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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cipro / latex / peaches / Laminaria
Attending: ___.
Chief Complaint:
Hypoxemic respiratory failure
Major Surgical or Invasive Procedure:
___ Intubation
___ Extubation
History of Present Illness:
Ms. ___ is a ___ year old woman with history of
hypertension, obesity, asthma, headaches, seizure d/o on
lamotrigine, chiari 1 malformation s/p surgical decompression,
and chronic mobility and social issues, presenting on post
partum
day 6 after C-section for twins with respiratory distress s/p
intubation, found to have low ___ transferred to ___ and ED for
further management of peripartum cardiomyopathy.
She was recently discharged on ___ after C-section on ___ for
C
section complicated by peripartum hemorrhage requiring suction
D&C and 2UpRBC. She was feeling well until the day prior to
admission, when she began having some orthopnea. On the morning
of admission, she had sudden dyspnea waking her up for sleep.
She
also reported feeling as if her chest was collapsing on her. She
presented to ___, where she was found to be hypoxic
to mid-high ___ on NRB. She was unable to tolerate biPAP and was
therefore intubated at 6:30am. Sedation was difficult and she
was
paralyzed with rocuronium. She was also started on nitro gtt for
high blood pressures. She had CTA that was negative for PE, but
showed RML pneumonia. She received 80mg IV Lasix with 1100cc out
prior to transfer. She was transferred to ___ by med-flight
for
further management.
In the ED, vitals were notable for HR in 110s, BP
130s-150s/90s-100s, intubated with O2 sat 93-98%. Patient was
notably quite hypoxic on the ventilator, with PEEP up to 18 and
Fio2 50% and TV 400 with ABG ___ on transfer. She
continued to trigger the ventilator. Exam was notable for
diminished breath sounds, soft abdomen, pitting edema
bilaterally, and no evidence of vaginal hemorrhage.
Labs were notable for leukocytosis to 18.8, up from 13.2 at
discharge, Hgb 8.0 improved from 7.5 at last discharge, plt
count
546 up from normal at discharge. New transaminitis with AST 51,
normal ALT, alk phos elev to 241, LDH to 661. Trop 0.04, flat
MB,
BNP > 11K. Lactate was elevated to 2.8 and downtrended to 1.3
prior to transfer.
EKG was notable for sinus tachycardia at 118 bpm, normal axis,
normal RWP, isolated ST elevation in V2, no TWI or Q waves. She
received vancomycin and cefepime for potential pneumonia, and
was
kept on nitroglycerin and propofol gtts.
OB was consulted in the ED and recommended pre-ecclampsia
evalution given her history of seizrues and chronic
hypertension.
Cardiology was consulted and bedside ___ revealed EF 20%,
anterior hypokinesis, and mild MR. ___ was ordered.
She has a socially complex history, with father of children
currently imprisoned. Her friend, ___, is currently caring for
the newborn twins. ___ was consulted in the ED to send an
emergency team to evaluate situation with friend and if newborns
can stay there. On recent admission, SW had filed 51A out of
concern that twins may be at risk for neglect and plan was to
contact the patient this week.
On arrival to the CCU, the patient was intubated and sedated.
Past Medical History:
Cardiac History:
- Hypertension
Other PMH:
- obesity
- asthma
- headaches
- seizure d/o on lamotrigine, history of non-adherence
- chiari 1 malformation s/p surgical decompression
- chronic mobility and social issues
- G2Po112
Social History:
___
Family History:
- Hypertension in father
- ___ and MI in paternal grandmother
- CAD in paternal grandfather
- Early MI in paternal uncle in ___
- ___ cancer in aunt, diagnosed in early ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
GENERAL: Intubated and sedated.
HEENT: Normocephalic, atraumatic.
NECK: Supple. JVP elevated.
CARDIAC: Tachycardic, regular rhythm. Distant heart sounds.
LUNGS: Intubated. No wheezes.
ABDOMEN: Soft, non-tender, non-distended. No palpable
hepatomegaly or splenomegaly.
EXTREMITIES: Warm, well perfused. ___ edema. Mildly
cool.
SKIN: No significant lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
NEURO: Intubated and sedated.
DISCHARGE PHYSICAL EXAM:
========================
GENERAL: resting comfortably, able to converse in full
sentences
without any dyspnea, NAD
NECK: Supple, JVP < 5cm
CARDIAC: regular rate/rhythm, normal S1 and S2, no M/R/G
LUNGS: clear to auscultation bilaterally
ABDOMEN: Soft, nd, nt. Incision site healing well without
tenderness
EXTREMITIES: Warm, trace lower extremity edema.
NEURO: AOx3, no focal deficits.
Pertinent Results:
ADMISSION LABS:
===============
___ 08:10AM BLOOD WBC-18.8* RBC-2.78* Hgb-8.0* Hct-26.7*
MCV-96 MCH-28.8 MCHC-30.0* RDW-16.0* RDWSD-54.2* Plt ___
___ 08:10AM BLOOD ___ PTT-26.3 ___
___ 08:10AM BLOOD Glucose-92 UreaN-17 Creat-0.7 Na-140
K-4.3 Cl-107 HCO3-13* AnGap-20*
___ 08:10AM BLOOD Albumin-3.0* Calcium-8.1* Phos-5.7*
Mg-2.0
DISCHARGE LABS:
===============
___ 06:28AM BLOOD WBC-10.2* RBC-3.58* Hgb-10.2* Hct-34.5
MCV-96 MCH-28.5 MCHC-29.6* RDW-17.2* RDWSD-56.9* Plt ___
___ 06:28AM BLOOD Glucose-95 UreaN-13 Creat-0.7 Na-143
K-5.1 Cl-108 HCO3-22 AnGap-13
___ 06:28AM BLOOD Calcium-9.5 Phos-4.3 Mg-2.3
RELEVANT IMAGING:
=================
___ CXR
Marked interval improvement in pulmonary opacities.
___ CXR
No comparison. The patient is intubated, with the tip of the
endotracheal
tube projecting approximately 3 cm above the carinal. The
course of the
feeding tube is unremarkable, the tip is not visualized on the
image. Lung volumes are low. Moderate cardiomegaly is
present. The very extensive right medial and basal parenchymal
opacity with air bronchograms is visualized, the location would
be consistent with aspiration. There also is an accompanying
mild to moderate right pleural effusion. No evidence of
pulmonary edema.
___ ___
Normal left ventricular wall thickness and biventricular cavity
sizes with severe global left ventricular hypokinesis in a
pattern most c/w a non-ischemic cardiomyopathy. Right
ventricular free wall hypokinesis. Mild mitral regurgitation
with normal valve morphology. High normal estimated pulmonary
artery systolic pressure.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheeziness
2. Docusate Sodium 100 mg PO BID
3. Ferrous Sulfate 325 mg PO BID
4. Symbicort (budesonide-formoterol) 2 PUFF IH BID
5. Omeprazole 20 mg PO BID
6. norethindrone (contraceptive) 0.35 mg oral DAILY
7. LaMICtal XR (lamoTRIgine) 300 mg oral qAM
8. LaMICtal XR (lamoTRIgine) 400 mg oral qhs
9. Propranolol 20 mg PO BID
10. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
11. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
12. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
13. FoLIC Acid 1 mg PO DAILY
14. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE:PRN allergic reaction
with trouble breathing
15. Diazepam 2 mg PO DAILY:PRN anxiety
16. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
Discharge Medications:
1. Apixaban 5 mg PO/NG BID
2. Metoprolol Succinate XL 200 mg PO DAILY
3. Sacubitril-Valsartan (97mg-103mg) 1 TAB PO BID
4. Spironolactone 25 mg PO DAILY
5. Torsemide 10 mg PO EVERY OTHER DAY
6. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
7. Diazepam 2 mg PO DAILY:PRN anxiety
8. Docusate Sodium 100 mg PO BID
9. EPINEPHrine (EpiPEN) 0.3 mg IM ONCE:PRN allergic reaction
with trouble breathing
10. Ferrous Sulfate 325 mg PO BID
11. FoLIC Acid 1 mg PO DAILY
12. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
13. LaMICtal XR (lamoTRIgine) 300 mg oral qAM
14. LaMICtal XR (lamoTRIgine) 400 mg oral QHS
15. Omeprazole 20 mg PO BID
16. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
17. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
18. Symbicort (budesonide-formoterol) 2 PUFF IH BID
19. HELD- Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB, wheeziness
This medication was held. Do not restart Albuterol Inhaler until
you meet with your primary care doctor.
20. HELD- norethindrone (contraceptive) 0.35 mg oral DAILY This
medication was held. Do not restart norethindrone
(contraceptive) until you meet with your outpatient
gynecologist. You received the Depot Provera injection while you
were hospitalized.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
Peripartum cardiomyopathy
Secondary diagnoses:
Non-sustained ventricular tachycardia
Supraventricular tachycardia
Anemia
Thrombocytosis
Acute hypoxemic respiratory failure
Seizure disorder
Asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (uses
walker at baseline).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with hypoxia and shortness of breath*** WARNING ***
Multiple patients with same last name!// ?cardiomegaly, pneumonia, effusions
?cardiomegaly, pneumonia, effusions
IMPRESSION:
No comparison. The patient is intubated, with the tip of the endotracheal
tube projecting approximately 3 cm above the carinal. The course of the
feeding tube is unremarkable, the tip is not visualized on the image. Lung
volumes are low. Moderate cardiomegaly is present. The very extensive right
medial and basal parenchymal opacity with air bronchograms is visualized, the
location would be consistent with aspiration. There also is an accompanying
mild to moderate right pleural effusion. No evidence of pulmonary edema.
Radiology Report
EXAMINATION: Chest radiograph, portable AP semi-upright.
INDICATION: PICC line placement
COMPARISON: Prior examination from ___.
FINDINGS:
A PICC line terminates in the lower superior vena cava. Patient is intubated.
Endotracheal tube terminates about 3 cm above the carina. An orogastric tube
terminates in the stomach. Heart is normal in size. Mediastinal and hilar
contours appear within normal limits. Small layering pleural effusions are
suspected bilaterally. No pneumothorax. Hazy opacities are bilateral but
include somewhat prominent right basilar interstitial thickening including
peribronchial cuffing. Findings are on the whole most likely due to pulmonary
edema.
IMPRESSION:
1. PICC line terminating in the lower superior vena cava. Endotracheal tube
terminating 3 cm above the carina. Orogastric tube terminating in the
stomach.
2. Suspected bilateral pleural effusions and pulmonary edema. Possibility of
developing pneumonia in the right lower lobe is doubted but if it is a
possible clinical concern short-term follow-up repeat radiographs may be
helpful.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US RIGHT
INDICATION: ___ year old woman with history of hypertension, obesity, asthma,
headaches, seizure d/o on lamotrigine, chiari 1 malformation s/p surgical
decompression, and chronic mobility and social issues, presenting on post
partum day 6 after C-section for twins with respiratory distress s/p
intubation, found to have low ___ transferred to ___ and ED for further
management of peripartum cardiomyopathy. Noted to have new swelling,
tightness, and pain in R forearm this evening// Evaluate for right upper
extremity DVT
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
veins.
The right internal jugular, axillary, and brachial veins are patent, show
normal color flow, spectral doppler, and compressibility. The right basilic,
and cephalic veins are patent, compressible and show normal color flow.
There is nonspecific edema about the right forearm without focal fluid
collection.
IMPRESSION:
1. No evidence of deep vein thrombosis in the right upper extremity.
2. Subcutaneous edema about the right forearm is nonspecific. No focal fluid
collection.
Radiology Report
EXAMINATION: Chest radiograph, AP portable upright.
INDICATION: Respiratory failure due to heart failure.
COMPARISON: Prior day.
FINDINGS:
Endotracheal tube terminates about 2.5 cm above the carina. Orogastric tube
terminates in the stomach. Left-sided PICC line appears unchanged terminating
at the cavoatrial junction. Cardiac, mediastinal and hilar contours appear
stable. Marked interval improvement in bilateral lung opacities including
along the right lower lung no definite pleural effusion. No pneumothorax..
IMPRESSION:
Marked interval improvement in pulmonary opacities.
Gender: F
Race: WHITE
Arrive by HELICOPTER
Chief complaint: Dyspnea, Transfer
Diagnosed with Oth complications of the puerperium, NEC, Heart failure, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: ua
level of acuity: 1.0 | Ms. ___ is a ___ year old woman with history of
hypertension, obesity, asthma, headaches, seizure d/o on
lamotrigine, chiari 1 malformation s/p surgical decompression,
and chronic mobility and social issues, presenting on post
partum day 6 after C-section for twins with respiratory distress
s/p intubation, found to have low ___ transferred to ___ for
further management of peripartum cardiomyopathy. ___ ___ showed
LVEF 15%, severe global LV hypokinesis c/w non-ischemic
cardiomyopathy, RV free wall hypokinesis, mild MR, and high PA
systolic pressure. She was extubated on ___ and was actively
diuresed and started on PO meds. New discharge meds included:
torsemide 10mg qod, metoprolol XL 200mg qd, Entresto 97mg-103mg
bid, spironolactone 25mg qd, apixaban 5mg bid for cardioembolic
prophylaxis given global LV hypokinesis. She will follow up with
outpatient PCP, ___, and Dr ___ with f/u ___
at that time.
ACUTE ISSUES:
=============
# Hypoxemic respiratory failure
# Peripartum cardiomyopathy
# Acute systolic HF exacerbation
# RML consolidation
Presented with sudden onset dyspnea and hypoxia requiring
intubation at OSH. This was ___ pulmonary edema in setting of
peripartum cardiomyopathy ___ edema, elevated BNP, orthopnea at
home) as resp status improved with diuresis. She was
successfully extubated on ___. CTA was negative for PE. She
received ceftriaxone for coverage of possible pneumonia, though
this was discontinued. She was started on apixaban 5mg bid for
cardioembolic prophylaxis, given EF<15%, global LV hypokinesis.
She was discharged on torsemide 10mg qod, metoprolol XL 200mg
qd, Entresto 97mg-103mg bid, spironolactone 25mg qd.
Discharge weight: 86.2 kg, 190.04 lbs (diuresis plan: torsemide
10mg qod).
# RUE Swelling
Noted to have tense and significant RUE swelling following
admission. RUE U/S unremarkable. Surgery consulted, and felt
this likely was related to her PIV. Her exam improved following
removal of PIV and elevation of the arm.
# Seizure disorder
Has history of seizures transitioned from oxcarbazapien to
lamictal, prior history of setting house on fire with seizure.
Seizures are usually absence, not generalized tonic clonic.
Stable since ___ on current lamotrigine dosing. Continued home
lamotrigine.
# Thrombocytosis
# S/p C-section and post-partum hemorrhage
# Normocytic Hypochromic Anemia
Recently underwent massive transfusion protocol in setting of
hemorrhage complications during delivery. Continued to have
slowly downtrending Hgb during admission, thought secondary to
continued slow post-partum hemorrhage. DIC labs negative. ___
consulted who felt no surgical intervention was required.
# Social
Estranged from parents, lives in public housing, concerns for
neglect on recent admission, father of baby is currently
imprisoned. SW was consulted.
# Asthma
Continued home inhalers, advair as symbicort not on formulary.
TRANSITIONAL ISSUES
====================
[]Discharge weight: 86.2 kg, 190.04 lbs (diuresis plan:
torsemide 10mg qod).
[]Has ___ and outpatient f/u scheduled with Dr ___
(Cardiology).
[]Discharged with life vest given low EF and recurrent episodes
of NSVT. Consider EP follow-up.
[]Recommend minimizing or d/c'ing use of albuterol given
recurrent episodes of NSVT (though pt on this for asthma). |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
abdominal pain and emesis
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ yo F PMHx significant for liver transplant ___ at ___
___ who presented with 1 day of abdominal pain,\ nausea and
bilious emesis. Per report, she was in her usual state of health
until 4:30AM on ___ when she awoke with nausea, epigastric
abdominal pain and emesis. She initially felt better but then
the epigastric pain, nausea and emesis recurred at 11am and
again at
1pm. At time of presentation, her last flatus was ___, her last
BM was ___ am. She has had no flatus or bowel movements since.
She describes the pain as similar to a contraction: intense,
focal in the epigastric region lasting for approximately
10seconds then relaxing. At those instances she feels like her
abdomen is slightly more distended. She denies any pain with
riding here in the car going over bumps. She also reports she
has had no prior episodes of this. In the ED her nausea resolved
with Zofran. She also reported mild improvement in abdominal
pain after administration of NGT.
Labs were significant for a mild leukocytosis with WBC 10.5,
mild increase in creatinine 1.8 (baseline ~ 1.5-1.7), and normal
lactate 0.8.
KUB in the ED significant for c/f small bowel obstruction. CT
scan in ED confirmed SBO.
Past Medical History:
Amyloidosis
Alcoholic cirrhosis, s/p liver transplant ___
CKD stage 3
Hypertension
Hypercholesteremia
Gout
Peripheral neuropathy
Chronic fatigue
Hyperparathyroidism
Anemia (iron deficiency)
Depression
Social History:
___
Family History:
Mother heart d/o
father heart d/o,
uncle HTN
P uncle DM2/HTN
Physical Exam:
T: 98.1
BP: 149/54
HR: 63
RR: 18
O2: 96% on RA
GEN: alert, pleasant, sitting up in bed
HEENT: NCAT, mucous membranes moist, no scleral icterus
PULM: breathing comfortably on room air
CARD: warm and well-perfused
ABD: diffusely, mildly tender without rebound or guarding.
EXT: no ___ clubbing or edema
NEURO: alert and mentating appropriately
Pertinent Results:
CT ABD & PELVIS W/O CON ___
1. Gas and fluid distention of multiple small bowel loops with a
likely
transition point in the mid abdomen near the pelvic brim (series
601, image
25), concerning for an at least partial small bowel obstruction.
At the area
of transition, there is aerated material which is suggestive of
a bezoar,
alternatively this could represent fecalized small bowel
material. No free
fluid. No free air. There is some mesenteric stranding seen in
the area of
the possible bezoar.
2. Status post liver transplant with substantial pneumobilia
which is
presumably secondary to the hepaticojejunostomy. The left mid
abdominal small
bowel-small bowel anastomosis also contains fecalized material
but otherwise
appears intact.
3. Mesenteric lymphadenopathy, with prominent periportal and
right periaortic
nodes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Furosemide 80 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. amLODIPine 10 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
7. Losartan Potassium 50 mg PO DAILY
8. diflunisal 250 mg oral DAILY
9. FoLIC Acid 1 mg PO DAILY
10. Pravastatin 40 mg PO QPM
11. Tacrolimus 0.5 mg PO Q12H
12. Cyanocobalamin 1000 mcg PO DAILY
13. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild/Fever
2. Allopurinol ___ mg PO DAILY
3. amLODIPine 10 mg PO DAILY
4. Cyanocobalamin 1000 mcg PO DAILY
5. diflunisal 250 mg oral DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Furosemide 80 mg PO DAILY
8. Losartan Potassium 50 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
11. Pravastatin 40 mg PO QPM
12. Tacrolimus 0.5 mg PO Q12H
13. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with partial SBO, now on regular diet with
increased bloating// Please assess for resolution of SBO
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: Abdominal radiograph and CT abdomen and pelvis dated ___
FINDINGS:
Small bowel dilatation has improved compared to radiographs from ___. There is a prominent loop of jejunum in the left upper quadrant
measuring up to 3.1 cm, and scattered air-fluid levels within small bowel
loops on the upright view. Gas is seen throughout the large bowel.
Pneumobilia is incidentally noted and better characterized on CT dated ___.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Interval improvement of small bowel obstruction seen on prior radiographs from
___. Prominent loop of jejunum in the left upper quadrant measuring
up to 3.1 cm, and scattered air-fluid levels within small bowel on the upright
view.
Gender: F
Race: AMERICAN INDIAN/ALASKA NATIVE
Arrive by WALK IN
Chief complaint: Abd pain, Vomiting
Diagnosed with Unsp intestnl obst, unsp as to partial versus complete obst
temperature: 98.8
heartrate: 82.0
resprate: 18.0
o2sat: 97.0
sbp: 124.0
dbp: 57.0
level of pain: 8
level of acuity: 3.0 | Ms. ___ presented to the ED on ___ with acute onset
epigastric abdominal pain and emesis. CT showed small bowel
obstruction. Given her history of liver transplant in ___, Ms.
___ was admitted to the transplant surgery service for
management of her SBO, which was medically managed with NPO
status, an NG tube for suction, and IV fluid resuscitation. Ms.
___ continued to received her tacrolimus while inpatient. Her
stay was uneventful and she was hemodynamically stable
throughout her hospitalization. NG tube was dc'ed on ___ and
she was advanced from NPO to a clear liquid diet. Her pain
lessened and resolved with medical management-she did not
require pain medications during her hospitalization. She was
advanced to regular diet with appropriate return of bowel
function.
During this hospitalization, the patient ambulated early and
frequently, and actively participated in the plan of care.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
elective admission to address myasthenia medications
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ is a ___ year-old Right-handed man, pmh of
myasthenia ___ who is sent in by ___ neurology for
admission for plex for worsening myasthenia. History is per
patient, family, and outpatient neurologist, Dr. ___
(cell ___ office ___.
Briefly, he was diagnosed with ocular myasthenia in ___
frequent eye blinking, intmt diplopia, dysarthria, difficulties
swallowing; EMG confirmation). He was well controlled, but when
his primary neurologist retired, he stopped his myasthenia
medications. He had a crisis in ___, where he presented with
difficulties with handling his own secretions, dysphagia and
dysarthria. He was intubated during this admission and received
IVIG x 5 days, but symptoms were eventually controlled on
prednisone and cellcept. IN the past year, he has been having
diarrhea a few times a day, but in the past month has increased
watery diarrhea to ___ times nightly. Per outpatient
neurologist, it was felt that the diarrhea were ___ to cellcept
induced colitis (rather than mestinon induced).
He presented to hospital in ___ with persistent diarrhea,
shortness of breath, and was found to be severely dehydrated,
acidotic with an ___. He was not intubated or required dialysis.
He and his family denied symptoms of myasthenia, but discharge
summary noted, he had difficultly with chewing and swallowing.
His outpt neurologist added propantheline and decreased
cellcept, which transiently improved diarrhea. C.Diff was
negative. He was treated for a klebsiella UTI with CTX.
After discharge, family notes he has had progressive lower
extremity weakness. He has had lower extremity weakness over the
past year, but it has worsened in the last month, to the point
where he must use his arms to put his legs into the car. He has
had two falls in the past week. He attributes one to his shoe
getting caught in the rug and difficultly picking up his right
foot. He notes he was previously prescribed a right foot brace,
which he wears only occasionally. Outpatient neurologist did
trial a lower dose of mestinon (30 mg TID) for a few days, but
this lead to worsened lower extremity weakness.
She also did a trial of IVIG x 3 days ___ last dose
was in ___. He met with outpatient neurologist on ___. He
did not have improvement in his symptoms (lower extremity
weakness) from IVIG. Per discussion with outpatient neurologist,
he has previously been ___ motor strength throughout, but was
___ in R IP, 4+/5 in R tibial; ___ L IP, L Tib, L foot drop. He
did not have head weakness, bulbar weakness or ptosis (but she
notes he does have "droopy eyelids"). His outpatient neurologist
sent him to ___ for elective admission for plasma exchange x 5
days (which he has not previously had). Her long-term goal is to
discontinue cellcept and start Imuran with living IVIG,
prednisone in the interim. On ___, She has also increased his
propantheline (30 mg TID to 15 mg TID, 30 mg qHS), cellcept
(500/1000mg to 1000 mg BID) and prednisone (20 mg to 30 mg
daily).
On my visit, He endorse fatigue, diarrhea (with occasional
incontinence from not reaching bathroom in time) and blurry
vision. He attributes blurry vision to cataracts, as blurry
vision improved in left eye with cataract removal of left eye;
right eye cataract still pending. His vision is stable through
the course of the day; no changes during the course of the day.
He otherwise denies double vision, dysarthria.
He has difficultly with swallowing daily; solids > liquids. He
has had nasal regurgitation previously (last was 8 month prior).
He has occasional difficultly with jaw closure and chewing. He
reports difficulty with gait over the past year, but has
worsened in the past month. He attributes gait to weakness,
tiredness, and difficultly with balance.
Family notes many of these symptoms have been occurring over
past year, but is all progressively worsening after the
hospitalization in ___.
Past Medical History:
Myasthenia ___ -- Had a exacerbation in ___
Macular Degeneration
Decubitus Ulcer
"Heart Disease" s/p pacemaker
?Unclear if he had heart attack
Emphysema
Social History:
___
Family History:
Heart Attack (Mother, Father), Cancer
Physical Exam:
Gen: sitting in chair, appears comfortable, in NAD
HEENT: supple neck, no meningismus
Pulm: no tachypnea or accessory muscle use, breathing
comfortably on room air
CV: RRR
Abd: soft, nondistended, nontender
Ext: warm, well perfused
Neurological examination
- MS intact, deep voice without nasal quality, counts to 25 in
single breath. Able to sniff, suck through straw, whistle. No
dysarthria.
- CN- Chronic bilat ptosis, fatiguable upgaze, palate elev symm,
tongue strong
- Motor- Neck flex 4+/5, ext ___. Fatiguable with 30 delt pumps
(___), bilat R>L triceps, bilat biceps breakable. RLE foot
drop, lumbar root weakness, bilat ___.
- Reflexes: dropped at ankles
- Sensory: reduced vibration and JPS at toes
- Gait: difficulty rising to stand, but able to walk with narrow
base
Pertinent Results:
*****************
LABS ON ADMISSION
___ 12:20PM BLOOD WBC-13.3* RBC-3.79* Hgb-10.9* Hct-35.1*
MCV-93 MCH-28.8 MCHC-31.1* RDW-14.5 RDWSD-49.0* Plt ___
___ 12:20PM BLOOD Neuts-93.2* Lymphs-3.5* Monos-2.3*
Eos-0.1* Baso-0.2 Im ___ AbsNeut-12.40* AbsLymp-0.47*
AbsMono-0.31 AbsEos-0.01* AbsBaso-0.02
___ 12:20PM BLOOD Glucose-179* UreaN-39* Creat-1.7* Na-137
K-4.3 Cl-109* HCO3-18* AnGap-14
___ 12:20PM BLOOD Calcium-8.8 Phos-2.5* Mg-1.6
*****************
LABS ON DISCHARGE
___ 06:15AM BLOOD WBC-9.2 RBC-3.47* Hgb-10.0* Hct-31.5*
MCV-91 MCH-28.8 MCHC-31.7* RDW-14.4 RDWSD-47.8* Plt ___
___ 06:15AM BLOOD Glucose-95 UreaN-32* Creat-1.2 Na-139
K-3.8 Cl-108 HCO3-21* AnGap-14
___ 06:15AM BLOOD Calcium-8.8 Phos-2.8 Mg-1.7
*****************
IMAGING
CT C-spine ___
IMPRESSION:
1. Severe multilevel degenerative changes as described above.
2. A 1.6 cm right thyroid nodule, for which further evaluation
with ultrasound is suggested by current ACR limitations for
incidentally noted thyroid nodules.
CT L-spine ___
IMPRESSION:
Severe multilevel degenerative changes with severe
neuroforaminal narrowing at L2-3 on the left, bilaterally at
L3-4 and on the left at L4-5 and L5-S1.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pyridostigmine Bromide 60 mg PO Q8H
2. Propantheline Bromide 15 mg PO TID
3. Propantheline Bromide 30 mg PO QHS
4. Mycophenolate Mofetil 1000 mg PO BID
5. Aspirin 81 mg PO DAILY
6. PredniSONE 20 mg PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. Metoprolol Tartrate 37.5 mg PO TID
9. NIFEdipine CR 60 mg PO DAILY
10. HydrALAZINE 10 mg PO BID
Discharge Medications:
1. Rolling walker
2. Aspirin 81 mg PO DAILY
3. HydrALAZINE 10 mg PO TID
RX *hydralazine 10 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
4. Metoprolol Tartrate 50 mg PO TID
RX *metoprolol tartrate 25 mg 2 tablet(s) by mouth three times a
day Disp #*180 Tablet Refills:*0
5. Mycophenolate Mofetil 1000 mg PO DAILY
RX *mycophenolate mofetil 500 mg 2 tablet(s) by mouth daily Disp
#*60 Tablet Refills:*0
6. NIFEdipine CR 60 mg PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. PredniSONE 40 mg PO DAILY
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
9. Propantheline Bromide 15 mg PO TID
10. Propantheline Bromide 30 mg PO QHS
11. Pyridostigmine Bromide 60 mg PO Q8H
12. Vitamin D 1000 UNIT PO DAILY
13. Fosfomycin Tromethamine 3 g PO ONCE Duration: 1 Dose
Dissolve in ___ oz (90-120 mL) water and take immediately
RX *fosfomycin tromethamine [Monurol] 3 gram 1 packet(s) by
mouth once Disp #*1 Packet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
myasthenia ___
cervical spondylosis
lumbar spondylosis
urinary tract infection
acute kidney injury
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 weakness // Please eval for any evidence of an
infection
TECHNIQUE: Frontal and lateral views of the chest.
COMPARISON: None.
FINDINGS:
The lungs are clear. The cardiomediastinal silhouette is within normal
limits. Left chest wall dual lead pacing device is noted with tips in the
right ventricular apex and right atrium. No acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: ___ year old man with signs of cervical and lumbar radiculopathy,
suspected cervical stenosis // Evaluate for cervical stenosis Evaluate
for cervical stenosis
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 13.9 s, 21.2 cm; CTDIvol = 29.0 mGy (Body) DLP =
576.6 mGy-cm.
Total DLP (Body) = 586 mGy-cm.
COMPARISON: None.
FINDINGS:
There is mild 2 mm retrolisthesis of C3 on C4 and anterolisthesis of C4 on C5.
No acute fractures are identified.There is severe multilevel degenerative
changes with loss of disc height, anterior and posterior osteophytes and disc
vacuum phenomenon at nearly every level.
A disc protrusion and posterior osteophytes at C2-3 causes mild canal
narrowing and in conjunction with facet arthropathy cause moderate left and
mild right neural foraminal narrowing.
At C3-C4, intervertebral osteophyte and disc protrusion results in moderate
spinal canal narrowing. There is severe bilateral neural foraminal narrowing,
secondary to uncovertebral and facet arthropathy.
A disc bulge at C4-5 causes mild canal narrowing and in conjunction with facet
arthropathy causes moderate right greater than left neuroforaminal narrowing.
A calcified disc bulge at C5-6 causes in mild canal narrowing. There is no
significant neural foraminal narrowing.
A disc bulge and posterior osteophytes at C6-7 cause moderate canal narrowing
and moderate bilateral neuroforaminal narrowing greater on the right than the
left.
At C6-C7, there is no significant spinal canal or neural foraminal narrowing.
There is an 1.6 cm right thyroid nodule. There is a partially calcified 4 mm
nodule in the right lung apex. Bilateral pleural parenchymal scarring as well
as paraseptal emphysematous changes is also noted. There is no prevertebral
soft tissue swelling. Scattered dental caries are partially visualized.
Punctate calcification of the left parotid gland may represent a
nonobstructing sialolith versus vascular calcification.
IMPRESSION:
1. Severe multilevel degenerative changes as described above.
2. A 1.6 cm right thyroid nodule, for which further evaluation with ultrasound
is suggested by current ACR limitations for incidentally noted thyroid
nodules.
Radiology Report
EXAMINATION: CT L-SPINE W/O CONTRAST Q331 CT SPINE
INDICATION: ___ year old man with signs of cervical and lumbar radiculopathy,
suspected cervical stenosis // Evaluate for lumbrosacral disc disease
Evaluate for lumbrosacral disc disease
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 15.8 s, 24.1 cm; CTDIvol = 15.2 mGy (Body) DLP =
345.9 mGy-cm.
Total DLP (Body) = 361 mGy-cm.
COMPARISON: None.
FINDINGS:
There is dextro convex curvature of the lumbar spine with apex at L2-L3 with
compensatory levoconvex curvature with apex at L4-L5. 7 mm right lateral
listhesis of L3 on L4 is identified. There is mild 2 mm retrolisthesis of L3
on L4. The remainder of the lumbar alignment is anatomic. No acute fractures
are identified. . A sclerotic focus in T11 likely represents a bone
island.There are severe degenerative changes with loss of disc height,
anterior and posterior osteophytes and disc vacuum phenomenon at nearly every
level.
At L1-2 a disc bulge and posterior osteophytes cause mild canal narrowing and
mild bilateral neuroforaminal narrowing.
At L2-3 posterior osteophytes causes moderate canal narrowing and severe left
and mild right neuroforaminal narrowing
At L3-4 posterior osteophytes and a disc bulge causes moderate canal narrowing
and severe bilateral neuroforaminal narrowing.
At L4-5 facet arthropathy causes severe left neuroforaminal narrowing. There
is no significant spinal canal narrowing.
At L5-S1 facet arthropathy and posterior osteophytes with a disc bulge causes
moderate right and severe left neuroforaminal narrowing. Intervertebral
osteophyte and disc results in mild spinal canal narrowing.
