
symphysis were obtained after uneventful administration of intravenous and
enteric contrast. Multiplanar reformations were performed to generate coronal
and sagittal images.
DLP: 365.63 mGy-cm.
FINDINGS: The lung bases and imaged portion of the heart are unremarkable.
ABDOMEN: There is persistent pneumobilia within the intrahepatic biliary
ductal system, consistent choledochoduodenostomy. Otherwise, the liver
enhances homogeneously, without focal abnormality. The patient is status post
cholecystectomy. There is a poorly delineated hypodense pancreatic head mass
with evidence of local invasion, which is not particularly well visualized on
this study. The appearance is largely similar to the previous study. The
spleen, adrenal glands and kidneys appear normal.
The stomach is dilated and contrast can be seen filling the lumen and
progressing through the patent duodenal stent and across midline within the
duodenum until it curves anteriorly and abruptly tapers (2H:27). No contrast
has progressed beyond this point. The stomach and duodenum up to this
transition point are mildly dilated and an appearance similar to prior
studies. Distal to this, there are multiple loops of decompressed small bowel
as well as fluid-filled, nondilated colon. There is no ascites, fluid
collection, or pneumoperitoneum.
The portal and splenic veins appear patent. The superior mesenteric vein
appears to be invaded by the pancreatic mass and no contrast can be seen
within it. This is stable from the prior examinations. The abdominal aorta
is tortuous with extensive atherosclerotic calcifications, with stable
stenosis at the origin of the SMA. Several prominent lymph nodes within the
celiac chain, all of which are unchanged from the prior study.
PELVIS: There is air and fluid within the rectum and sigmoid colon. There is
no mass or focal wall thickening. The prostate is stably enlarged. The
bladder and seminal vesicles appear normal. There is no pelvic or inguinal
lymphadenopathy.
MUSCULOSKELETAL: There are extensive stable degenerative changes of the
lumbosacral spine. There are no aggressive-appearing osseous lesions
concerning for malignancy.
IMPRESSION:
Gastric and duodenal dilation up to an abrupt transition point in the distal
duodenum, which may indicate early or partial small bowel obstruction. The
duodenal stent is patent. The findings may also be due to insufficient
transit time of contrast.
A delayed scan may be obtained to assess for interval progression of p.o.
contrast.
Otherwise, stable examination from prior study, including a large pancreatic
head mass with probable involvement of the SMV and other incidental findings
as outlined above.
Radiology Report
G-tube placement
INDICATION: ___ man with pancreatic CA with bowel obstruction.
OPERATORS: Drs. ___ (fellow) and ___ (attending
physician). Dr. ___ was present throughout the procedure.
CONTRAST: Sterile 30 mL Optiray 320 in the stomach and proximal small bowel.
SEDATION: Moderate sedation with divided doses of intravenous ___ mcg of
fentanyl and 2 mg Versed over 1 hour and 30 minutes, during which patient's
hemodynamic status was continuously monitored by a trained radiology nurse.
PROCEDURE AND FINDINGS: Initial scout fluoroscopic image demonstrated
nasogastric tube tip below the level of the diaphragm. After insufflating the
stomach with about 60 mL of gas, an appropriate site was chosen on the left
anterior upper abdominal wall. Under aseptic conditions, and after
infiltrating the skin with subcutaneous tissues with adequate amounts of 1%
lidocaine, three T-fasteners were placed sequentially under fluoroscopic
guidance. Placements were confirmed by injecting a small amount of sterile
contrast material. A 19-gauge needle was then placed amidst the T-tack access
points, again under fluoroscopic guidance. A small amount of sterile contrast
material was injected to confirm position. A 0.035 ___ wire was advanced
through the needle and coiled within the stomach. After making a skin
incision at the access site, the needle was removed to place a 7 ___ ___
tip sheath. After removing the inner cannula, a small amount of contrast was
injected through the sidearm to confirm position. A 5 ___ Kumpe catheter
was then placed alongside the ___ wire and within the sheath. Another
0.035 ___ wire was placed within the Kumpe catheter and the combination
was negotiated to the distal stomach, then via the gastric antrum/duodenal
stent and into the distal duodenum/proximal jejunum. The ___ wire was
then exchanged for a 0.035 stiff Glidewire, which was then used to negotiate
the Kumpe catheter further into the proximal jejunum. After exchanging the
Glidewire for a stiff 0.035 Amplatz wire, the catheter, safety wire and
subsequently, ___ sheath were removed. The tract was sequentially
dilated under fluoroscopy with 10, 14, 16, 18 and 20 ___ dilators under
fluoroscopy. After exchanging the Amplatz wire for the stiff Glidewire with
the help of the Kumpe catheter, attempts were initially made to place a 16
___ MIC GJ tube, however, it could we could not advance past the proximal
portion of the distal gastric/proximal duodenal stent. Further attempts were
made to advance a 14 ___ ___ transgastric jejunal tube, however, we ran
into the same difficulty at the proximal portion of the metallic stent.
Decision was then made to just place a gastric tube.
A 7 ___ ___ sheath was placed over the wire and advanced in to the
stomach. Another ___ wire was placed besides the Stiff Glide and coiled
within the stomach. Stiff Glide and sheath were removed to place a 12 ___
___ gastric tube. After removing the wire, the string was
withdrawn, locked and trimmed to form the retention pigtail loop in the
gastric lumen. A small amount of sterile contrast material was injected to
confirm position. Catheter was cleared by sterile saline, and was secured by
0 silk sutures and Flexi-Trak. Site was dressed in appropriate fashion.
Patient tolerated the procedure well and no immediate post-procedure
complication was seen.
IMPRESSION: Uncomplicated fluoroscopy-guided placement of a 12 ___
___ gastric tube with its retention pigtail loop in the gastric
lumen. Prior to it, attempts were made to place a 16 ___ MIC GJ and a 14
___ ___ transgastric jejunal tube; however, we were unsuccessful.
Findings were discussed over the telephone with Dr. ___, GI fellow
at 12:37 p.m. on ___.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with INTESTINAL OBSTRUCT NOS, MALIG NEO PANCREAS NOS, ATRIAL FIBRILLATION, SARCOIDOSIS
temperature: 97.5
heartrate: 62.0
resprate: 16.0
o2sat: 100.0
sbp: 121.0
dbp: 76.0
level of pain: 8
level of acuity: 3.0 | ___ yo M with hx of advanced unresectable pancreatic ca (s/p
palliative choledochojejunostomy & gastroenterostomy) with hx of
SBO s/p duodenal stent with multiple recurrent partial SBOs who
presented 1 day after discharge with recurrent abdominal pain
and symptoms of bowel obstruction.
# Partial SBO - The patient presented with his ___ partial SBO
despite stent placement in ___. He was initially made NPO and
his abdominal pain was relieved with NGT placement (and put to
suction). A repeat CT was again concerning for a pSBO and
ultimately the patient was taken to ___ for G-J tube placement.
A J tube was unable to be placed due to the duodenal stent, but
a G-tube was successfully placed. The patient was started on
tube feeds, but will limited success due to developing bowel
discomfort. Ultimately we attempted to perform tube feeds at
night and venting during the the day via the G-tube, but he
remained unable to tolerate this. Pain and nausea were
controlled as needed with medication. He was transitioned to
hospice and goals of care were shifted to comfort measures only.
# Pancreatic cancer - The patient underwent cycle 2 of
FOLFIRINOX starting on ___, and completed treatment on ___
without complication other than low counts. No obvious clinical
improvement and pt unwilling to continue with chemotherapy in
the absence of evidence of clinical benefit. A pallative care
consult was obtained and he switched to comfort measures only.
His CODE status was made DNR/DNI.
# History of Nonsustained VT and bradycardia: He evaluated by
cardiology during a prior hospitalization. Cardiology
previously documented that there is "no indication for
pacemaker or ICD, given lack of symptoms and patient's poor
prognosis and short life expectance; No need to obtain
echocardiogram, as this would not change management." They
recommended avoiding BB, CCB and reccommended caffeine intake.
Electrolytes were repleted in the usual fashion
# Atrial flutter: CHADS2 score 0, had been on ASA in the past,
currently not anticoagulated due to thrombocytopenia.
# Achalasia and GERD: Continued outpatient PPI BID. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Code stroke for left sided weakness and dysarthria
Major Surgical or Invasive Procedure:
___ - Cerebral Angiogram with unsuccessful catheterization
and recanalization of the proximal right internal carotid artery
History of Present Illness:
___ with no significant medical history (he reports having not
seen a physician in ___ years) who noted acute onset of
light-headedness and dysequilibrium followed by left
sided-weakness and significant dysarthria at 7:30 AM after
taking
a shower. Code stroke called given his significant acute
deficits.
The patient had been previously fit and well until 7:50 AM. Upon
coming out of the shower, he was light-headed and experienced a
sensation of rocking backwards and forwards followed by
sudden-onset left-sided weakness. He fell backward, hitting his
back and right elbow. During this time he also noticed left
finger-tip numbness and significant dysarthria, such that his
son
had difficulty making out any words. He was initially reluctant
to call EMS, but his son did. He was transferred to the ___
ED.