Degenerative changes of the sacroiliac joints are noted. There is no
prevertebral soft tissue swelling. Note is made of dense atherosclerotic
calcifications of the abdominal aorta and common iliac vessels. Otherwise,
the remainder the visualized prevertebral paraspinal soft tissues are
unremarkable.
IMPRESSION:
Severe multilevel degenerative changes with severe neuroforaminal narrowing at
L2-3 on the left, bilaterally at L3-4 and on the left at L4-5 and L5-S1.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Diarrhea
Diagnosed with Diarrhea, unspecified, Myasthenia gravis without (acute) exacerbation
temperature: 98.4
heartrate: 59.0
resprate: 20.0
o2sat: 100.0
sbp: 138.0
dbp: 54.0
level of pain: 0
level of acuity: 2.0 | ___ was admitted for management of his myasthenia
___ and chronic diarrhea and workup of his progressive lower
extremity weakness and worsening gait, which was persistent
despite treatment for his myasthenia with 3 days of IVIG
treatment (___) and numerous changes in medications
(___). His examination is notable for mild myasthenic symptoms
(ptosis, fatiguable upgaze, minimal facial and neck flexion
weakness, and fatiguable weakness of proximal muscles). However,
on admission he was found to be weak in a cervical and
lumbrosacral radicular pattern and bilateral upper motor neuron
pattern lower extremity weakness in a distribution atypical for
NMJ disease. He was thought to have a multifactorial etiology of
his weakness with majority of his functional decline more
attributable to cervical spondylosis and stenosis, rather than
acute myasthenia flare. The neuromuscular service was consulted
and through discussions with his outpatient neurologist his
cellcept was decreased and prednisone was increased. His
myasthenic symptoms were stable after the change. His diarrhea
improved; he still had intermittent loose stools. He was found
to have a urinary tract infection and was treated with
ceftriaxone (4 days). His culture grew pansensitive klebsiella
and ecoli resistant to ampicillin and cefazolim and he will
complete his course of treatment with fosfomycin based on
sensitivities and his myasthenia. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
small bowel obstruction
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ old man who had a traumatic fall from
80+ft in ___, for which he underwent an exploratory
laparotomy with drainage of retroperitoneal hematoma from a R
renal laceration as well as fixation of the anterior symphysis.
He had been recovering well from these injuries and surgeries
until now. He presents to the ED with abdominal pain, nausea and
vomiting of one day duration. The emesis was bilious,
non-bloody.
Imaging at ___ revealed an SBO, and an NGT was placed. He was
transferred to ___ for continued care because of his previous
surgical history at ___.
Past Medical History:
___: hyperglycemia, scoliosis
PSH: exploratory laparotomy with drainage of retroperitoneal
hematoma, fixation of anterior symphysis, surgery on testicles,
R shoulder surgery
Social History:
___
Family History:
NC
Physical Exam:
Gen: AAOx3, NAD, lying comfortably in bed
HEENT: MMM, no scleral icterus
Resp: nl effort, CTABL, no wheezes/rales/rhonchi
CV: RRR, nl S1/S2, no S3/S4, no murmurs/rubs/gallops
Abd: +BS, soft, NT/ND
Old midline incision is well-healed
Ext: WWP, no edema, 2+ DP
Pertinent Results:
___ 07:40AM BLOOD WBC-7.0 RBC-5.34 Hgb-13.8 Hct-42.7
MCV-80* MCH-25.8* MCHC-32.3 RDW-15.5 RDWSD-44.1 Plt ___
___ 07:40AM BLOOD Glucose-102* UreaN-6 Creat-0.8 Na-137
K-3.8 Cl-100 HCO3-26 AnGap-15
Medications on Admission:
paroxetine HCl 20'
Discharge Medications:
1. PARoxetine 20 mg PO DAILY Duration: 30 Doses
Discharge Disposition:
Home
Discharge Diagnosis:
Small bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with bowel obstruction // please assess flow of
contrast distally
TECHNIQUE: Two views frontal upright and supine abdominal radiographs.
COMPARISON: Abdominal radiograph dated ___.
FINDINGS:
There are no consolidations in the visualized lung bases.
There is an enteric tube with its tip and side port within the stomach.
Oral contrast from recent CT study is seen predominantly in the cecum and
ascending colon. There are some mildly dilated loops of small bowel, which
represents an interval improvement from prior abdominal radiograph from ___.
There is no free intraperitoneal air.
Patient has a right pelvis and sacrum fixation screw, that is unchanged from
prior study.
IMPRESSION:
1. Interval improvement in small bowel dilation compared to prior abdominal
radiograph from ___, representing a resolving, ileus versus partial
small bowel obstruction.
2. PO contrast from prior CT study is seen predominantly in the cecum and
ascending colon.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Unspecified abdominal pain
temperature: 97.2
heartrate: 67.0
resprate: 16.0
o2sat: 94.0
sbp: 158.0
dbp: 109.0
level of pain: 4
level of acuity: 2.0 | Mr. ___ presented to ___ Department on ___ as a
transfer from an OSH. He had initially presented to OSH with
nausea/vomiting and intolerable abdominal pain. CT scan was
concerning for a small bowel obstruction, especially given Mr.
___ past surgical history of an exploratory laparotomy this
past ___ for a renal laceration s/p traumatic fall. An NGT was
placed at the OSH and he was transferred to ___ for further
care given his surgical history at this institution.
Given findings and the lack of peritoneal signs, the patient was
treated conservatively with NPO/IVF, NGT for decompression, and
awaiting return of bowel function. His pain was treated with IV
pain medications, and his nausea was addressed as well. With the
NGT decompression, he began to experience return of bowel
function on HD#1 with a KUB showing resolving ileus vs. SBO. On
HD#2, the NGT was D/C'd, he was passing flatus, and tolerating
full liquid diet with no nausea or vomiting. He was discharged
on HD#3, tolerating regular diet with no nausea/vomiting,
continuing to pass flatus, and with resolved abdominal pain.
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: F
Service: MEDICINE
Allergies:
Penicillins / Cephalosporins / Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
confusion, fever, cellulitis
Major Surgical or Invasive Procedure:
LP ___ (failed)
History of Present Illness:
Ms. ___ is a ___ retired elementary school
___ with a PMH pertinent for osteoarthritis s/p bilaterally
TKR's, depression, asthma, HTN, GERD, morbid obesity, gout,
endometrial cancer s/p TAH-BSO (___), bilateral breast cancer
(R
stage 1 ER+ invasive ductal cancer, L DCIS) s/p lumpectomies
(___) & on letrozole who presented to the ED in the evening
___ for altered mental status, fever, LLE cellulitis. The
limited history was provided by husband/son given patient's
confusion.
Patient was in her usual state of health until ___ when patient
became febrile (Tmax ___ at home) and developed malaise,
weakness, worsening confusion, and was noted to have worsening
lower left leg redness and swelling. She was also noted to have
urinary incontinence. Husband notes that about a week per he was
ill for a few days and his illness involved fevers,
fatigue/malaise, and confusion. Upon arrival to the ED, patient
had some mild nausea that spontaneously resolved but family
denies she had complaints about headache, visions changes, neck
stiffness, chest pain, cough, shortness of breath, abdominal
pain, vomiting, diarrhea, melena, BRBPR, or dysuria.
ROS: Denies pain, headache, neck stiffness, weakness, shortness
of breath, nausea but ROS not reliable given patient's altered
mental status.
ED course:
-VS: Tmax 102.8 (1:23am ___, HR ___, BP 120s-150s/60s-90s, RR
___, 95-99% on RA -> 92% on 2L NC (developed hypoxia).
-Initial exam pertinent for left lower extremity being warm,
tender, and erythematous from ankle to ___ up calf. Also,
patient confused/disordered. No headache, neck stiffness.
-Pertinent labs: WBC 14.2 (92% neutrophils), CMP wnl except Mg
1.4, Phos 0.8. Lactate 2.7->2.2. UA with just trace leuk
esterase, neg nitrate, 3 WBC, few bact. Type & screen sent.
-Pertinent micro: urine culture pending, 2 blood cultures sent.
-Pertinent imaging: CXR showing vascular congestion without
pulmonary edema, no focal consolidation, no effusions, no
pneumothorax.
-Meds administered:
Allopurinol ___, atenolol 50, bupropion 150, fluoxetine 80,
gabapentin 300 (x2), omeprazole 20, vancomycin 1g (3AM), Mag
sulfate 2g, Phos 500mg.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
Osteoarthritis s/p bilaterally TKR's (L in ___, R in ___
Depression
Asthma
Hypertension
GERD
Morbid obesity (BMI 77)
Gout
Choledocholithiasis s/p cholecystectomy
Endometrial cancer s/p TAH-BSO (___)
Bilateral breast cancer (R stage 1 ER+ invasive ductal cancer, L
DCIS) s/p lumpectomies (___) & on letrozole,
ONCOLOGY HISTORY:
Patient was diagnosed with endometrial cancer in ___. She had
her surgery with a TAH-BSO at the ___ by Dr ___. This showed a
grade I, well differentiated endometrial cancer, stage IB.
Patient is followed by Dr. ___ Oncology
(Atrius) given her history of bilateral breast cancer (Stage I
invasive ductal cancer of the right breast and DCIS of the left
breast).
___ prior right breast biopsy showed intraductal
hyperplasia
and fibrocystic changes.
___ routine mammograms showed a 7 mm mass in the right
UOQ
and a possible asymmetry in the left breast
___ she had additional mammograms and bilateral
ultrasound. This showed a spiculated mass in the right breast
measuring 0.7 x 0.6 x 0.6 cm is suspicious for malignancy and
ultrasound-guided biopsy is recommended. Hypoechoic mass in the
left breast corresponds to a developing asymmetry on mammography
and while this may represent a deep complicated cyst the walls
are slightly irregular and therefore ultrasound-guided biopsy is
recommended.
___ she had bilateral ultrasound guided biopsies. This
showed:
A. RIGHT BREAST, 10 O'CLOCK, 9 CM FROM NIPPLE, ULTRASOUND-GUIDED
CORE BIOPSY: Invasive ductal carcinoma, well differentiated
___ grade II/III), involving 4 of 5 cores,
measuring approximately 0.7 cm. There is no
ductal carcinoma in situ identified. Lymphatic/vascular invasion
is NOT identified. The cancer was ER positive (>95%), PR
positive
(>95%) and HER 2/neu 1+ negative
B. LEFT BREAST, 2 O'CLOCK, 9 CM FROM NIPPLE, ULTRASOUND-GUIDED
CORE BIOPSY: Atypical ductal hyperplasia present within a
densely
hyalizined stroma. Surgical consultation is advised. Presence of
ADH on the left is incidental as the lesion revolved during
biopsy and felt to represent a cyst
___ she was seen by Dr ___
___ she underwent bilateral lumpectomies and right
sentinel LN mapping at the ___. This showed:
Left breast: DCIS, grade 2, fibroadenoma, biopsy site changes
and
close margins
Right breast: invasive ductal cancer, grade I, measuring 0.7 cm.
There was severe atypical intraductal proliferation bordering on
DCIS. There was ALH/LCIS. There was no LVI. A total of 3 SLNs
were removed and all were negativ. Stage T1bN0, stage I
___ Dr ___ has advised additional excision of the
left
breast.
Interval history ___: Since her initial consult on ___
she is undergone a left breast reexcision by Dr. ___ on
___ at the ___. This showed no residual DCIS. She has noted
no breast masses nor nipple discharge.
Social History:
___
Family History:
Her mother had colon cancer in her late ___. There is no family
history of breast, ovarian or uterine cancer.
Physical Exam:
ADMISSION EXAM
VITALS:
T 97.5, BP 137/71, HR 78, RR 20, 93% on 2L NC
Weight: 344, Height: 56, BMI: 77.1.
GENERAL: Very large woman in hospital bed appearing confused, in
no apparent distress.
EYES: Anicteric, PERRL, slightly injected bilaterally.
ENT: Ears and nose without visible erythema, masses, or trauma.
Poor dentition. Oropharynx without visible lesion, erythema or
exudate.
NECK: Neck supple, no lymphadenopathy.
CV: RRR, no S3 or S4, ___ SEM best heard at RUSB, no JVP
although difficult assessment.
RESP: Breathing comfortably on 2L NC. Bibasilar crackles. No
wheezes.
GI: Normoactive bowel sounds. Obese. Abdomen non-distended,
non-tender to palpation.
GU: Purewick in place. No suprapubic fullness or tenderness to
palpation.
VASCULAR: Palpable pulses in all distal extremities.
SKIN: Left lower extremity with indurated, warm, tender,
erythematous circumferential area beginning at the ankle and
extending over ___ the way up the leg. Marked with pain.
NEURO: Alert. Oriented to person and general situation. Poor
attention. Unable to identify hospital, remember basic facts
like
her prior vocation (___). Able to follow most basic
commands. Face symmetric, gaze conjugate with EOMI. Speech
fluent
but word finding difficulties. Moves all limbs without obvious
limitations.
PSYCH: Cooperative, confused, appropriate affect.
Pertinent Results:
ADMISSION LABS:
___ 01:05AM BLOOD WBC-14.2* RBC-4.52 Hgb-14.5 Hct-43.4
MCV-96 MCH-32.1* MCHC-33.4 RDW-13.6 RDWSD-48.1* Plt ___
___ 07:30PM BLOOD WBC-22.6* RBC-4.20 Hgb-13.5 Hct-39.8
MCV-95 MCH-32.1* MCHC-33.9 RDW-14.3 RDWSD-49.1* Plt ___
___ 01:05AM BLOOD Neuts-92.3* Lymphs-3.0* Monos-3.4*
Eos-0.1* Baso-0.4 Im ___ AbsNeut-13.11* AbsLymp-0.42*
AbsMono-0.48 AbsEos-0.01* AbsBaso-0.05
___ 10:45AM BLOOD ___
___ 01:05AM BLOOD Glucose-108* UreaN-17 Creat-0.9 Na-136
K-4.2 Cl-100 HCO3-22 AnGap-14
___ 07:30PM BLOOD Glucose-107* UreaN-20 Creat-0.9 Na-134*
K-3.8 Cl-100 HCO3-21* AnGap-13
___ 01:05AM BLOOD ALT-22 AST-30 AlkPhos-92 TotBili-0.9
___ 07:30PM BLOOD ALT-24 AST-40 AlkPhos-65 TotBili-0.7
___ 10:45AM BLOOD LD(LDH)-359*
___ 01:05AM BLOOD Albumin-4.0 Calcium-9.9 Phos-0.8* Mg-1.4*
___ 07:30PM BLOOD Albumin-3.4* Calcium-8.7 Phos-2.6* Mg-1.8
___ 08:40AM BLOOD Vanco-12.7
___ 01:09AM BLOOD Lactate-2.7*
___ 07:54AM BLOOD Lactate-2.2*
___ EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ year old woman with new hypoxia// eval for PE
r/o
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 = 14.9 mGy
(Body) DLP = 3.0
mGy-cm.
2) Stationary Acquisition 1.4 s, 0.2 cm; CTDIvol = 37.2 mGy
(Body) DLP =
7.4 mGy-cm.
3) Spiral Acquisition 5.1 s, 33.3 cm; CTDIvol = 25.6 mGy
(Body) DLP = 834.7
mGy-cm.
Total DLP (Body) = 845 mGy-cm.
COMPARISON: No prior chest CT available for direct comparison.
Correlation
with chest radiograph dated ___.
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified
to the
subsegmental level without filling defect to indicate a
pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of
dissection or
intramural hematoma. The heart is normal in size. Coronary
artery
calcifications are noted. The pericardium, and great vessels
are within
normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or
hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Gravity dependent atelectasis is present in both
lower lobes.
Faint ground-glass opacities in the lateral aspect of the right
middle lobe
could be infectious or inflammatory in nature. 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: The patient is status post cholecystectomy. Included
portion of the
upper abdomen is otherwise unremarkable.
BONES: There are degenerative changes throughout the spine and
in both
shoulders. No suspicious osseous abnormality is seen.? There is
no acute
fracture.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Faint ground-glass opacities in the lateral aspect of the
right middle lobe are nonspecific, and could be infectious or
inflammatory in nature.
___ EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with fever, encephalopathy,
left-sided
weakness, aphasia, and facial droop// please rule-out acute
bleed so we can
proceed with LP.
TECHNIQUE: Contiguous axial images of the brain were obtained
without
contrast.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 50.0 mGy
(Head) DLP =
940.0 mGy-cm.
2) Stationary Acquisition 3.0 s, 11.4 cm; CTDIvol = 49.5 mGy
(Head) DLP =
564.0 mGy-cm.
Total DLP (Head) = 1,504 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute large territorial
infarction,hemorrhage,edema,
or mass. There is mild prominence of the ventricles and sulci
suggestive of
mild involutional changes. There are bilateral periventricular
and
subcortical white matter hypodensities, nonspecific but
compatible with
sequelae of chronic small vessel ischemic disease. Slight
asymmetry in the
hypodensities of the right frontal lobe could be due to small
vessel disease.
There is no evidence of fracture. There is complete
opacification the right
maxillary sinus and right anterior and middle ethmoid air cells.
There is
partial opacification of the bilateral mastoid air cells.
Otherwise, the
visualized portion of the paranasal sinuses and middle ear
cavities are clear.
The visualized portion of the orbits are unremarkable.
IMPRESSION:
No evidence of acute intracranial abnormality. Basal cisterns
are patent and there is no mass effect seen.
___ EXAMINATION: MRI ___ AND MRA NECK PT13 MR HEAD
INDICATION: ___ year old woman with fever, and per OMR, improved
dysarthria,
aphasia, left facial droop and left-sided weakness// stroke?
TECHNIQUE: Brain imaging was performed with diffusion, T1,
FLAIR, T2,
gradient echo technique, and T1 postcontrast imaging.
Dynamic MRA of the neck was performed during administration
intravenous
contrast.
T1 post contrast imaging was then performed.
Three dimensional maximum intensity projection and segmented
images were
generated. This report is based on interpretation of all of
these images. The
examination was performed using a 1.5T MRI.
COMPARISON: CT head ___
FINDINGS:
MRI BRAIN without and with contrast:
There is no evidence of acute infarction, hemorrhage, edema,
masses, mass
effect, or midline shift. There is no abnormal enhancement
after contrast
administration. Mild-to-moderate chronic small-vessel ischemic
disease..
Moderate bilateral parietal lobe atrophy.
The right maxillary sinus is near completely opacified and
contains an
air-fluid level. Additionally, there is partial opacification
of the right
anterior ethmoid air cells with mild mucosal thickening
throughout the
bilateral anterior ethmoid air cells. There is near complete
opacification of
the right mastoid air cells and middle ear cavity. There is
partial
opacification of the left mastoid air cells.
MRA NECK with contrast:
Suboptimally seen bilateral vertebral artery origins secondary
to artifact,
there is probably mild bilateral vertebral artery origin
narrowing.
Otherwise, the origins of the great vessels and subclavian
arteries appear
normal bilaterally. The common, internal and external carotid
arteries appear
normal. There is no evidence of internal carotid artery
stenosis by NASCET
criteria.
3 cm right thyroid nodule, ultrasound recommended according to
guidelines.
Heterogeneous, nodular remainder of the thyroid gland.
IMPRESSION:
1. No acute intracranial abnormality.
2. Suboptimally seen origin of vertebral arteries, probably mild
bilateral
narrowing.
3. Moderate opacification mastoids, may be reactive,
inflammatory, consider
otomastoiditis.
4. Acute paranasal sinusitis, most prominent at the right
maxillary sinus..
5. 3 cm thyroid nodule, guidelines below.
RECOMMENDATION(S): Thyroid nodule. Ultrasound 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.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Letrozole 2.5 mg PO DAILY
2. Allopurinol ___ mg PO DAILY
3. Atenolol 50 mg PO DAILY
4. Gabapentin 900 mg PO QHS
5. FLUoxetine 80 mg PO DAILY
6. BuPROPion (Sustained Release) 150 mg PO BID
7. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of
breath/wheezing
Discharge Medications:
1. Cephalexin 500 mg PO Q6H Duration: 7 Days
RX *cephalexin 500 mg 1 capsule(s) by mouth every six (6) hours
Disp #*28 Capsule Refills:*0
2. Doxycycline Hyclate 100 mg PO Q12H cellulitis Duration: 7
Days
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth every
twelve (12) hours Disp #*14 Capsule Refills:*0
3. Fluconazole 100 mg PO/NG Q24H Duration: 6 Days
RX *fluconazole [Diflucan] 100 mg 1 tablet(s) by mouth once
daily Disp #*2 Tablet Refills:*0
4. Albuterol Inhaler ___ PUFF IH Q4H:PRN shortness of
breath/wheezing
5. Allopurinol ___ mg PO DAILY
6. Atenolol 50 mg PO DAILY
7. BuPROPion (Sustained Release) 150 mg PO BID
8. FLUoxetine 80 mg PO DAILY
9. Gabapentin 900 mg PO QHS
10. Letrozole 2.5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Hypoxemic respiratory failure
Cellulitis
Toxic metabolic encephalopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - uses walker.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with fever, AMS// Fever, AMS
TECHNIQUE: Chest PA and lateral
COMPARISON: None
FINDINGS:
Lung volumes are slightly low. There is pulmonary vascular congestion without
frank pulmonary edema. No focal consolidation to suggest pneumonia.
Subsegmental atelectasis in the lower lobes. Cardiomediastinal silhouette and
hila are normal. No pleural effusion or pneumothorax.
IMPRESSION:
1. No focal consolidation to suggest pneumonia.
2. Pulmonary vascular congestion without frank pulmonary edema.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ year old woman with new hypoxia// eval for PE r/o
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 = 14.9 mGy (Body) DLP = 3.0
mGy-cm.
2) Stationary Acquisition 1.4 s, 0.2 cm; CTDIvol = 37.2 mGy (Body) DLP =
7.4 mGy-cm.
3) Spiral Acquisition 5.1 s, 33.3 cm; CTDIvol = 25.6 mGy (Body) DLP = 834.7
mGy-cm.
Total DLP (Body) = 845 mGy-cm.
COMPARISON: No prior chest CT available for direct comparison. Correlation
with chest radiograph dated ___.
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. The heart is normal in size. Coronary artery
calcifications are noted. The pericardium, and great vessels are within
normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Gravity dependent atelectasis is present in both lower lobes.
Faint ground-glass opacities in the lateral aspect of the right middle lobe
could be infectious or inflammatory in nature. 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: The patient is status post cholecystectomy. Included portion of the
upper abdomen is otherwise unremarkable.
BONES: There are degenerative changes throughout the spine and in both
shoulders. No suspicious osseous abnormality is seen.? There is no acute
fracture.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Faint ground-glass opacities in the lateral aspect of the right middle lobe
are nonspecific, and could be infectious or inflammatory in nature.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with fever, encephalopathy, left-sided
weakness, aphasia, and facial droop// please rule-out acute bleed so we can
proceed with LP.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 50.0 mGy (Head) DLP =
940.0 mGy-cm.
2) Stationary Acquisition 3.0 s, 11.4 cm; CTDIvol = 49.5 mGy (Head) DLP =
564.0 mGy-cm.
Total DLP (Head) = 1,504 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute large territorial infarction,hemorrhage,edema,
or mass. There is mild prominence of the ventricles and sulci suggestive of
mild involutional changes. There are bilateral periventricular and
subcortical white matter hypodensities, nonspecific but compatible with
sequelae of chronic small vessel ischemic disease. Slight asymmetry in the
hypodensities of the right frontal lobe could be due to small vessel disease.
There is no evidence of fracture. There is complete opacification the right
maxillary sinus and right anterior and middle ethmoid air cells. There is
partial opacification of the bilateral mastoid air cells. Otherwise, the
visualized portion of the paranasal sinuses and middle ear cavities are clear.
The visualized portion of the orbits are unremarkable.
IMPRESSION:
No evidence of acute intracranial abnormality. Basal cisterns are patent and
there is no mass effect seen.
Radiology Report
EXAMINATION: MRI ___ AND MRA NECK PT13 MR HEAD
INDICATION: ___ year old woman with fever, and per OMR, improved dysarthria,
aphasia, left facial droop and left-sided weakness// stroke?
TECHNIQUE: Brain imaging was performed with diffusion, T1, FLAIR, T2,
gradient echo technique, and T1 postcontrast imaging.
Dynamic MRA of the neck was performed during administration intravenous
contrast.
T1 post contrast imaging was then performed.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images. The
examination was performed using a 1.5T MRI.
COMPARISON: CT head ___
FINDINGS:
MRI BRAIN without and with contrast:
There is no evidence of acute infarction, hemorrhage, edema, masses, mass
effect, or midline shift. There is no abnormal enhancement after contrast
administration. Mild-to-moderate chronic small-vessel ischemic disease..
Moderate bilateral parietal lobe atrophy.
The right maxillary sinus is near completely opacified and contains an
air-fluid level. Additionally, there is partial opacification of the right
anterior ethmoid air cells with mild mucosal thickening throughout the
bilateral anterior ethmoid air cells. There is near complete opacification of
the right mastoid air cells and middle ear cavity. There is partial
opacification of the left mastoid air cells.
MRA NECK with contrast:
Suboptimally seen bilateral vertebral artery origins secondary to artifact,
there is probably mild bilateral vertebral artery origin narrowing.
Otherwise, the origins of the great vessels and subclavian arteries appear
normal bilaterally. The common, internal and external carotid arteries appear
normal. There is no evidence of internal carotid artery stenosis by NASCET
criteria.
3 cm right thyroid nodule, ultrasound recommended according to guidelines.
Heterogeneous, nodular remainder of the thyroid gland.
IMPRESSION:
1. No acute intracranial abnormality.
2. Suboptimally seen origin of vertebral arteries, probably mild bilateral
narrowing.
3. Moderate opacification mastoids, may be reactive, inflammatory, consider
otomastoiditis.
4. Acute paranasal sinusitis, most prominent at the right maxillary sinus..
5. 3 cm thyroid nodule, guidelines below.
RECOMMENDATION(S): Thyroid nodule. Ultrasound 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 older.
Suspicious findings include: Abnormal lymph nodes (those displaying
enlargement, calcification, cystic components and/or increased enhancement) or
invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White
Paper of the ACR Incidental Findings Committee". J ___ ___
12:143-150.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status, Fever
Diagnosed with Cellulitis of left lower limb, Disorientation, unspecified, Fever, unspecified
temperature: 99.1
heartrate: 88.0
resprate: 16.0
o2sat: 99.0
sbp: 149.0
dbp: 67.0
level of pain: 0
level of acuity: 2.0 | ___ woman with a complicated PMH including bilaterally
TKR's, morbid obesity, and recent bilateral breast cancer (R
stage 1 ER+ invasive ductal cancer, L DCIS) s/p lumpectomies
(___) & on letrozole who is admitted after presenting to the
ED in the evening ___ with fever to 102, encephalopathy, and
leukocytosis
#Acute metabolic encephalopathy
#Severe sepsis with unclear source
#Left-sided weakness, aphasia, dysarthria
There was initially concern for stroke or TIA on the second
hospital day, but these findings were not noted when she was
initially admitted or in the ER. At the time of discovery, she
had dysarthria, aphasia, and left-sided weakness (___), but she
was out of the window for possible tPA. Head CT ___ did not
show any acute process. She received ASA 325mg PO ___
MRI/MRA head and neck ___ showed no acute process either. (She
needed large MRI which caused 1-day delay). LP attempted on
___ AM out of concern for meningitis, but unsuccessful. In
particular, excess soft tissue made this difficult. ___ was then
consulted, but said that after someone has full ASA, they are
ineligible for LP for 5 days. At 5 days, study would be
non-diagnostic, so will not be pursued. Thankfully, towards the
end of the day on ___, the symptoms had largely resolved.
She was placed on Vancomycin and Cipro on ___ out of concern
for possible meningitis. Cellulitis was very notable on her LLE,
and there was possible PNA on CT (not very convincing) and no
evidence of UTI. Blood cultures were drawn and showed no
growth. Her WBC was as high as 22.6, but improved to normal
after receiving antibiotics. Ultimately, the possibility of
bacterial meningitis was low, so after receiving Vancomycin and
Cipro, this was changed to keflex and doxy on discharge for
extended course for cellulitis. Swallow consult for diet safety
had no issues on ___. With thrombocytopenia, viral illness is
also on the differential, but LFTs normal. Flu swab was
negative.
#Acute hypoxemic respiratory failure
She presented requiring 4L of nasal oxygen. CTA negative for PE
but did show atelectasis and possible aspiration or infection.
She received standing Duonebs, which seemed to help. OSA/OHS
and atelectasis were the likely largest culprits. She was able
to wean O2 to RA several days prior to discharge.
#Hx of bilateral breast cancer
Diagnosed late ___ with R stage 1 invasive ductal cancer and L
DCIS), now s/p lumpectomies/partial mastectomy (___) and now
on letrozole given cancer was ER-positive. Per review of
records,
patient was not recommended chemotherapy or radiation therapy.
Followed by Dr. ___ at ___ On___ (___). Last
seen in ___. She continued home letrozole 2.5mg daily
#Hypophosphatemia and hypomagnesemia - replaced
#Hypertension - continue home at atenolol 50mg daily
#Fungal skin rashes - skin care and anti-fungal cream ___
changed to Fluconazole 200mg PO x1 on ___ and then 100mg PO
daily ___.
# Morbid obesity - outpatient exercise program
# Gout - She continued home allopurinol ___ daily
#Outstanding issues
[]changed to keflex and doxy on discharge for extended course
for cellulitis (total duration of treatment ___ days)
[] For fungal rash started Fluconazole 200mg PO x1 on ___ and
then 100mg PO daily ___.
>30 min spent on discharge planning including face to face time |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
prednisone / aspirin / vancomycin
Attending: ___.
Chief Complaint:
drainage from wounds
Major Surgical or Invasive Procedure:
___ - spinal cord stimulator removal and washout
History of Present Illness:
Ms. ___ is a ___ F well known to the neurosurgical
service for spinal cord stimulator placement placed on ___ ___ complicated by a wound infection requiring 3 admissons
for IV ABX and s/p a wound washout ___. Patient reports
purulent drainage coming from both mid back and low back
incisions beginning ___. She denies any fever , chills or
night sweats, weakness, numbness, tingling, nausea, vomiting.
Past Medical History:
Asthma, anxiety, sleep apnea, vitamin D deficiency, anemia,
multiple wound infections.
Social History:
___
Family History:
Non-contributory
Physical Exam:
On Admission:
O: T:98.2 BP: 137/64 HR:87 R16 O2Sats 98%on RA
Purulent drainage easily expressible from small ~4mm opening in
midback incision and from pinpoint opening in low back incision
Otherwise exam is nonfocal
On Discharge:
Awake, Alert, MAE
Medications on Admission:
calcium w/ D, centrum, colace,
miralax, oxycontin, vitamin B-12, albuterol sulfate HFA,
baclofen, vitamin D3, iron 325mg, effexor xr, seroquel
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB, wheezing
3. Baclofen 10 mg PO QID
4. CefazoLIN 2 g IV Q8H
5. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*60 Tablet Refills:*0
6. Venlafaxine XR 225 mg PO DAILY
7. QUEtiapine Fumarate 25 mg PO BID
8. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
9. Polyethylene Glycol 17 g PO DAILY
10. Docusate Sodium 100 mg PO BID
11. OxyCODONE SR (OxyconTIN) 80 mg PO TID pain
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Infected Spinal Cord Stimulator
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PRE-OP PA AND LAT)
INDICATION: ___ year old woman with wound infection going to OR on ___,
please evaluate for infectious process. // ___ year old woman with wound
infection going to OR on ___, please evaluate for infectious process.
TECHNIQUE: CHEST (PRE-OP PA AND LAT)
COMPARISON: ___
IMPRESSION:
PA and lateral upright chest radiograph reviewed
Heart size and mediastinum are stable. The PICC line has been discontinued.
Hardware is projecting over the spine. Lungs are clear. There is no pleural
effusion or pneumothorax
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with picc // l power picc 51cm iv ___ ___
Contact name: ___: ___ l power picc 51cm iv ___ ___
COMPARISON: Chest radiographs ___.
IMPRESSION:
Left PIC line can be traced as far as the origin of the SVC be on which it
would be obscured by spinal hardware. Lungs lung volume but clear.
Cardiomediastinal silhouette unremarkable. No pleural abnormality.
NOTIFICATION: PIC line position was discussed over the telephone by Dr. ___
with IV nurse ___.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with picc // l picc 51cm, repeat x-ray d/t
radiology unable to see the picc tip, iv ping ___ l picc 51cm, repeat
x-ray d/t radiology unable to see the pi
COMPARISON: Chest radiographs since ___ most recently ___
at 4:05 p.m.
IMPRESSION:
Lateral view shows the left PIC line passes to the low SVC. On the frontal
view it is obscured by spinal hardware as noted on the report of the prior
study. Heart size is normal. Lungs clear. No pleural abnormality.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Back pain, BACK INFECTION
Diagnosed with DUE TO NERVOUS SYSTEM DEVICE,IMPLANT AND GRAFT, ABN REACT-SURG PROC NEC
temperature: 98.2
heartrate: 87.0
resprate: 16.0
o2sat: 98.0
sbp: 137.0
dbp: 64.0
level of pain: 7
level of acuity: 2.0 | ___ y/o F with history of spinal cord stimulator presents with
wound drainage. Patient is other intact. Cultures were obtained
on admission and vancomycin was started. On ___, she was
consented and pre-oped for the OR for wound washout and removal
of spinal cord stimulator. ID was consulted who agreed with
continuation of vancomycin.
On ___, the patient was taken to the OR for removal of spinal
cord stimulator and wound washout. Intraoperative cultures were
taken. ID continued to be involved.
On ___ She continued on vancomycin. A PICC line was ordered.
On ___, the patient was stable from a neurologic persepctive.
Infectious disease adjusted the patient's antibiotics based on
sesitivities and switched her to cefazolin 2g Q8h. She had an
episode of chest pain that did later resolve. An EKG was
ordered which was found to be unremarkable. Cardiac enzymes
were ordered as well which were unremarkable. DC was planned
___ after her AM dose of antibiotics. ID follow up was
scheduled. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ yof with a history of mental retardation,
HTN and newly diagnosed CHF presenting with hypoxia. Patient was
seen two days prior to admission by her PCP for ___ routine visit.
She was found to be hypoxic to the low ___ on room air, she
declined an inpatient admission at that time. A chest x-ray
performed at that time showed no evidence of pneumonia but had
findings consistent with CHF. Night prior to admission, patient
was tachypnic and unable to sleep according to her sister, she
also has had a cough that was productive of sputum of unknown
color/consistency for past 5 days. She was seen by her PCP and
again found to be hypoxic to 82% on room air and was sent to the
ED. Patient did not check temperature at home. Patient has had
dyspnea with exertion for past year, and has not had much
lifelong PCP follow up. ___ has had decreased po intake and last
BM was at least 3 days prior to admission. Patient has orthopnea
and report of foul smelling urine. Per family, patient will
under report any symptoms. No falls at home.
In the ED:
-100.6 96 162/80 18 99% 5L
-Levofloxacin 750mg x1
On the floor: 98.0 156/84 HR 87 RR 18 sat 95% on 4L NC
ROS: no chest pain, dysuria, diarrhea or abdominal pain
Past Medical History:
CHF dx ___
Hyperlipidemia
Hypertension
Mental Retardation
COPD?-on combivent
Social History:
___
Family History:
non-contributory
Physical Exam:
Admission:
Vitals: Tm 100.6 Tc 97.5 120-150/80 HR ___ sat 94-96% on 3L NC
Gen: NAD
HEENT: moist mucosa
Neck: supple, JVP could not be assessed
Pulm: crackles bilaterally with R>L
CV: NR, RR, no murmurs
Abd: NT, ND, soft
Ext: no peripheral edema
Skin: no lesions noted
Neuro: A&Ox3, mental status at baseline per family, moves all
ext, no gross deficit
Psych: labile affect
Discharge:
Vitals: afebrile 98.8 100-110/60-70 HR ___ sat 93-96% 2L NC
Gen: NAD
HEENT: moist mucosa
Neck: supple
Pulm: crackles in R base, few crackles in left base
CV: NR, RR, no murmurs
Abd: NT, ND, soft
Ext: no peripheral edema
Skin: no lesions noted
Neuro: A&Ox3, mental status at baseline per family, moves all
ext, no gross deficit
Psych: appropriate
Pertinent Results:
___ 01:45PM BLOOD WBC-10.2 RBC-4.42 Hgb-12.8 Hct-40.2
MCV-91 MCH-28.9 MCHC-31.8 RDW-13.7 Plt ___
___ 05:30AM BLOOD WBC-10.5 RBC-4.09* Hgb-11.5* Hct-36.5
MCV-89 MCH-28.1 MCHC-31.6 RDW-13.8 Plt ___
___ 01:45PM BLOOD Neuts-60.6 ___ Monos-5.7 Eos-1.2
Baso-0.4
___ 05:25AM BLOOD Neuts-70.9* ___ Monos-5.5 Eos-1.1
Baso-0.2
___ 05:30AM BLOOD Glucose-91 UreaN-18 Creat-0.7 Na-139
K-4.7 Cl-96 HCO3-33* AnGap-15
___ 01:45PM BLOOD Glucose-106* UreaN-13 Creat-0.5 Na-145
K-3.7 Cl-103 HCO3-34* AnGap-12
___ 05:45AM BLOOD CK-MB-3 cTropnT-0.05*
___ 09:35PM BLOOD CK-MB-3 cTropnT-0.06*
___ 01:45PM BLOOD CK-MB-3 cTropnT-0.06* proBNP-796*
___ 05:30AM BLOOD Calcium-9.2 Phos-4.5 Mg-2.1
___ 02:04PM BLOOD Lactate-1.5
ECHO, transthoracic ___: The left atrium is elongated. 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>55%). Doppler parameters are most consistent with
Grade II (moderate) left ventricular diastolic dysfunction.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets are moderately thickened. The aortic
valve is not well seen. There is mild aortic valve stenosis
(valve area 1.2-1.9cm2). Mild to moderate (___) aortic
regurgitation is seen. The mitral valve leaflets are
structurally normal. Trivial mitral regurgitation is seen. The
pulmonary artery systolic pressure could not be determined.
There is no pericardial effusion. IMPRESSION: Suboptimal image
quality. Normal biventricular function. Mild AS. Mild-moderate
AR.
EKG ___ TRACING #1 : Sinus rhythm. Inferior T wave
inversions with concurrent T wave inversions in leads V1-V6
concerning for ongoing ischemia. Clinical correlation is
suggested. No previous tracing available for comparison.
EKG ___ TRACING #2: Sinus rhythm. Diffuse ST-T wave
abnormalities as previously described. No major change from the
previous tracing.
CXR ___: Moderate pulmonary edema
CXR ___: Marked improvement in pulmonary edema.
Improving left
retrocardiac opacity, likely atelectasis, but continued followup
may be
helpful to exclude underlying pneumonia given clinical suspicion
for this
entity.
___ 8:14 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. 10,000-100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- 8 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- <=1 S
Blood cx ___: NGTD
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Simvastatin 40 mg PO DAILY
3. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN shortness of breath
4. Vitamin D 400 UNIT PO DAILY
5. Calcium Carbonate 500 mg PO DAILY
6. Furosemide Dose is Unknown PO DAILY
started by PCP, in ___ but not filled yet
Discharge Medications:
1. Calcium Carbonate 500 mg PO DAILY
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*0
2. oxygen
hypoxic. ambulatory saturations of 82% on room air. please
provide supplemental oxygen.
3. Furosemide 40 mg PO DAILY Duration: 1 Doses
RX *furosemide 40 mg 1 tablet(s) by mouth once daily in morning
Disp #*30 Tablet Refills:*0
4. Lisinopril 20 mg PO DAILY
RX *lisinopril 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Simvastatin 40 mg PO DAILY
RX *simvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
6. Vitamin D 400 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
7. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour apply patch to skin once daily Disp
#*30 Transdermal Patch Refills:*5
8. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 1 Days
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth once in morning, once at night Disp #*4
Tablet Refills:*0
9. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN shortness of breath
RX *ipratropium-albuterol [Combivent] 18 mcg-103 mcg (90
mcg)/actuation ___ puffs inh every 6 hours as needed Disp #*1
Inhaler Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
CHF exacerbation, Pneumonia (CAP), UTI
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Hypoxia.
TECHNIQUE: Upright AP and lateral views of the chest.
COMPARISON: None.
FINDINGS:
There is moderate enlargement of cardiac silhouette. There is moderate
pulmonary edema. No definite large pleural effusion is noted. There is no
pneumothorax. Mediastinal contours are within normal limits. There are no
acute osseous abnormalities.
IMPRESSION:
Moderate pulmonary edema.
Radiology Report
PA AND LATERAL CHEST OF ___
COMPARISON: ___ radiograph.
FINDINGS: Cardiac silhouette remains enlarged, but bilateral pulmonary edema
has dramatically improved with only minimal residual perihilar haziness
remaining, accompanied by peribronchial cuffing and pulmonary vascular
engorgement. Left retrocardiac opacity has also improved and probably
represents a combination of atelectasis and dependent edema. Additional
linear areas of atelectasis are noted posteriorly at the lung bases on the
lateral view, and there are also small pleural effusions.
IMPRESSION: Marked improvement in pulmonary edema. Improving left
retrocardiac opacity, likely atelectasis, but continued followup may be
helpful to exclude underlying pneumonia given clinical suspicion for this
entity.
Gender: F
Race: BLACK/AFRICAN
Arrive by WALK IN
Chief complaint: HYPOXIA
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, UNSPECIFIED INTELLECTUAL DISABILITIES, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 100.6
heartrate: 96.0
resprate: 18.0
o2sat: 99.0
sbp: 162.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ yof with a history of mild mental
retardation, HTN and newly diagnosed CHF presenting with hypoxia
with pulmonary edema on CXR.
# CHF: Diagnosed ___. BNP elevated. Echo ___ shows
diastolic dysfunction, Mild to moderate (___) aortic
regurgitation and preserved EF.
-continued Lasix 20mg po daily, discharged on 40mg and should be
adjusted at next PCP visit pending lytes and volume status
-continued home Lisinopril
-We could not completely wean oxygen so was discharged with home
oxygen. Patient desatted to <88% on RA with ambulation. This was
discussed with family, and there is obvious concern with her
smoking at home. She agreed to stop, and lives with Nephew who
was going to be there as well. Patient and family was repeatedly
warned of risks with going home with O2, but this was preferred
to rehab by patient and family.
# Recent Fever: No fevers since admission. Possibly pneumonia
given productive cough with R>L lung sounds although not seen on
CXR. Repeat CXR after diuresis negative for PNA. UA negative but
urine cx ___ growing E.coli 10,000-100,000.
-completed 5 day course Levofloxacin (day 1 = ___
-completed Bactrim 3 days (day ___ for urine since E.coli
resistant to fluroquinolones
# Hypertension
-continued home Lisinopril
-continued Lasix
# Mental Retardation: Maintained at baseline mental status per
family.
# COPD
-continued home Combivent
# Hyperlipidemia
-continued home Simvastatin
# Social: Per sister, patient lives alone and likely requires
home care. Sister may try to be her full time caretaker.
-___ consult
-Case Management involvement
# CODE: Full-confirmed with HCP
# CONTACT: ___ (sister/HCP) ___
___son) ___
## TRANSITIONAL ISSUES:
-will follow up with PCP and check electrolytes
-please consider decreasing home Lasix from 40mg to 20mg at next
office visit pending her creatinine, electrolytes, and clinical
appearance on exam
-please re-eval need for home O2 at future visits, and discuss
risks with continued smoking |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
ciprofloxacin
Attending: ___.
Chief Complaint:
Altered mental status, seizure
Major Surgical or Invasive Procedure:
continuous EEG
History of Present Illness:
___ is a ___ yo lady with HTN, HLD who ___ transferred
to
us from ___ with confusion that started yesterday and today
progressed to unresponsiveness, also noted to have a seizure at
___.
As per patient's daughters, Ms. ___ was in her USOH all day
yesterday but at 1600, one of her daughters noted that she was
talking about events that did not make sense. For instance, she
said that she still worked at ___ and that the police was out
to get her. However, she has been intermittently saying things
that don't make sense since she had shingles last month, so the
daughter thought that this would pass. This AM, one of her
daughters ___ called her at 11:30 and the patient's other
daughter ___ who lives with the patient handed the phone to
the
patient. However, Ms. ___ was unable to move her hand to
reach
the phone and when she placed the receiver next to her, Ms.
___ was unable to talk. Daughter ___ arrived to the house
at 12:30 and noted that the patient was lying on her side in bed
with her left arm flexed at the elbow and her right leg flexed
at
the knee "as if she was ready to run." Her gaze was deviated to
the left and she would not move them to respond. When ___
asked her, "Mama can you hear me?", the patient responded, "I
told you what you need to know to lay a good foundation." She
also said "I need to vomit," and "I need to go to the bathroom"
but did not speak after that. ___ called ___ but prior to
ambulance arrival, patient appeared to become unconscious.
Ms. ___ was taken to ___ where a ___ was
negative as per report. Labs including CBC and Chemistry were
unrevealing. She was reportedly noted to have a tonic clonic
seizure while there although no details about this are
available.
She was given Ativan and transferred to ___.
Her daughters do not recall and recent illness except Shingles
last month or any recent trauma. Ms. ___ is DNR/DNI although
daughters are willing to reconsider this if her prognosis is
good
ie they do not want to prolong suffering but do not want DNI to
interfere with medical management, such as Ativan for seizures,
if her overall outcome is promising.
Past Medical History:
HTN
HLD
COPD
No prior CVA
Social History:
___
Family History:
no seizures or strokes
Physical Exam:
Admission Physical Exam:
General: In bed, eyes are shut, does not respond to voice.
HEENT: NC/AT, no scleral icterus noted, oxygen mask in place
Neck: Supple
Pulmonary: Lungs CTA bilaterally
Cardiac: RRR, nl.
Abdomen: soft.
Extremities: Cool
Skin: Multiple bruises all over.
Neurologic:
-Mental Status: Does not open eyes to her name or to vocal
stimuli. Does not follow simple commands like squeeze my hands.
Grimaces as well as groans to pain and localizes pain.
-Cranial Nerves:
II: Pupils are 1mm and minimally reactive.
III, IV, VI: There is no gaze deviation. Corneals intact.
VII: No facial droop, grimace appears symmetric
-Motor: Normal bulk. There is intermittent tonic extension of
arms and legs with pronation of arms, every ___. There is some
spontaneous antigravity movement of right arm, left arm moves to
pain (localizes).
-Sensory: Withdraws to pain in all extremities.
-DTRs:
Bi Pat Ach
L 2 unable to elicit
R 2 unable to elicit
Plantar response was mute bilaterally.
DISCHARGE EXAM:
Pertinent Results:
___ 06:34PM BLOOD WBC-9.4 RBC-3.93* Hgb-12.1 Hct-37.7
MCV-96 MCH-30.9 MCHC-32.2 RDW-13.7 Plt ___
___ 06:34PM BLOOD Neuts-86.3* Lymphs-7.3* Monos-5.8 Eos-0.1
Baso-0.4
___ 06:34PM BLOOD ___ PTT-23.7* ___
___ 06:34PM BLOOD Glucose-122* UreaN-20 Creat-1.2* Na-141
K-4.6 Cl-104 HCO3-25 AnGap-17
___ 06:34PM BLOOD ALT-13 AST-24 AlkPhos-83 TotBili-0.6
___ 06:34PM BLOOD Albumin-4.1 Calcium-9.7 Phos-4.2 Mg-1.5*
___ 04:49AM BLOOD Phenyto-11.1
___ 05:54AM BLOOD Phenyto-6.8*
___ 12:44PM BLOOD Phenyto-12.5
___ 05:34AM BLOOD Phenyto-11.9
___ 06:37AM BLOOD Phenyto-11.5
___ 06:25PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 06:25PM URINE RBC-1 WBC-<1 Bacteri-FEW Yeast-NONE
Epi-<1
___ 06:34PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
___ 03:30PM CEREBROSPINAL FLUID (CSF) WBC-4 RBC-3* Polys-6
___ ___ 03:30PM CEREBROSPINAL FLUID (CSF) TotProt-50*
Glucose-52 LD(LDH)-32
IMAGING
CTA Head/Neck ___
IMPRESSION:
1. Unremarkable noncontrast CT scan of the head.
2. Unremarkable CTA of the head
3. Calcification of the carotid bifurcations bilaterally with
mild narrowing of the right proximal internal carotid artery. No
significant stenosis by NASCET criteria.
MRI ___
IMPRESSION:
No acute infarct or mass effect. Some degree of diffuse
parenchymal volume loss and nonspecific cerebral white matter
changes.
EEG ___
This is an abnormal continuous EEG monitoring study because of
occasional multifocal broad-based, blunted epileptiform
discharges in the
right frontotemporal region, right posterior quadrant, and left
frontotemporal regions, indicative of independent potentially
epileptogenic cortex in those regions. These findings may be
seen in patients with underlying inflammatory (e.g. vasculitis)
or infectious processes. There is mild attenuation and
continuous moderate focal delta slowing in the right hemisphere,
as well as a poorly seen right posterior dominant rhythm,
indicative of right hemispherefocal cerebral dysfunction. There
is intermittent moderate focal delta/theta slowing in the left
hemisphere indicative of focal cerebral dysfunction in the left
hemisphere. There are intermittent bursts of bifrontally
predominant
polymorphic rhythmic delta activity with diffuse background
slowing indicative of a mild to moderate diffuse encephalopathy
which is non-specific as to etiology.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 25 mg PO DAILY
2. Simvastatin 40 mg PO DAILY
3. Vitamin B-100 Complex (vitamin B complex) subq Weekly
4. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
daily
5. Docusate Sodium 100 mg PO BID
6. Aspirin 81 mg PO DAILY
7. Aciphex (RABEprazole) 20 mg oral daily
8. Mirtazapine 7.5 mg PO TID
9. Lactulose 25 mL PO DAILY
10. ValACYclovir 1000 mg PO Q8H
11. 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) 10 billion cell
oral daily
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Lactulose 25 mL PO DAILY
4. Simvastatin 40 mg PO DAILY
5. Aciphex (RABEprazole) 20 mg oral daily
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Mirtazapine 7.5 mg PO TID
8. Probiotic
(B.breve-L.acid-L.rham-S.thermo;<br>L.acidophilus-Bif.
animalis;<br>L.___
acidophilus;<br>lactobacillus comb no.10;<br>lactobacillus
combination no.4;<br>lactobacillus combo no.11) 10 billion cell
oral daily
9. Vitamin B-100 Complex (vitamin B complex) 0 SUBQ WEEKLY
10. Vitamin D3 (cholecalciferol (vitamin D3)) 1,000 unit oral
daily
11. Phenytoin Sodium Extended 300 mg PO HS
RX *phenytoin sodium extended 300 mg 1 capsule(s) by mouth At
night Disp #*30 Capsule Refills:*5
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Seizures
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: Seizure.
COMPARISON: None.
TECHNIQUE: Frontal chest radiograph.
FINDINGS:
A left subclavian central venous catheter terminates at the confluence of the
brachiocephalic vein and SVC. The heart size is normal. The hilar and
mediastinal contours are within normal limits. There is central pulmonary
vascular congestion but no overt edema. There is no pneumothorax. A trace
left pleural effusion is present.
IMPRESSION:
Small left pleural effusion. No focal consolidation.
Radiology Report
EXAMINATION: Fluoroscopically-guided lumbar puncture
INDICATION: ___ year old woman with POSSIBLE ENCEPHALITIS // CSF STUDY
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient and informed consent was obtained. The patient was
subsequently transported to the fluoroscopy suite. A preprocedure time-out was
performed confirming the patient's identity, relevant history, and intended
procedure. The lower back was prepped and draped in sterile fashion. The L3-L4
interspace was localized and local anesthesia was obtained with 1%
subcutaneous lidocaine. A 20-gauge spinal needle was guided into the thecal
sac under fluoroscopic control. A fluoroscopic image was obtained confirming
the needle's position and archived in PACS. The opening pressure measured 14
cm H2O. Approximately 16 mL of clear, colorless cerebrospinal fluid was
extracted. The needle was subsequently removed without immediate complications
and a sterile bandage was applied.
The CSF was sent to the laboratory with orders per the ordering team.
This procedure was performed by Dr. ___ Dr. ___.
COMPARISON: None.
FINDINGS:
1. 16 mL of clear, colorless fluid was obtained at the L3-L4 interspace.
2. Opening pressure measured 14 cm H2O.
IMPRESSION:
1. Successful fluoroscopically-guided lumbar puncture.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK
INDICATION: History: ___ with ams, ?seizure // bleed?
TECHNIQUE: Contiguous axial images were obtained through the brain without
contrast. Subsequently, rapid axial imaging was performed from the aortic arch
through the brain during infusion of Omnipaque intravenous contrast material.
Three dimensional images were generated on a separate workstation.
DOSE: DLP: 2400 mGy-cm; CTDI: 170 mGy
COMPARISON: No prior imaging of the brain available.
FINDINGS:
Head CT: There is no evidence of hemorrhage, edema,, mass effect, or
infarction. The ventricles and sulci are prominent likely secondary to age
related involutional change. No fractures are identified. Patient is status
post bilateral cataract surgery. Mild ethmoidal mucosal thickening, right
more than left.
Sphenoid sinuses 2 septations, the left inserts on the left carotid groove.
Head CTA: The intracranial carotid and vertebral arteries and their major
branches are patent with no evidence of stenoses, occlusions or aneurysm more
than 3 mm. There is calcification of the cavernous portions of the internal
carotid arteries bilaterally with for contour irregularity, likely related to
atherosclerotic disease versus tiny superficial aneurysms without significant
stenosis.
Neck CTA:
There is a common origin of the brachiocephalic artery and the left common
carotid artery.
Calcified and noncalcified plaques are noted in the subclavian arteries, left
more than right.
Imaging of the neck reveals no evidence of arterial stenosis or occlusion.
There is no evidence of internal carotid artery stenosis by NASCET criteria.
There is calcification seen of the carotid bifurcations bilaterally extending
into the proximal cervical internal carotid arteries, right more than left
with mild narrowing of the right proximal internal carotid artery. There is
contour irregularity of the right distal cervical internal carotid artery,
with a tiny outpouching like appearance that can relate to atherosclerotic
disease given the location. - Series 601b, image 19
The distal right ICA measures 5.6 mm. The distal left ICA measures 5.6 mm.
The left vertebral artery is dominant.
There is likely fenestration in the left transverse sinus series 601b, image
37 versus related to volume averaging.
CT neck:
The salivary glands are unremarkable.
The thyroid gland is normal.
There is no significant cervical lymphadenopathy.
The lung apices are clear.
Degenerative changes are noted throughout the cervical spine with mild canal
and moderate to severe foraminal narrowing at multiple levels. .
IMPRESSION:
1. No acute intracranial hemorrhage or mass effect.
2. Patent major intracranial arteries as described above, without focal
flow-limiting stenosis, occlusion or aneurysm more than 3 mm within the
resolution of the study.
Contour irregularity of the cavernous carotid segments on both sides, can
relate to atherosclerotic disease with or without any tiny aneurysmal
outpouchings.
Differentiation is difficult on imaging.
3. Calcification of the carotid bifurcations bilaterally with mild narrowing
of the right proximal internal carotid artery. No significant stenosis by
NASCET criteria.
4. Degenerative changes in the cervical spine with mild canal and moderate to
severe foraminal narrowing at multiple levels.
Other details as above.
Radiology Report
INDICATION: ___ year old woman with left gaze deviation and left weakness and
altered mental status // ?stroke
TECHNIQUE: MRI of the head without IV contrast
COMPARISON: CTA ___, no prior study
FINDINGS:
No acute infarct, suspicious focus of intracranial hemorrhage or mass effect.
A few nonspecific cerebral white matter FLAIR hyperintense foci are noted.
Chronic lacune or prominent CSF space in the left cerebellar hemisphere
related to prior volume loss series 9 and 10, image 4.
There is mild to moderate dilation of the lateral and the third ventricles
along with prominent CSF spaces, sulci and cerebellar folia, related to some
degree of diffuse parenchymal volume loss.
The major intracranial arterial flow voids are noted, with a dominant left
vertebral artery.
Sella, pineal gland and the craniocervical junction regions are unremarkable.
Minimal ethmoidal mucosal thickening.
The mastoid air cells are clear.
Status post bilateral lens replacement.
IMPRESSION:
No acute infarct or mass effect.
Some degree of diffuse parenchymal volume loss and nonspecific cerebral white
matter changes.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status, Transfer
Diagnosed with ALTERED MENTAL STATUS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 13
level of acuity: 1.0 | ___ lady with HTN and HLD who presents with left side gaze
preference and left hemiparesis which progressed to
unresponsiveness. She was taken to OSH where workup was
unrevealing but reportedly was noted to have a tonic clonic
seizure. She received Ativan and Keppra and was transferred to
___. At ___, the patient was unresponsive to vocal stimuli,
eyes were shut and there was no gaze deviation. There was
spontaneous movement of the right arm but none on the left
although she did localize, grimace and moan to pain. Pupils were
1mm and minimally responsive. CT head was negative for acute
bleed or loss of gray white differentiaton and CTA head and neck
did not reveal any major vessel cuttoff. Lumbar puncture did not
reveal any signs of infection. She was initially drowsy, likely
secondary to medication effect, but eventually regained her
baseline level of arousal. She was started on Dilantin and had
no other seizure activity. She evaluated by ___ who
recommended discharge to a rehab. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Amoxicillin
Attending: ___.
Chief Complaint:
Candidemia
Major Surgical or Invasive Procedure:
transesophageal echo
tracheostomy decannulation (___)
History of Present Illness:
___ with recent prolonged hospital course beginning in ___ for
bacterial and candidal endocarditis with flail mitral valve s/p
CABG/MRV with multiple complications incl. cardiac arrest,
respiratory failure s/p trach/peg admitted with positive
candical culture from his rehab today. The patient denies
fevers or chills. He complains of ongoing nausea, diarrhea, and
poor appetite since his discharge. He is very disheartened by
his lack of mobility and progress.
In the ED, initial VS: 98.2 104 136/84 16 96% RA. The patient
was seen by ___, who pulled his hemodialysis catheter. Catheter
tip was sent for culture. ID was also consulted by phone, and
he was recommended to start micafungin 100 mg IV daily. Cardiac
surgery recommended admission to medicine. VS prior to
transfer: 103 145/84 16 97%.
Currently, the patient reports feeling horribly depressed by
what he has been through. Review of systems negative as below.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
chest pain, abdominal pain, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
s/p CABG with MVR
Recent admission for endocarditis complicated by multiorgan
failure
atrial fibrillation during previous hospitalization
CKD, on HD following circulatory compromise during previous
admission
Ischemic colitis
Asthma
seizure disorder
chronic hyponatremia since ___
BPH
depression
history of syncope
s/p bilateral knee replacement
Social History:
___
Family History:
Non-contributory.
Physical Exam:
Admission Physical Exam:
General: Pleasant man in NAD; trach collar in place
HEENT: EOMI, PERRL, MMM, oropharynx clear
Neck: NO lymphadenopathy or thyromegaly; trach in place, capped
CV: Normal S1, S2, ___ holosystolic murmur
Lungs: Bibasilar crackles
Abdomen: Soft, mildly distended, non-tender, normoactive bowel
sounds
GU: foley in place draining clear yellow urine
Ext: trace ankle edema
Neuro: Grossly intact, diminished strength in upper and lower
extremities bilaterally; paucity of arm and leg movement during
exam
Skin: Median sternotomy covered in dry gauze; incision CDI,
Surrounding skin with mild blistering and erythema; abdominal
incision CDI
Discharge physical exam:
98.3 152/76 (148-153 / 76-92) 100 (98-100)
GEN: Resting in bed, NAD
HEENT: Moist MMM, dressing overlying tracheostomy site in place
COR: RRR, +S1S2, no m/r/g
PULM: CTAB
___: + G-tube in place. +BS. Soft, non-tender, non-distended
EXT: WWP, no c/c/e.
INCISIONS: sternotomy site c/d/i, midabdominal incision c/d/I
with staples taken out
NEURO: Alert, appropriate. Generalized weakness but moving all
extremities.
Pertinent Results:
Admission Labs:
___ 05:40PM BLOOD WBC-14.9*# RBC-3.38* Hgb-10.6* Hct-32.6*
MCV-96 MCH-31.4 MCHC-32.6 RDW-15.5 Plt ___
___ 05:40PM BLOOD Neuts-59.3 ___ Monos-4.9 Eos-1.2
Baso-0.5
___ 05:40PM BLOOD ___ PTT-26.4 ___
___ 05:40PM BLOOD Glucose-105* UreaN-55* Creat-2.0* Na-139
K-3.9 Cl-101 HCO3-27 AnGap-15
___ 08:20AM BLOOD ALT-59* AST-58* LD(LDH)-260* AlkPhos-129
TotBili-0.4
___ 08:20AM BLOOD Phenyto-3.8*
___ 05:45PM BLOOD Lactate-1.2
Relevant Labs:
___ 08:10AM BLOOD WBC-17.9* RBC-3.23* Hgb-10.4* Hct-31.2*
MCV-96 MCH-32.1* MCHC-33.3 RDW-15.3 Plt ___
___ 08:00AM BLOOD WBC-17.8* RBC-3.01* Hgb-9.5* Hct-29.4*
MCV-98 MCH-31.6 MCHC-32.3 RDW-15.0 Plt ___
___ 07:50AM BLOOD WBC-13.3* RBC-2.76* Hgb-9.1* Hct-26.8*
MCV-97 MCH-32.9* MCHC-34.0 RDW-15.3 Plt ___
___ 09:10AM BLOOD WBC-12.6* RBC-3.17* Hgb-10.1* Hct-30.6*
MCV-97 MCH-31.9 MCHC-33.1 RDW-14.7 Plt ___
___ 09:03AM BLOOD WBC-14.6* RBC-3.00* Hgb-9.7* Hct-29.2*
MCV-97 MCH-32.2* MCHC-33.1 RDW-15.1 Plt ___
___ 08:00AM Creat-1.3*
___ 07:50AM Creat-1.1
___ 09:03AM Creat-0.9
Discharge Labs:
___ 07:12AM BLOOD WBC-13.9* RBC-3.03* Hgb-9.6* Hct-29.5*
MCV-97 MCH-31.7 MCHC-32.6 RDW-14.8 Plt ___
___ 07:12AM BLOOD Glucose-114* UreaN-27* Creat-1.2 Na-139
K-3.9 Cl-105 HCO3-22 AnGap-16
___ 07:12AM BLOOD Calcium-8.7 Phos-3.9 Mg-1.9
Pertinent Micro/Path:
___ 5:40 pm BLOOD CULTURE STAPHYLOCOCCUS EPIDERMIDIS.
Isolated from only one set in the previous five days.
SENSIS REQUESTED BY ___ ON ___ @
10:40AM.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
Rifampin should not be used alone for therapy.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
|
CLINDAMYCIN----------- =>8 R
ERYTHROMYCIN---------- =>8 R
GENTAMICIN------------ =>16 R
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
RIFAMPIN-------------- <=0.5 S
TETRACYCLINE---------- 4 S
VANCOMYCIN------------ 1 S
Aerobic Bottle Gram Stain (Final ___: GRAM POSITIVE
COCCI IN CLUSTERS.
___ 7:35 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
___. >100,000 ORGANISMS/ML..
SERRATIA MARCESCENS. >100,000 ORGANISMS/ML..
This organism may develop resistance to third
generation
cephalosporins during prolonged therapy. Therefore,
isolates that
are initially susceptible may become resistant within
three to
four days after initiation of therapy. For serious
infections,
repeat culture and sensitivity testing may therefore be
warranted
if third generation cephalosporins were used.
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
___
| SERRATIA MARCESCENS
| |
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN---------<=0.25 S <=0.25 S
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- 128 R 256 R
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- <=1 S <=1 S
___ 5:55 pm BLOOD CULTURE: NO GROWTH.
___ 7:05 pm CATHETER TIP-IV WOUND CULTURE (Final ___:
No significant growth.
___ 8:20 am BLOOD CULTURE ( MYCO/F LYTIC BOTTLE)
BLOOD/FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
BLOOD/AFB CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
___ 8:20 am BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:20 am BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:21 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
URINE CULTURE (Final ___:
___. 10,000-100,000 ORGANISMS/ML..
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
___
___.
GRAM NEGATIVE ROD #2. ~5000/ML. SECOND MORPHOLOGY.
___ 12:50 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 8:00 am BLOOD CULTURE
Blood Culture, Routine (Pending):
___ 7:50 am BLOOD CULTURE
Blood Culture, Routine (Pending):
Pertinent Imaging and Studies:
Liver/GB U/S ___. Sludge and stones within the gallbladder. No signs of
cholecystitis. No ductal dilatation
2. Right pleural effusion.
EEG ___
IMPRESSION: This is an abnormal routine EEG in the awake and
drowsy states
due to the presence of left temporal sharp waves, as well as
bilateral
temporal slowing, left more than right. These findings suggest
the presence
of a potential focus of epileptogenesis in the left temporal
region, as wellas subcortical dysfunction in both temporal
regions. No electrographic
seizures are seen. Note is made of a regular tachycardia.
CXR ___
Tracheostomy is in adequate position in this patient with prior
sternotomy.
Right basal pleural effusion is minimal. Left lower lobe is
chronically
atelectatic with adjacent moderate pleural effusion. There is
no new lung
consolidation.