Of note, over the past 2 months, the patient had been very
stressed and had initially daily episodes of an odd feeling
which
he had great difficulty in describing save that it felt as if
"something was grabbing hold of me". He attributed these to his
heart and they eased after he took a deep breath. These lessened
in frequency over the past 1 month but were still frequent. He
did however note that he had been very stressed over this period
as he has family and financial worries. He denies any prior
weakness or numbness or vision loss. No neck pain or trauma in
recent past. No stroke-like symptoms.
At ___ ED, the patient was hypertensive to 190s, had left
hemiplegia, hemisensory dusturbance, neglect, and right gaze
deviation. There was evidence of a right MCA and ICA occlusion
on
CTA. CTP shows right MCA hypoperfusion. He was given IV tPA at
9:12 AM. After this, his symptoms significantly improved by
assessment at 10:45 AM, with NIHSS then 3. However, by 11:30
after his blood pressure dipped to SBP 140-160s, his weakness
and
gaze deviated reappeared, with evidence of left hemisensory
deficit. Due to his initial improvement, Neurointerventional
radiology were not keen to intervene, but he did go to the
angiosuite after the above worsening, but the vessel could not
be
opened.
Past Medical History:
No known issues but has not seen a doctor in ___ years; possible
remote history of hypertension
Social History:
___
Family History:
Mother - breast ca
Father - blocked neck arteries per patient ahd had ? CEA, no
strokes, prostate ca
Sibs - sisters - breast ca
Children - 5 well 1 with soem learning difficulties
.
There is no history of seizures, developmental disability,
migraine headaches, strokes less than 50, neuromuscular
disorders, or movement disorders.
Physical Exam:
At admission:
Vitals: T:Afebrile P:70 SR R:14 BP:156/77 SaO2: 100%RA
General: Awake, cooperative left hemiparesis initially improved
and mild and then fluctuated and returned to dens left
hemiparesis.
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. Calves SNT.
Skin: Large hematoma right olecranon following fall and bruises
on back.
Neurologic:
___ Stroke Scale score at 10:45 was 2 and 11:30 was 10
1a. Level of Consciousness: 0
1b. LOC Question: 0
1c. LOC Commands: 0
2. Best gaze: 0 at ___. Visual fields: 0
4. Facial palsy: 1 at ___. Motor arm, left: 1 at ___. Motor arm, right: 0
6a. Motor leg, left: 0 at ___. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 0 at ___. Language: 0
10. Dysarthria: 0 at ___. Extinction and Neglect: 0
-Mental Status:
ORIENTATION - Alert, oriented x 3
The pt. had good knowledge of current events.
SPEECH
Able to relate history without difficulty.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors.
Speech was not dysarthric initially then mild dysarthria.
NAMING Pt. was able to name both high and low frequency objects.
READING - Able to read without difficulty
ATTENTION - Attentive, able to name ___ backward without
difficulty.
REGISTRATION and RECALL
Pt. was able to register 3 objects and recall 3/ 3 at 5
minutes.
COMPREHENSION
Able to follow both midline and appendicular commands
There was no evidence of apraxia or neglect
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation. Funduscopic
exam revealed no papilledema, exudates, or hemorrhages.
III, IV, VI: EOMI without nystagmus initially then at 11:30
right
gaze deviation butr could look to left.
V: Facial sensation intact to light touch.
VII: Mild left facial weakness.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally initially then
considerable weakness on left.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. Initial assessment mild
left pronator drift then dens left hemiparesis.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Initial assessment post tPA.
Delt Bic Tri WrE FFl FE IP Quad Ham TA ___
L 5 5 4+ 4+ ___ 5 4 4+ 5 5
R 5 ___ ___ 5 5 5 5 5
Following this, had deterioration in exam with dense left
hemiparesis with minimal left foot movement and only distal left
hand movement.
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout on right. On left
decreased temperature whole left side, decreased pinprick to
knee
in ___ and whole of left UE, decreased vibration to ankle on
leftLE and sme decreased proprioception in left foot to ankle.
No
extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 1 1
R 2 2 2 2 1
Plantar response was flexor bilaterally with contraction of TFL
on left.
-Coordination: No intention tremor. No dysmetria on FNF or HKS
bilaterally but some difficulty with weakness on initail
assessment.
-Gait: Deferred
At transfer from NeuroICU to stroke floor:
normal mental status, improved right gaze preference and no
longer has L neglect. Mild DSS extinction on left to sensory and
less so visual. left facial droop with dysarthria, left
hemiparesis - flaccid in LUE, joint position sense impairment in
LUE, somewhat improved, sensation intact to light touch
bilaterally, extensor toe on left.
.
At Discharge:
Neurological Exam Prior to Discharge:
Mental Status: Awake, Alert, Oriented to person, place, month,
day year, able to name months of year backwards
Cranial Nerves: Notable for Left Facial droop, on left lateral
gaze does not entirely bury the sclerae, saccadic intrusions on
lateral gaze, sensation equal V1-V3 bilaterally, tongue midline,
unable to raise Left shoulder (CN XI), inconsistent visual
fields (on one trial extinguished to visual double simultaneous
stimulation)
Motor: ___ in left upper and left lower extremity
Reflexes: unable to elicit reflexes on the L, right biceps and
right patella 2; upgoing toe on right
Sensory: No extinguishing to double simultaneous tactile
stimulation (using face and arm)
Pertinent Results:
LABS ON ADMISSION:
___ 08:50AM BLOOD WBC-9.0 RBC-5.11 Hgb-14.4 Hct-42.6 MCV-83
MCH-28.2 MCHC-33.9 RDW-13.5 Plt ___
___ 08:50AM BLOOD ___ PTT-33.6 ___
___ 08:50AM BLOOD Plt ___
___ 05:14PM BLOOD ___ 08:50AM BLOOD UreaN-16
___ 08:51AM BLOOD Creat-1.0
___ 05:14PM BLOOD Glucose-104* UreaN-12 Creat-0.8 Na-140
K-3.8 Cl-108 HCO3-25 AnGap-11
___ 05:14PM BLOOD CK(CPK)-149
___ 01:17AM BLOOD ALT-15 AST-25 CK(CPK)-273 AlkPhos-76
TotBili-0.7
___ 05:14PM BLOOD Calcium-7.6* Phos-2.9 Mg-1.8
___ 01:17AM BLOOD Albumin-4.0 Calcium-8.0* Phos-2.5* Mg-1.8
Cholest-175
___ 05:14PM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG Tricycl-NEG
___ 08:58AM BLOOD Glucose-107* Na-141 K-3.5 Cl-101
calHCO3-26
.
CARDIAC ENZYMES:
___ 05:14PM BLOOD CK-MB-3 cTropnT-<0.01
___ 01:17AM BLOOD CK-MB-5 cTropnT-<0.01
.
STROKE RISK FACTORS:
___ 01:17AM BLOOD %HbA1c-5.4 eAG-108
___ 01:17AM BLOOD Triglyc-76 HDL-47 CHOL/HD-3.7 LDLcalc-113
___ 01:17AM BLOOD TSH-0.44
.
___ 10:34 am MRSA SCREEN Source: Nasal swab.
**FINAL REPORT ___
MRSA SCREEN (Final ___: No MRSA isolated.
CTA/CTP brain:
Final Report
INDICATION: Stroke, question fall.
COMPARISON: Retrieved on the OMR.
TECHNIQUE: CT head without contrast; CT angiogram of the head
and neck with
IV contrast; CT cerebral perfusion study. With reformations of
the arteries
and _____ color maps.
FINDINGS:
NON-CONTRAST CT HEAD: There is dense appearance of the right
middle cerebral
artery, representing thrombus within. There is a hypodense area
noted in the
right corona radiata, which is likely chronic.
There is no acute intracranial hemorrhage or mass effect at this
point. There
is mild prominence of the ventricles and extra-axial CSF spaces
related to
volume loss.
No suspicious osseous lesions are noted. Moderate mucosal
thickening is noted
in the ethmoid air cells on both sides.
The cerebral perfusion study: There is a large area of increased
MTT with
decreased blood flow and slightly decreased blood volume
presenting a large
area of ischemia in the right MCA territory. Associated small
acute infarct
is possible in addition with a large penumbra.
CT ANGIOGRAM OF THE HEAD AND NECK: The origins of the arch
vessels are
patent. On the left, there is mixed atherosclerotic disease
noted at the
right common carotid artery bifurcation, with calcified and
noncalcified
plaques. Except for a short segment at the origin, there is
total complete
occlusion of the right cervical internal, marked narrowing of
the right
cervical internal carotid artery, with minimal flow within. In
the petrous
and the cavernous carotid segments, there is no flow noted. As
also in the
supraclinoid segment. There is no flow noted in the right middle
cerebral
artery. A few peripheral collaterals are noted.