ECHO ___
IMPRESSION: No vegetations seen. Normally functioning mitral
valve bioprosthesis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO/PR Q4H:PRN temperature >38.0
2. Amiodarone 200 mg PO DAILY
3. Aspirin 81 mg NG DAILY
4. Atorvastatin 20 mg PO DAILY
5. Bisacodyl ___AILY:PRN constipation
6. Docusate Sodium 100 mg PO BID
7. Heparin Dwell (1000 Units/mL) ___ UNIT DWELL PRN
dialysis
Dwell to CATH Volume
8. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
9. Ipratropium Bromide MDI 6 PUFF IH Q6H
10. Lidocaine 5% Patch 1 PTCH TD DAILY
11. Lidocaine Viscous 2% 10 mL PO QID:PRN mouth sores
12. MethylPHENIDATE (Ritalin) 2.5 mg PO BID
13. Neomycin-Polymyxin-Bacitracin 1 Appl TP ASDIR
14. Nephrocaps 1 CAP PO DAILY
15. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
16. Phenytoin (Suspension) 100 mg PO QAM
17. Phenytoin (Suspension) 100 mg PO QPM
18. Phenytoin (Suspension) 100 mg PO QHS
19. PredniSONE 10 mg PO 3X/WEEK (___)
20. QUEtiapine Fumarate 50 mg PO QHS
21. Vitamin D ___ UNIT PO DAILY
22. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea
23. Florastor *NF* (saccharomyces boulardii) 250 mg Oral daily
24. Ondansetron 4 mg PO Q8H:PRN nausea, vomiting
25. Magnesium Oxide 400 mg PO TID
26. Furosemide 100 mg PO BID
27. caspofungin *NF* 250 ml Injection daily
28. PredniSONE 5 mg PO 4X/WEEK (___)
29. Vancomycin Oral Liquid ___ mg PO Q6H
Discharge Medications:
1. Acetaminophen 650 mg PO/PR Q4H:PRN temperature >38.0
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea
3. Amiodarone 200 mg PO DAILY
4. Aspirin 81 mg NG DAILY
5. Atorvastatin 20 mg PO DAILY
6. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
7. Lidocaine 5% Patch 1 PTCH TD DAILY
8. Lidocaine Viscous 2% 10 mL PO QID:PRN mouth sores
9. Neomycin-Polymyxin-Bacitracin 1 Appl TP ASDIR
10. PredniSONE 10 mg PO 3X/WEEK (___)
11. PredniSONE 5 mg PO 4X/WEEK (___)
12. Vancomycin Oral Liquid ___ mg PO Q6H
Please take through ___
13. Vitamin D ___ UNIT PO DAILY
14. Fluconazole 200 mg PO Q24H Duration: 3 Days
Continue through ___
15. LeVETiracetam 500 mg PO BID
16. Bisacodyl ___AILY:PRN constipation
17. caspofungin *NF* 250 ml Injection daily
18. Docusate Sodium 100 mg PO BID
19. Florastor *NF* (saccharomyces boulardii) 250 mg Oral daily
20. Ipratropium Bromide MDI 6 PUFF IH Q6H
21. Magnesium Oxide 400 mg PO TID
22. MethylPHENIDATE (Ritalin) 2.5 mg PO BID
23. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
24. QUEtiapine Fumarate 25 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary diagnosis: Candidemia
Secondary diagnoses: Clostridium dificile colitis, urinary tract
infection, gram-positive cocci bacteremia, seizure
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
PORTABLE AP CHEST X-RAY
INDICATION: CABG, MVR, ___ bacterial endocarditis with complicated by
cardiac arrest, multiorgan failure, recurrent fungemia, now with cough, rule
out infection.
COMPARISON: ___ to ___.
FINDINGS:
Tracheostomy is in adequate position in this patient with prior sternotomy.
Right basal pleural effusion is minimal. Left lower lobe is chronically
atelectatic with adjacent moderate pleural effusion. There is no new lung
consolidation.
Radiology Report
HISTORY: Abnormal LFTs.
TECHNIQUE: Right upper quadrant ultrasound.
COMPARISON: ___.
FINDINGS:
The liver is of normal echotexture and demonstrates no focal liver lesions.
The gallbladder contains several layering stones as well as sludge but there
is no evidence pericholecystic fluid or gallbladder wall edema. There is no
intra or extrahepatic ductal dilatation. There is a right pleural effusion is
noted. The main portal vein is patent. No hydronephrosis of the right kidney
is noted.
IMPRESSION:
1. Sludge and stones within the gallbladder. No signs of cholecystitis. No
ductal dilatation
2. Right pleural effusion.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: +BLOOD CX
Diagnosed with MYCOSES NEC & NOS
temperature: 98.2
heartrate: 104.0
resprate: 16.0
o2sat: 96.0
sbp: 136.0
dbp: 84.0
level of pain: 0
level of acuity: 2.0 | ___ with recent prolonged hospital course beginning in ___ for
bacterial and candidal endocarditis with flail mitral valve s/p
CABG/MRV with multiple complications including cardiac arrest,
respiratory failure s/p trach/peg admitted with recurrent
candidemia and diarrhea.
Active Diagnoses
# Candidemia: Found on surveillance cultures from rehab. The
patient's HD catheter was pulled in the ED as a likely source
(he had not required HD since discharge in early ___. CXR did
not show evidence of pneumonia. TEE was negative for
bioprosthetic valve vegetation. Ophtho was consulted and were
not concerned for endophthalmitis. The patient was treated with
iv Micafungin ___. He was switched to po fluconazole ___,
once weaned off Dilantin for his seizures. Per ID
recommendations, he will have a 7 day course of fluconazole
which should continue through ___ (to end on ___.
Blood cultures were negative for fungemia while in house. He
will need repeat fungal cultures one week after discontinuation
of fluconazole (to be drawn on ___.
# Possible Coag Negative Staph bacteremia: Grew out on ___ BCx
on ___. While it was possibly a contaminant, the patient was
started on iv vanc for a 7day course given his complicated
recent course of infections per recommendations of ID. Repeated
blood cultures did not grow out any bacteria.
# Seizures: Patient had EEG significant for epileptiform
activity with bitemporal activity. Neurology was consulted, and
they recommended weaning of phenytoin in favor of Keppra. He was
started on Keppra while weaning off of phenytoin without any
seizure-like activity during the bridging process. Last dose of
phenytoin was ___. The patient will be continued on Keppra 500mg
po bid.
#C. difficile colitis: This was thought to be likely secondary
to C. diff. Although it was not documented, the patient was
started on vancomycin PO at the rehab on ___, and is planned to
have a course to complete ___ after iv antibiotics complete
(this course should be continued through ___. Symptoms
mildly improved since initiating antibiotics though he continued
to have intermittent loose stool during the hospitalization.
# S/P hypoxic Respiratory failure: Patient was trach'ed during
prior hospitalization. Lasix held starting day 2 of admission
out of concern for impending hypovolemia. Per interventional
pulmonary consult, the cuff was removed and the trach was capped
on ___. After tolerating this for 48 hours with O2sat>96, the
trach was decannulated. The site was dressed with care. Healing
and improvement of the patient's voice is expected over the next
several weeks.
# ___: Last admission complicated by ___ secondary to
hypotension requiring HD, which he has not required since prior
hospitalization. He was noted to have residual impairment of
renal function on admission. Creatinine has improved throughout
hospitalization.
# Malnutrition: Patient with poor nutrition since his prior
complicated hospitalization course. During the hospitalization,
he has been on G-tube feeds at night. Speech and swallow cleared
the patient for regular diet, although he was fearful of
aspiration. Nutrition followed the patient throughout
hospitalization. As the patient continues to bolster his PO
intake, he tube feed requirements will need to be readdressed.
He should be evaluated by nutrition while in rehab.
# S/P cardiac surgery: Patient had recent complicated and
prolonged hospitalization course. After admission for bacterial
and candidial endocarditis c/b mitral flail, he had a CABG/MVR
complicated by respiratory failure and cardiac arrest. Staples
were removed from abdominal incision. Patient will need to
follow-up with Dr. ___. He was continued on his daily statin
and aspirin therapy.
CHRONIC DIAGNOSES
# Depression: Patient has been previously diagnosed wth
depression, and he noted difficulty coping with his complex
medical situation. In latter stages of hospitalization, the
patient's mood improved, as he expressed hope to regain mobility
and to be near his wife. He was continued on quetiapine.
#Atrial fibrillation: Patient had history of atrial
fibrillation. He was kept on amiodarone. He was monitored on
telemetry until ___, and he was in sinus rhythm without notable
events. Given prior GIB, the patient is not being started on
anticoagulation beyond aspirin.
#Asthma: Patient has been on steroids long-term for asthma. This
was continued at 10mg ___ and 5mg ___. There
was no asthmatic exacerbations during hospitalization. It is
recommended that the patient eventually undergo a long steroid
taper in the future.
#History of chronic hyponatremia: The patient had chemistries
trended with normal serum sodium throughout hospitalization. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
increased secretions
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ year old gentleman, with a history of Down Syndrome
w/ trach, G-tube and foley, stage 4 sacral decub, who is
presenting from nursing home with fever and increased secretions
from his trach
Patient reportedly starting having increased secretions from
nursing home earlier in the last day. PAtient also reportedly
had fevers that spiked to 104. Patient was given extra strength
tylenol but was still spiking. Of note, patient completed a 14
day course of IV Ceftaz TID 1g for trach site infection/possible
pneumonia from sputum cultures that grew Morganella and
Pseudomonas when he was discharged from ___.
Blood Cx during this admission were negative. Sputum cultures
have been negative at nursing home.
Patient was reportedly highly functionning with a job until
___ of last year. He was living at a facility for people
with Down Syndrome. He was found down one day and taken to
hospital where he was found to have C1/C2 injury. He underwent
laminectomy but also suffered respiratory failure and required
trach and G-tube placement. Since then, he has had numerous
infections with his trach.
In the ED, initial vitals: 102.4 106 108/68 26 100% trach mask.
Patient received rectal tylenol after triggering in ED for
fevers and tachypnoea to the ___. Patient's labs were normal on
admission. He was given vancomycin, cefepime and levaquin and
2L of IV NS.
On transfer, vitals were: 99.7 104 126/76 31 96% TM
On arrival to the MICU, patient looked comfortable.
Past Medical History:
Down's Syndrome
Living in a facility (high functionning C1/C2 injury ___
Laminectomy for decompression in ___, Respiratory arrest)
Tracheostomy
G-tube placement
Chronic Foley
Stage 4 Sacral ulcer
Social History:
___
Family History:
unable to obtain
Physical Exam:
ADMISSION PHYSICAL:
Vitals- T:98 BP:107/63 P:109 R: 18 O2:99
GENERAL: Alert, no acute distress, non-communicative
HEENT: Sclera anicteric, dry mucous membranes. Poor dentition
NECK: supple, JVP not elevated, no LAD
LUNGS: Bilaterally rhonchorous
CV: Tachycardic, normal S1 S2, no murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Large sacral ulcer
NEURO: PERLA. Alert.
DISCHARGE PHYSICAL EXAM:
Tmax: 37.1 °C (98.8 °F)
Tcurrent: 36.8 °C (98.2 °F)
HR: 92 (80 - 105) bpm
BP: 87/54(61) {79/45(54) - 159/127(136)} mmHg
RR: 21 (14 - 31) insp/min
SpO2: 94%
Heart rhythm: SR (Sinus Rhythm)
Wgt (current): 54.1 kg (admission): 55.6 kg
Height: 60 Inch
GENERAL: trached, intermittently has uncontrolled movements of
upper extremities
HEENT: Sclera anicteric, dry mucous membranes. Poor dentition.
Scaley erythematous rash on nose/face/chest.
NECK: supple, JVP not elevated, no LAD
LUNGS: Bilaterally coarse breath sounds, thick secretions in
trach
CV: regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: Large sacral ulcer
NEURO: PERLA. Alert.
Pertinent Results:
ADMISSION LABS:
___ 07:00PM PLT COUNT-356
___ 07:00PM NEUTS-69.1 ___ MONOS-5.3 EOS-1.2
BASOS-0.9
___ 07:00PM WBC-9.7 RBC-4.59* HGB-12.4* HCT-40.0 MCV-87
MCH-26.9* MCHC-30.9* RDW-19.0*
___ 07:00PM estGFR-Using this
___ 07:00PM GLUCOSE-119* UREA N-16 CREAT-0.6 SODIUM-137
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-28 ANION GAP-13
___ 07:50PM LACTATE-1.5
___ 08:10PM URINE MUCOUS-RARE
___ 08:10PM URINE RBC-28* WBC-101* BACTERIA-FEW YEAST-NONE
EPI-0
___ 08:10PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-100
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-LG
___ 08:10PM URINE COLOR-Yellow APPEAR-Hazy SP ___
PERTINENT LABS:
___ 02:11AM BLOOD Glucose-94 UreaN-11 Creat-0.5 Na-139
K-4.0 Cl-107 HCO3-27 AnGap-9
___ 04:50AM BLOOD Glucose-121* UreaN-8 Creat-0.5 Na-141
K-4.2 Cl-105 HCO3-26 AnGap-14
___ 03:33AM BLOOD Glucose-116* UreaN-9 Creat-0.4* Na-140
K-4.3 Cl-105 HCO3-29 AnGap-10
___ 02:36AM BLOOD Glucose-111* UreaN-12 Creat-0.6 Na-134
K-4.4 Cl-98 HCO3-31 AnGap-9
___ 09:30PM BLOOD ___ pO2-25* pCO2-46* pH-7.43
calTCO2-32* Base XS-3
SED RATE BY MODIFIED 36 H < OR = 20 mm/h
___ 02:36AM BLOOD ALT-33 AST-21 AlkPhos-150* TotBili-0.1
___ 03:15AM BLOOD CRP-76.6*
___ 03:49AM BLOOD WBC-5.0 RBC-3.57* Hgb-9.9* Hct-31.9*
MCV-89 MCH-27.6 MCHC-30.9* RDW-19.1* Plt ___
___ 03:49AM BLOOD Neuts-60.4 ___ Monos-5.4
Eos-10.2* Baso-1.1
___ 02:36AM BLOOD WBC-5.4 RBC-3.83* Hgb-10.2* Hct-33.6*
MCV-88 MCH-26.7* MCHC-30.4* RDW-19.0* Plt ___
___ 02:36AM BLOOD Neuts-49.5* ___ Monos-6.0
Eos-10.7* Baso-1.3
___ 04:12AM BLOOD WBC-6.0 RBC-3.72* Hgb-10.0* Hct-32.6*
MCV-88 MCH-26.8* MCHC-30.6* RDW-18.9* Plt ___
___ 04:12AM BLOOD Neuts-52.6 ___ Monos-7.6 Eos-9.4*
Baso-1.2
___ 04:15AM BLOOD WBC-5.7 RBC-3.67* Hgb-10.0* Hct-32.4*
MCV-88 MCH-27.1 MCHC-30.7* RDW-19.2* Plt ___
___ 04:15AM BLOOD Neuts-49.0* ___ Monos-8.7
Eos-9.9* Baso-1.5
DISCHARGE LABS:
MICROBIOLOGY:
Blood Culture, Routine (Final ___: NO GROWTH.
Blood Culture, Routine (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. OF TWO COLONIAL
MORPHOLOGIES.
Isolated from only one set in the previous five days.
SENSITIVITIES PERFORMED ON REQUEST..
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ @ 6:10PM
___.
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
LINEZOLID------------- 1 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ =>32 R
MRSA SCREEN (Final ___:
POSITIVE FOR METHICILLIN RESISTANT STAPH AUREUS.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
RESPIRATORY CULTURE (Final ___:
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
ACINETOBACTER BAUMANNII. 10,000-100,000 ORGANISMS/ML..
"Note, for Amp/sulbactam, higher-than-standard dosing
needs to be
used, since therapeutic efficacy relies on intrinsic
activity of
the sulbactam component".
Piperacillin/tazobactam sensitivity testing available
on request.
PSEUDOMONAS AERUGINOSA. ~3000/ML.
___. ___ (___) REQUESTED FOR THE WORK UP ON
___.
Isolates are considered potential pathogens in amounts
>=10,000
cfu/ml.
CIPROFLOXACIN sensitivity testing performed by ___
___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ACINETOBACTER BAUMANNII
| PSEUDOMONAS AERUGINOSA
| |
AMPICILLIN/SULBACTAM-- 4 S
CEFEPIME-------------- 32 R 16 I
CEFTAZIDIME----------- =>64 R 4 S
CIPROFLOXACIN--------- =>4 R S
GENTAMICIN------------ 8 I 4 S
LEVOFLOXACIN---------- =>8 R
MEROPENEM------------- 8 I <=0.25 S
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ 8 I <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING:
PORTABLE CXR ___
IMPRESSION:
Increased opacification of the bilateral bases may represent
atelectasis,
aspiration, or pneumonia in the appropriate clinical setting.
CXR ___
IMPRESSION:
Mild pulmonary edema and small left pleural effusion are new.
Patient is
rotated to his left. Leftward mediastinal shift is minimal,
unchanged, left hemidiaphragm still elevated. Findings suggest
atelectasis in the left lower lobe.
Tracheostomy tube is in standard placement, caliber
substantially less than half the diameter of the trachea.
Clinical evaluation suggested to see if this is appropriate.
CXR ___
IMPRESSION:
Interval placement of right subclavian PICC line which has its
tip in the
distal SVC near the cavoatrial junction. The tracheostomy tube
is unchanged in position. No pneumothorax is seen. Streaky
bibasilar opacities have improved suggesting resolving
atelectasis. No pulmonary edema. No pneumothorax. Overall
cardiac and mediastinal contours likely unchanged given
differences in patient positioning.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Scopolamine Patch 1 PTCH TD Q72H
2. Ferrous Sulfate 325 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Ascorbic Acid ___ mg PO BID
5. LaMOTrigine 150 mg PO BID
6. Enoxaparin Sodium 30 mg SC Q12H
Start: ___, First Dose: First Routine Administration Time
7. Senna 8.6 mg PO BID:PRN constipation
8. Docusate Sodium 100 mg PO BID
9. Vitamin D 800 UNIT PO DAILY
10. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Ascorbic Acid ___ mg PO BID
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 30 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
5. Ferrous Sulfate 325 mg PO DAILY
6. LaMOTrigine 150 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. Scopolamine Patch 1 PTCH TD Q72H
9. Senna 8.6 mg PO BID:PRN constipation
10. Vitamin D 800 UNIT PO DAILY
11. CefTAZidime 2 g IV Q8H Duration: 12 Days
12. Glycopyrrolate 1 mg PO BID
13. Sulfameth/Trimethoprim Suspension 40 mL PO BID Duration: 10
Days
14. Triamcinolone Acetonide 0.025% Cream 1 Appl TP DAILY
Duration: 2 Weeks
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Acinetobacter Baumannii Pneumonia
Psuedomonas Aeruginosa Pneumonia
Enterococcal colonization of the urine
Secondary: Chronic Tracheostomy
Discharge Condition:
Mental Status: Confused - always.
Activity Status: Bedbound.
Level of Consciousness: Lethargic but arousable.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with trach, fever, increased secreations // eval for PNA
TECHNIQUE: Portable chest x-ray.
COMPARISON: None available.
FINDINGS:
Portable semi-upright radiograph of the chest demonstrates increased
opacification of the bilateral bases, which may represent atelectasis,
aspiration, or pneumonia in the appropriate clinical setting. Heart and
mediastinal contours are unremarkable. The patient is status post
tracheostomy, which ends 4.5 cm from the carina.
IMPRESSION:
Increased opacification of the bilateral bases may represent atelectasis,
aspiration, or pneumonia in the appropriate clinical setting.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)CHEST (PORTABLE AP)i
INDICATION: ___ year old man with shortness of breath // ?interval worsening
COMPARISON: Chest radiographs ___.
IMPRESSION:
Mild pulmonary edema and small left pleural effusion are new. Patient is
rotated to his left. Leftward mediastinal shift is minimal, unchanged, left
hemidiaphragm still elevated. Findings suggest atelectasis in the left lower
lobe.
Tracheostomy tube is in standard placement, caliber substantially less than
half the diameter of the trachea. Clinical evaluation suggested to see if this
is appropriate.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with new R PICC // 36cm R basilic SL PICC -
___ ___ Contact name: ___: ___ R basilic SL PICC -
___ ___
COMPARISON: Comparison to prior study ___ at 03:50
FINDINGS:
Portable semi-erect chest film ___ at 10:12 is submitted.
IMPRESSION:
Interval placement of right subclavian PICC line which has its tip in the
distal SVC near the cavoatrial junction. The tracheostomy tube is unchanged
in position. No pneumothorax is seen. Streaky bibasilar opacities have
improved suggesting resolving atelectasis. No pulmonary edema. No
pneumothorax. Overall cardiac and mediastinal contours likely unchanged given
differences in patient positioning.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever
Diagnosed with SEPTICEMIA NOS, PNEUMONIA,ORGANISM UNSPECIFIED, SEPSIS , ACCIDENT NOS, TRACHEOSTOMY STATUS
temperature: 102.4
heartrate: 106.0
resprate: 26.0
o2sat: 100.0
sbp: 108.0
dbp: 68.0
level of pain: 13
level of acuity: 2.0 | This is a ___ year old gentleman, with a history of Down Syndrome
w/ trach, G-tube and foley, stage 4 sacral decub, who is
presenting from nursing home with fever and increased secretions
from his trach.
#SEPSIS: Patient's Tmax in the ED was 102. Patient meeting SIRS
criteria with likely source of infection. Given that he is
having increased secretions and CXR shows evidence of right
lower lobe consolidation, patient likely has new pneumonia.
Patient also tachypneic to the ___. CURB 65 score of 2, but
given increased secretions he required admission to ICU given
level of care. Patient placed on vancomycin, cefepime and flagyl
(given hx of prior resistant organisms), Day 1= ___. BAL
studies grwoing GNRs which speciated to Acinetobacter Baumannii
and Psuedomonas Aeurginosa. The Acinetobacter was found to be
multidrug resistant. Infectious Disease was consulted for
recommendations in antibiotic management. He was started on IV
Bactrim for the Acinetobacter for a planned ___dditionally, Ceftazadime was started for Psuedomonal coverage
for a planned 14 day course. The patient remained afebrile and
showed some evidence of improvement in respiratory status
(slight decrease in frequency of suctioning). He was
transitioned to oral suspension Bactrim given that he was
clinically very stable.
#SECRETIONS: Patient is s/p trach and G-tube on ___. ICU
transfer for increased secretions. Patient underwent frequent
suctionning and managed with scopolamine patch. Glycopyrrolate
was additionally added given that secretions are thick and
persistent.
#SACCRAL SORE: Stage 4 ulcer. Wound care advised was consulted
and recommended packing loosely with Aquacel Ag rope and
covering by 4x4's and an ABD. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Bactrim
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
Laparoscopic Appendectomy
History of Present Illness:
Mr. ___ is a ___ male who presents to the ER with 40
hours of progressively worsening right lower quadrant abdominal
pain. He reports initially having some anorexia associated with
this, however over the last 24 hours has felt hungry. Does have
intermittent nausea which waxes and wanes, but no vomiting. He
denies fevers, chills, chest pain, shortness of breath, or
changes in bowel habits. No dysuria.
Past Medical History:
ADHD
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
T 97.8 HR 98 BP 149/90 RR 16 99% RA
GEN: A&Ox 3, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: Clear to auscultation b/l, no respiratory distress
ABD: Soft, nondistended, focal RLQ tenderness to palpation w
voluntary guarding, no rebound, no palpable masses or hernias
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
Physical exam:
Gen: NAD, AxOx3
Card: RRR, no m/r/g
Pulm: CTAB, no respiratory distress
Abd: Soft, mildly tender, non-distended, normal bs. Hematoma in
LLQ.
Wounds: c/d/i
Ext: No edema, warm well-perfused
Pertinent Results:
Admission Labs:
___ 10:56AM BLOOD WBC-6.7 RBC-6.51* Hgb-12.9* Hct-39.9*
MCV-61* MCH-19.8* MCHC-32.3 RDW-22.9* RDWSD-43.3 Plt ___
___ 10:56AM BLOOD ___ PTT-33.7 ___
___ 10:56AM BLOOD Glucose-89 UreaN-14 Creat-0.9 Na-140
K-4.0 Cl-103 HCO3-27 AnGap-10
___ 10:56AM BLOOD ALT-13 AST-14 AlkPhos-56 TotBili-1.4
___ 10:56AM BLOOD Lipase-17
___ 10:56AM BLOOD Albumin-4.4 Calcium-9.1 Phos-3.1 Mg-2.1
___ 11:05AM BLOOD Lactate-1.1
Discharge Labs:
___ 05:59AM BLOOD WBC-7.9 RBC-5.75 Hgb-11.5* Hct-35.2*
MCV-61* MCH-20.0* MCHC-32.7 RDW-22.5* RDWSD-44.3 Plt ___
___ 05:59AM BLOOD Glucose-88 UreaN-15 Creat-1.0 Na-140
K-4.3 Cl-103 HCO3-28 AnGap-9*
Imaging:
CT Abd/Pelvis ___
IMPRESSION:
1. Acute appendicitis. No drainable fluid collection or
extraluminal gas.
2. Sigmoid diverticulosis without evidence of acute
diverticulitis.
3. Splenomegaly.
GASTROINTESTINAL: No bowel obstruction is seen. Diverticulosis
of the sigmoid colon is noted, without evidence of wall
thickening and fat stranding. The appendix is distended with
wall thickening and dilated to 1.0 cm, with surrounding fat
stranding. There is no fluid collection identified. There is
no free intraperitoneal air.
PATHOLOGY: Pending
Medications on Admission:
Adderall 20mg XR QAM, 10mg ___ Qpm
Discharge Medications:
1. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Do not take and operate heavy machinery.
2. Adderall 20mg XR QAM, 10mg ___ Qpm
Discharge Disposition:
Home
Discharge Diagnosis:
Uncomplicated appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with RLQ TTP, reboundNO_PO
contrast// eval appendicitis
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 0.5 cm; CTDIvol = 24.1 mGy (Body) DLP =
12.0 mGy-cm.
2) Spiral Acquisition 6.5 s, 51.1 cm; CTDIvol = 11.6 mGy (Body) DLP = 594.7
mGy-cm.
Total DLP (Body) = 607 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is a subcentimeter hypodensity in segment 8, too small to characterize
on CT. 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 attenuation throughout, without evidence of
focal lesions. Spleen is enlarged at 16.0 cm.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
A subcentimeter hypodensity in the lower pole of the right kidney is too small
to characterize by CT, but likely represents a cyst. No hydronephrosis is
seen. There is no perinephric abnormality.
GASTROINTESTINAL: No bowel obstruction is seen. Diverticulosis of the sigmoid
colon is noted, without evidence of wall thickening and fat stranding. The
appendix is distended with wall thickening and dilated to 1.0 cm, with
surrounding fat stranding. There is no fluid collection identified. There is
no free intraperitoneal air.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is a
small amount of 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.
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. Acute appendicitis. No drainable fluid collection or extraluminal gas.
2. Sigmoid diverticulosis without evidence of acute diverticulitis.
3. Splenomegaly.
Gender: M
Race: ASIAN
Arrive by WALK IN
Chief complaint: RLQ abdominal pain
Diagnosed with Unspecified acute appendicitis, Right lower quadrant pain
temperature: 97.8
heartrate: 98.0
resprate: 16.0
o2sat: 99.0
sbp: 149.0
dbp: 90.0
level of pain: 4
level of acuity: 3.0 | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal/pelvic CT revealed WBC was WNL at 7.9. The
patient underwent laparoscopic appendectomy, which went well
without complication (reader referred to the Operative Note for
details). After a brief, uneventful stay in the PACU, the
patient arrived on the floor tolerating clears, and took
oxycodone for pain control. The patient was hemodynamically
stable.
When tolerating a diet, the patient was converted to oral pain
medication with continued good effect. Diet was progressively
advanced as tolerated to a regular diet with good tolerability.
The patient voided without problem. During this hospitalization,
the patient ambulated early and frequently, was adherent with
respiratory toilet and incentive spirometry, and actively
participated in the plan of care. The patient received
subcutaneous heparin and venodyne boots were used during this
stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall, SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with a history of HFrEF (EF 40%),
HTN, HL, DM, AFib not on AC d/t hemorrhagic stroke, CKD, and
dementia admitted for CHF exacerbation and rib fracture. He was
recently admitted ___ for acute decompensated heart
failure, discharged home on torsemide 20 mg at 202 lbs. At his
follow-up appointment on ___ he was noted to be 212 pounds, his
torsemide was increased to 20mg BID. Per ___ clinic note, it
appears there was concern over dietary indiscretions at his
rehab facility. He was seen again in ___ clinic ___ with stable
weight of 212 with mild JVP elevation. Was also in persistent
afib with more rapid ventricular rates, and his metoprolol succ
was increased from 50mg to 75mg daily. Due to his recent gain
and concerns about medications and diet at the nursing home Dr.
___ him to the ED for admission.
He has also had recent falls, at least 2 within the past week at
his rehab facility. He was seen at ___ on ___ for a
fall with R rib fracture. The ED note states there are no bed
alarms at his rehab facility (___) and case management
reported not being able to transfer him to a facility with bed
alarms.
In the ED initial vitals were: T 98.5 HR 73 BP 149/90 RR 18 O2
99% RA
He was seen by trauma.
CTA C/A/P revealed:
-Posterolateral tenth and eleventh rib fractures, similar to the
CT from ___. No evidence of new traumatic injury
-New right lower lobe subsegmental pulmonary embolism.
-15 mm left lower lobe pulmonary nodule. Recommend PET-CT for
further evaluation.
-Bilateral adrenal nodules are incompletely evaluated and
statistically likely to reflect adenomas.
-Similar aneurysmal dilation of the ascending thoracic aorta to
4.6 cm and aneurysm dilation of the left common iliac artery.
-Dilated pulmonary artery suggestive of pulmonary hypertension.
-Cardiomegaly and trace bilateral pleural effusions.
EKG:
Labs/studies notable for:
Patient was given: IV Lasix 40mg, torsemide 20mg PO, lisinopril
40mg, metoprolol succinate 50mg
Vitals on transfer: T 98.2 HR 78 BP 161/87 RR 18 O2 98% RA
On the floor he appears comfortable, resting, in no acute
distress. Reports his breathing is better but is unable to give
much history about his symptoms or what brought him to the
hospital. Denies any chest pain, SOB.
Past Medical History:
- HFrEF- EF 40% ___ ? of cardiac amyloid, biopsy deferred per
cardiology notes
- Diabetes
- Hypertension
- Dyslipidemia
-Plasma cell dyscrasia, smoldering multiple myeloma (10% yearly
risk of progression to active MM requiring treatment)
-Dementia (A&O to self)
-Hemorrhagic CVA per OMR in ___- left frontal hemorrhage s/p 2
EVDs
-Ischemic stroke ___
-CKD Stage III
-BPH
-Vitamin d deficiency
-Abdominal aortic aneurysm
Social History:
___
Family History:
Non-contributory. Father with hypertension.
Physical Exam:
ADMISSION EXAM:
=====================
VS: T 98.7 BP 164/85 HR 77 RR 18 O2 98% SAT
Weight on admission: 98.2kg
Prior discharge weight: 91.9 kg
GENERAL: Lying flat in NAD. Oriented to person, place, and time
but unable to give much history. Mood, affect appropriate.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP of 10 cm at 30 degrees.
CARDIAC: Irregular rate and rhythm. Normal S1, S2. No murmurs,
rubs, or gallops. No thrills or lifts.
LUNGS: Tenderness to palpation R lower ribs. Respiration is
unlabored with no accessory muscle use. No crackles, wheezes or
rhonchi.
ABDOMEN: Soft, non-tender, non-distended. No hepatomegaly. No
splenomegaly.
EXTREMITIES: Warm, well perfused. 1+ pitting edema to mid calf
bilaterally
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE EXAM:
=====================
VS: 98.4 ___ BP 96-108/60s RR 18 97% RA
Weight: 91.9 (___) <- 92.8 <- 92.3 <- 90.7 <- 90.4 <- 93.5 <-
93.1 <- 92.5 <- 92.6, (weight was 91.9 kg ___ d/c from ___
service)
I/O: ___
GENERAL: Laying in bed comfortably in NAD. Oriented to person,
place, and time but unable to give much history.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
NECK: Supple. JVP not appreciated
CARDIAC: Irregular rate and rhythm. Normal S1, S2. II/VI
diastolic murmur at apex, no rubs or gallops. No thrills or
lifts.
LUNGS: Tenderness to palpation R lower ribs. Respiration is
unlabored with no accessory muscle use. Minimal bibasilar
crackles.
ABDOMEN: suprapubic ttp
Pertinent Results:
ADMISSION LABS:
===================
___ 09:54PM BLOOD WBC-6.4 RBC-3.56* Hgb-9.0* Hct-30.0*
MCV-84 MCH-25.3* MCHC-30.0* RDW-17.1* RDWSD-52.4* Plt ___
___ 09:54PM BLOOD Glucose-129* UreaN-17 Creat-1.0 Na-140
K-3.5 Cl-101 HCO3-31 AnGap-12
___ 09:54PM BLOOD proBNP-1602*
___ 04:35PM BLOOD ALT-12 AST-14 AlkPhos-85 TotBili-0.3
___ 08:49PM BLOOD ___ pO2-77* pCO2-60* pH-7.33*
calTCO2-33* Base XS-3 Comment-GREEN TOP
DISCHARGE LABS:
===================
___ 04:42AM BLOOD WBC-4.7 RBC-4.23* Hgb-10.6* Hct-34.6*
MCV-82 MCH-25.1* MCHC-30.6* RDW-17.4* RDWSD-51.0* Plt ___
___ 04:42AM BLOOD Plt ___
___ 04:35AM BLOOD ___ PTT-31.2 ___
___ 04:42AM BLOOD Glucose-122* UreaN-57* Creat-1.7* Na-141
K-4.2 Cl-94* HCO3-28 AnGap-23*
___ 01:19PM BLOOD Glucose-262* UreaN-52* Creat-1.9* Na-134
K-4.2 Cl-92* HCO3-24 AnGap-22*
___ 04:42AM BLOOD Calcium-9.2 Phos-3.9 Mg-2.6
MICRO:
======
URINE CULTURE (Final ___:
Culture workup discontinued. Further incubation showed
contamination
with mixed skin/genital flora. Clinical significance of
isolate(s)
uncertain. Interpret with caution.
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
PROTEUS MIRABILIS. 10,000-100,000 CFU/mL.
PRESUMPTIVE IDENTIFICATION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
| PROTEUS MIRABILIS
| |
AMPICILLIN------------ <=2 S <=2 S
AMPICILLIN/SULBACTAM-- <=2 S <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S <=1 S
CEFTAZIDIME----------- <=1 S <=1 S
CEFTRIAXONE----------- <=1 S <=1 S
CIPROFLOXACIN--------- =>4 R 2 I
GENTAMICIN------------ <=1 S <=1 S
MEROPENEM-------------<=0.25 S <=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S <=4 S
TOBRAMYCIN------------ <=1 S <=1 S
TRIMETHOPRIM/SULFA---- =>16 R <=1 S
IMAGING:
===================
CT C/A/P ___:
1. Minimally displaced right posterolateral tenth and eleventh
rib fractures, similar to the CT from ___. No
evidence of new traumatic injury in the chest, abdomen or
pelvis.
2. New right lower lobe subsegmental pulmonary embolism.
3. 15 mm left lower lobe pulmonary nodule. Recommend PET-CT for
further
evaluation.
4. Bilateral adrenal nodules are incompletely evaluated and
statistically
likely to reflect adenomas.
5. Similar aneurysmal dilation of the ascending thoracic aorta
to 4.6 cm and aneurysm dilation of the left common iliac artery.
6. Dilated pulmonary artery suggestive of pulmonary
hypertension.
7. Cardiomegaly and trace bilateral pleural effusions.
___ US ___:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
CT HEAD ___:
1. There are no acute findings.
2. There are chronic multiple infarcts which are stable.
MRI BRAIN W/O CONTRAST ___:
1. No acute infarct or acute hemorrhage.
2. Numerous chronic infarcts with associated volume loss, as
described.
3. Numerous scattered areas of chronic microhemorrhage in the
bilateral basal ganglia, bilateral thalamus, brainstem and
bilateral cerebellar hemispheres in a distribution suggestive of
chronic hypertensive encephalopathy.
4. Moderate global atrophy with diffuse white matter signal
abnormality
suggestive of chronic small vessel ischemic disease.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glargine 10 Units Breakfast
2. Lisinopril 40 mg PO DAILY
3. Torsemide 20 mg PO BID
4. Aspirin 325 mg PO DAILY
5. Donepezil 10 mg PO QHS
6. MetFORMIN (Glucophage) 250 mg PO BID
7. Metoprolol Succinate XL 75 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Sertraline 100 mg PO DAILY
11. Simvastatin 20 mg PO QPM
12. Tamsulosin 0.4 mg PO QHS
13. Vitamin D ___ UNIT PO 1X/WEEK (WE)
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H
2. Ampicillin 500 mg PO Q6H
END DATE ___, will complete 7 day course for UTI then
3. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN Rib pain
4. Spironolactone 25 mg PO DAILY
5. Glargine 10 Units Breakfast
6. Lisinopril 30 mg PO DAILY
7. Metoprolol Succinate XL 50 mg PO BID
8. Torsemide 40 mg PO BID
9. Aspirin 325 mg PO DAILY
10. Donepezil 10 mg PO QHS
11. MetFORMIN (Glucophage) 250 mg PO BID
12. Multivitamins 1 TAB PO DAILY
13. Omeprazole 20 mg PO DAILY
14. Sertraline 100 mg PO DAILY
15. Simvastatin 20 mg PO QPM
16. Tamsulosin 0.4 mg PO QHS
17. Vitamin D ___ UNIT PO 1X/WEEK (WE)
18.Outpatient Lab Work
Please check electrolytes on ___ (Na, K, Cl, HCO3, BUN, Cr,
Mg) and fax them to ___ at ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses:
=====================
Acute on chronic systolic heart failure exacerbation
Right subsegmental pulmonary embolism
Secondary Diagnoses:
======================
Right rib fracture
Dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with congestive heart failure and dyspnea on
exertion. Please evaluate for pulmonary edema.
TECHNIQUE: PA and lateral chest radiographs were obtained.
COMPARISON: Chest radiograph from ___.
FINDINGS:
The heart continues to be enlarged with mild to moderate CHF. Possible
minimal blunting of both costophrenic angles could reflect small bilateral
effusions. There is bibasilar atelectasis. No focal consolidation or
pneumothorax is detected.
Right-sided rib fractures are better seen on the dedicated chest CT.
IMPRESSION:
Cardiomegaly with mild CHF. Possible very small bilateral effusions.
Radiology Report
INDICATION: ___ male with congestive heart failure, dementia,
unwitnessed fall and right flank ecchymosis and tenderness. The patient has
posterior lower rib crepitus on this exam. Evaluate for intrathoracic or
intra- abdominal 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) = 1,641 mGy-cm.
COMPARISON: CT torso from ___.
FINDINGS:
CHEST:
HEART AND VASCULATURE: There is aneurysmal dilation of the ascending aorta
and aortic arch measuring 4.6 cm and 4.2 cm, similar to prior exam (series
3:image 35). A bovine arch is incidentally noted (series 601b:image 69). The
descending aorta is tortuous with mild calcified and noncalcified plaque along
the left posterior aspect. The heart is enlarged, and no pericardial effusion
is seen. There is dilation of the main pulmonary artery measuring 3.6 cm.
There is a new filling defect in a right lower lobe posterolateral
subsegmental branch (series 2:image 69). There is no evidence of right heart
strain.
AXILLA, HILA, AND MEDIASTINUM: No axillary, supraclavicular or hilar
lymphadenopathy is present. A top-normal in size right paratracheal lymph
node is noted measuring 10 mm in short axis (series 3:image 16). No
mediastinal mass or hematoma.
PLEURAL SPACES: There are trace pleural effusions.
LUNGS/AIRWAYS: Again noted is a left lower lobe 15 mm pulmonary nodule
(series 3:image 65). 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.
The thyroid gland is unremarkable.
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. The hepatic and portal veins are patent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesion or laceration. An accessory spleen is noted.
ADRENALS: Bilateral adrenal nodules are again noted, which are incompletely
evaluated on this exam (series 2:image 106, 96).
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of hydronephrosis. Bilateral small subcentimeter renal
hypodensities are too small to characterize but likely reflective of cysts.
Right upper pole cortical thinning may be due to prior insult such as ischemia
or infection (series 2:image 105). There is no perinephric abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. The small bowel loops
demonstrate normal caliber, wall thickness, and enhancement throughout. Few
scattered colonic diverticula are noted. The appendix is normal. There is no
evidence of mesenteric injury. There is no free fluid or free air in the
abdomen.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. A
prominent left para-aortic lymph node measures 9 mm and is not multiple
enlarged by CT size criteria (series 2:image 161). There is no pelvic or
inguinal lymphadenopathy.
VASCULAR: There is ectasia of the infrarenal aorta measuring 2.4 cm. There is
aneurysmal dilation of the left common iliac artery measuring 2.0 cm. Ectasia
of the right common iliac artery measures 1.7 cm. Moderate atherosclerotic
disease is noted. The abdominal aorta and its major branches are patent. A
left retroaortic renal vein is incidentally noted.
BONES: There are minimally displaced posterolateral right tenth and eleventh
rib fractures, similar to prior exam. No focal suspicious osseous
abnormality.
SOFT TISSUES: Soft tissue swelling along the right flank overlying the
aforementioned rib fractures is again noted.
IMPRESSION:
1. Minimally displaced right posterolateral tenth and eleventh rib fractures,
similar to the CT from ___. No evidence of new traumatic injury
in the chest, abdomen or pelvis.
2. New right lower lobe subsegmental pulmonary embolism.
3. 15 mm left lower lobe pulmonary nodule. Recommend PET-CT for further
evaluation.
4. Bilateral adrenal nodules are incompletely evaluated and statistically
likely to reflect adenomas.
5. Similar aneurysmal dilation of the ascending thoracic aorta to 4.6 cm and
aneurysm dilation of the left common iliac artery.
6. Dilated pulmonary artery suggestive of pulmonary hypertension.
7. Cardiomegaly and trace bilateral pleural effusions.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 10:18 AM, 1 minutes after
updated findings.
Radiology Report
EXAMINATION: ___ DUP EXTEXT BIL (MAP/DVT)
INDICATION: ___ year old man with CHF. newly diagnosed R subsegmental PE,
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 is
demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with afib, PMH hemorrhagic strokes, CHF, found
down at rehab // Intracranial hemorrhage
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.1 cm; CTDIvol = 49.9 mGy (Head) DLP =
903.1 mGy-cm.
Total DLP (Head) = 903 mGy-cm.
COMPARISON: Head CT ___
FINDINGS:
There is chronic infarct involving medial left thalamus. There are stable
chronic lacunar infarct involving right upper thalamus, anterior limb right
internal capsule, right putaminal, left caudate head. There are extensive
bihemispheric chronic cortical infarcts involving bilateral frontal, bilateral
parietal, left occipital, right temporal lobes, stable. There is no evidence
of new or acute infarction, hemorrhage, edema, or mass. The ventricles and
sulci are normal in size and configuration.
There is right frontal burr hole. There is no evidence of fracture. There is
submucosal retention cyst in the right maxillary sinus. The visualized
portion of the remaining paranasal sinuses, mastoid air cells, and middle ear
cavities are clear. The visualized portion of the orbits are unremarkable.
IMPRESSION:
1. There are no acute findings.
2. There are chronic multiple infarcts which are stable.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST ___ MR HEAD
INDICATION: History of intraparenchymal hemorrhage with new pulmonary embolus
requiring heparin. Evaluate for micro bleed or stroke.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON Noncontrast head CTs dating from ___ through ___.
FINDINGS:
There is unchanged encephalomalacia from bifrontal, biparietal, right
occipital and right temporal infarcts. There is an additional chronic left
thalamic infarct as well as a small lacunar infarct in the right thalamus.
There is no new focus of slowed diffusion to suggest acute infarction. There
is no evidence of hemorrhage, edema, masses, mass effect, midline shift or
infarction. There is prominence of the ventricles and sulci suggestive of
involutional changes. Background areas of confluent pontine, periventricular,
subcortical and deep white matter T2/FLAIR hyperintensity likely reflect a
combination of infarct and chronic small vessel ischemic disease.
The principal intracranial vascular flow voids are preserved. The vertebral
arteries, basilar artery, anterior and middle cerebral arteries appear
ectatic.
There is postsurgical change from a right frontal burr hole. There are
numerous areas of susceptibility artifact in the bilateral basal ganglia,
thalami, midbrain, pons, medulla and bilateral cerebellar hemispheres, in a
pattern suggestive of chronic hypertensive encephalopathy. A few other
scattered areas of chronic microhemorrhage are seen in the bilateral parietal
lobes at the gray-white matter junction, with some in areas of prior infarct.
There is a tiny mucous retention cyst in the inferior aspect of the right
maxillary sinus. The remainder of the paranasal sinuses are grossly clear.
The orbits are grossly unremarkable.
IMPRESSION:
1. No acute infarct or acute hemorrhage.
2. Numerous chronic infarcts with associated volume loss, as described.
3. Numerous scattered areas of chronic microhemorrhage in the bilateral basal
ganglia, bilateral thalamus, brainstem and bilateral cerebellar hemispheres in
a distribution suggestive of chronic hypertensive etiology.
4. Moderate global atrophy with diffuse white matter signal abnormality
suggestive of chronic small vessel ischemic disease.
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Dyspnea, unspecified
temperature: 98.5
heartrate: 73.0
resprate: 18.0
o2sat: 99.0
sbp: 149.0
dbp: 90.0
level of pain: 0
level of acuity: 3.0 | ___ male with a history of HFrEF (EF 40%), HTN, HL, DM,
AFib not on AC d/t hemorrhagic stroke, CKD, and dementia
admitted for CHF exacerbation and new R subsegmental PE.
#ACUTE ON CHRONIC SYSTOLIC HEART FAILURE EXACERBATION: After
last discharge in ___ gained approx. ___ pounds with
increasing edema and JVD. Despite cardiology instructions to
increase diuretics, it appears there were concerns about nursing
home medication compliance and dietary adherence. On admission
BNP 1600, stable from ___ admission for CHF. Patient was
diuresed with IV Lasix and transitioned to PO regimen of
torsemide 40 mg BID. For afterload, patient discharged on
lisinopril 30 mg (previous dose 40 mg; decreased for lower blood
pressures). Metoprolol succinate XL was increased from 75 mg
daily to 75 mg QAM and 50 mg ___ for better heart rate control.
Discharge weight 91.9 kg.
#R SUBSEGMENTAL PE: New subsegmental PE seen on CT angiogram
performed in the Emergency Department. He has atrial
fibrillation but has only been on aspirin due to a history of
cerebral hemorrhage ___. HDS, no O2 requirement, no signs of R
heart strain on ECG on admission. Neurology was consulted given
history of intracranial hemorrhage. Recommended heparin drip w/o
bolus and MRI to help in determine risks of longterm
anticoagulation. However, based on discussions with patient's
outpatient cardiologist (Dr. ___ and patient's son, the
decision was made to defer antiocoagulation due to patients CVA
hemorrhage and frequent falls. Patient remained HDS throughout
hospital course.
# UTI: Patient had complaint of abdominal pain in RLQ to
suprapubic region. UA, UCx revealed E. coli and proteus. Patient
initially started on IV ceftriaxone ___ but narrowed to
ampicillin when sensitivities resulted. He will complete course
of ampicillin ___.
#AFIB: History of afib, recently persistent. CHADSVASC of 6,
however has not been on full anticoagulation given history of
intracranial hemorrhage in ___. Patient was monitored on
telemetry during hospital course and had rates up to 140s. The
decision was made to increased Metoprolol succinate XL from 75
mg daily to 75 mg QAM and 50 mg QPM for better rate control.
#RIB FRACTURE: Reported frequent falls at rehab, and per OSH
records no bed alarms at rehab facility. s/p rib fracture from a
fall. Stable R rib fracture with pain on exam. Pain controlled
with Tylenol and lidocaine patch as needed.
___ on CKD stage 3: baseline 1.1-1.6. Cr monitored while
inpatient. Did have rise in Cr to 1.9. Improved by withholding
Lasix dose. Cr on discharge 1.7. Please check BMP day after
discharge and fax to ___ clinic: ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins / lisinopril /
nitrofurantoin
Attending: ___.
Chief Complaint:
Confusion and left side weakness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with COPD, CAD s/p CABG, and
HTN who was brought to OSH via EMS after being found down.
History obtained per report as patient does not remember what
happened. She lives alone in elderly housing, and her neighbor
saw her out yesterday afternoon. Her neighbor found her today on
the floor of her living room in a puddle of urine. Unknown how
long she was on the floor, but neighbor thinks she fell only
5min
prior. When EMS arrived, she was talking and denied any head,
neck, or back pain. She was found with her left arm under her.
She is not on any blood thinners.
She endorsed a headache. At OSH, had head CT that showed concern
for hemorrhagic transformation of a right basal ganglia infarct
vs hemorrhagic mass
Unclear what her baseline is, but per ED dash, she lives alone
and is independent.
Past Medical History:
COPD, CAD s/p CABG, osteoporosis, HTN, Raynaud's
Social History:
___
Family History:
no history of stroke
Physical Exam:
ADMISSION EXAM:
===============
Vitals: T: 96.8F HR: 81 BP: 143/55 RR: 16 SaO2: 100% RA
General: NAD, frail
HEENT: wound on left cheek, no oropharyngeal lesions, neck
supple
___: RRR, no M/R/G
Pulmonary: low air flow throughout
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, oriented to self and ___.
Knows that she is turning ___ this year. Unable to relate history
but able to follow simple commands. Able to repeat "today is a
___ day." Has trouble naming low frequency objects, unclear if
this is due to visual difficulties. Able to read. Mild
dysarthria.
- Cranial Nerves: PERRL 3->2 brisk. Does not BTT on the left,
+BTT on right. EOMI, no nystagmus. V1-V3 without deficits to
light touch bilaterally. Left lower facial droop. Hearing intact
to finger rub bilaterally. Palate elevation symmetric.
SCM/Trapezius strength ___ bilaterally. Tongue midline.
- Sensorimotor: moves RUE spontaneously and uses it to localize
to noxious on the left side of her body, LUE triple flex, BLE
withdraw to tickle
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 3+ 3+ 3+ 3+ 2
R 3+ 3+ 3+ 3+ 2
Plantar response upgoing on the left
- Sensory: decreased sensation to pin on the left arm, bilateral
lower extremities intact to pin and light touch
- Coordination: No dysmetria with finger to nose testing on the
right
- Gait: deferred
DISCHARGE EXAM:
===============
Gen: Pt is comfortable
Pulm: Non-labored breathing
Pertinent Results:
LABS:
=====
___ 09:13PM BLOOD WBC-15.1* RBC-5.11 Hgb-15.6 Hct-45.2*
MCV-89 MCH-30.5 MCHC-34.5 RDW-13.0 RDWSD-42.1 Plt ___
___ 06:15AM BLOOD WBC-9.2 RBC-3.96 Hgb-11.9 Hct-36.4 MCV-92
MCH-30.1 MCHC-32.7 RDW-13.4 RDWSD-45.6 Plt ___
___ 09:13PM BLOOD Neuts-89.8* Lymphs-1.5* Monos-8.0
Eos-0.1* Baso-0.1 Im ___ AbsNeut-13.60* AbsLymp-0.23*
AbsMono-1.21* AbsEos-0.01* AbsBaso-0.01
___ 09:13PM BLOOD ___ PTT-30.2 ___
___ 05:20AM BLOOD ___ PTT-27.4 ___
___ 09:13PM BLOOD Glucose-91 UreaN-29* Creat-0.7 Na-141
K-3.8 Cl-101 HCO3-20* AnGap-20*
___ 06:15AM BLOOD Glucose-110* UreaN-13 Creat-0.4 Na-142
K-3.6 Cl-106 HCO3-25 AnGap-11
___ 09:13PM BLOOD ALT-29 AST-80* CK(CPK)-3005* AlkPhos-75
TotBili-0.4
___ 06:05AM BLOOD ALT-23 AST-59* LD(LDH)-326* CK(CPK)-1119*
AlkPhos-58 TotBili-0.4
___ 06:15AM BLOOD CK(CPK)-191
___ 09:13PM BLOOD CK-MB-98* MB Indx-3.3
___ 09:13PM BLOOD cTropnT-0.07*
___ 05:20AM BLOOD CK-MB-49* MB Indx-3.0 cTropnT-0.09*
___ 01:10PM BLOOD CK-MB-20* cTropnT-0.08*
___ 09:13PM BLOOD Albumin-3.6 Calcium-8.9 Phos-4.0 Mg-1.9
___ 06:15AM BLOOD Calcium-7.8* Phos-2.5* Mg-1.7
___ 05:20AM BLOOD %HbA1c-5.0 eAG-97
___ 05:20AM BLOOD Triglyc-114 HDL-37* CHOL/HD-3.8
LDLcalc-80
___ 09:13PM BLOOD TSH-0.34
___ 05:20AM BLOOD TSH-0.25*
___ 06:05AM BLOOD TSH-0.31
___ 06:05AM BLOOD Free T4-1.3
___ 05:20AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:01PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 08:29AM URINE Color-Yellow Appear-Clear Sp ___
___ 05:30PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 09:01PM URINE Blood-MOD* Nitrite-NEG Protein-100*
Glucose-NEG Ketone-40* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 08:29AM URINE Blood-SM* Nitrite-NEG Protein-30*
Glucose-TR* Ketone-40* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 05:30PM URINE Blood-MOD* Nitrite-POS* Protein-100*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG*
___ 09:01PM URINE RBC-1 WBC-2 Bacteri-NONE Yeast-NONE Epi-1
___ 08:29AM URINE RBC-4* WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 05:30PM URINE RBC-121* WBC->182* Bacteri-MOD*
Yeast-NONE Epi-<1
___ 09:01PM URINE Mucous-FEW*
___ 05:30PM URINE Mucous-RARE*
___ 09:01PM URINE CastHy-7*
___ 03:55AM URINE bnzodzp-NEG barbitr-NEG opiates-POS*
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ 09:50PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
MICRO:
======
/___ 8:29 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. 10,000-100,000 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
IMAGING/STUDIES:
================
CTA HEAD AND NECK ___:
IMPRESSION:
There are multiple filling defects seen in the right M1 and M2
segments of the
MCA suggesting emboli with decreased opacification an
arborization of the M2,
M3 and M4 segments. Hypodense changes in the right MCA
distribution
suggestive of a large territory acute right MCA territory
infarct.
A few foci of hyperdensity in the right basal ganglia is
concerning for
hemorrhagic transformation/petechial hemorrhage.
There is complete occlusion of the right CCA from the T1 level
distally also
involving almost the entire right ICA. There is collateral
filling of the
terminal right ICA.
There is 40-50% stenosis of the left ICA by NASCET criteria.
Soft tissue
plaque also present in the distal left CCA.
ECHO ___:
Conclusions
The left atrial volume index is normal. No atrial septal defect
is seen by 2D or color Doppler. The estimated right atrial
pressure is ___ mmHg. There is mild symmetric left ventricular
hypertrophy with normal cavity size. Regional left ventricular
wall motion is normal. Left ventricular systolic function is
hyperdynamic (EF>75%). No masses or thrombi are seen in the left
ventricle. Tissue Doppler imaging suggests an increased left
ventricular filling pressure (PCWP>18mmHg). There is a mild
resting left ventricular outflow tract obstruction (19 mmHg).
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) are mildly thickened. No masses or
vegetations are seen on the aortic valve. There is no valvular
aortic stenosis. The increased transaortic velocity is likely
related to high cardiac output. No aortic regurgitation is seen.
The mitral valve leaflets are mildly thickened. There is no
mitral valve prolapse. No mass or vegetation is seen on the
mitral valve. There is moderate pulmonary artery systolic
hypertension. No vegetation/mass is seen on the pulmonic valve.
There is no pericardial effusion.
IMPRESSION: No definite cardiac source of embolism identified.
Mild basal septal left ventricular hypertrophy with normal
cavity size, and hyperdynamic systolic function. Increased PCWP.
Mild resting left ventricular outflow tract obstruction in the
setting of hyperdynamic left ventricular function and basal
septal hypertrophy. Moderate pulmonary artery systolic
hypertension.
___ ___:
IMPRESSION:
1. Evolving acute infarct in the right MCA territory, in the
region of
decreased blood flow seen on CTA. There is localized mass
effect with sulcal
effacement. No midline shift. Basal cisterns remain patent.
2. No significant change in small area of hyperdensity in the
right basal
ganglia indicating hemorrhage . No new intracranial hemorrhage.
3. Unchanged dense right middle cerebral artery.
CT L-SPINE W/O CONTRAST ___:
IMPRESSION:
1. Inferior compression deformity of the L1 vertebral body, and
superior
endplate compression deformities of the L2, L3 and L4 vertebral
bodies, are
likely chronic in nature. There is no prevertebral soft tissue
swelling to
indicate acute injury. No retropulsion of bony fragments into
the spinal
canal.
2. Multilevel degenerative changes, worst at T12-L1 where there
is moderate
spinal canal narrowing.
MR HEAD W & W/O CONTRAST ___:
IMPRESSION:
1. Redemonstrated large right MCA territory late acute to
subacute infarct to
include the right lentiform nucleus where there is evidence of
hemorrhage
centered within the putamen.
2. Scattered foci of late acute to subacute infarct involving
the left centrum
semiovale and genu of the left corpus callosum.
3. Loss of the normal flow void of the right intracranial ICAs
compatible with
slow flow versus occlusion correlating with that seen on the
recent CTA head.
4. Evidence of an old right occipital lobe infarct.
5. Extensive white matter chronic small vessel ischemic disease.
6. Generalized parenchymal volume loss, likely age related.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Levothyroxine Sodium 100 mcg PO DAILY
3. Metoprolol Succinate XL 100 mg PO BID
4. Pravastatin 40 mg PO QPM
5. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PR Q6H:PRN Pain or Fever
2. Hyoscyamine 0.125 mg SL QID:PRN excess secretions
3. LORazepam 0.5 mg PO Q2H:PRN anxiety/distress
RX *lorazepam [Ativan] 0.5 mg 1 tablet by mouth every two (2)
hours Disp #*12 Tablet Refills:*0
4. Morphine Sulfate (Concentrated Oral Solution) 20 mg/mL 5 mg
PO Q3H:PRN Pain - Mild
RX *morphine concentrate 100 mg/5 mL (20 mg/mL) 0.25 mL by mouth
every three (3) hours Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right basal ganglia infarct
Infarct involving the left centrum semiovale and corpus callosum
Hemorrhagic conversion
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old woman with what appears to be a right basal ganglia
stroke c/b hemorrhagic conversion// stroke, suspect hemorrhagic conversion but
?other process that could lead to bleeding ie mass
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of Gadavist intravenous contrast, axial imaging was performed
with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE
imaging was performed and re-formatted in axial and coronal orientations.
COMPARISON: CT head without contrast, CTA head and neck ___.
FINDINGS:
Redemonstrated is a large right MCA territory late acute to subacute infarct
to include the right lentiform nucleus where there is evidence of hemorrhage.
There is also evidence of scattered foci of slow diffusion involving the left
centrum semiovale and genu of the left corpus callosum. These regions of slow
diffusion demonstrate corresponding FLAIR signal abnormality. There is no
evidence of midline shift. There is evidence of an old right occipital lobe
infarct.
Prominence of the ventricles and cerebral sulci are compatible with age
related involutional changes. There are extensive superimposed Sub
subcortical cortical, deep and periventricular white matter T2/FLAIR
hyperintensities are nonspecific but compatible with chronic small vessel
ischemic disease. There is no abnormal enhancement after contrast
administration.
There is loss of the normal flow void involving the right intracranial ICA.
The paranasal sinuses, mastoid air cells and orbits are normal.
IMPRESSION:
1. Redemonstrated large right MCA territory late acute to subacute infarct to
include the right lentiform nucleus where there is evidence of hemorrhage
centered within the putamen.
2. Scattered foci of late acute to subacute infarct involving the left centrum
semiovale and genu of the left corpus callosum.
3. Loss of the normal flow void of the right intracranial ICAs compatible with
slow flow versus occlusion correlating with that seen on the recent CTA head.
4. Evidence of an old right occipital lobe infarct.
5. Extensive white matter chronic small vessel ischemic disease.
6. Generalized parenchymal volume loss, likely age related.
Radiology Report
INDICATION: ___ year old woman admitted with R IPH, now febrile// Assess for
consolidation
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Lung volumes have improved. Cardiomediastinal silhouette is stable. There is
no pleural effusion. No pneumothorax is seen. There is no evidence of
pneumonia. No evidence for edema
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman admitted w/ R-sided IPH now with decreased
alertness// Assess for interval change in R-sided IPH
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: CTA head and neck on ___
FINDINGS:
Study is mildly degraded by motion. Compared with CT head ___,
there is increased hypodensity in the right MCA territory including the right
frontal, parietal and temporal lobes, with loss of gray-white matter
differentiation, compatible with evolving infarct in the region of decreased
blood flow seen on CTA. There is localized mass effect with sulcal
effacement. There is no midline shift. Basal cisterns remain patent. Small
amount of acute hemorrhage centered in the right basal ganglia is not
significantly changed. There is no new intracranial hemorrhage. Areas of
encephalomalacia in the right parietal and occipital lobes are unchanged,
consistent with chronic infarct. There is prominence of the ventricles and
sulci suggestive of involutional changes. Subcortical and periventricular
white matter hypodensities are nonspecific, however likely represent sequela
of chronic small vessel ischemic disease. Slight apparent hyperdense
appearance of the right MCA M1 segment is not significantly changed.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
1. Evolving acute infarct in the right MCA territory, in the region of
decreased blood flow seen on CTA. There is localized mass effect with sulcal
effacement. No midline shift. Basal cisterns remain patent.
2. No significant change in small area of hyperdensity in the right basal
ganglia indicating hemorrhage . No new intracranial hemorrhage.
3. Unchanged dense right middle cerebral artery.
Radiology Report
INDICATION: ___ year old woman with Doboff.// Evaluate Doboff position.
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
The Dobhoff tube projects over the stomach. Lungs are clear. Heart size is
normal. There is no pleural effusion. No pneumothorax is seen
Radiology Report
EXAMINATION: CT L-SPINE W/O CONTRAST Q331 CT SPINE
INDICATION: ___ year old woman with Hx osteoporosis transferred w/ R-sided
IPH, found on OSH abdominal CT to have ?L1-L3 compression fractures.// Assess
?L1-L3 compression fractures noted on OSH abdominal CT
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 18.6 s, 28.4 cm; CTDIvol = 15.2 mGy (Body) DLP =
411.2 mGy-cm.
Total DLP (Body) = 427 mGy-cm.
COMPARISON: Life image CT scan of the lumbar spine dated ___ from
___
FINDINGS:
Alignment is normal. The bones are diffusely osteopenic. There is a chronic
appearing deformity of the inferior endplate of L1. There are mild superior
endplate compression deformities of the L2, L3 and L4 vertebral bodies,
chronic appearing. No definite acute fracture. There are multilevel
degenerative changes with disc space narrowing, posterior disc bulges, and
thickening of the ligamentum flavum, worst at T12-L1 where a large posterior
disc bulge results in moderate spinal canal narrowing and deformity of the
anterior thecal sac. There is no severe neural foraminal narrowing. There is
no prevertebral edema.
An enteric tube terminates in the stomach. There is vicarious excretion of
contrast in the gallbladder. There is delayed contrast excretion in the
collecting systems bilaterally from to recent CTA. There is colonic
diverticulosis. There is extensive atherosclerotic calcification in the
visualized abdominal aorta and its branches.
IMPRESSION:
1. Inferior compression deformity of the L1 vertebral body, and superior
endplate compression deformities of the L2, L3 and L4 vertebral bodies, are
likely chronic in nature. There is no prevertebral soft tissue swelling to
indicate acute injury. No retropulsion of bony fragments into the spinal
canal.
2. Multilevel degenerative changes, worst at T12-L1 where there is moderate
spinal canal narrowing.
Radiology Report
INDICATION: ___ year old woman with tachypnea and occasional fevers.//
Evaluate for pulmonary edema vs PNA.
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
Feeding tube extends below the level the diaphragm but beyond the field of
view of this radiograph. The patient is post median sternotomy and CABG.
Trace bilateral pleural effusions are present subjacent atelectasis.
Superimposed pneumonia, particularly in the left lower lung would be hard to
exclude in the proper clinical context. No pneumothorax. The size of the
cardiac silhouette is within normal limits.
IMPRESSION:
Trace bilateral pleural effusions and subjacent atelectasis. A superimposed
pneumonia, particularly at the left lung base would be hard to exclude in the
proper clinical context.
Radiology Report
INDICATION: ___ year old woman with tachypnea and poor UOP.// Evaluate for
interval change.
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
Feeding tube extends below the level the diaphragm but beyond the field of
view of this radiograph.
There is a small left pleural effusion with subjacent opacities, increased
since prior. Atelectasis is present at the right lung base. There is
interstitial prominence again noted likely related to chronic lung disease.
The lungs appear hyperexpanded but unchanged.
IMPRESSION:
Increased size of the left pleural effusion and subjacent opacities. These
may reflect atelectasis however superimposed pneumonia would be hard to
exclude.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with pulmonary effusion. Evaluation for
interval change.
TECHNIQUE: Chest portable AP
COMPARISON: Chest radiographs from ___.
FINDINGS:
Enteric tube extends below the field of view and into the stomach. Median
sternotomy wires are intact and aligned.
No significant interval change in small left pleural effusion with subjacent
atelectasis. Stable right basilar atelectasis. Mild pulmonary vascular
congestion with no overt pulmonary edema. Cardiomediastinal silhouette is
stable and within normal limits.