The right A1 segment is partially occluded. There is likely flow
within the
more distal parts of the right anterior cerebral artery through
the anterior
communicating artery.
The left common carotid artery and the cervical internal carotid
arteries are
patent without focal flow-limiting stenosis or occlusion. Mixed
atherosclerotic plaques are noted at the left common carotid
bifurcation
causing some degree of stenosis, approximately 50-60% stenosis.
No flow
limitation is noted distally. There are also vascular
calcifications noted in
the cavernous carotid segment on the left side with a few
calcifications.
There is no flow limitation. The left anterior and the middle
cerebral
arteries are patent, including the peripheral branches.
The vertebral arteries are patent throughout their course
without focal
flow-limiting stenosis, occlusion or aneurysm. Scattered
calcifications are
noted in the distal vertebral arteries and the V4 segments,
predominantly on
the left side with moderate short segment stenosis. The major
branches of the
vertebral and basilar arteries are patent. The basilar artery is
diminutive
in size with fetal PCA pattern, with prominent posterior
communicating
arteries and diminutive P1 segments.
The thyroid is unremarkable. A few small scattered nodes are
noted in both
sides of the neck, not enlarged by CT size criteria. Mild
fullness is noted
in the left pyriform sinus.
A small subpleural based focus is noted in the right lung. In
the apex, which
can be correlated with dedicated CT chest imaging.
Mild degenerative changes are noted in the cervical spine,
better assessed on
the concurrent CT C-spine study.
IMPRESSION:
1. No acute intracranial hemorrhage or mass effect.
2. Large area of perfusion abnormality in the right middle
cerebral artery
territory.
3. The large area of ischemia along with a possible small area
of acute
infarction. If there is continued concern, for the extent of
infarction, MRI
can be considered.
4. New total occlusion of the right cervical internal carotid
artery,
occlusion of the right petrous, and the intracranial segments of
the internal
carotid artery and the right middle cerebral artery.
Possibilities include
dissections/thrombosis. Partial occlusion of the right A1
segment.
Please see the subsequent conventional angiogram study.
Short segment narrowing of the left distal vertebral artery from
calcified
plaques, moderate degree. 50-60% narrowing of the left common
carotid artery
at the bifurcation.
CT C-spine without contrast:
Final Report
INDICATION: ___ man with recent fall, with concern for
stroke, to
evaluate for C-spine fracture.
COMPARISON: None available.
TECHNIQUE: MDCT images were acquired through the cervical spine
without
intravenous contrast. Sagittal and coronal reformats were
generated and
reviewed.
FINDINGS: No acute cervical spine fracture or malalignment is
detected. The
prevertebral soft tissues are normal. The vertebral body heights
are normal.
There is mild reduction of the intervertebral disc height at
C5-C6, C6-C7 and
C7-T1 levels. Mild degenerative changes are seen throughout the
cervical
spine, with mild uncovertebral hypertrophy seen in the lower
cervical spine,
causing narrowing of neural foramina at multiple levels. Some of
the
osteophytes are obliquely oriented with lucencies; midl
displacement of the
anterior longitudinal ligament is noted. No significant spinal
canal stenosis
is seen in the cervical level. There is some degree of rotation
at C1 and C2-
correlate clinically-? positional. The imaged portion of the
thyroid gland
is normal. A subpleural nodular focus is noted in the right lung
apex.
Vascular calcifications and scattered nodes are noted. Fullness
in the
piriform sinuses-correlate clinically.
IMPRESSION: No acute cervical spine fracture or malalignment.
Multilevel
degenerative changes with foraminal narrowing. Correlate
clinically to decide
on the need for further workup.
Cerebral angiogram:
Final Report
CLINICAL HISTORY:
___ male with history of sudden onset of left
hemiplegia. CT
angiogram demonstrates a possible total occlusion of the right
internal
carotid artery and thrombus in the right middle cerebral artery.
Informed consent was obtained from the patient after explaining
the risks,
indications and alternative management. Risks and indications
were also
discussed with the patient's son.
The patient was brought to the neurointerventional suite and
prepared for
General Anesthesia and was ready for puncture at 2:20 p.m.
Access to the right common femoral artery was obtained under
local anesthesia
with aseptic precautions. A 4 ___ Berenstein catheter was
introduced into
the right common carotid artery and the following blood vessels
were
selectively catheterized and arteriograms were performed:
RIGHT COMMON CAROTID ARTERY:
LEFT COMMON CAROTID ARTERY:
RIGHT COMMON CAROTID ARTERY FINDINGS:
There is almost total occlusion of the right internal carotid
artery noted at
its origin with questionable trickle of contrast into the
cervical portion of
the right internal carotid artery. There is the distal
reconstitution of the
supraclinoid right internal carotid artery noted with extensive
thrombus in
the cervical portion of the right internal carotid artery and M2
segment of
the middle cerebral artery on the right.
Later the catheter was withdrawn and the left common carotid
artery was
catheterized.
LEFT COMMON CAROTID ARTERY FINDINGS:
There is moderate irregular plaque noted in the proximal left
internal carotid
artery. There is good flow noted in the distal left internal
carotid artery,
anterior and middle cerebral arteries on the left. There is
cross flow noted
across the anterior communicating artery into the A2 branch of
the anterior
cerebral artery on the right.
The system was upgraded to a 9 ___ system and ___ balloon
catheter was
introduced into the right common carotid artery. A rapid transit
catheter and
a gold tip Glidewire was introduced to catheterize the right
internal carotid
artery. Multiple attempts to catheterize the proximal right
internal carotid
artery using gold tip glide wire were unsucessful. At this
point, findings
were discussed with Dr. ___ suggested to abort the
procedure. 2
milligrams of TPA was introduced into the proximal right
internal carotid
artery.
IMPRESSION:
1. Unsuccessful catheterization and recanalization of the
proximal right
internal carotid artery.
2. 2 mg of TPA was introduced into the proximal right internal
carotid
artery.
ECG:
Sinus rhythm. Normal tracing. No previous tracing available for
comparison.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
71 188 86 ___
MRA Brain without contrast:
Final Report
INDICATION: Right ICA and MCA occlusion with attempted
thrombolysis. MRI to
evaluate for stroke.
COMPARISON: CTA head from ___ and cerebral angiogram
from ___.
TECHNIQUE: MRI and MRA of the brain was performed without
contrast per
departmental protocol.
FINDINGS:
MRI HEAD: There is an area of slow diffusion with accompanying
FLAIR signal
abnormality involving the right basal ganglia, posterior limb of
the right
internal capsule with extension into the corona radiata. A small
central focus
of abnormal susceptibility in the right basal ganglia infarct
likely
represents small hemorrhagic component. Multiple tiny scattered
foci of slow
diffusion are also seen in the distal right MCA territory. There
is no mass
effect, or edema seen. A chronic lacunar infarct is seen in the
right centrum
semiovale.
There is no hydrocephalus or midline shift. Visualized orbits,
paranasal
sinuses, and mastoid air cells are unremarkable.
MRA OF THE BRAIN: As seen on the prior CTA and recent carotid
angiogram,
there is persistent occlusion of the right internal carotid
artery. There is
filling of the right ACA and MCA via collaterals from the circle
of ___.
The right MCA, however, appears attenuated. There is an overall
paucity of
the peripheral cortical branches of the right MCA. The left
internal carotid
artery, left anterior cerebral and middle cerebral arteries
appear patent with
no evidence of stenosis, occlusion, dissection, or aneurysm
formation.
Bilateral vertebral arteries, basilar artery and their major
branches are
patent with no significant stenosis or occlusion.
IMPRESSION:
1. Early subacute infarct with small central component of
hemorrhagic
transformation, involving the right basal ganglia and posterior
limb of the
internal capsule, with extension into the right corona radiata,
as described
above.
2. Multiple small scattered foci of slow diffusion in the right
MCA
distribution, concerning for acute embolic infarcts.
3. Chronic lacunar infarct in the right centrum semiovale.
4. Persistent right ICA occlusion with reconstitution of the
right ACA and
MCA. However, the right MCA appears attenuated with an overall
paucity of
distal cortical branches.
R groin vascular U/S:
Final Report
INDICATION: Patient with recent diagnostic angiogram. Assess for
aneurysm
formation in the right groin.
COMPARISONS: None available.
FINDINGS:
Grayscale and color Doppler images of common femoral artery and
vein
demonstrate patent vessels. There is no evidence of
pseudoaneurysm or AV
fistula. Appropriate arterial and venous waveforms are
demonstrated. No focal hematoma in this region is seen.
IMPRESSION:
No evidence of pseudoaneurysm, AV fistula, or adjacent hematoma
involving
right common femoral vessels.
TTE:
Conclusions
The left atrium and right atrium are normal in cavity size. No
atrial septal defect or patent foramen ovale is seen by 2D,
color Doppler or saline contrast with maneuvers. There is mild
symmetric left ventricular hypertrophy with normal cavity size
and regional/global systolic function (LVEF>55%). There is an
apically displaced muscle band. Right ventricular chamber size
and free wall motion are normal. The aortic arch is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Trace aortic regurgitation is
seen. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
preserved global and regional biventricular systolic function.