IMPRESSION:
No significant interval change from prior day's radiograph, with stable
appearance of small left pleural effusion with subjacent atelectasis.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status, Transfer
Diagnosed with Cerebral infarction, unspecified
temperature: 95.6
heartrate: 80.0
resprate: 16.0
o2sat: 99.0
sbp: 184.0
dbp: 89.0
level of pain: UA
level of acuity: 2.0 | Ms. ___ is a ___ woman with COPD, CAD s/p CABG, and
HTN who was found down and was confused and had left-sided
weakness. She was taken to ___ where a ___
showed a right basal ganglia infarct with hemorrhagic
conversion. EKG at ___ also showed diffuse
hyperacute T waves, deep TWI in leads V1, V2 and aVL, QTC 516
mSec. She was transferred to ___ on ___. In the ___
emergency room, EKG confirmed results of previous EKG and she
was noted to have elevated CK 3005, mild elevation in troponin
T(0.07) and elevated CK-MB (98+) revealing evidence of
rhabdomyolysis and NSTEMI. Cardiology was consulted and ECHO
showed EF>75% without evidence of thrombus. CTA head and neck
showed right M1 & M2 defects of MCA suggestive of emboli,
hemorrhagic transformation in right basal ganglia, and complete
occlusion of right ICA. MR ___ confirmed a large R MCA
territory stroke, hemorrhage of right putamen, foci of infarct
involving the left centrum semiovale, and infarct of the genu of
the left corpus callosum, old right occipital lobe infarct, and
extensive chronic small vessel ischemic disease. Although
atheroembolic disease would explain the R MCA stroke, it would
not explain the left-sided infarcts. Therefore, a more proximal
source (cardioembolic) is likely. Her mental status
progressively worsened. A Doboff was placed for feeding and
medication due to AMS and swallowing deficits. A family meeting
including HCP resulted in the choice to make her comfort
measures only. Medications and Doboff were discontinued. She was
kept very comfortable and discharged to hospice. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Dilantin Kapseal / Phenobarbital / sulfasalazine
Attending: ___
Chief Complaint:
abdominal pain, nausea, emesis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with recent SBO s/p ex-lap
with extensive lysis of adhesions no ___ now with days of
abdominal pain associated with one week of constipation, nausea,
and vomiting.
Of note, she had been hospitalized from ___ here at ___
after presenting with abdominal pain and found to have SBO. She
underwent exploratory laparotomy and had LOA, SBR, mesh
placement, two surgical drains placed, and closure on ___.
She
required NGT for recurrent emesis and post-operative ileus. She
completed a 5 day course of IV flagyl. She slowly regained bowel
function and was able to pass gas. Around POD9 she was advanced
to clears and then regular diet, which she tolerated well. She
was started on a bowel regimen and had formed bowel movements.
She ultimately did not qualify for rehab or SNF so although the
patient requested discharge to facility, and she was ultimately
sent home. She was tolerating a regular diet on discharge and
had
___ set up to help for her JP drains and abdominal wound
dressings.
Since her operation, she was seen in the ___ clinic twice. Most
recently during a ___ visit, her RLQ drain was removed and two
vertical mattress nylon sutures were placed at the midline
incision which had opened superficially. There was discussion
about setting up a wound vac with her ___. She had endorsed
constipation to her surgeon and was told to increase her bowel
regimen and take miralax.
On ___, she developed worsening abdominal pain, nausea, and
emesis, prompting presentation.
On arrival, vital signs were unremarkable other than soft BP and
tachycardia:
T 97.5 HR 118 BP ___ RR 26 O2 Sat 96% RA
Her labs were notable for normal chem panel (Cr 1.0), normal CBC
other than Platelet 141, normal coags other than PTT 20.2, and
normal LFTs other than Lipase 113.
Her trop was 0.02 -> 0.01.
She was not pregnant and a UA showed 30 protein and trace
ketones.
She CT scan which did not show SBO.
Surgery saw the patient and felt that her wound is granulating
well and her fascia is intact. Her labs, exam, and CT are
otherwise unremarkable, so they recommended a PO challenge and
enema. She did have an enema with significant bowel movement.
Originally, she was obs'd and planned for discharge.
However, at 7AM on ___, she subsequently developed a new oxygen
requirement to 3L, so a CTA was done. It revealed no PE but did
show Scattered ground-glass opacities within the left upper
lobe,
along with a micronodule within the right upper lobe. Her
clinical presentation is not consistent with pneumonia, so
antibiotics were not initiated.
Ultimately the patient was admitted to medicine for new O2
requirement, dyspnea, and emesis despite IV Zofran.
In the ED, she had received IV Zofran 4mg x 1, PO Zofran 4mg x
1,
home mes (lisinopril and prednisone), acetaminophen and about
2.5L fluids (still on 125cc/hr of LR on arrival to the floor).
Vitals on transfer:
T 98.8 HR 94 BP 119/84 RR 20 O2 Sat 96% 3L
Upon arrival to the floor, she reports that she has not had any
emesis until earlier this afternoon but she is not able to take
in much. She tried chicken noodle soup and could not stomach it.
She took two bites of a burger earlier and felt queasy. She is
still having some abdominal discomfort, worse than baseline, but
she is also attributing some of it to discomfort of the
abdominal
binder.
She denies dyspnea or shortness of breath (her NC is on her
forehead and not on her nose) but reports she had NC placed
because the ED told her she needed it. She states that she was
not symptomatic at the time. She has never required oxygen. She
does snore.
REVIEW OF SYSTEMS: Complete ROS obtained.
Positive for numbness and tingling in right foot (chronic due to
ankle surgery)
Positive for some numbness in left foot (recent)
Positive for some abdominal discomfort.
No fever, chills, cough, shortness of breath.
ROS is otherwise negative.
Past Medical History:
h/o PE and DVT in ___ for PE and ___ for DVT
lupus anticoagulant syndrome
s/p ovarian cyst removal c/b bowel perforation with
hemicolectomy and colostomy
IDDM (diagnosed ___
HLD
HTN
rheumatoid arthritis (longstanding for > ___ years)
History of ovarian cyst removal in ___ complicated by
bowel perforation
History of ___ exlap, sigmoid colectomy, transverse
coloscopy, and abdominal wall debridement
Social History:
___
Family History:
Non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 98.8 BP 119 / 84 HR 94 RR 20 O2 Sat 96 3L
General: Well-appearing female in no acute distress, obese. In
no
acute distress
Neck: No nodules.
CV: Regular rate and rhythm, no murmurs appreciated
Resp: Normal work of breathing, +CTAB, no wheezes or crackles
Abdomen: Soft, obese, non-distended, non-tender. Well-healing
midline wound with sutures, with an abdominal binder in place.
There is no erythema or drainage to suggest infection. Did not
auscultation any bowel sounds.
Extremities: Warm, well-perfused, no lower extremity edema
Neuro: Alert, oriented, no acute distress.
Psych: Appropriate affect.
On Discharge,
Alert and oriented, no acute distress, lungs bilaterally clear
to auscultation, heart with regular rate and rhythm, abdomen
soft nontender, midline wound with wound VAC in place, no
erythema or drainage, no lower extremity edema, face
symmetrical, speech clear, moving all 4 extremities, appropriate
affect
Pertinent Results:
___ 08:35PM ___ PTT-20.2* ___
___ 08:35PM PLT COUNT-141*
___ 08:35PM NEUTS-38.5 ___ MONOS-11.2 EOS-4.6
BASOS-0.8 IM ___ AbsNeut-2.42 AbsLymp-2.80 AbsMono-0.70
AbsEos-0.29 AbsBaso-0.05
___ 08:35PM WBC-6.3 RBC-4.64 HGB-13.3 HCT-42.1 MCV-91
MCH-28.7 MCHC-31.6* RDW-14.2 RDWSD-47.0*
___ 08:35PM ALBUMIN-3.6
___ 08:35PM LIPASE-113*
___ 08:35PM ALT(SGPT)-13 AST(SGOT)-24 ALK PHOS-105 TOT
BILI-1.2
___ 08:35PM estGFR-Using this
___ 08:35PM GLUCOSE-165* UREA N-6 CREAT-1.0 SODIUM-144
POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-22 ANION GAP-15
___ 09:10AM cTropnT-0.02*
___ 01:00PM URINE MUCOUS-RARE*
___ 01:00PM URINE RBC-0 WBC-0 BACTERIA-NONE YEAST-NONE
EPI-9
___ 01:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-TR* BILIRUBIN-NEG UROBILNGN-2* PH-6.5
LEUK-NEG
___ 01:00PM URINE COLOR-Yellow APPEAR-Clear SP
___
___ 01:00PM URINE UCG-NEG
___ 01:00PM URINE HOURS-RANDOM
___ 03:00PM %HbA1c-9.3* eAG-220*
___ 03:00PM cTropnT-<0.01
___ 03:00PM GLUCOSE-170* UREA N-5* CREAT-1.0 SODIUM-140
POTASSIUM-4.1 CHLORIDE-105 TOTAL CO2-20* ANION GAP-15
___ 03:08PM PLT COUNT-124*
Images
======
CT Abdomen and pelvis
IMPRESSION:
1. Postsurgical changes of interval ventral hernia repair.
Small bowel loops
are apposed to the ventral abdominal wall, without evidence of
recurrent
hernia. No bowel obstruction. Mild stranding noted adjacent to
the right
lower quadrant enteroenteric anastomosis, presumably
postoperative, without
evidence of leak or focal fluid collection.
CTA Chest
IMPRESSION:
1. No evidence of pulmonary embolism, noting that distal
segmental and
subsegmental branches in the bilateral lung bases are not well
assessed
secondary to respiratory motion and suboptimal timing of the
contrast bolus.
2. Scattered bandlike opacities within the right middle lobe,
lingula, and
bilateral lower lobes favor atelectasis, though superimposed
infection is not
excluded.
3. Subtle peribronchovascular ground-glass changes in the
bilateral upper
lobes, which could be infectious or inflammatory.
4. Bilateral pulmonary nodules measuring up to 3 mm. See below
for
recommendations.
RUQ US
IMPRESSION:
1. Cholelithiasis with a 9 mm nonmobile stone in the gallbladder
neck.
However, there is no gallbladder wall thickening, distension, or
other
findings of acute cholecystitis.
2. Echogenic liver, consistent with steatosis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Polyethylene Glycol 17 g PO DAILY
3. Senna 8.6 mg PO BID
4. PredniSONE 10 mg PO DAILY
5. Rosuvastatin Calcium 10 mg PO QPM
6. Lisinopril 20 mg PO DAILY
7. HumaLOG Mix ___ KwikPen (insulin lispro protamin-lispro) 54
units subcutaneous BREAKFAST
8. HumaLOG Mix ___ KwikPen (insulin lispro protamin-lispro) 26
units subcutaneous DINNER
9. Pantoprazole 40 mg PO Q24H
10. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Medications:
1. Senna 17.2 mg PO BID
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
3. HumaLOG Mix ___ KwikPen (insulin lispro protamin-lispro)
54 units subcutaneous BREAKFAST
4. HumaLOG Mix ___ KwikPen (insulin lispro protamin-lispro)
26 units subcutaneous DINNER
5. Lisinopril 20 mg PO DAILY
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Pantoprazole 40 mg PO Q24H
8. Polyethylene Glycol 17 g PO DAILY
9. PredniSONE 10 mg PO DAILY
10. Rosuvastatin Calcium 10 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis
================
Constipation
Nausea
Hypoxia
Secondary diagnosis
===================
Diabetes Mellitus Type II
Rheumatoid arthritis
Hypertension
Hyperlipidemia
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 desaturation to 85% after 1L fluids. // eval
re pulmonary edema.
TECHNIQUE: Portable AP chest radiograph.
COMPARISON: Multiple prior chest radiographs the most recent from ___.
FINDINGS:
The lung volume is low, exaggerating bronchovascular markings. No focal
consolidation. There are mild pulmonary edema and vascular congestion. There
are bilateral small pleural effusions. No pneumothorax. The
cardiomediastinal silhouette is unchanged. No acute osseous abnormalities.
IMPRESSION:
Mild pulmonary edema and vascular congestion.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: History: ___ with sob, recent surgery now tachypneic and hypoxic
// 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) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 21.3 mGy (Body) DLP =
10.6 mGy-cm.
2) Spiral Acquisition 3.6 s, 28.1 cm; CTDIvol = 16.2 mGy (Body) DLP = 454.4
mGy-cm.
Total DLP (Body) = 465 mGy-cm.
COMPARISON: CT abdomen and pelvis ___. Chest x-ray ___. Chest CTA ___.
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is adequately opacified to the
subsegmental level in the bilateral upper lobes, and proximal segmental level
in the remainder of the lungs, without filling defect to indicate a pulmonary
embolus. Distal segmental and subsegmental branches in the bilateral lung
bases are not well assessed secondary to respiratory motion and suboptimal
timing of the contrast bolus. The thoracic aorta is normal in caliber without
evidence of dissection or intramural hematoma. Mild to moderate coronary
artery calcifications. Heart size is normal. No pericardial effusion is
seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There is minimal centrilobular and paraseptal emphysema.
Calcified granuloma within the right apex (___) and right middle lobe
(3:123). There are a few scattered noncalcified pulmonary nodules, for
example a 2 mm nodule in the right upper lobe (03:54) and 3 mm nodule in the
left upper lobe (series 3, image 89), unchanged compared to CT chest from ___, with no more remote prior imaging available for comparison.
There is subtle peribronchovascular ground-glass changes in the bilateral
upper lobes, which could be infectious or inflammatory. Scattered bandlike
opacities within the right middle lobe, lingula, and bilateral lower lobes
favor atelectasis, though superimposed infection is not excluded. The airways
are patent to the level of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Please refer to the separate report of the CT abdomen and pelvis
performed one day prior for subdiaphragmatic characterization.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
Moderate to severe multilevel degenerative changes of the thoracic spine.
IMPRESSION:
1. No evidence of pulmonary embolism, noting that distal segmental and
subsegmental branches in the bilateral lung bases are not well assessed
secondary to respiratory motion and suboptimal timing of the contrast bolus.
2. Scattered bandlike opacities within the right middle lobe, lingula, and
bilateral lower lobes favor atelectasis, though superimposed infection is not
excluded.
3. Subtle peribronchovascular ground-glass changes in the bilateral upper
lobes, which could be infectious or inflammatory.
4. Bilateral pulmonary nodules measuring up to 3 mm. See below for
recommendations.
RECOMMENDATION(S): For incidentally detected multiple solid pulmonary nodules
smaller than 6 mm, no CT follow-up is recommended in a low-risk patient, and
an optional CT follow-up in 12 months is recommended in a high-risk patient.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN) PORT
INDICATION: ___ year old female with recent SBO s/p ex-lap with extensive
lysis of adhesions no ___ now with days of abdominal pain associated with one
week of constipation, nausea, and vomiting. CT A/P with contrast
unremarkable. // eval for liver/gallbladder pathology
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen and pelvis from ___
FINDINGS:
LIVER: The liver is diffusely echogenic. The contour of the liver is smooth.
There is no focal liver mass. The main portal vein is patent with hepatopetal
flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 4 mm
GALLBLADDER: Cholelithiasis without gallbladder wall thickening. A 9 mm stone
in the gallbladder neck does not move with change in patient positioning.
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.
KIDNEYS: Limited views of the right kidney shows no hydronephrosis.
RETROPERITONEUM: The visualized portions of the aorta and IVC are within
normal limits.
IMPRESSION:
1. Cholelithiasis with a 9 mm nonmobile stone in the gallbladder neck.
However, there is no gallbladder wall thickening, distension, or other
findings of acute cholecystitis.
2. Echogenic liver, consistent with steatosis.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abd pain, Nausea
Diagnosed with Hypoxemia
temperature: 97.5
heartrate: 118.0
resprate: 26.0
o2sat: 96.0
sbp: 97.0
dbp: 78.0
level of pain: 5
level of acuity: 2.0 | Ms. ___ is a ___ year old female with recent SBO s/p ex-lap
with extensive lysis of adhesions on ___ who presented with
abdominal pain, emesis, and constipation with concern for SBO.
TRANSITION ISSUES
=================
[] 9mm stone noted on RUQ, consider additional biliary workup if
patient experiences RUQ pain
[] Consider outpatient sleep study to evaluate for OSA, new O2
equirement on admission
[] A1c 9.3 on admission, continue to titrate insulin and
consider swallow study for possible gastroparesis if
nausea/abdominal pain persists.
#CODE: FULL CODE presumed
#CONTACT: ___ ___
ACUTE ISSUES
============
# Nausea, vomiting, and constipation
# Recent SBO s/p ex-lap w/ LOA
CT a/p showed post-surgical changes but no acute abnormality and
no evidence of obstruction. She had enema in the ED with
significant bowel movement so presumably does not have
significant constipation on arrival to the floor. Likely some
contribution for gastroparesis given poorly controlled diabetes.
In addition, ___ have had mild ileus. Of note, she is also on
chronic prednisone for her rheumatoid arthritis so may have
secondary adrenal insufficiency with inadequate response to
stress. She takes Tylenol at home for pain but has not been
taking any constipating opioids. She does follow a bowel regimen
at home. RUQUS with so evidence of cholecystitis or biliary
dilation but does have a 9mm stone lodge in the neck. Started
with clear liquids now advanced to full diet. Due to wound
deheisence, a wound vac was placed. She was treated with IV
zolfran and prochlorperzine for nausea and emesis along with
agressive bowel regimen, which included enema. Pain control was
achieved with tylenol 1g and low dose oxycodone.
Has wound vac in place per surgical service.
#Hypoxia
#New O2 requirement
Patient found to be hypoxic while in the ED, but she was
reportedly asymptomatic and awake. CTA PE showing no PE but
showing nonspecific opacities and ground glass changes. She
denies any cough or respiratory distress. Differential includes
atelectasis (recent long hospital stay) vs. obesity
hypoventilation syndrome vs aspiration pneumonia vs. pneumonitis
in the setting of recurrent emesis vs. underlying sleep apnea
that may not have been diagnosed (reports history of snoring).
She has no known COPD but did smoke for ___ years in the past.
Patient iniately required 3L NC, but was quickly wean to RA
without much difficulty.
# Rheumatoid arthritis
- Continued home prednisone 10mg daily
- Note that she has not had any stress dosing. If her abdominal
discomfort, nausea and emesis persists, consider stress dosing
for relative adrenal insufficiency with prednisone 30mg x 3 days
and then re-evaluate
# Diabetes: Her A1c is 9.3 on this presentation
On insulin at home: Humalog ___ 54U breakfast and 26U dinner;
initially held given poor PO intake and stable sugars. Restarted
on Insulin and titrated back to home regiment prior to
dishcarge.
TI: Needs close follow-up on discharge
CHRONIC ISSUES
==============
# History of PE, lupus anticoagulant syndrome: Last event ___.
Previously on warfarin but this was discontinued about ___ years
ago.
# GERD
- Continued omeprazole
# Hypertension
- On lisinopril at home; initially held given recurrent emesis
and relative soft blood pressures, restarted prior to discharge
# HLD
- Continued rosuvastatin
Patient seen and evaluated in the morning. Reports feeling
well. No nausea vomiting abdominal pain today. Ambulating
independently at her baseline. Wound VAC functioning fine,
replaced with a portable unit. Medically stable for discharge
today. Discharge plan discussed with patient in detail, she
understands and agrees. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
The pt is a ___ year-old R-handed F w/ PMH of HTN and DMII who
presents with seizure-like events x 2. Hx obtained from pt and
husband at bedside.
Pt reports initially being at family friend's home around 4pm at
which time she developed "waves" of nausea and lightheadedness.
She and her husband then drove home where she rested on the sofa
due to fatigue. Per husband, ~7pm he was performing errands
around house when he heard pt call his name. He came into living
room where pt sat up and took his arms, stating she was going to
be sick. She subsequently developed UE tremors and
unresponsiveness described as a "change in her eyes". The
shaking stopped after 30 seconds following which she fell back
with LOC and eyes rolled up. No associated head trauma. Pt woke
up after ___ minutes when EMS arrived with postictal
confusion/lethargy lasting ~15 minutes. Associated bruising of
tongue but no urinary incontinence. Pt was subsequently brought
to ___ where she had ___ event 1 hour after initial
event, with semiology and duration approximately the same per
husband. Following this event pt was given Ativan 2mg and taken
for ___ which was
unremarkable. Pt was reported to have significant postictal
lethargy for 30 minutes. She was loaded w/ Dilantin 1g and noted
to have Na of 123 on lab workup. She was transferred to ___
for further evaluation.
According to pt, prior to initial event she felt fuzzy and that
"something was not right". Particularly, she described strange
thoughts (couldn't say ___ or ___ and
indescribable gustatory aura, but no olfactory aura or
epigastric rising sensation. She next remembers waking up in
ambulance to hospital with fatigue and feeling of mental
slowness. At OSH she had same
strange thoughts prior to ___ event, with next thing remembered
speaking to her family at bedside.
Denies any prior hx of seizures except for febrile seizure at
age ___ (does not know if simple or complex). No hx of head trauma
or CNS infection. Family history notable for childhood epilepsy
("petit mal") in her sister who grew out of it at puberty.
Denies recent infxn or sick contacts. Lives in ___ and has had
multiple recent mosquito bites but unaware of any tick bites. No
recent acute stressors, substance use, or sleep deprivation. She
reports being consistent with her meals and staying relatively
well hydrated, as well as maintaining her blood sugars in
adequate range.
Neurologic ROS negative except as noted above
General ROS positive for lower back pain
Past Medical History:
DMII
HTN
Social History:
___
Family History:
Sister-childhood epilepsy
Physical Exam:
ON ADMISSION
============
Vitals: T: 97.9 P: 85 BP: 95/70 RR: 16 O2sat: 95% RA
General: Mildly somnolent, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, mild bruising over
anterior aspect of tongue
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity,
Kernig/Brudzinski's signs neg
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: trace edema present in ___, 2+ radial, DP
pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to person, place, and month
(unsure if ___ or ___. Able to relate history moderately
well.
Attentive, able to name ___ backward without difficulty.
Language
is fluent with intact repetition and comprehension. Normal
prosody. There were no paraphasic errors. Pt was able to name
both high and low frequency objects. Speech was not dysarthric.
Able to follow both midline and appendicular commands. Pt was
able to register 3 objects and recall ___ with MCQ) at 5
minutes. There was no evidence of apraxia or neglect.
-Cranial Nerves:
II, III, IV, VI: PERRL 4 to 2mm and brisk. EOMI with vertical
nystagmus on upgaze. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No 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 ___ ___ 4* 5 5 5 5 5 5
R 5 ___ ___ 5 5 5 5 5 5 5
*giveway
-Sensory: No deficits to light touch, pinprick, cold sensation,
or proprioception throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 1
R 2 2 2 3 1
Plantar response was WD bilaterally.
-Coordination: No intention tremor. No dysmetria on FNF or HKS
bilaterally.
-Gait: Able to stand with feet apart without difficulty.
Moderate
sway when attempting to stand with feet together or ambulate,
specifically falling backwards.
ON DISCHARGE
============
Vitals: Afebrile. BP 1120-140s/70-80s. HR 60-80s. RR ___, SpO2
97-100% RA
General: Awake, pleasant, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, mild bruising over
anterior aspect of tongue
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: trace edema present in ___, 2+ radial, DP
pulses
bilaterally.
Skin: chronic venous changes of upper and lower extremities.
Neurologic:
-Mental Status: Alert, oriented to person, place, and date. Able
to relate history moderately well. Attentive, able to name ___
backward without difficulty. Language is fluent with intact
repetition and comprehension. 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. Slight difficulty with calculation which she
feels is abnormal for her.
-Cranial Nerves:
II, III, IV, VI: PERRL 4 to 2mm and brisk. EOMI with no
nystagmus. Normal saccades. VFF to confrontation.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis noted. Strength tested limited by pain in ___ legs
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L 5 ___ ___ 4 5 5 5 5 5 5
R 5 ___ ___ 4 5 4 5 5 5 5
*Strength testing limited by pain in ___ legs
-Sensory: No deficits to light touch, pinprick, cold sensation,
or proprioception throughout. No extinction to DSS.
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 1
R 2 2 2 3 1
Plantar response was WD bilaterally.
-Coordination: No intention tremor. No dysmetria on FNF or HKS
bilaterally.
-Gait: Able to stand with feet apart without difficulty.
Pertinent Results:
ADMISSION LABS
==============
___ 02:48AM BLOOD WBC-12.8* RBC-3.85* Hgb-12.0 Hct-33.5*
MCV-87 MCH-31.2 MCHC-35.8 RDW-11.3 RDWSD-35.8 Plt ___
___ 02:48AM BLOOD Neuts-84.3* Lymphs-10.5* Monos-3.1*
Eos-0.3* Baso-0.3 Im ___ AbsNeut-10.77* AbsLymp-1.34
AbsMono-0.39 AbsEos-0.04 AbsBaso-0.04
___ 02:48AM BLOOD Plt ___
___ 09:20AM BLOOD ___ PTT-23.5* ___
___ 02:48AM BLOOD Glucose-150* UreaN-9 Creat-0.5 Na-119*
K-3.5 Cl-85* HCO3-20* AnGap-14
___ 02:48AM BLOOD ALT-22 AST-30 CK(CPK)-761* AlkPhos-53
TotBili-0.4
___ 02:48AM BLOOD Lipase-14
___ 02:48AM BLOOD cTropnT-<0.01
___ 02:48AM BLOOD Albumin-4.0 Calcium-8.4 Phos-2.7 Mg-1.7
___ 02:48AM BLOOD Osmolal-248*
___ 02:48AM BLOOD TSH-0.99
___ 06:25AM BLOOD Cortsol-15.0
___ 02:48AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:45AM URINE Color-Straw Appear-Clear Sp ___
___ 01:45AM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-300* Ketone-40* Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 03:30PM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
___ 10:25AM URINE Hours-RANDOM UreaN-396 Na-<20
___ 01:45AM URINE Osmolal-537
___ 01:45AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
PERTINENT/DISCHARGE LABS
========================
___ 09:20AM BLOOD Glucose-112* UreaN-7 Creat-0.4 Na-122*
K-3.3 Cl-87* HCO3-20* AnGap-15
___ 01:24PM BLOOD Na-121*
___ 05:43PM BLOOD Glucose-147* UreaN-4* Creat-0.5 Na-130*
K-3.9 Cl-97 HCO3-21* AnGap-12
___ 06:57PM BLOOD Na-132*
___ 10:03PM BLOOD Na-134
___ 02:50AM BLOOD Na-134
___ 06:25AM BLOOD Glucose-193* UreaN-<3* Creat-0.5 Na-136
K-3.2* Cl-101 HCO3-20* AnGap-15
___ 10:05AM BLOOD Glucose-143* UreaN-<3* Creat-0.5 Na-137
K-3.4 Cl-101 HCO3-21* AnGap-15
___ 12:40PM BLOOD Glucose-158* UreaN-3* Creat-0.5 Na-136
K-3.5 Cl-100 HCO3-21* AnGap-15
___ 03:15PM BLOOD Glucose-234* UreaN-<3* Creat-0.5 Na-136
K-3.6 Cl-101 HCO3-20* AnGap-15
___ 04:37PM BLOOD Glucose-157* UreaN-4* Creat-0.5 Na-137
K-3.8 Cl-102 HCO3-21* AnGap-14
___ 07:00PM BLOOD Glucose-163* UreaN-4* Creat-0.4 Na-136
K-4.0 Cl-101 HCO3-21* AnGap-14
___ 02:15AM BLOOD Na-133
___ 06:15AM BLOOD Glucose-239* UreaN-<3* Creat-0.5 Na-132*
K-4.0 Cl-96 HCO3-20* AnGap-16
___ 02:47PM BLOOD Na-137
___ 09:35PM BLOOD Na-137
___ 06:20AM BLOOD Glucose-143* UreaN-4* Creat-0.4 Na-137
K-4.4 Cl-100 HCO3-22 AnGap-15
___ 12:45PM BLOOD Na-133
___ 06:50AM BLOOD Glucose-138* UreaN-6 Creat-0.5 Na-139
K-4.9 Cl-99 HCO3-23 AnGap-17*
___ 09:20AM BLOOD CK(CPK)-___*
___ 01:24PM BLOOD CK(CPK)-3821*
___ 05:43PM BLOOD CK(CPK)-4893*
___ 10:03PM BLOOD CK(CPK)-6660*
___ 02:50AM BLOOD ___
___ 06:25AM BLOOD ___
___ 10:05AM BLOOD ___
___ 12:40PM BLOOD ___
___ 04:37PM BLOOD ___
___ 06:15AM BLOOD ___
___ 06:20AM BLOOD ___
___ 06:50AM BLOOD ___
___ 09:20AM BLOOD Osmolal-252*
___ 01:24PM BLOOD Osmolal-255*
___ 05:43PM BLOOD Osmolal-265*
___ 10:03PM BLOOD Osmolal-280
___ 02:50AM BLOOD Osmolal-279
___ 06:25AM BLOOD Osmolal-276
___ 10:05AM BLOOD Osmolal-276
___ 12:40PM BLOOD Osmolal-275
___ 04:37PM BLOOD Osmolal-278
___ 07:00PM BLOOD Osmolal-279
___ 02:15AM BLOOD Osmolal-274*
___ 06:15AM BLOOD Osmolal-276
___ 02:47PM BLOOD Osmolal-276
___ 09:35PM BLOOD Osmolal-278
___ 06:20AM BLOOD Osmolal-280
___ 12:45PM BLOOD Osmolal-277
___ 06:50AM BLOOD Osmolal-283
IMAGING
=======
MRI head w/ contrast ___:
1. The study is significantly degraded by motion artifact.
2. No intracranial mass, hemorrhage or infarct.
MICROBIOLOGY
============
URINE CULTURE (Final ___: < 10,000 CFU/mL.
___ 9:20 am BLOOD CULTURE
Blood Culture, Routine (Pending):
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bystolic (nebivolol) 5 mg oral DAILY
2. valsartan-hydrochlorothiazide 160-12.5 mg oral DAILY
3. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
4. LORazepam 0.5 mg PO DAILY:PRN anxiety
Discharge Medications:
1. LORazepam 0.5 mg PO DAILY:PRN anxiety
2. MetFORMIN XR (Glucophage XR) 1000 mg PO DAILY
3. HELD- Bystolic (nebivolol) 5 mg oral DAILY This medication
was held. Do not restart Bystolic until told to do so by your
primary care doctor
4. HELD- valsartan-hydrochlorothiazide 160-12.5 mg oral DAILY
This medication was held. Do not restart
valsartan-hydrochlorothiazide until told to do so by your
primary care doctor
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Hyponatremia
Rhabdomyolysis
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 T9112 MR HEAD
INDICATION: ___ year old woman with new seizure// Eval for structural cause of
seizure
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: Outside CT head done ___
FINDINGS:
The study is significantly degraded by motion artifact.
The brain is normal in structure. Normal appearance and signal intensity of
the hippocampi. The ventricular profile is normal. No areas of slow
diffusion. No intracranial hemorrhage. Mild generalized brain parenchymal
atrophy, most prominent at the vertex, including very posterior frontal,
parietal lobes.. No pathological enhancing lesions post contrast. The
intracranial vessels appear patent. No cerebellopontine angle masses. The
orbits appear normal. The paranasal sinus are essentially clear. The dural
venous sinuses are patent.
IMPRESSION:
1. The study is significantly degraded by motion artifact.
2. No intracranial mass, hemorrhage or infarct.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with breakthrough seizures in setting of
hyponatremia// Evaluate for pulmonary abnormalities
IMPRESSION:
In comparison with the study of ___,, the cardiac silhouette is slightly
more prominent and there is engorgement of ill defined pulmonary vessels
consistent with elevated pulmonary venous pressure. No evidence of pleural
effusion or acute focal pneumonia. Mild elevation of the right
hemidiaphragmatic contour.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal sodium level, Seizure
Diagnosed with Hypo-osmolality and hyponatremia
temperature: 97.9
heartrate: 85.0
resprate: 16.0
o2sat: 95.0
sbp: 95.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | Ms ___ is a ___ year-old R-handed F who presented with
multiple seizure-like events. Her evaluation was notable for
hyponatremia to as low as 119 on admission, which is the most
likely cause of her seizure. Seizures consisted of episodes of
an aura of "strange thoughts" and gustatory sensation, followed
by UE tremors w/ fixed gaze, then eyes rolled back. Postictally
she had lethargy/confusion.
# Seizure: Likely provoked by hyponatremia, although her family
history of seizure as well as prior episodes of "strange
thoughts" does raise concern for a primary epilepsy. MRI showed
no structural cause for seizure. EEG has been normal with no
epileptiform discharges. She did not have any further seizures
during admission. As this is felt to be a one-time, provoked
seizure occurrence, she was not started on anti-epileptic
medications.
# Hyponatremia: as above, this is felt to be the most likely
cause of her seizures. Her urine Na on admission was <20, with
initially concentrated urine, suggesting hypovolemia as the
cause of her hyponatremia. Her diuretic use as well as extensive
time spent outside in the hot weather may explain the
hypovolemia. After volume replenishment, her Na corrected to 130
on ___. This was slightly quicker than the recommended
correction of 8mEq in 24 hours, so D5W was started to prevent a
rapid rise in her sodium. Her sodium afterwards remained stable.
Furthermore, her blood pressure was persistently in the low 100s
early on in her hospitalization, despite all of her
anti-hypertensives being held. This again argues for significant
volume depletion.
# Rhabdomyolysis: On ___, CK was noted to rise, with subsequent
myoglobinuria on UA. Her renal function remained stable. She had
significant thigh pain but was otherwise asymptomatic. She was
hydrated as above with D5W. CK peaked at ___ and then
downtrended to ___ prior to discharge. Etiology is likely
seizure. |
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, fatigue
Major Surgical or Invasive Procedure:
Permanent pacemaker ___
History of Present Illness:
Mr. ___ is an ___ year old male with PMH notable for HTN, HLD,
DM2, and history of paroxysmal complete heart block presenting
with dyspnea and fatigue and found to be in 2:1 AVB.
Of note, pt. has a history of complete heart block in ___ in
the setting of hyperkalemia and acute renal failure that was
thought to be due to increased vagal tone. At that time, an EP
study was done which showed a mildly prolonged HV interval, AV
nodal wenckebach at heart rates of approximately 110 beats per
minute, evidence of intraHis conduction delay with higher heart
rates evidence by split His electrograms. Given intraHis
conduction delay occurred only at higher heart rates, no
pacemaker was placed. The patient had not followed up with
cardiology since then, and had not needed to.
Since approximately ___ the patient has been
experiencing loss of energy, and dyspnea with exertion, and
lightheadedness (predominantly with standing.) He has not had
chest pain, palpitations, syncope.
In the ED, initial vitals were: T 98.4 HR 42 BP 160/66 RR 20
SpO2 100% on RA.
ECG showed sinus rhythm with 2:1 AVB, incomplete RBBB, LAFB, PR
226.
Initial labs notable for Cr 1.6 (stable), HCO3 19, TnT <0.01,
and normal hemogram
On the floor, the patient reports feeling relatively well. He
denies current chest pain, orthopnea (laying nearly flat now),
dyspnea, lightheadedness.
Past Medical History:
1. CARDIAC RISK FACTORS: Diabetes, Dyslipidemia, Hypertension
2. macular Degeneratiopn
3. Anemia
4. Diabetic Retinopathy
5. Glaucoma
Social History:
___
Family History:
mother with diabetes, hx MI, brother diabetes.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION EXAM:
================
Vital Signs: 98.4, 42, 160/66, 20, 100% on RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, neck supple,
JVP not elevated, no LAD
CV: Bradycardic, 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
DISCHARGE EXAM:
================
Vitals: 99.5/99.4 137/70 86 18 96/RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, neck supple,
JVP not elevated, no LAD
CV: RRR, normal S1 + S2, no murmurs, rubs, gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, BS+, no rebound or
guarding
GU: No foley
Ext: Warm, well perfused, pulses difficult to palpate, no
clubbing, cyanosis or edema
Pertinent Results:
ADMISSION LABS:
==================
___ 07:25PM BLOOD WBC-10.0 RBC-5.23 Hgb-14.0 Hct-41.3
MCV-79* MCH-26.8 MCHC-33.9 RDW-13.6 RDWSD-38.6 Plt ___
___:25PM BLOOD Neuts-74.0* Lymphs-16.8* Monos-6.8
Eos-1.3 Baso-0.6 Im ___ AbsNeut-7.42* AbsLymp-1.68
AbsMono-0.68 AbsEos-0.13 AbsBaso-0.06
___ 10:05PM BLOOD Glucose-235* UreaN-27* Creat-1.6* Na-139
K-4.6 Cl-105 HCO3-19* AnGap-20
___ 10:05PM BLOOD cTropnT-<0.01
___ 07:00AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.1
___ 10:05PM BLOOD TSH-1.4
KEY INTERIM LABS:
===================
___ Blood (LYME) Lyme IgG-FINAL; Lyme IgM-FINAL
INPATIENT
STUDIES:
==================
CXR ___: Compared to chest radiographs in ___.
New left trans subclavian right atrial and right ventricular
pacer leads
follow their expected courses from the new left pectoral
generator. No
pneumothorax pleural effusion or mediastinal widening. Heart
size is normal.
No pulmonary edema.
MICRO:
==================
None
DISCHARGE LABS:
==================
___ 06:30AM BLOOD WBC-8.7 RBC-4.96 Hgb-12.7* Hct-39.8*
MCV-80* MCH-25.6* MCHC-31.9* RDW-13.2 RDWSD-37.9 Plt ___
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD Glucose-180* UreaN-19 Creat-1.5* Na-137
K-4.4 Cl-103 HCO3-19* AnGap-19
___ 06:30AM BLOOD Calcium-9.2 Phos-3.8 Mg-2.2
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with pacemaker eval for lead position // eval
for lead position eval for lead position
IMPRESSION:
Compared to chest radiographs in ___.
New left trans subclavian right atrial and right ventricular pacer leads
follow their expected courses from the new left pectoral generator. No
pneumothorax pleural effusion or mediastinal widening. Heart size is normal.
No pulmonary edema.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Bradycardia
Diagnosed with Bradycardia, unspecified
temperature: 98.4
heartrate: 42.0
resprate: 20.0
o2sat: 100.0
sbp: 160.0
dbp: 66.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is an ___ year old male with PMH notable for HTN, HLD,
DM2, and history of paroxysmal complete heart block presenting
with dyspnea and fatigue and found to be in 2:1 AVB.
#) SYMPTOMATIC BRADYCARDIA: Most likely etiology at his age is
senescence of conduction tissue. Despite provocative maneuvers
at bedside (bearing down, carotid sinus pressure), arm exercise,
there was no effect on AVB, and PR interval appeared constant on
telemetry. Patient has evidence of other conduction disease with
incomplete RBBB and LAFB and has relatively preserved PR
interval (226 ms), which is suggestive of infranodal block. TSH
was within normal limits and lyme serologies were negative.
Given concurrent symptoms, patient was considered a candidate
for permanent pacemaker, which was placed on ___.
Post-procedurally patient was stable, unremarkable interrogation
by EP, without events on telemetry, and a CXR confirmed
placement of permanent pacemaker. |
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 pain.
Major Surgical or Invasive Procedure:
___ - Irrigation and debridement right elbow septic
arthritis.
History of Present Illness:
___ RHD with 3 d h/o worsening right elbow pain and swelling
with increasing limited range of motion. Reports subjective
fevers, chills. Denies recent injury or trauma, no similar sx
in the past, has h/o elbow dislocation ? fracture as a teenager
treated with surgically in ___, no hardware that he can recall
as none was removed, with right elbow asymptomatic since. Right
elbow joint aspirated by ED with wbc 335k with 87% polys.
Orthopaedic surgery consulted for evaluation and treatment.
Past Medical History:
Hypertension
Hyperlipidemia
Asthma
Social History:
___
Family History:
Non-contributory.
Physical Exam:
EXAM ON DISCHARGE:
Vital signs - Afebrile with stable vital signs
General - No acute distress
Abdomen - Soft, non-tender, non-distended
Right upper extremity Fires extensor pollicis longus, opponens
pollicis, and interossei. Sensation intact to light touch in
axillary, median, radial, and ulnar distributions. Radial pulse
1+, distal extremity warm and well-perfused, capillary refill
less than 2 seconds. Compartments soft with no pain on passive
range of motion of the digits, wrist, or elbow. Incisions
clean/dry/intact with no erythema or discharge.
Pertinent Results:
___ 05:00PM JOINT FLUID ___ POLYS-87*
___ ___ 06:55AM BLOOD Vanco-5.2*
___ 02:55PM BLOOD CRP-140.5*
___ 06:55AM BLOOD CRP-199.3*
___ 06:55AM BLOOD ALT-71* AST-74* AlkPhos-108 TotBili-1.4
___ 11:10AM BLOOD ALT-95* AST-72*
___ 02:55PM BLOOD Glucose-122* UreaN-14 Creat-1.3* Na-138
K-3.7 Cl-101 HCO3-28 AnGap-13
___ 06:55AM BLOOD Glucose-128* UreaN-9 Creat-1.3* Na-140
K-3.7 Cl-103 HCO3-26 AnGap-15
___ 02:55PM BLOOD ESR-51*
___ 06:55AM BLOOD ESR-80*
___ 02:55PM BLOOD Plt ___
___ 06:55AM BLOOD Plt ___
___ 02:55PM BLOOD Neuts-67.0 ___ Monos-8.6 Eos-0.3
Baso-0.3
___ 06:55AM BLOOD Neuts-60.3 ___ Monos-9.5 Eos-0.6
Baso-0.9
___ 02:55PM BLOOD WBC-8.1 RBC-5.20 Hgb-14.9 Hct-45.9 MCV-88
MCH-28.7 MCHC-32.5 RDW-13.2 Plt ___
___ 06:55AM BLOOD WBC-7.0 RBC-4.45* Hgb-12.9* Hct-39.3*
MCV-88 MCH-28.9 MCHC-32.8 RDW-12.7 Plt ___
___ 2:00 pm JOINT FLUID SYNOVIAL FLUID RT ELBOW.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___:
Reported to and read back by ___ ___
12:56PM.
BETA STREPTOCOCCUS GROUP B. SPARSE GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
___ 3:00 pm TISSUE Site: BONE BONE RT ELBOW.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Final ___:
BETA STREPTOCOCCUS GROUP B. RARE GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # ___-___
___.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON DIRECT SMEAR.
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary):
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Medications on Admission:
Lisinopril
Atenolol
Simvastatin
Hydrochlorothiazide
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
2. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4 hours Disp #*60
Tablet Refills:*0
3. Penicillin G Potassium 2 Million Units IV Q4H Duration: 4
Weeks
RX *penicillin G pot in dextrose 2 million unit/50 mL 2 million
iv every four (4) hours Disp #*168 Bag Refills:*0
4. iv
iv pump and supplies
5. Atenolol 25 mg PO DAILY
6. Hydrochlorothiazide 37.5 mg PO DAILY
7. Lisinopril 5 mg PO DAILY
8. Simvastatin 40 mg PO HS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right elbow septic arthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Elbow pain, swelling, no trauma.
TECHNIQUE: 3 views of the right elbow.
COMPARISON: None.
FINDINGS:
There are marked degenerative changes at the elbow joint with areas of
heterotopic ossification, joint space narrowing, and some proliferative
change. There appears to be resorption of the proximal radius; correlate with
history of prior injury/infection at this site. Anterior and posterior elbow
joint effusions are present which raise concern for fracture; although no
discrete fracture line is seen, occult fracture may be present.
Alternatively, joint effusion may be secondary to infection/inflammatory
process including septic arthritis, particularly if this patient has not had
recent injury to this site.
IMPRESSION: Anterior and posterior joint effusions with irregularity of the
elbow joint is concerning for septic arthritis, particularly in the absence of
trauma. Joint effusions can also be seen in the setting of acute fracture-no
fracture line is seen, but an occult fracture could be present.
Radiology Report
AP CHEST, 11:42 A.M., ___
HISTORY: Septic right elbow. Check PICC line placement.
IMPRESSION: AP chest reviewed in the absence of prior chest radiographs:
No radiopaque central catheter is seen. Heart size top normal. Lungs clear.
No pleural abnormality. Dr. ___ and I discussed these findings by
telephone.
Radiology Report
INDICATION: ___ year old man with elevated LFTs
REASON FOR THIS EXAMINATION: elevated LFTs
COMPARISON: None
TECHNIQUE: Sonographic grayscale and Doppler images were obtained of the
abdomen.
FINDINGS:
The liver demonstrates normal contour, echogenicity and architecture. No
focal lesions are identified. Portal vein is hepatopetal and patent. However,
there is some noted lack of respiratory wave in the portal vein which could
suggest underlying increaseing liver fibrosis.
The gallbladder is distended without cholelithiasis, gallbladder wall
thickening or pericholecystic fluid. No intrahepatic or extrahepatic biliary
ductal dilatation. The common bile duct measures 3 mm.
The visualized portions of the midline structures are partially obscured by
overlying bowel gas. No gross abnormality about the pancreas.
The spleen measures 8.8 cm in craniocaudal dimension.
The right kidney measures 10.7 cm in craniocaudal dimension. The left kidney
measures 11.6 cm in craniocaudal dimension. No evidence of hydronephrosis,
nephrolithiasis or obvious mass in either kidney.
The visualized portions of the aorta and IVC are normal.
Both lower quadrants demonstrate no evidence of ascites.
IMPRESSION:
Noted lack of respiratory wave in the portal vein which could suggest
underlying increaseing liver fibrosis. Otherwise, portal vein is patent. No
focal liver lesions.
Radiology Report
CHEST RADIOGRAPH
INDICATION: PICC line placement.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the patient has received a
left-sided PICC line. The course of the line is unremarkable, the tip of the
line projects over the lower SVC. There is no evidence of complications,
notably no pneumothorax.
Otherwise, unchanged radiograph with normal size of the cardiac silhouette and
normal appearance of the hilar and mediastinal structures.
Gender: M
Race: BLACK/AFRICAN
Arrive by WALK IN
Chief complaint: R ELBOW SWELLING
Diagnosed with PYOGEN ARTHRITIS-UP/ARM, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 97.5
heartrate: 64.0
resprate: 16.0
o2sat: 94.0
sbp: 135.0
dbp: 70.0
level of pain: 10
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. A joint aspiration was
performed and the patient was found to have right elbow septic
arthritis and was admitted to the orthopedic surgery service.
He was started on empiric vancomycin, and he was taken to the
operating room on ___ for irrigation and debridement of
right elbow infection, 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. Blood cultures
drawn at the time of presentation were positive for beta
streptococcus group b, and the infectious disease team was
consulted. Per the recommendations of the infectious disease
team, the patient's antibiotics were changed to Nafcillin and a
TTE was obtained that showed no cardiac involement. The
patients home medications were continued throughout this
hospitalization. The patient worked with ___ who determined
that discharge to home was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient was afebrile with stable
vital signs that were within normal limits, pain was well
controlled with oral medications, incisions were
clean/dry/intact, and the patient was voiding/moving bowels
spontaneously. The patient is weight bearing as tolerated in the
right upper extremity with range of motion as tolerated. The
patient will follow up in two weeks with Dr. ___ routine.
A thorough discussion was had with the patient regarding the
diagnosis and expected post-discharge course, and all questions
were answered prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Anemia
Major Surgical or Invasive Procedure:
#Thoracentesis by interventional radiology (___)
#___ line placed by ___ team, repositioned by interventional
radiology (___)
History of Present Illness:
___ y/o F with history of ETOH cirrhosis presents to ED after
found to have hgb of 7.7.
Patient denies any sob, cp, dyspnea, abdominal pain, diarrhea,
hematemesis, coffee ground emesis, black stools, BRBPR. Had last
___ last ___ after receiving FFP and platelets.
In the ED, initial vitals were: 98.2 74 138/43 20 100%
- Labs were significant for Hgb 7.2 (baseline 7.4-8), INR 2.5
- CXR revealed small R pleural effusion, likely right lower lung
atelectasis, difficult to exclude pna
- The patient was given pantoprazole 40mg IV
Vitals prior to transfer were: 97.8 94 127/37 20 100% RA
Upon arrival to the floor, patient has no complaints.
Past Medical History:
-EtOH abuse (sober since ___
-Cirrhosis ___ EtOH: c/b refractory ascites, hepatorenal
syndrome, HE, SBP, coagulopathy, thrombocytopenia, and
esophageal varices
-B12 deficiency
-Subclinical hypothyroidism
Social History:
___
Family History:
Father: dementia, deceased
No h/o liver disease.
Physical Exam:
Admission exam
Vitals: 97.8, 144/42, 78, 18, 100% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear on left, decreased breath sounds on R lower lobe,
+dullness to percussion ___ up on right
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding, +fluid wave and
shifting dullness
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing/cyanosis. 2+
edema up to knees L>R
Neuro: CNII-XII grossly intact, no asterixis
Discharge exam
VS - Tmax 97.9 Tc 98.3 HR 84 BP 131/52 RR 16 02 sat 98% on RA
General: Comfortable, NAD.
HEENT: MMM, EOMI. Sclera anicteric.
Neck: no JVD, no LAD
CV: RRR, muffled S1/S2
Lungs: CTAB with no wheeze, rales, rhonchi. Air penetration much
improved since ___.
Abdomen: Distended with moderate ascites, soft, nontender.
Ext: warm and well perfused, pulses symmetrical. LLE edema.
Neuro: Alert and oriented. No asterixis.
Pertinent Results:
Admission labs
___ 10:30PM BLOOD WBC-2.3* RBC-2.30* Hgb-7.2* Hct-22.0*
MCV-96 MCH-31.3 MCHC-32.7 RDW-16.3* RDWSD-56.3* Plt Ct-29*
___ 10:30PM BLOOD ___ PTT-48.5* ___
___ 10:30PM BLOOD Glucose-74 UreaN-32* Creat-1.1 Na-133
K-4.7 Cl-100 HCO3-20* AnGap-18
___ 10:30PM BLOOD ALT-25 AST-84* AlkPhos-103 TotBili-3.4*
___ 10:30PM BLOOD Albumin-3.1* Calcium-9.2 Phos-3.6 Mg-1.8
Discharge Labs
___ 10:33AM BLOOD WBC-2.8* RBC-3.17* Hgb-9.7* Hct-29.4*
MCV-93 MCH-30.6 MCHC-33.0 RDW-15.6* RDWSD-52.5* Plt Ct-38*
___ 10:33AM BLOOD Plt Ct-38*
___ 06:06AM BLOOD Glucose-93 UreaN-30* Creat-1.3* Na-135
K-3.7 Cl-99 HCO3-25 AnGap-15
___ 06:06AM BLOOD ___ PTT-50.9* ___
___ 05:05AM BLOOD ALT-30 AST-66* TotBili-6.5*
___ 05:05AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.5*
Imaging:
___ CXR: Small right pleural effusion, likely right lower
lung atelectasis, difficult to exclude pneumonia.
___ CXR: Successful repositioning of existing 46 cm left arm
approach single-lumen PICC into the distal SVC. The line is
ready for use.
___: 1. Ultrasound guided therapeutic right thoracentesis
with removal of 1.3 L of right pleural fluid.
2. Insufficient fluid for paracentesis. No paracentesis
performed.
Micro: none
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea / wheezing
3. FoLIC Acid 1 mg PO DAILY
4. Cyanocobalamin 500 mcg PO DAILY
5. Ipratropium Bromide Neb 1 NEB IH Q6H
6. Lactulose 30 mL PO DAILY
7. Levothyroxine Sodium 25 mcg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Rifaximin 550 mg PO BID
10. Spironolactone 100 mg PO DAILY
11. Thiamine 100 mg PO DAILY
12. Torsemide 40 mg PO DAILY
13. TraZODone 50 mg PO QHS:PRN insomnia
14. Nystatin Oral Suspension 5 mL PO TID
15. Lidocaine 5% Patch 1 PTCH TD QAM
16. Levofloxacin 500 mg PO Q24H
17. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
Discharge Medications:
1. Cyanocobalamin 500 mcg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Ipratropium Bromide Neb 1 NEB IH Q6H
4. Lactulose 30 mL PO DAILY
5. Levofloxacin 500 mg PO Q24H
6. Levothyroxine Sodium 25 mcg PO DAILY
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Torsemide 40 mg PO DAILY
9. Thiamine 100 mg PO DAILY
10. Spironolactone 100 mg PO DAILY
11. OxycoDONE (Immediate Release) 5 mg PO Q8H:PRN pain
12. Nystatin Oral Suspension 5 mL PO TID
13. Rifaximin 550 mg PO BID
14. Acetaminophen 650 mg PO Q6H:PRN Pain
15. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea /
wheezing
16. Pantoprazole 40 mg PO Q24H
17. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
#Cirrhosis complicated by diuretic-refractory ascites and
hydrothorax
#Anemia, acute on chronic
#Coagulopathy, secondary to chronic liver disease
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 c/o right upper back pain with SOB // ? PNA and any
increase to known right pleural effusion
COMPARISON: Prior chest x-ray from ___.
FINDINGS:
PA and lateral views of the chest provided. There is a small residual right
pleural effusion. Mild elevation of the right hemidiaphragm is again noted,
with probable subjacent atelectasis, cannot exclude pneumonia. Left lung is
clear. No pneumothorax. No edema. Cardiomediastinal silhouette appears
grossly stable. Bony structures are intact.
IMPRESSION:
Small right pleural effusion, likely right lower lung atelectasis, difficult
to exclude pneumonia.
Radiology Report
EXAMINATION: UNIAT LOWER EXT VEINS
INDICATION: ___ year old woman with cirrhosis, peripheral edema L>R // r/o
DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of the left common
femoral, superficial femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the left lower extremity veins.
Radiology Report
EXAMINATION: US INTERVENTIONAL PROCEDURE
INDICATION: ___ year old woman with EtOH cirrhosis complicated by refractory
ascites and right pleural effusions, with weekly thoracentesis.
TECHNIQUE: Ultrasound guided 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: After reviewing the patient's coagulation lab values, it was
decided that the patient should receive FFP and platelets prior to
thoracentesis to prevent increased risk of bleeding during the procedure. The
procedure will be performed following transfusion.
IMPRESSION:
Ultrasound-guided thoracentesis deferred until the patient can receive blood
products to correct coagulation abnormalities.
Radiology Report
EXAMINATION: US INTERVENTIONAL PROCEDURE
INDICATION: ___ year old woman with recurrent refractory ascites. Therapeutic
paracentesis.
TECHNIQUE: Ultrasound guided therapeutic paracentesis
COMPARISON: None
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a small
amount of perihepatic ascites.
PROCEDURE: Given the lack of sufficient fluid, the procedure was deferred.
IMPRESSION:
Therapeutic paracentesis deferred for lack sufficient ascites.
Radiology Report
INDICATION: ___ year old woman with EtOH cirrhosis c/b refractory ascites and
R pleural effusions, with weekly ___ // please perform paracentesis
and R thoracentesis
TECHNIQUE: 1. Ultrasound guided therapeutic thoracentesis.
2. No paracentesis performed.
COMPARISON: CXR ___, ultrasound ___
FINDINGS:
THORACENTESIS: 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.
PARACENTESIS: Limited grayscale ultrasound imaging of abdominal quadrants
demonstrates trace intra-abdominal ascites. There is insufficient fluid for
paracentesis.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
A 5 ___ catheter was advanced into the largest fluid pocket in the right
posterior mid scapular line and 1.3 L of clear, straw-colored fluid was
removed.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ personally supervised the trainee during the procedure and
reviewed and agrees with the trainee's findings.
IMPRESSION:
1. Ultrasound guided therapeutic right thoracentesis with removal of 1.3 L of
right pleural fluid.
2. Insufficient fluid for paracentesis. No paracentesis performed.
Radiology Report
INDICATION: Pt had a left picc,46cm ___ ___
___ year old woman with PICC. // Pt had a left picc,46cm ___ ___
Contact name: ___: ___
EXAMINATION: CHEST PORT. LINE PLACEMENT
TECHNIQUE: Portable Chest radiograph, frontal view
COMPARISON: Chest radiograph ___
FINDINGS:
Left PICC loops within the left brachiocephalic vein and terminates in left
brachiocephalic vein at the level of left clavicular head. Elevated right
hemidiaphragm is chronic. There is at least small right pleural effusion.
There is no pneumothorax. Cardiac silhouette is normal size.
IMPRESSION:
Left PICC loops in the left brachiocephalic vein and terminates in left
brachiocephalic vein at the level of left clavicular head.
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: ___ year old woman with cirrhosis, refarctory pleural effusions.
// proper placement of PICC Contact name: ___, MD, ___: ___
proper placement of PICC
IMPRESSION:
In comparison with the earlier study of this date, there is been little change
in the malpositioned left PICC line, which extends into the brachiocephalic
vein before coiling about on itself with the tip in the subclavian vein.
Otherwise little change.
Radiology Report
INDICATION: ___ year old woman with cirrhosis s/p picc placement // PICC
reposition
COMPARISON: Chest x-ray from ___
TECHNIQUE: OPERATORS: Dr. ___ radiology fellow) and Dr. ___
___ radiology attending) performed the procedure. The attending,
Dr. ___ was present and supervising throughout the procedure. Dr. ___,
___ radiologist, personally supervised the trainee during the key
components of the procedure and reviewed and agreed with the trainee's
findings.
ANESTHESIA: None.
MEDICATIONS: None.
CONTRAST: None.
FLUOROSCOPY TIME AND DOSE: 0.3 min, 1 mGy
PROCEDURE: 1. Repositioning of left PICC.
PROCEDURE DETAILS: Using sterile technique, the existing PICC line was
aspirated and then flushed using a 10 cc syringe with sterile saline. The
existing PICC line was successfully repositioned into the superior vena cava
(SVC).
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. Existing right arm approach PICC with tip in the right brachiocephalic vein
successfully repositioned with a power flush into the distal SVC.
IMPRESSION:
Successful repositioning of existing 46 cm left arm approach single-lumen PICC
into the distal SVC. The line is ready for use.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with PICC line. // eval for PICC line
placement. Contact name: ___: ___
IMPRESSION:
As compared to the prior study of several hr earlier, a left PICC has been
successfully repositioned, terminating in the lower superior vena cava. No
other relevant changes.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, R Upper back pain
Diagnosed with ANEMIA NOS, MELENA, ALCOHOL CIRRHOSIS LIVER
temperature: 98.2
heartrate: 74.0
resprate: 20.0
o2sat: 100.0
sbp: 138.0
dbp: 43.0
level of pain: 9
level of acuity: 2.0 | ___ w/ h/o EtOH Cirrhosis c/b diuretic-resistant ascites,
diuretic-resistant hydrothorax, SBP, hepatorenal syndrome, HE,
and esophageal varices, who presents with acute on chronic
anemia now s/p PRBC tranfusion, thoracentesis and PICC line
placement. |
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, Dysuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ M with a history of ESRD due to PKD s/p
DDRT in ___ who presented to the ___ today with fevers and
concern for urinary tract infection.
He was in his usual state of health up through about ___ days
ago when he developed dysuria, as well as urinary frequency and
sensation of incomplete bladder emptying with urine dribbling.
He had nocturia x 2 nightly. This prompted concern re: UTI and
he presented to his PCP, where his RLQ allograft was reportedly
tender to palpation. The patient feels that he always has a
certain degree of tenderness when the graft is pushed hard
enough. He was started on ciprofloxacin. He underwent CT scan as
well evaluating for possible appendicitis- we do not have these
results but apparently there was neither evidence of
appendicitis or pyelo on the CT scan.
Pt reports that he felt fatigued and slept throughout the day.
He was nauseated and vomited. Patient unable to take Cipro as
well as his CsA/MMF and pred since yesterday evening. This
morning he had a fever to 101 this morning at home and he was
instructed to go to the ___. There he had pyuria on UA,
leukocytosis, concerning for UTI. He received a liter of fluid
and ceftriaxone, blood and urine cxs were sent and he was
transferred to ___.
He arrived febrile nearly to 102 in our ___ but was
hemodynamically stable and received acetaminophen. Rpt UA, Ucx
were sent.
Currently patient has no complaints and feel as though his
symptoms have resolved. He has no rigoring, chest pain or
pressure, coughing, flank pain or hematuria. He wants to eat and
is thirsty.
ROS: per HPI, denies fever, chills, night sweats, headache,
vision changes, rhinorrhea, congestion, sore throat, cough,
shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, BRBPR, melena, hematochezia,
dysuria, hematuria.
Past Medical History:
- htn
- PKD c/b ESRD on HD for ___ years now s/p DDRT in ___, bl
1.3-1.6
- hyperparathyroidism
Social History:
___
Family History:
No HTN, CKD, CAD, CVA. Mom has COPD. Dad died of throat cancer,
was an alcoholic.
Physical Exam:
ADMISSION PHYSICAL EXAM:
98.1 119/68 62 18 97RA
GENERAL: well appearing, in NAD
HEENT: MMM, OP is clear
PULM: CTA ___
CARDS: RRR no MRG
ABDOMEN: soft, mild ttp over RLQ grafted kidney (patient reports
baseline), no rebound or guarding
EXT: no cce.
NEURO moves all 4 extremities purposefully and without incident,
no facial droop.
DISCHARGE PHYSICAL EXAM:
VITALS: 98.8 97.8 114/76 62 18 100% RA
I/Os: PO 940 | IV 100 | UOP 1175 | BM x 1
GENERAL: Well appearing, well-nourished male in NAD
HEENT: EOMI, PERRLA, MMM, clear oropharynx.
PULM: CTAB.
CARDS: RRR, normal s1/s2, no m/r/g.
ABDOMEN: Soft, non-distended, mild tenderness to palpation over
RLQ grafted kidney, no rebound or guarding.
EXT: Warm, well-perfused, no edema.
NEURO: moves all 4 extremities purposefully and without
incident, no facial droop.
Pertinent Results:
ADMISSION LABS:
___ 09:50PM BLOOD WBC-8.1 RBC-4.93 Hgb-13.3* Hct-42.1
MCV-85 MCH-27.1 MCHC-31.7 RDW-12.7 Plt ___
___ 09:50PM BLOOD ___ PTT-29.9 ___
___ 09:50PM BLOOD Glucose-116* UreaN-23* Creat-1.6* Na-138
K-4.4 Cl-104 HCO3-26 AnGap-12
___ 09:50PM BLOOD Calcium-9.8 Phos-3.4 Mg-1.8
___ 06:20PM URINE Color-Yellow Appear-Clear Sp ___
___ 06:20PM URINE Blood-MOD Nitrite-NEG Protein-100
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-MOD
___ 06:20PM URINE RBC-110* WBC-40* Bacteri-FEW Yeast-NONE
Epi-<1
DISCHARGE LABS:
___ 09:50PM BLOOD Cyclspr-LESS THAN
___ 06:58AM BLOOD Cyclspr-59*
___ 06:58AM BLOOD WBC-6.3 RBC-4.54* Hgb-12.5* Hct-39.3*
MCV-86 MCH-27.5 MCHC-31.8 RDW-12.8 Plt ___
___ 06:58AM BLOOD Glucose-89 UreaN-21* Creat-1.4* Na-141
K-5.0 Cl-107 HCO3-25 AnGap-14
___ 06:58AM BLOOD Calcium-9.7 Phos-2.8 Mg-1.9
MICRO:
___ Urine Culture NG
___ Blood Culture pending
IMAGING:
Renal Transplant US ___
IMPRESSION: Normal renal transplant ultrasound.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CycloSPORINE (Sandimmune) 100 mg PO Q12H
2. Mycophenolate Mofetil 500 mg PO BID
3. Cinacalcet 30 mg PO DAILY
4. Amlodipine 10 mg PO DAILY
5. PredniSONE 5 mg PO DAILY
Discharge Medications:
1. Cinacalcet 30 mg PO DAILY
2. Mycophenolate Mofetil 500 mg PO BID
3. PredniSONE 5 mg PO DAILY
4. CycloSPORINE (Sandimmune) 100 mg PO Q12H
5. Amlodipine 10 mg PO DAILY
6. Cefpodoxime Proxetil 400 mg PO Q12H
Please continue antibiotics for a ___ay ___ and
to be completed ___.
RX *cefpodoxime 200 mg Take 2 tablets by mouth every 12 hours
Disp #*42 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Urinary Tract Infection, End Stage Renal
Disease secondary to Polycystic Kidney Disease s/p Renal
Transplant
Secondary Diagnosis: Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY:
___ man with tenderness to palpation over the transplanted kidney.
TECHNIQUE: Grayscale and Doppler ultrasound images of the renal transplant
were obtained.
COMPARISON: Comparison is made to transplant kidney ultrasound from ___.
FINDINGS:
The renal morphology is normal. Specifically, the cortex is of normal
thickness and echogenicity, pyramids are normal, and there is no
pelvi-infundibular thickening and the renal sinus fat is normal. There is no
hydronephrosis and no perinephric fluid collection is identified.
The resistive indices of the intrarenal arteries range from 0.65-0.75, within
the normal range. Acceleration times and peak systolic velocities of the main
renal arterie is normal. The vascularity is symmetric throughout the
transplant. The renal vein is patent and shows normal waveform.
IMPRESSION:
Normal renal transplant ultrasound.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FEVER
Diagnosed with URIN TRACT INFECTION NOS
temperature: 99.1
heartrate: 80.0
resprate: 14.0
o2sat: 100.0
sbp: 116.0
dbp: 60.0
level of pain: 4
level of acuity: 2.0 | Mr. ___ is a ___ year old male s/p DDRT ___ here with
fevers and symptoms of urinary tract infection, possibly
pyelnephritis versus cystitis.
ACTIVE ISSUES
# FEVERS/DYSURIA
Patient presents with positive UA, fevers consistent with UTI.
Pt with pain over grafted kidney so pyelo is a possibility
however he says this is baseline and CT scan from OSH negative
for pyelo. Urine culture had no growth. Was initially treated
with ceftriaxone and transitioned to cefpodoxime with clinic
improvement and a plan for 1 ___HRONIC ISSUES
# S/P DDRT
Creatinine appears to fall within the range of his normal over
the past few years. It is elevated from two days ago, likely
reflecting some ___ in response to systemic inflammation.
Continued CsA, MMF, and prednisone.
# HTN
Continued home amlodipine.
# HYPERPARATHYROIDISM
Continued home sensipar. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
left shoulder dislocation
Major Surgical or Invasive Procedure:
L shoulder closed reduction
History of Present Illness:
___ male with history of HLD, HTN and prior traumatic
anterior dislocation of the left shoulder who presents with
complaint of left shoulder dislocation. States that yesterday he
had episode in which when he reached over his head he felt a
popping sensation and then felt his shoulder pop back into
place.