Dilated aortic arch. No definite cardiac source of embolism
identified.
CLINICAL IMPLICATIONS:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
Ankle Xray:
FINDINGS: The mortise is congruent. No fractures or dislocations
are
observed. No significant soft tissue swelling is observed. The
soft tissue
is unremarkable. There is very minimal degenerative changes seen
in the ankle and tarsal joints including small osteophyte
formation around the
talonavicular joint and tiny calcaneal enthesophytes.
IMPRESSION: No fractures or dislocations. Mild degenerative
changes seen in the ankle and tarsal joints.
CXR:
FINDINGS: There is no evidence of rib fractures. Both lungs are
clear.
Heart size is normal. Mediastinal and hilar contours are
unremarkable. There is no pleural abnormality.
IMPRESSION: No evidence of rib fracture; however, since this
technique is not dedicated for evaluation of bones, should the
clinical concern for rib
fracture persists, dedicated rib views are recommended for
further evaluation.
.
LABS AT TIME OF DISCHARGE:
___ 05:00AM BLOOD WBC-6.8 RBC-4.37* Hgb-12.3* Hct-36.4*
MCV-83 MCH-28.0 MCHC-33.7 RDW-13.2 Plt ___
___ 05:35AM BLOOD ___ PTT-83.7* ___
___ 05:35AM BLOOD Calcium-8.9 Phos-3.3 Mg-1.9
Medications on Admission:
Aspirin 325mg qd
Nil OTC
Discharge Medications:
1. acetaminophen 650 mg/20.3 mL Solution Sig: One (1) PO Q6H
(every 6 hours) as needed for pain.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. warfarin 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. lisinopril 20 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
- infarct with small central component of hemorrhagic
transformation, involving the right basal ganglia and posterior
limb of the internal capsule, with extension into the right
corona radiata
- embolic infarcts in the right MCA distribution
in the setting of Right Internal Carotid Artery Occlusion,
Right Middle Cerebral Artery Occlusion (since recanalized)
Secondaty Diagnoses: Hypertension, Hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
.
Neurological Exam Prior to Discharge:
Mental Status: Awake, Alert, Oriented to person, place, month,
day year, able to name months of year backwards
Cranial Nerves: Notable for Left Facial droop, on left lateral
gaze does not entirely bury the sclerae, saccadic intrusions on
lateral gaze, sensation equal V1-V3 bilaterally, tongue midline,
unable to raise Left shoulder (CN XI), inconsistent visual
fields (on one trial extinguished to visual double simultaneous
stimulation)
Motor: ___ in left upper and left lower extremity
Reflexes: unable to elicit reflexes on the L, right biceps and
right patella 2; upgoing toe on right
Sensory: No extinguishing to double simultaneous tactile
stimulation (using face and arm)
Followup Instructions:
___
Radiology Report
INDICATION: ___ male status post fall and left ankle pain status post
struck.
COMPARISON: None available.
TECHNIQUE: AP, mortise and lateral radiographs of the left ankle.
FINDINGS: The mortise is congruent. No fractures or dislocations are
observed. No significant soft tissue swelling is observed. The soft tissue
is unremarkable. There is very minimal degenerative changes seen in the ankle
and tarsal joints including small osteophyte formation around the
talonavicular joint and tiny calcaneal enthesophytes.
IMPRESSION: No fractures or dislocations. Mild degenerative changes seen in
the ankle and tarsal joints.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Evaluate for rib fractures.
TECHNIQUE: Portable upright chest view was reviewed. No prior chest
radiographs were available for comparison.
FINDINGS: There is no evidence of rib fractures. Both lungs are clear.
Heart size is normal. Mediastinal and hilar contours are unremarkable. There
is no pleural abnormality.
IMPRESSION: No evidence of rib fracture; however, since this technique is not
dedicated for evaluation of bones, should the clinical concern for rib
fracture persists, dedicated rib views are recommended for further evaluation.
Radiology Report
INDICATION: Stroke, question fall.
COMPARISON: Retrieved on the OMR.
TECHNIQUE: CT head without contrast; CT angiogram of the head and neck with
IV contrast; CT cerebral perfusion study. With reformations of the arteries
and _____ color maps.
FINDINGS:
NON-CONTRAST CT HEAD: There is dense appearance of the right middle cerebral
artery, representing thrombus within. There is a hypodense area noted in the
right corona radiata, which is likely chronic.
There is no acute intracranial hemorrhage or mass effect at this point. There
is mild prominence of the ventricles and extra-axial CSF spaces related to
volume loss.
No suspicious osseous lesions are noted. Moderate mucosal thickening is noted
in the ethmoid air cells on both sides.
The cerebral perfusion study: There is a large area of increased MTT with
decreased blood flow and slightly decreased blood volume presenting a large
area of ischemia in the right MCA territory. Associated small acute infarct
is possible in addition with a large penumbra.
CT ANGIOGRAM OF THE HEAD AND NECK: The origins of the arch vessels are
patent. On the left, there is mixed atherosclerotic disease noted at the
right common carotid artery bifurcation, with calcified and noncalcified
plaques. Except for a short segment at the origin, there is total complete
occlusion of the right cervical internal, marked narrowing of the right
cervical internal carotid artery, with minimal flow within. In the petrous
and the cavernous carotid segments, there is no flow noted. As also in the
supraclinoid segment. There is no flow noted in the right middle cerebral
artery. A few peripheral collaterals are noted.
The right A1 segment is partially occluded. There is likely flow within the
more distal parts of the right anterior cerebral artery through the anterior
communicating artery.
The left common carotid artery and the cervical internal carotid arteries are
patent without focal flow-limiting stenosis or occlusion. Mixed
atherosclerotic plaques are noted at the left common carotid bifurcation
causing some degree of stenosis, approximately 50-60% stenosis. No flow
limitation is noted distally. There are also vascular calcifications noted in
the cavernous carotid segment on the left side with a few calcifications.
There is no flow limitation. The left anterior and the middle cerebral
arteries are patent, including the peripheral branches.
The vertebral arteries are patent throughout their course without focal
flow-limiting stenosis, occlusion or aneurysm. Scattered calcifications are
noted in the distal vertebral arteries and the V4 segments, predominantly on
the left side with moderate short segment stenosis. The major branches of the
vertebral and basilar arteries are patent. The basilar artery is diminutive
in size with fetal PCA pattern, with prominent posterior communicating
arteries and diminutive P1 segments.
The thyroid is unremarkable. A few small scattered nodes are noted in both
sides of the neck, not enlarged by CT size criteria. Mild fullness is noted
in the left pyriform sinus.
A small subpleural based focus is noted in the right lung. In the apex, which
can be correlated with dedicated CT chest imaging.
Mild degenerative changes are noted in the cervical spine, better assessed on
the concurrent CT C-spine study.
IMPRESSION:
1. No acute intracranial hemorrhage or mass effect.
2. Large area of perfusion abnormality in the right middle cerebral artery
territory.
3. The large area of ischemia along with a possible small area of acute
infarction. If there is continued concern, for the extent of infarction, MRI
can be considered.
4. New total occlusion of the right cervical internal carotid artery,
occlusion of the right petrous, and the intracranial segments of the internal
carotid artery and the right middle cerebral artery. Possibilities include
dissections/thrombosis. Partial occlusion of the right A1 segment.
Please see the subsequent conventional angiogram study.
Short segment narrowing of the left distal vertebral artery from calcified
plaques, moderate degree. 50-60% narrowing of the left common carotid artery
at the bifurcation.
Other details as above. Wet read was entered on the OMR soon after the study.
Radiology Report
INDICATION: ___ man with recent fall, with concern for stroke, to
evaluate for C-spine fracture.
COMPARISON: None available.
TECHNIQUE: MDCT images were acquired through the cervical spine without
intravenous contrast. Sagittal and coronal reformats were generated and
reviewed.
FINDINGS: No acute cervical spine fracture or malalignment is detected. The
prevertebral soft tissues are normal. The vertebral body heights are normal.
There is mild reduction of the intervertebral disc height at C5-C6, C6-C7 and
C7-T1 levels. Mild degenerative changes are seen throughout the cervical
spine, with mild uncovertebral hypertrophy seen in the lower cervical spine,
causing narrowing of neural foramina at multiple levels. Some of the
osteophytes are obliquely oriented with lucencies; midl displacement of the
anterior longitudinal ligament is noted. No significant spinal canal stenosis
is seen in the cervical level. There is some degree of rotation at C1 and C2-
correlate clinically-? positional. The imaged portion of the thyroid gland
is normal. A subpleural nodular focus is noted in the right lung apex.
Vascular calcifications and scattered nodes are noted. Fullness in the
piriform sinuses-correlate clinically.
IMPRESSION: No acute cervical spine fracture or malalignment. Multilevel
degenerative changes with foraminal narrowing. Correlate clinically to decide
on the need for further workup.
Radiology Report
CLINICAL HISTORY:
___ male with history of sudden onset of left hemiplegia. CT
angiogram demonstrates a possible total occlusion of the right internal
carotid artery and thrombus in the right middle cerebral artery.
Informed consent was obtained from the patient after explaining the risks,
indications and alternative management. Risks and indications were also
discussed with the patient's son.
The patient was brought to the neurointerventional suite and prepared for
General Anesthesia and was ready for puncture at 2:20 p.m.
Access to the right common femoral artery was obtained under local anesthesia
with aseptic precautions. A 4 ___ Berenstein catheter was introduced into
the right common carotid artery and the following blood vessels were
selectively catheterized and arteriograms were performed:
RIGHT COMMON CAROTID ARTERY:
LEFT COMMON CAROTID ARTERY:
RIGHT COMMON CAROTID ARTERY FINDINGS:
There is almost total occlusion of the right internal carotid artery noted at
its origin with questionable trickle of contrast into the cervical portion of
the right internal carotid artery. There is the distal reconstitution of the
supraclinoid right internal carotid artery noted with extensive thrombus in
the cervical portion of the right internal carotid artery and M2 segment of
the middle cerebral artery on the right.
Later the catheter was withdrawn and the left common carotid artery was
catheterized.
LEFT COMMON CAROTID ARTERY FINDINGS:
There is moderate irregular plaque noted in the proximal left internal carotid
artery. There is good flow noted in the distal left internal carotid artery,
anterior and middle cerebral arteries on the left. There is cross flow noted
across the anterior communicating artery into the A2 branch of the anterior
cerebral artery on the right.
The system was upgraded to a 9 ___ system and ___ balloon catheter was
introduced into the right common carotid artery. A rapid transit catheter and
a gold tip Glidewire was introduced to catheterize the right internal carotid
artery. Multiple attempts to catheterize the proximal right internal carotid
artery using gold tip glide wire were unsucessful. At this point, findings
were discussed with Dr. ___ suggested to abort the procedure. 2
milligrams of TPA was introduced into the proximal right internal carotid
artery.
IMPRESSION:
1. Unsuccessful catheterization and recanalization of the proximal right
internal carotid artery.
2. 2 mg of TPA was introduced into the proximal right internal carotid
artery.
Radiology Report
INDICATION: Right ICA and MCA occlusion with attempted thrombolysis. MRI to
evaluate for stroke.
COMPARISON: CTA head from ___ and cerebral angiogram from ___.
TECHNIQUE: MRI and MRA of the brain was performed without contrast per
departmental protocol.
FINDINGS:
MRI HEAD: There is an area of slow diffusion with accompanying FLAIR signal
abnormality involving the right basal ganglia, posterior limb of the right
internal capsule with extension into the corona radiata. A small central focus
of abnormal susceptibility in the right basal ganglia infarct likely
represents small hemorrhagic component. Multiple tiny scattered foci of slow
diffusion are also seen in the distal right MCA territory. There is no mass
effect, or edema seen. A chronic lacunar infarct is seen in the right centrum
semiovale.
There is no hydrocephalus or midline shift. Visualized orbits, paranasal
sinuses, and mastoid air cells are unremarkable.
MRA OF THE BRAIN: As seen on the prior CTA and recent carotid angiogram,
there is persistent occlusion of the right internal carotid artery. There is
filling of the right ACA and MCA via collaterals from the circle of ___.
The right MCA, however, appears attenuated. There is an overall paucity of
the peripheral cortical branches of the right MCA. The left internal carotid
artery, left anterior cerebral and middle cerebral arteries appear patent with
no evidence of stenosis, occlusion, dissection, or aneurysm formation.
Bilateral vertebral arteries, basilar artery and their major branches are
patent with no significant stenosis or occlusion.
IMPRESSION:
1. Early subacute infarct with small central component of hemorrhagic
transformation, involving the right basal ganglia and posterior limb of the
internal capsule, with extension into the right corona radiata, as described
above.
2. Multiple small scattered foci of slow diffusion in the right MCA
distribution, concerning for acute embolic infarcts.
3. Chronic lacunar infarct in the right centrum semiovale.
4. Persistent right ICA occlusion with reconstitution of the right ACA and
MCA. However, the right MCA appears attenuated with an overall paucity of
distal cortical branches.
Radiology Report
INDICATION: Patient with recent diagnostic angiogram. Assess for aneurysm
formation in the right groin.
COMPARISONS: None available.
FINDINGS:
Grayscale and color Doppler images of common femoral artery and vein
demonstrate patent vessels. There is no evidence of pseudoaneurysm or AV
fistula. Appropriate arterial and venous waveforms are demonstrated. No focal
hematoma in this region is seen.
IMPRESSION:
No evidence of pseudoaneurysm, AV fistula, or adjacent hematoma involving
right common femoral vessels.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: EU CRITICAL 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 | Mr. ___ is a ___ RHM with no significant medical history (he
reports having not seen a physician in ___ years) who noted
acute onset of light-headedness and dysequilibrium followed by
left sided-weakness and significant dysarthria at 7:30 AM (___)
after taking a shower. He presented to the ___ ___ and was
admitted to the Stroke Service for further evaluation and care.
He was discharged on ___ to rehabilitation.
.
#Right Basal Ganglia Infract from Right Internal Carotid Artery
Occlusion (and Right Middle Cerebral Artery Occlusion - since
recanalized): Initially on admission a code stroke called given
his significant acute deficits. At ___ ED, the patient was
hypertensive to 190s and initial NIHSS was 17 with left
hemiplegia, hemisensory dusturbance, neglect, and right gaze
deviation. There was evidence of a right MCA and ICA occlusion
on CTA concerning for dissection. CTP showed a large area of
right MCA hypoperfusion. He was administered IV tPA at 9:12 AM.
After this, his symptoms initially significantly improved with
good antigravity on the left with NIHSS then 3. However, as his
blood pressure dipped to SBP 140-160s, his weakness worsened and
the gaze deviation reappeared, with evidence of left hemisensory
deficit. Accordingly, the Neurointerventional radiology team was
called and he was taken to the angiosuite given the worsening
deficits. Unfortunately, the ICA could not be opened. (The
difficulty passing the catheter through the ICA was thought to
be suggestive of an occlusion from plaque rather than
dissection.)
.
The patient was started on heparin gtt. A subsequent MRI showed
patent R MCA later that night. His goal PTT was 50-70, and was
checked every 6 hours. Dosing adjustments were made accordingly.
In the acute setting the patient required a nicardipine gtt with
goal SBP 140-190's, he eventually did not require this anymore.
After his first two hospital days, the patient was started on
lisinopril which was uptitrated to 20mg QD with a goal SBP of
140-180; some degree of autoregulation was desired to maintain
adequate cerebral perfusion in the setting of the fixed deficit
(ie the persistent R ICA occlusion). He was continuually
monitored on cardiac telemetry without any adverse events or
evidence of cardiac arrhythmias.
.
His stroke risk factors were assessed: FLP 175, ___ 76, HDL 47,
LDL 113, A1C 5.4. As his LDL was not at goal <70 the patient was
started on high dose Atorvastatin 80mg QD. A TTE was obtained
(see full report above) which did not show an ASD/PFO/thrombus,
and the patient had a preserved EF. A Speech and Swallow
evaluation was obtained, and the patient was cleared for a
regular diet. The patient was evaluated by Physical Therapy and
Occupational Therapy, and has been recommended for ___
rehab. Also, the patient will have a follow-up CTA in 3 months,
to be reviewed at his follow-up appointment with Dr. ___ in
Neurology (scheduled prior to discharge).
.
#Hypertension: Patient has had goal SBP 140's-180's, he
previously was not on any anti-HTN medications. We started the
patient on lisinopril and uptitrated to 20mg QD. We have
maintained an elevated blood pressure in order to maintain his
cerebral perfusion. In about 2 days post discharge (___) his
SBP range can be lowered to 120-140's, with uptitration of his
lisinopril.
.
#Left Rib Pain, Left Ankle Pain s/p fall: Patient had a CXR and
a Left Ankle Xray without evidence of fracture. He was treated
with acetaminophen for pain and tolerated this well.
.
#Antiocoagulation: Patient will need anticoagulation for his
occlusion for at least 3 months. His goal INR is ___. His INR
was 2.2 on day of discharge, and he will continue his coumadin
dosing and management at his rehabilitation facility.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
ERCP
Biopsy of the choledocal cyst was performed after
sphincterotomy.
History of Present Illness:
Pt is a ___ y/o M with no significant PMHx, who presented to ___
with epigastric pain x 3 days. Pain was initially sharp, located
in the epigastrum and RUQ, non-radiating. Associated with
diaphoresis. Pain initially resolved after a few minutes. Then,
on the following day, pain returned, less intense but more
persistent. Pain has been present since then. No
nausea/vomiting. Pain is not worsened by eating.
Given persistance of pain, pt presented to ___, where labs were
notable for bilirubin of 8, lipase of 3000. U/S showed dilated
pancreatic and common bile duct without stones or any clearcut
cause. He was transferred for ERCP evaluation.
ED Course:
Initial VS: 98.6 60 158/80 16 98% ra
Labs significant for ALT 484 AST 231 ALP 182 TB 7.8 Lipase 2306.
Cr 1.3
Imaging: MRCP performed, read pending
Meds given: none
VS prior to transfer: 99.4 77 147/87 16 98% RA
ED team spoke with ERCP fellow who requested CT and MRCP and
admission to ___ for possible ERCP. ED deferred CT
given elevated Cr without known baseline.
On arrival to the floor, the patient reports that his pain has
resolved. He has no acute concerns at this time. He does reports
that his urine has been dark recently.
ROS: As above. Denies headache, lightheadedness, dizziness, sore
throat, sinus congestion, chest pain, heart palpitations,
shortness of breath, cough, nausea, vomiting, diarrhea,
constipation, muscle or joint pains, focal numbness or tingling,
skin rash. The remainder of the ROS was negative.
Past Medical History:
- Occular hypertension, on timolol
- Episode of abdominal pain ___ years ago, initially thought to be
related to GB issues but negative work up. Ultimately, treated
with doxycycline empirically for possible tick-borne illness.
Serologies were negative, but symptoms resolved with this
treatment.
Social History:
___
Family History:
Father died of ? pancreatitis, potentially malignancy-related,
details unclear. 3 brothers with prostate cancer.
Physical Exam:
Exam on admission:
VS - 99.1 145/80 74 16 99%RA Pain ___
GEN - Alert, NAD
HEENT - NC/AT, OP clear, scleral icterus, L pupil non-reactive
___ prior trauma
NECK - Supple, no cervical or supraclavicular LAD noted
CV - RRR, no m/r/g
RESP - CTA B
ABD - S/NT/ND, BS present, no masses appreciated
EXT - No ___ edema
SKIN - No apparent rashes
NEURO - Non-focal
PSYCH - Calm, appropriate
Exam on discharge:
T98.7, 120-150s/80-90s, HR ___, RR 18, 100%RA
Abd: soft, NT, ND, normal bowel sounds
Neuro: A&Ox3, normal gait
Pertinent Results:
___ 07:30PM BLOOD WBC-7.5 RBC-4.61 Hgb-14.8 Hct-43.2 MCV-94
MCH-32.0 MCHC-34.2 RDW-12.6 Plt ___
___ 07:30PM BLOOD Neuts-71.3* ___ Monos-6.7 Eos-1.6
Baso-0.5
___ 07:30PM BLOOD ___ PTT-32.3 ___
___ 07:30PM BLOOD Glucose-88 UreaN-13 Creat-1.3* Na-141
K-3.7 Cl-105 HCO3-25 AnGap-15
___ 07:30PM BLOOD ALT-484* AST-231* AlkPhos-182*
TotBili-7.8* DirBili-5.8* IndBili-2.0
___ 07:30PM BLOOD Lipase-2306*
___ 07:30PM BLOOD Albumin-4.2 Calcium-9.1 Phos-3.1 Mg-2.0
Blood Cx PENDING x 2
___ 06:35AM BLOOD WBC-5.3 RBC-4.13* Hgb-13.6* Hct-39.2*
MCV-95 MCH-32.9* MCHC-34.6 RDW-12.4 Plt ___
___ 06:40AM BLOOD Glucose-105* UreaN-6 Creat-1.3* Na-141
K-4.0 Cl-107 HCO3-28 AnGap-10
___ 06:35AM BLOOD ALT-259* AST-81* AlkPhos-126 TotBili-1.7*
=
=
=
================================================================
MRCP ___:
IMPRESSION:
1. 8 mm choledochocele with mild mass effect against the
adjacent pancreatic
duct and mild upstream pancreatic duct dilation to 5 mm. The CBD
measures up
to 6 mm. Mild prominence of the intrahepatic bile ducts.
2. No concerning intrahepatic or pancreatic mass. Small
hepatic cysts or
biliary harmartomas and hemangiomas.
3. Mild non-specific gallbladder wall edema, but no evidence
for acute
cholecystitis.
4. Replaced left hepatic artery arising from the left gastric.
5. Accessory left renal artery.
ERCP ___:
Procedures: A sphincterotomy was performed in the 12 o'clock
position using a sphincterotome over an existing guidewire.
The biliary tree was swept with a 9-12mm balloon starting at the
bifurcation. No stones or sludge were seen.
Biopsy of the choledocal cyst was performed after
sphincterotomy.
Impression: A 20 mm bulging of the major papilla was noted.
Cannulation of the biliary duct was unsuccessful with a
sphincterotome using a free-hand technique. Subsequently a
pre-cut needle knife sphincterotomy was performed using a
free-hand technique. This was followed by successful cannulation
attempt of the biliary duct with a sphincterotome using a
free-hand technique.
A small type III choledocal cyst that was causing partial
obstruction was seen at the biliary tree.
There was a small comon channel between PD and CBD, presenting
abnormal pancreatobiliary junction.
Post-obstructive dilation at the CBD and CHD was present with
CBD measuring 8 mm. The left and right hepatic ducts and all
intrahepatic branches were normal. Opacification of the
gallbladder was incomplete.
The final occlusion cholangiogram showed no evidence of filling
defects in the CBD. Excellent bile and contrast drainage was
seen endoscopically and fluoroscopically.
A sphincterotomy was performed in the 12 o'clock position using
a sphincterotome in order to improve bile flow and remove
potential stones.
The biliary tree was swept with a 9-12mm balloon starting at the
bifurcation. No stones or sludge were seen.
Biopsy of the choledocal cyst was performed after sphincterotomy
in order to evaluate if the cyst is lined by biliary or duodenal
epithelium and to exclude dysplasia, which caries prognostic
importance for cholangiocarcinoma risk assessment.
Otherwise normal ercp to third part of the duodenum
=
=
=
================================================================
Labs at ___ (in computer):
7.8>16.3/48<199
Creatinine 1.44 BUN 13
Na:138, K4.1, Cl 100, Bicarb 25, Ca 9.9
Alb:4.5
AST: 262
ALT: 551
Alk Phos: 204
TBili 8.24
Lipase:3000
U/A negative
___ U/S: Dilated pancreatic duct (up to 5 mm) and dilated
common bile duct (1 cm). There is some gallbladder wall
thickening which seems focal. No stones in the gallbladder or
the common duct. No visible mass in the head of the pancreas.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
Discharge Medications:
1. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
Discharge Disposition:
Home
Discharge Diagnosis:
Pancreatitis
Choledocal cyst with sphincterotomy performed
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Epigastric abdominal pain with CBD dilation. Concern for stones
or obstructive mass.
COMPARISON: Ultrasound available from ___.
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired within a 1.5 Tesla magnet, including 3D dynamic sequences performed
prior to, during, and following the uneventful administration of 9 cc of
Gadovist intravenous contrast. 1 cc of Gadovist mixed with 50 cc of water
were administered for oral contrast.
MRI OF THE ABDOMEN WITH AND WITHOUT IV CONTRAST:
Included views of the lung bases are clear. There is no pericardial or
pleural effusion. The heart size is normal.
The hepatic parenchyma demonstrates normal signal intensity on T1- and
T2-weighted images. Arising from segment ___ and V are 6 mm and 8 mm lesions,
repectively, demonstrating very high signal intensity on T2-weighted images
with no appreciable internal contrast enhancement, compatible with hepatic
cysts or biliary hamartomas (5:7,24). Within the left anterior aspect of
segment V is a 4 mm T2 hyperintense lesion which is gradually less conspicuous
on delayed phase images (1102:61), likely a small hemangioma. No concerning
intrahepatic mass is detected. An ill-defined 8 mm focus of arterial
hyperenhancement in the subcapsular portion of segment VII (1101:38) has no T2
or delayed phase correlate, denoting transient hepatic intensity differences.
A replaced left hepatic artery arises from the left gastric (1101:34). The
portal and hepatic veins are patent.
There is mild prominence of the intrahepatic bile duct. The CBD measures up
to 5 mm. No ductal stones are detected. No gallstones are seen. There is
trace gallbladder wall edema (4:15), without neighboring hyperenhancement or
gallbladder distention. The cystic duct is normal in caliber.
The CBD and pancreatic duct tapers smoothly to the level of the ampulla,
however, there is an 8 mm T2 hyperintense nonenhancing cystic lesion at the
level of the ampulla, protruding into the second portion of the duodenum
(7:1), appearing to communicate with the CBD, and causing mild deviation of
the adjacent pancreatic duct, representing a choledochocele (1102:92).
The pancreatic parenchyma demonstrates normal signal intensity on T1- and
T2-weighted images. The pancreatic duct is smooth and mildly dilated to 5 mm
at the proximal body (7:1). No pancreatic mass is detected.
The spleen, adrenal glands, stomach, and intra-abdominal loops of small and
large bowel are normal. A 10 x 8 mm lesion arising from the lower pole of the
left kidney demonstrates high signal intensity on T2-weighted images without
appreciable internal contrast enhancement, denoting simple cyst. The kidneys
are otherwise normal.
The abdominal aorta, celiac trunk, SMA, and renal arteries are present. An
accessory left renal artery is present (1101:87).
There is no mesenteric or retroperitoneal lymphadenopathy, and no ascites.
There are no bony lesions concerning for malignancy or infection.
IMPRESSION:
1. 8 mm choledochocele with mild mass effect against the adjacent pancreatic
duct and mild upstream pancreatic duct dilation to 5 mm. The CBD measures up
to 6 mm. Mild prominence of the intrahepatic bile ducts.
2. No concerning intrahepatic or pancreatic mass. Small hepatic cysts or
biliary harmartomas and hemangiomas.
3. Mild non-specific gallbladder wall edema, but no evidence for acute
cholecystitis.
4. Replaced left hepatic artery arising from the left gastric.
5. Accessory left renal artery.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: NEED ERCP
Diagnosed with CHOLELITHIASIS NOS
temperature: 98.6
heartrate: 60.0
resprate: 16.0
o2sat: 98.0
sbp: 158.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | ___ y/o M with no significant PMHx, who presented to ___ with
epigastric pain x 3 days, found to have acute pancreatitis.
# Acute Pancreatitis: The cause of the pancreatitis was found to
be due to a choledochocele. An MRCP from ___ revealed an
8 mm choledochocele with mild mass effect against the adjacent
pancreatic duct and mild upstream pancreatic duct dilation to 5
mm. The CBD measures up to 6 mm. Mild prominence of the
intrahepatic bile ducts. The patient had an ERCP on ___,
with sphincterotomy performed and biospy of the choledocal cyst
done afterwards. The patient was also noted to have the presence
of an abnormal pancreatobiliary junction. He was able to
tolerate a normal diet the following day and made a bowel
movement prior to discharge. The biopsy results will need to be
followed up on and he will need a referral to a
gastroenterologist specializing in endoscopy. His LFTs also
downtrended post-procedure and are expected to normalize. A
repeat check of LFTs in ___ weeks will be at the discretion of
the patient's PCP. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
acetaminophen-codeine / lisinopril
Attending: ___
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HMED ATTENDING INITIAL NOTE
DATE: ___
TIME SEEN 330 AM
==================================
HPI:
___ yo female with history of pulmonary hypertension, multiple
myeloma, presents after syncope. She was getting into her
daughter's car when she was noted to be unresponsive, eyes
rolling to the back of her head and was noted to have shaking
movements. She was pulled out onto the curb and layed flat, she
was noted to have continued shaking movements without enuresis.
No fecal incontinence. After she recovered consciousness on the
order of minutes she was noted to be oriented. Patient denies
any prodrome other than "feeling funny" to the ED physician but
to author she reports feeling very short of breath. She felt as
though she was going to die. She denies feeling as though the
curtains were closing and she was going to pass out. She denied
shortness of breath with baseline activity but her dtr reported
to her RN that she does get SOB with exertion. She reported L
sided anterior ___ chest pain, worse with inspiration.
She does not report other pains. She was wearing a scarf when
this occurred but this is normal for her in the winter. No sx
when she turns her head. She felt well prior to the incident and
had eaten dinner approximately an hour before her daughter came
to pick her up. She denies chest pain on exertion. At baseline
she has lower extremity edema but this is improved compared to
her baseline. She had a good full BM in the ED in the commode
prior to coming to the floor. No report of dark or bloody stool.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: As per HPI
HEENT: [X] All normal
RESPIRATORY: [+] Per HPI
CARDIAC: [+] per HPI
GI: As per HPI
GU: [X] All normal
SKIN: [X] All normal
MUSCULOSKELETAL: [X] All normal
NEURO: [+] L hand resting tremor
ENDOCRINE: [X] All normal
HEME/LYMPH: [X] All normal
PSYCH: [X] All normal
All other systems negative except as noted above
Past Medical History:
ONCOLOGIC HISTORY: Mrs. ___ is a ___ ___ female
with a past medical history of osteoporosis and multiple
traumatic compression fractures who presented with new back and
right hip pain in ___. Initial X-rays revealed lumbar
spine degenerative changes, most pronounced at L5-S1, no
compression fractures, but multiple subtle lucencies were seen.
She was admitted on ___ for pain control and was noted to
have anorexia, fatigue, and a 20 lb weight loss over the last 6
months. Her initial imaging was notable for 2 subcentimeter
lesions in the mid femur on the right causing endosteal
scalloping and cortical thinning up to 50%, but without
associated stress fracture, cortical breakthrough or soft tissue
component. She was felt to be too high risk for surgery as she
was found to have severe pulmonary HTN and severe 4+ TR by ECHO.
V/Q scan was low likelihood for PE. She received radiation to
her
R femur from ___ to ___ (20 Gy total). Bone marrow
biopsy
on ___ confirmed a hypercellular BM with involvement by a
plasma cell dyscrasia, with 37% plasma cells seen on aspirate
and
making up 70-80% of marrow cellularity by CD138 staining.
Cytogenetics revealed a normal karyotype, but ___ nuclei were
positive for 13q deletion and ___ nuclei showed IGH-CCND1
rearrangement. Her initial labs were notable for Ca ___, alb
3.3; B2 microglobulin 6.2; SPEP abnormal with IgG of 4284
(monoclonal IgG kappa), IgA 38, IgM 15; free K/L ratio 18.90;
and
UPEP negative for Bence ___ protein. She began her first cycle
of velcade/dexamethasone on ___. She developed pain in her R
humerus and received 800 cGy in a single fraction on ___.
Her
second cycle began on ___. She received Zometa on ___.
She started her ___ cycle on ___. She was admitted from
___ due to R groin pain and she was found to have
fractures of the R hemisacrum, superior and inferior pubic rami.
These were managed medically with rest and pain medication. She
was discharged to rehab but started C4 velcade/dexamethasone on
___ and received Zometa on ___ as well. She started C5 of
velcade/dexamethasone on ___, but her D8 and D11 treatments
were held due to persistent eye symptoms. She resumed treatment
on ___ and received C6, C7, and C8 on schedule. She was on a
treatment holiday from ___ until ___ but due to a
slight increase in her SPEP, she was started on Revlimid
maintenance on ___, 10mg PO daily for three weeks followed
by
one week off. Revlimid held in ___ due to deconditioning and
failure to thrive at home thought not to be secondary to
multiple myeloma.
OTHER PAST MEDICAL HISTORY
Osteoporosis
HTN
Pulmonary hypertension
Social History:
___
Family History:
Daughter with breast cancer.- pt could not remember this
Mom died at ___ due to bleeding after tooth extraction.- per OMR
Dad had DM.
Physical Exam:
On Admission:
orthostatic VS in ED:
Orthostatic Laying
77 128/77 19
Orthostatic Sitting
73 125/79 21 100% RA
Orthostatic Standing
77 102/65 22 99% RA
Vitals: 98.7 PO 154 / 89 R 78 16 97 RA 0 0 9
10
CONS: NAD, comfortable appearing
HEENT: ncat anicteric MMM
Elevated JVP
CHEST: Positive kyphosis
+ chest wall tenderness
CV: s1s2 rrr ___ loud holosystolic murmur heard at the ___
RESP: b/l basilar crackles
GI: +bs, soft, NT, ND, no guarding or rebound
reducible ventral hernia present
MSK:no c/c/e DPP pulses barely palpable b/l
SKIN: brawny thickening of skin on b/l lower extremities
NEURO: face symmetric speech fluent
+ resting tremor of RUE
PSYCH: calm, cooperative
LAD: No cervical LAD
Discharge exam:
VITALS: 98.7, 133/83, 64, 18, 96% on RA
Orthostatic vitals negative yesterday
GEN: Chronically ill appearing, kyphotic, lying in bed
comfortably, right
sided resting tremor
HEENT: EOMI, sclerae anicteric, dry mucous membranes, OP clear
NECK: No LAD, no JVD
CARDIAC: Regular rate and normal rhythm, ___ SEM at RUSB
PULM: CTAB, no wheezing or rhonchi, severe kyphosis
GI: soft, protuberant abdomen ___ kyphosis, normoactive bowel
sounds, nontender throughout
MSK: No visible joint effusions or deformities. Left sided
anterior chest pain, reproducible on exam
DERM: No visible rash. No jaundice
NEURO: AAOx3. No facial droop, right sided resting tremor
PSYCH: Full range of affect
EXTREMITIES: WWP, no edema
Pertinent Results:
On Admission:
___ 11:27PM K+-3.9
___ 11:15PM GLUCOSE-136* UREA N-23* CREAT-1.1 SODIUM-137
POTASSIUM-3.7 CHLORIDE-99 TOTAL CO2-26 ANION GAP-16
___ 10:03PM K+-8.2*
___ 10:00PM URINE COLOR-Straw APPEAR-Hazy SP ___
___ 10:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-SM
___ 10:00PM URINE RBC-2 WBC-13* BACTERIA-FEW YEAST-NONE
EPI-2
___ 10:00PM URINE HYALINE-1*
___ 09:00PM GLUCOSE-154* UREA N-24* CREAT-1.1 SODIUM-135
POTASSIUM-5.8* CHLORIDE-98 TOTAL CO2-24 ANION GAP-19
___ 09:00PM estGFR-Using this
___ 09:00PM WBC-11.2*# RBC-4.73 HGB-11.4 HCT-37.0 MCV-78*
MCH-24.1* MCHC-30.8* RDW-15.1 RDWSD-42.8
___ 09:00PM NEUTS-87.1* LYMPHS-5.6* MONOS-6.1 EOS-0.2*
BASOS-0.3 IM ___ AbsNeut-9.77*# AbsLymp-0.63* AbsMono-0.69
AbsEos-0.02* AbsBaso-0.03
___ 09:00PM PLT COUNT-216
================================================================
Interval:
___ 11:15PM BLOOD CK-MB-4 cTropnT-0.10*
___ 07:50AM BLOOD CK-MB-3 cTropnT-0.04*
___ 01:05PM BLOOD CK-MB-3 cTropnT-0.03*
Imaging:
___ CXR
1. No definite evidence of pneumonia.
2. Stable cardiomegaly with vascular engorgement, but no overt
pulmonary
edema.
___ CT Head
Limited examination due to motion artifact and patient position.
Within these limitations, no evidence of fracture or
intracranial hemorrhage.
___ CTA
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Multiple thyroid nodules, measuring up to 1.2 cm on the
right.
3. Diffuse pancreatic ductal prominence within area focal
dilation measuring up to 8 mm, increased from ___.
Recommend correlation with prior abdominal imaging, if
available. Otherwise, recommend follow-up with CT or MRI, if not
recently performed, to exclude an obstructing lesion.
4. Multiple thoracic vertebral body compression fractures at
T3-T6 and T9-T10, similar to ___. Remote fractures of the
left lateral second rib and sternum.
RECOMMENDATION(S): Correlation with prior abdominal imaging to
determine
chronicity of pancreatic ductal dilation. If no recent imaging
is available, recommend follow-up with CT or MRI to exclude an
obstructing lesion.
___ ECHO
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is at least 15 mmHg. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal.
Regional left ventricular wall motion is normal. Left
ventricular systolic function is hyperdynamic (EF>75%). The
right ventricular free wall is hypertrophied. The right
ventricular cavity is moderately dilated with normal free wall
contractility. The diameters of aorta at the sinus, ascending
and arch levels are normal. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. Severe [4+] tricuspid
regurgitation is seen. There is severe pulmonary artery systolic
hypertension. There is a very small pericardial effusion. There
are no echocardiographic signs of tamponade.
Compared with the prior study (images reviewed) of ___,
no major change.
DISCHARGE LABS:
___ 07:37AM BLOOD WBC-8.5 RBC-4.45 Hgb-10.9* Hct-34.7
MCV-78* MCH-24.5* MCHC-31.4* RDW-15.1 RDWSD-42.3 Plt ___
___ 07:37AM BLOOD Plt ___
___ 07:37AM BLOOD Glucose-94 UreaN-18 Creat-0.8 Na-140
K-3.7 Cl-102 HCO3-26 AnGap-16
___ 07:45AM BLOOD ALT-68* AST-27 AlkPhos-40 TotBili-0.7
___ 07:37AM BLOOD Calcium-9.4 Phos-3.6 Mg-2.2
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Potassium Chloride 20 mEq PO DAILY
2. Acetaminophen 1000 mg PO TID
3. Aspirin 81 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic BID
6. Senna 17.2 mg PO DAILY
7. Acyclovir 400 mg PO Q8H
8. Mirtazapine 7.5 mg PO QHS
9. Docusate Sodium 100 mg PO BID
10. melatonin 3 mg oral QHS
11. Hydrochlorothiazide 12.5 mg PO DAILY
12. Donepezil 10 mg PO QHS
13. amLODIPine 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Acyclovir 400 mg PO Q8H
3. Aspirin 81 mg PO DAILY
4. Cyclosporine 0.05% Ophth Emulsion 0.05 % ophthalmic BID
5. Docusate Sodium 100 mg PO BID
6. Donepezil 10 mg PO QHS
7. Hydrochlorothiazide 12.5 mg PO DAILY
8. melatonin 3 mg oral QHS
9. Mirtazapine 7.5 mg PO QHS
10. Senna 17.2 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
orthostatic hypotension
syncope
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA CHEST
INDICATION: ___ year old woman with MM s/p syncopal episode with persistent
chest pressure after. Unable to rule out fracture on CXR per radiology given
severe osteopenia. // Please evaluate for fracture
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Total DLP: 132 mGy-cm
COMPARISON: Cervical spine CT ___, Chest CT ___,
thoracic spine CT ___, chest radiograph ___
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no
evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present.
Atherosclerotic calcifications are mild.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main and right pulmonary arteries are
normal in caliber, and there is no evidence of right heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
There are multiple hypodense thyroid nodules, measuring up to 1.2 cm on the
right (5:20).
Heart is mildly enlarged. There is no evidence of pericardial effusion.
There is no pleural effusion.
There are two right upper lobe nodules measuring 2-3 mm each (5:32), similar
to ___. There is also a 5 mm subpleural nodule in the left upper
lobe (3:39), which is not significantly changed from the prior study,
accounting for slight differences in technique. There is no focal
consolidation. The airways are patent to the subsegmental level.
There is diffuse prominence of the imaged pancreatic duct measuring up to 6 mm
in diameter, with 8 mm focal dilation in the pancreatic body (5:103). This
has progressed compared to the prior chest CT performed on ___. No
intrahepatic biliary dilation.
There is exaggeration of normal thoracic kyphosis due to multiple compression
fractures. Compression fractures are seen involving the T3 through T6
vertebral bodies, and T9-T10, which appear overall similar compared to the ___ thoracic spine MRI. There is a remote nondisplaced left lateral
second rib fracture (9:108), and a chronic displaced sternal fracture.
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic abnormality.
2. Multiple thyroid nodules, measuring up to 1.2 cm on the right.
3. Diffuse pancreatic ductal prominence within area focal dilation measuring
up to 8 mm, increased from ___. Recommend correlation with interval
prior abdominal imaging, if available. Otherwise, recommend follow-up with
MRCP (or CT pf thepancreas if patient cannot tolerate MRCP) to exclude an
obstructing lesion.
4. Multiple thoracic vertebral body compression fractures at T3-T6 and T9-T10,
similar to ___. Remote fractures of the left lateral second rib and
sternum.
RECOMMENDATION(S): Correlation with prior abdominal imaging to determine
chronicity of pancreatic ductal dilation. If no recent imaging is available,
recommend follow-up with CT or MRI to exclude an obstructing lesion.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Syncope
Diagnosed with Syncope and collapse
temperature: 98.0
heartrate: 95.0
resprate: 16.0
o2sat: 100.0
sbp: 177.0
dbp: 99.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is an ___ year old woman with a history of pulmonary
hypertension and multiple myeloma who presents with syncope
after getting into her daughters car.
# Syncope: Highest on the differential is orthostasis vs cardiac
etiology. Orthostatic signs are positive with precipitation of
her symptoms. Concern for worsening RV function in the setting
of pulmonary hypertension. No evidence of PE on CTA. EKG at
baseline, troponins elevated on admission, though downtrended.
CK-MB flat. Telemetry without evidence of arrhythmias. Low
suspicion for seizure activity or vasovagal. ECHO revealed no
changes from prior.
# Orthostatic hypotension: Patient presented with symptomatic
Orthostasis. Differential included worsening RV function as
above vs autonomic dysfunction, vs adrenal insufficiency, aging,
and the effect of medications. ECHO revealed no changes from
prior. AM cortisol was wnl. B12 level was WNL. Home
antihypertensives were initially held. She wore TEDS during her
admission and HOB was kept elevated 30 degrees. Side effect of
donepezil was also considered, but this was continued as her
orthostatic hypotension resolved with fluids and improved PO
intake.
# Multiple myeloma: S/P induction velcade with clinical and
laboratory response. Now off of treatment, though with evidence
of multiple compression fractures throughout on CT.
# Left sided chest pain: CTA with evidence of numerous
fractures, including left sided 2nd rib fracture, which is
consistent with where the patient is experiencing pain. Pain
control with standing Tylenol, lidocaine patch, and tramadol
PRN.
# Memory impairment: Continued donepezil
# Insomnia: Continued remeron
***TRANSITIONAL ISSUES***
- Pancreatic lesion: CTA at admission incidentally noted diffuse
pancreatic ductal prominence with an area of focal dilation
measuring up to 8mm, increased from ___. No interval
imaging available for comparison. Consider MRCP for further
evaluation as outpatient. Patient's lipase and LFTs overall
unremarkable and patient was asymptomatic. |