Today a similar event occurred around 9AM. He denies any trauma.
No numbness/weakness.
Past Medical History:
PMH: HTN, hyperlipidemia
Social History:
___
Family History:
noncontributory
Physical Exam:
General: Well-appearing male in no acute distress.
left upper extremity:
- Skin intact
- No edema, ecchymosis, erythema, induration
- Soft, non-tender arm and forearm
- Full, painless ROM, elbow, wrist, and digits
- Arm in sling
- Fires EPL/FPL/DIO
- SILT axillary/radial/median/ulnar nerve distributions
- 2+ radial pulse, WWP
Pertinent Results:
___ 07:15PM GLUCOSE-135* UREA N-10 CREAT-0.8 SODIUM-124*
POTASSIUM-3.4 CHLORIDE-85* TOTAL CO2-23 ANION GAP-16
___ 04:48PM BLOOD Na-120*
___ 01:15PM BLOOD Glucose-116* UreaN-8 Creat-0.7 Na-119*
K-3.2* Cl-86* HCO3-24 AnGap-9
___ 06:50AM BLOOD Glucose-122* UreaN-8 Creat-0.7 Na-121*
K-3.5 Cl-85* HCO3-26 AnGap-10
Medications on Admission:
Hydrochlorothiazide 25 mg PO DAILY
Discharge Medications:
Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours as
needed Disp #*100 Tablet Refills:*1
OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
don't drink/drive/operate heavy machinery while taking
RX *oxycodone 5 mg ___ tablet(s) by mouth every 4 hours as
needed Disp #*60 Tablet Refills:*0
Omeprazole 20 mg PO DAILY
Rosuvastatin Calcium 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
left shoulder dislocation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with left shoulder pain// Any dislocation or
fracture
TECHNIQUE: Four views of the left shoulder
COMPARISON: None.
FINDINGS:
The left humeral head is dislocated anteriorly and inferiorly in relation to
the glenoid. No acute fracture is seen. Left acromioclavicular joint is
intact. Partially imaged left upper outer lung field is grossly clear.
IMPRESSION:
Anterior, inferior left shoulder dislocation.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with left shoulder dislocation// any intrathoracic
pathology
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Patient's arm overlies the lateral view, partially obscuring the view. Given
this, no definite focal consolidation is seen. There is no pleural effusion
or pneumothorax. The cardiac and mediastinal silhouettes are unremarkable.
Left shoulder dislocation is seen, as reported at left shoulder radiographs.
IMPRESSION:
No acute cardiopulmonary process. Left shoulder dislocation.
Radiology Report
EXAMINATION: CT left shoulder without contrast.
INDICATION: ___ year old man with L anterior shoulder dislocation// CT L
shoulder requested for pt with shoulder dislocation prior to reduction.
TECHNIQUE: CT scan of left shoulder was performed without the IV
administration of contrast material.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.8 s, 23.6 cm; CTDIvol = 24.6 mGy (Body) DLP = 579.5
mGy-cm.
Total DLP (Body) = 580 mGy-cm.
COMPARISON: Chest x-ray ___.
FINDINGS:
The bones: Anterior and inferior dislocation of the humeral head with
impaction of the humeral head on the anterior inferior glenoid. Small
depression of the posterior superior humeral head is consistent with small
___ deformity. Faint amount of mineralization medial to the anterior
inferior glenoid likely represents a tiny component of osseous Bankart. AC
joint appears congruent. Healing fracture is seen of the anterior left fourth
rib. Mild degenerative changes of the visualized cervical spine.
Soft tissues: Dense calcifications of the coronary arteries and tubular
density question unusual calcification along the aortic arch (02:47)..
Air-fluid level within the esophagus may represent underlying dysmotility.
Small amount of subacromial subdeltoid fluid. Muscle bulk of the rotator cuff
appears preserved. Integrity of the rotator cuff is difficult to assess on
CT. Biceps tendon is seen within the bicipital groove. Small glenohumeral
joint effusion.
IMPRESSION:
1. Anteriorly inferior dislocated left humeral head and impacted on the
anterior inferior glenoid, alignment similar to prior x-ray. Small ___
deformity and likely tiny bony Bankart abnormality.
2. Healing fracture of the anterior portion of the left fourth rib.
3. Dense calcifications of the coronary arteries.
4. Air-fluid level within the esophagus may represent underlying esophageal
dysmotility. Is there clinical concern for aspiration?
Radiology Report
INDICATION: Left shoulder close reduction.
COMPARISON: CT scan from ___.
IMPRESSION:
There has been relocation of the previously seen left anterior shoulder
dislocation. No definite fractures are seen. Please refer to the procedure
note for additional details.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: L Shoulder pain
Diagnosed with Inferior dislocation of left humerus, initial encounter, Overexertion from prolonged static or awkward postures, init
temperature: 97.7
heartrate: 90.0
resprate: 20.0
o2sat: 98.0
sbp: 144.0
dbp: 93.0
level of pain: 9
level of acuity: 3.0 | Hospitalization Summary (ED Admit)
The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left dislocated shoulder and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for a closed shoulder reduction 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's preoperative Na was 124. His home HCTZ was
held and he was advised to not take it until he follows up his
PCP. His postop Na was 119. He was free water restricted and
given a sodium tablet. His Na was rechecked 3 hours later and
found to be 120. Throughout, he had no changes in mental status.
Of note, he drank lots of alcohol two days prior and drinks ___
drinks daily.
The plan for the patient was to continue free water restriction
and start IV NS at 75cc/hr. The patient declined to stay and
wanted to leave against medical advice because he runs a local
newspaper and could lose thousands of dollars if he did not get
home tonight. It was explained to the patient in detail why we
thought he needed to stay in the hospital. The patient still
wanted to leave. He was advised to follow up with his PCP as
soon as possible regarding his HCTZ and low sodium. He will
follow up with Dr. ___ in clinic in 2 weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right lower extremity claudication
Major Surgical or Invasive Procedure:
___: tPa pulse spray, angiojet thrombectomy x2, popliteal
artery percutaneous angioplasty and stent placement
History of Present Illness:
Mr. ___ is a ___ with history of acute right limb
ischemia
due to popliteal occlusion s/p arterial lysis (___) now
presenting from outpatient clinic with 3 days of worsening
claudication and findings of right popliteal artery occlusion on
duplex ultrasound (OSH). He states that he has been at his
baseline state of health until 3 days ago when he suddenly had
worsening right lower extremity claudication. He is unable to go
more than 300 feet without right leg/calf pain, needing to stop
walking to relieve the pain. He has been noncompliant with his
medications. He has not taken any home medications for more than
a few months, including aspirin and atorvastatin. He denies
symptoms of rest pain or leg weakness.
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:
Gen: NAD, AOx3
CV: RRR no MRG
Pulm: no respiratory distress
Abd: soft, NT, ND
Ext: no edema, no mottling, no cyanosis
Pulses:
fem pop DP ___
right p d d p
left p p d d
Pertinent Results:
___ 06:50AM BLOOD WBC-7.3 RBC-4.60 Hgb-14.4 Hct-42.7 MCV-93
MCH-31.3 MCHC-33.7 RDW-12.8 RDWSD-43.5 Plt ___
___ 06:50AM BLOOD Glucose-94 UreaN-13 Creat-0.8 Na-138
K-3.7 Cl-105 HCO3-24 AnGap-13
___ 06:00AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.0 Leuks-NEG
CXR ___
No acute cardiopulmonary process.
ECG ___
Marked sinus bradycardia. There are non-diagnostic Q waves in
the inferior leads. Non-specific St-T wave changes. Compared to
the previous tracing of ___ the rate is slower.
Intervals Axes
Rate PR QRS QT QTc (___)
41 ___ 526 30 40 65
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Losartan Potassium 50 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Gabapentin 100 mg PO TID
4. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Atorvastatin 40 mg PO QPM
2. Gabapentin 100 mg PO TID
3. Losartan Potassium 50 mg PO DAILY
4. Clopidogrel 75 mg PO DAILY
Once 30 day course is complete, please resume Aspirin
RX *clopidogrel 75 mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
5. Rivaroxaban 15 mg PO BID Duration: 2 Weeks
Please take 15 mg twice a day for two weeks. After two weeks
take 20 mg once per day
RX *rivaroxaban [___] 15 mg (42)- 20 mg (9) 1 tablets(s) by
mouth twice a day Disp #*1 Dose Pack Refills:*0
6. Rivaroxaban 20 mg PO DAILY
Please take 20 mg once per day AFTER you have completed a two
week course of 15 mg twice per day
RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth Daily Disp
#*90 Tablet Refills:*2
Discharge Disposition:
Home
Discharge Diagnosis:
Right popliteal artery rethrombosis
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 RLE acute onset claudication // pre-op CXR
Surg: ___ (thrombolysis)
TECHNIQUE: Chest AP view.
COMPARISON: Chest radiograph ___.
FINDINGS:
The cardiomediastinal and hilar contours are normal. There is no pleural
effusion or pneumothorax. The lungs are well-expanded and clear without focal
consolidation concerning for pneumonia.
IMPRESSION:
No acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: R Leg pain
Diagnosed with LOWER EXTREMITY EMBOLISM
temperature: 98.5
heartrate: 68.0
resprate: 18.0
o2sat: 98.0
sbp: 163.0
dbp: 73.0
level of pain: 7
level of acuity: 2.0 | Mr. ___ was admitted from clinic with a three day history
of new-onset RLE claudication and R popliteal artery occlusion
demonstrated on duplex US. He was taken to the endovascular
suite and underwent an arterial angiogram which confirmed the
popliteal occlusion and also showed some collateralization
suggecting acute-on-chronic disease. A tPa pulse spray and
angiojet thrombectomy x2 was performed, followed by an
angioplasty and stenting of the right popliteal artery. The
procedure was uncomplicated and Mr. ___ tolerated it
well. The post-intervention angiogram demonstrated an open
politeal artery, a ___ open to the foot, diminutive AT occluding
above the ankle and a peroneal occluding at the midleg,
consistent with his pre-operative status. Following the
procedure he was loaded with 300 mg of Plavix and restarted on a
heparin drip. He recovered quickly from surgery and by POD 1 was
eating, walking and voiding. He had no hematoma or bleeding
from his groin puncture site and his pain was well controlled on
PO medication. With all goals of care met and doing well
clinically, he was discharged on a 1 month course of Plavix and
a new ongoing regimen of Xarelto. After 1 month he will replace
the Plavix with Aspirin and will be on a Aspirin/Xarelto regimen
indefinitely. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vicodin
Attending: ___.
Chief Complaint:
cognitive decline
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx of chronic subdural, mild cognitive impairment, DM
presents with cognitive decline and hyponatremia over the past
few weeks.
Per the pt's daughter, the pt had a subdural in ___ and
lost some cognitive abilities at that point, some decline in
short term memory, and has 24h aid, but was still able to
function pretty independently and do word finds.
2wks ago the pt was trying to get toilet paper out of the closet
and hit her head on a wood bureau. She was taken to ___ where
she had a negative HCT. Last ___, she had an episode of
word finding difficulty, which resolved. ___ her daughter
noticed she was no longer able to do or understand the concept
of the word searches, which is very unusual for her, though she
was mainly oriented. Her daughter also noted that she was
increasingly fatigued, wanting to sleep most of the time.
On ___ she went to see her PCP and was diagnosed with a UTI and
started on macrobid for a 7 day course. She was also found to be
hyponatremic to 128 (has had SIADH off and on in the past) and
was instructed to fluid restrict and increase her salt intake.
She states she has only given her ___ glass of water a day, and
otherwise is giving juices and ginger ale. Her daughter notes
that for the last 3 days she has been nauseated with decreased
PO intake and "cotton mouth".
Of note, in the ___ the pt had an episode of SVT and an
episode of AFib and was started on Amiodarone in ___ by her
Cardiologist (Dr. ___. Since starting amio,
she has been incredibly constipated, and had one admission for
obstipation to an OSH. Pravastatin was recently dced in an
attempt to improve constipation.
Today, the pt was sent in for evaluation due to her progressive
decline. In the ED, initial vs were: 97.8 55 114/49 17 99%RA.
Labs were remarkable for Na 128. Patient was given 1L NS.
On the floor, pt was sleeping but easily arousable. A&Ox2.5
(remembered Deaconess when told she was still in the hospital).
Denied any pain, fatigue, confusion. Denied any problems.
Review of sytems:
(+) Per HPI
(-) Denies any symptoms.
Past Medical History:
AMAROSIS FUGAX
ATRIAL FIBRILLATION
BENIGN POSITIONAL VERTIGO
CATARACT
COLONOSCOPY
DIABETES TYPE II
DIVERTICULOSIS
DUE FOR PVAX
HEARING LOSS
HYPERTENSION
HYPOTHYROIDISM
MYELODYSPLATIC SYMDROME
MYOCARDIAL INFARCTION
RT DISTAL ULNAR FRACTURE
SQUAMOUS CELL CARCINOMA
RIGHT CHRONIC SUBDURAL HEMATOMA.
DEMENTIA
EXPLORATORY LAPAROTOMY SMALL BOWEL RESECTION AND ANASTOMOSIS X1
REPAIR INCARCERATED LEFT FEMORAL HERNIA ___
CERVICAL LYMPH NODE BX
LAPAROCOPIC CHOLECYSTECTOMY ___
BIL. INGUINAL HERNIA REPAIR ___ years ago
Social History:
___
Family History:
Family History:
- Father with CAD
- Mother with DM
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: 97.4 120/52 56 78 98%RA
General- Alert, oriented x1 to person only, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- fine Bibasilar crackles, otherwise Clear to auscultation
bilaterally, no wheezes, 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, ___
strength throughout, pronator drift on L.
DISCHARGE PHYSICAL EXAM:
=========================
Vitals: 97.9 ___ ___ 98%RA
General- Alert, oriented x2 to person and place only, no acute
distress
HEENT- No visible abrasions or bruising seen. EOMI, Sclera
anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- clear to auscultation bilaterally, no wheezes, 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, no CVAT
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
Skin- Resolving ecchymoses on arms, otherwise no cuts or skin
breakdown.
Neuro- Able to recite months of year backwards (missed ___,
and days of the week backwards. CN2-12 intact, ___ strength
throughout, sensation intact bilaterally.
Pertinent Results:
ADMISSION LABS:
===============
___ 01:20PM BLOOD Glucose-119* UreaN-16 Creat-0.8 Na-128*
K-4.3 Cl-91* HCO3-27 AnGap-14
___ 01:20PM BLOOD WBC-4.0# RBC-3.55* Hgb-12.6 Hct-32.5*
MCV-92 MCH-35.0*# MCHC-35.8* RDW-14.9 Plt ___
___ 01:20PM BLOOD Neuts-78.4* Lymphs-14.5* Monos-6.2
Eos-0.7 Baso-0.3
___ 01:20PM BLOOD ___ PTT-25.7 ___
___ 01:20PM BLOOD Osmolal-267*
___ 01:20PM BLOOD TSH-3.9
___ 01:20PM BLOOD Free T4-1.8*
___ 06:55AM BLOOD Cortsol-12.1
DISCHARGE LABS:
===============
___ 07:45AM BLOOD WBC-3.6* RBC-3.25* Hgb-10.8* Hct-29.9*
MCV-92 MCH-33.4* MCHC-36.2* RDW-15.3 Plt ___
___ 07:45AM BLOOD Glucose-115* UreaN-21* Creat-0.7 Na-129*
K-4.0 Cl-97 HCO3-26 AnGap-10
___ 07:45AM BLOOD Calcium-8.2* Phos-2.6* Mg-1.8
URINE:
======
___ 07:50PM URINE Color-Yellow Appear-Clear Sp ___
___ 07:50PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-300 Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 07:53PM URINE Hours-RANDOM Creat-48 Na-26 K-30 Cl-31
___ 07:53PM URINE Osmolal-368
MICROBIOLOGY:
=============
___ Blood culture ___ bottles positive aerobic for coag neg
staph; Final pending
___ Blood culture x1 negative to date, final pending
___ urine culture: No growth (final)
ECG:
====
___: Rate 55 Sinus bradycardia. Low QRS voltage in the limb
leads. Compared to the previous tracing of ___ no
diagnostic change.
IMAGING:
========
Head CT without contrast ___: No acute intracranial
abnormality.
(There is no evidence of hemorrhage, edema, mass effect, or
acute vascular territorial infarction. Previously noted right
frontal subdural collection has resolved. Again demonstrated is
moderate global atrophy with involvement of the medial temporal
lobes as may be seen in Alzheimer's disease. Slight asymmetry
of the temporal horn enlargement, right greater than left, is
unchanged. Periventricular white matter hypodensities are once
again noted and likely reflect sequelae of chronic small vessel
ischemic disease. Atherosclerotic calcifications are seen in
the intracranial vertebral and cavernous carotid arteries
bilaterally. No acute fracture is identified. Burr holes
within the right frontal and parietal bones are again noted.
Small right maxillary mucus retention cyst noted. Remaining
paranasal sinuses, mastoid air cells, and middle ear cavities
are clear. Globes are unremarkable.
Head CT without contrast ___: No evidence of hemorrhage.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 100 mg PO DAILY
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Losartan Potassium 25 mg PO BID
4. MetFORMIN (Glucophage) 500 mg PO BID
5. Metoprolol Tartrate 12.5 mg PO BID
6. Nitrofurantoin Monohyd (MacroBID) 100 mg PO Q12H
started on ___ for planned 7day course
7. Cyanocobalamin 500 mcg PO DAILY
8. Magnesium Oxide 400 mg PO DAILY ASDIRECTED
alternating 400mg and 800mg every other day
9. Multivitamins 1 TAB PO DAILY
10. Senna 2 TAB PO DAILY
11. Bisacodyl 10 mg PO DAILY
12. Acidophilus *NF* (L.acidoph &
___ acidophilus) unknown Oral
daily
Discharge Medications:
1. Amiodarone 100 mg PO DAILY
2. Bisacodyl 10 mg PO DAILY
3. Cyanocobalamin 500 mcg PO DAILY
4. Levothyroxine Sodium 50 mcg PO DAILY
5. Losartan Potassium 25 mg PO BID
6. MetFORMIN (Glucophage) 500 mg PO BID
7. Metoprolol Tartrate 12.5 mg PO BID
8. Multivitamins 1 TAB PO DAILY
9. Senna 2 TAB PO DAILY
10. Magnesium Oxide 400 mg PO DAILY ASDIRECTED
11. Acidophilus *NF* (L.acidoph &
___ acidophilus) 1 cap ORAL
DAILY
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Primary Diagnoses:
Dementia
Hyponatremia
Secondary Diagnoses:
Mechanical fall
Hypertension
Atrial fibrillation
Discharge Condition:
Stable,
Alert and oriented x 2
Ambulatory with walker
Followup Instructions:
___
Radiology Report
HISTORY: Altered mental status worsening over the last few weeks.
TECHNIQUE: AP and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
The cardiac, mediastinal and hilar contours are unchanged, with the heart size
within normal limits. There is diffuse calcification of the thoracic aorta.
Pulmonary vascularity is normal. Lungs are hyperinflated but clear. No focal
consolidation, pleural effusion or pneumothorax is seen. No acute osseous
abnormalities are detected.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: Worsening mental status and unsteady gait.
COMPARISON: ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Coronal and sagittal reformatted
images were generated.
FINDINGS: There is no evidence of hemorrhage, edema, mass effect, or acute
vascular territorial infarction. Previously noted right frontal subdural
collection has resolved. Again demonstrated is moderate global atrophy with
involvement of the medial temporal lobes as may be seen in Alzheimer's
disease. Slight asymmetry of the temporal horn enlargement, right greater
than left, is unchanged. Periventricular white matter hypodensities are once
again noted and likely reflect sequelae of chronic small vessel ischemic
disease. Atherosclerotic calcifications are seen in the intracranial
vertebral and cavernous carotid arteries bilaterally. No acute fracture is
identified. Burr holes within the right frontal and parietal bones are again
noted. Small right maxillary mucus retention cyst noted. Remaining paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. Globes are
unremarkable.
IMPRESSION: No acute intracranial abnormality.
Radiology Report
HISTORY: ___ woman with cognitive decline and history of subdural
hematoma status post unwitnessed fall. Evaluate for bleed.
COMPARISON: Multiple prior nonenhanced head CTs, most recently of ___.
TECHNIQUE: Contiguous axial multidetector CT images were acquired through the
brain without administration of IV contrast. Axial images were interpreted in
conjunction with coronal and sagittal reformations.
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect, or infarction. A
right frontal subdural collection, last seen on ___, is no longer
appreciated. Prominent ventricles and sulci are similar to prior and
consistent with atrophy. Periventricular white matter hypodensities are
consistent with chronic small vessel ischemic disease. Atherosclerotic
calcifications of the cavernous carotid and vertebral arteries are similar to
prior.
No fracture is identified. Burr holes in the right frontal and parietal bones
are unchanged. Small right maxillary sinus mucous retention cyst is
unchanged. The visualized paranasal sinuses, mastoid air cells, and middle
ear cavities are otherwise clear. The ocular lenses have been replaced.
IMPRESSION:
Chronic changes as described above. No evidence of hemorrhage.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Altered mental status
Diagnosed with ALTERED MENTAL STATUS
temperature: 98.1
heartrate: 57.0
resprate: 16.0
o2sat: 97.0
sbp: 141.0
dbp: 52.0
level of pain: 0
level of acuity: 2.0 | ___ year old woman with history of subdural bleed, cognitive
decline, afib on metop and amiodarone, presenting with cognitive
decline secondary to worsening dementia and hyponatremia. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins
Attending: ___.
Chief Complaint:
subacute cognitive decline and hallucinations
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
___ is a ___ yo RH F with h/o migraine
headaches, strabismus, and possible prior TIA who was referred
to
our ED by her outpatient neurologist Dr. ___ expedited
workup of rapidly progressive cognitive decline and
hallucinations over the past 9 months concerning for ___ Body
Dementia.
She reports to me that her symptoms started about 9 months ago,
in ___. At that time, she noticed new word-finding
difficulties that have progressed since then. She reports
difficulty with attention/concentration: will often get
distracted in the middle of telling a story and be unable to
finish it (for example when telling a friend about a story she
read in the newspaper). She needs to use a timer in order to
complete chores at home in a timely fashion. She has had memory
loss, though she has difficulty describing specific instances of
this. More concerning to her are frequent hallucinations of
women
and children that started 9 months ago. She knows that these are
hallucinations and does not find them disturbing. She denies
auditory or olfactory hallucinations (in fact, she lost her
sense
of smell ___ years ago). Also endorses parasomnias - for the
past
year she has started sleepwalking, sometimes waking up in the
main hallways of her apartment building. She told Dr. ___
___
she sometimes does not know whether she was awake or asleep.
Apparently she has also talked in her sleep recently, witnessed
by her son who heard her shout "get off me".
Patient also reports gait problems dating back to at least ___
years ago. She has most difficulties walking on uneven surfaces
like cobblestones. She has had several falls this past ___,
including one where she struck her ___ on black ice. She denies
any tremor, limb stiffness/rigidity/pain, or easy startle
reflex.
She was referred to Dr. ___ evaluation in ___. An
MRI was performed which showed only mild cortical atrophy and
minimal punctate susceptibility artifacts in the left occipital
subcortical white matter and bilateral posterior temporal lobes
thought to be ferritin deposition or petichial hemorrhages. Dr.
___ an EEG performed during awake, drowsy and
sleeping
states which showed very subtle left temporal delta slowing just
during drowsiness, and no epileptiform features. Extensive
labwork was also performed for dementia workup, all negative
(see
below).
At some point in ___, she reportertedly had a fall and
presented to an OSH where she was apparently treated for a UTI.
She was sent home on an oral antibiotic which she did not pick
up
from the pharmacy -- believes it begins with a "B". She was
recently seen by neighbors wandering the streets, getting lost
while driving, and has called the police frequently. Reports
indicate that her home is in disarray and she is not taking her
medications as prescribed. As her symptoms have been
progressing
and she has no family nearby, Dr. ___ she was unsafe at
home and asked for Neurology admission.
Neuro and General ROS are positive per above, otherwise
negative.
Past Medical History:
- ?TIA (___): admitted to ___ for
left-sided hemiataxia, with MRI//MRA negative for stroke and
resolution of symptoms. TTE showed no PFO and Holter did not
show
dysrhythmia. She was placed on Plavix and Simvastatin at that
time.
- Hypercholesterolemia
- Osteopenia
- Abnormal MRI, thoracic spine
- Migraine equivalent syndrome (initially thought to be TIA)
- Strabismus
- Exophoria
- Cataract, nuclear sclerotic senile
- PVD (posterior vitreous detachment)
- Diplopia
- Chronic constipation
- Overweight
- S/P hysterectomy with oophorectomy
- Vitamin D insufficiency
Social History:
___
Family History:
No known family history of dementia. Allergies in her
sister; ___ in her mother; CAD/PVD (age of onset: ___) in
her father; CAD/PVD (age of onset: ___) in her brother; ___ in her father; ___ in her father; ___
in her father and sister; ___ (age of onset: ___) in her
mother; and ___ (age of onset: ___) in her sister.
Physical Exam:
Admission Exam:
- Vitals: 98.9 86 165/84 16 99% ra
- General: Awake, cooperative, NAD.
- HEENT: NC/AT
- Neck: Supple, no carotid bruits appreciated. No nuchal
rigidity
- Pulmonary: CTABL
- Cardiac: RRR, no murmurs
- Abdomen: soft, nontender, nondistended
- Extremities: no edema, pulses palpated
- Skin: no rashes or lesions noted.
NEURO EXAM:
- Mental Status: Awake, alert, oriented x 3. Affect is slightly
disinhibited with occasional inappropriate laughter. Able to
relate a fairly complete history but she has difficulty with
details and dates and has to refer to her calendar frequently.
Speech is circumloculatory, has word retrieval difficulties. No
frontal signs present. Luria sequencing not tested. Attentive,
able to name ___ backward without difficulty. Language is fluent
with intact repetition and comprehension. Normal prosody. There
were no paraphasic errors. Able to name both high and low
frequency objects. Speech was not dysarthric. Able to follow
midline, appendicular and crossed-body commands. Able to
register
3 objects, delayed word recall is ___ at 5 minutes ___ with
categorical prompting). No evidence of apraxia or neglect.
- Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
- Motor: Normal bulk and tone throughout. No axial or
appendicular rigidity. No tremor or 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, cold sensation, vibratory
sense, proprioception throughout. No extinction to DSS.
- DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 0
R 2 2 2 2 0
Plantar response was flexor bilaterally.
- Coordination: No intention tremor, no dysdiadochokinesia
noted.
No dysmetria on FNF or HKS bilaterally.
- Gait: Good initiation. Slightly hesitant but otherwise normal,
narrow-based stride and arm swing. Able to walk in tandem
without
difficulty. Romberg absent.
Discharge Exam:
Awake, alert, language fluent, oriented x3, knows current
events, naming/repetition intact, memory intact for what she
ordered for breakfast. Slow on tests of attention, difficulty
with Luria task. Able to name animals without difficulty. No
hallucinations currently.
Exotropia, EOMI, R facial droop.
Strength ___, R cupping, + grasp, + palmomental, - glabellar,
normal tone. Negative Romberg.
Intact FNF, fast finger tap.
Gait narrow based, independent.
Pertinent Results:
___
CXR
No evidence for pneumonia. Small bilateral pleural effusions.
___
EEG
IMPRESSION: This telemetry captured no pushbutton activations.
It showed a mildly disorganized and occasionally slow background
in wakefulness but
reaching and 8 Hz frequency posteriorly at times. There was very
minimal
theta slowing and occasional sharp features in the right
temporal region but no area of persistent focal slowing and no
clear spike or sharp and slow wave discharges. There were no
electrographic seizures.
___
MR ___ w/wo contrast
1. No acute intracranial abnormality.
2. Scattered FLAIR hyperintensities in the white matter,
nonspecific but
commonly seen due to mild chronic small vessel ischemic disease.
Brain volume appears normal for age.
3. Right parietal and left frontal calvarial lesions, not well
characterized and indeterminate in nature. These lesions may be
hemangiomas. Other etiologies, such as metastatic disease,
cannot be excluded. If further characterization is clinically
relevant, noncontrast CT of the ___ could be performed for
better evaluation of the calvarium.
___
EEG
IMPRESSION: This telemetry captured no pushbutton activations.
It showed a mildly slow and disorganized background throughout.
This suggests a mild encephalopathy. There were no areas of
prominent focal slowing, and there were no epileptiform
features. There were no electrographic seizures.
___
CT ___
1. No acute intracranial abnormality.
2. Unchanged right parietal and left frontal calvarial lesions,
that appear typical of hemangiomas.
___ 07:30PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-2875*
Polys-27 ___ Monos-2 Eos-69
___ 07:30PM CEREBROSPINAL FLUID (CSF) WBC-19 RBC-7600*
Polys-35 Bands-3 ___ Monos-1 Eos-56
___ 07:30PM CEREBROSPINAL FLUID (CSF) TotProt-37 Glucose-62
___ 08:02AM BLOOD WBC-19.0* RBC-4.82 Hgb-14.1 Hct-41.9
MCV-87 MCH-29.2 MCHC-33.6 RDW-14.1 Plt ___
___ 08:02AM BLOOD Neuts-25.8* Lymphs-9.3* Monos-2.1
Eos-62.5* Baso-0.3
___ 07:33AM BLOOD Glucose-88 UreaN-15 Creat-0.9 Na-141
K-4.2 Cl-104 HCO3-29 AnGap-12
___ 07:33AM BLOOD ALT-74* AST-49* LD(LDH)-259* AlkPhos-119*
TotBili-0.2
___ 07:33AM BLOOD Calcium-9.5 Phos-4.2 Mg-2.3
___:33AM BLOOD Cortsol-9.5
___ 07:33AM BLOOD ANCA-PND
___ 07:33AM BLOOD CRP-4.6
___ 07:33AM BLOOD HIV Ab-PND
___ 07:33AM BLOOD SED RATE-PND
___ 07:33AM BLOOD STRONGYLOIDES ANTIBODY,IGG-PND
___ 07:33AM BLOOD HTLV I AND II, WITH REFLEX TO WESTERN
BLOT-PND
Atrius Labs (___):
- CBC: WBC 7.4 (70.8% N, 18.6% L, 7.0% M, 2.7% E, 0.9% B)
- B12 352 (normal)
- TSH ___ (normal)
- Lyme Ab 0.57 (negative)
- RPR nonreactive
- ESR 12 (normal)
- CRP 2.2 (normal)
- Ceruloplasmin 36 (normal)
- Vitamin E 7.1 (normal)
- Vitamin B1 124 (normal)
- ___ negative
- TTG IgA negative
- Anti-Gliadin Ab negative
- Serum copper 103 (normal)
MRI Brain (Atrius, ___, images unavailable for my review):
1. Mild atrophy, with rare T2 hyperintense tiny nonspecific
white matter foci. No evidence of mass lesion or definitive
acute significant intra-axial lesion is identified.
2. Three discrete tiny brain susceptibility foci within the left
occipital subcortical white matter as well as the bilateral
posterior temporal lobes white matter. These could represent the
sequela of petechial hemorrhage, as could be seen with traumatic
injury or possibly amyloid angiopathy, versus other causes.
3. Two discrete calvarial lesions as discussed. Overall these
have likely benign appearance although confirmation of
nonneoplastic process is difficult by MRI. Consider bone scan
assessment to exclude active lesions, if clinically warranted.
4. Atypical left frontal sinus lesion as discussed. ___
uncertain. This lesion cannot be further assessed by imaging,
except by followup studeies and assessment of interval change in
size.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Venlafaxine XR 75 mg PO DAILY
2. Pravastatin 40 mg PO HS
3. Clopidogrel 75 mg PO DAILY
Discharge Medications:
1. Clopidogrel 75 mg PO DAILY
2. Pravastatin 40 mg PO HS
3. Donepezil 5 mg PO HS
RX *donepezil 5 mg 1 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*3
4. TraZODone 25 mg PO HS
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth daily Disp
#*45 Tablet Refills:*3
5. Venlafaxine XR 37.5 mg PO DAILY Duration: 1 Week
Take daily for 1 week. Then stop this medication.
RX *venlafaxine 37.5 mg 1 capsule(s) by mouth daily Disp #*7
Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
___ Body Dementia
Eosinophilia, etiology unknown
REM sleep behavior disorder
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ woman presenting with altered mental status and
leukocytosis.
COMPARISON: None available.
FINDINGS:
The lungs are clear. The hilar and cardiomediastinal contours are normal.
There is no pneumothorax. There are small bilateral pleural effusions.
Pulmonary vascularity is normal.
IMPRESSION:
No evidence for pneumonia. Small bilateral pleural effusions.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old woman with rapidly progressive dementia with
hallucinations as well as gait instability. // R/O structural abnormalities
TECHNIQUE: MRI of the head was performed before and following the intravenous
administration of 8 cc Gadavist.
COMPARISON: None.
FINDINGS:
There is no definite evidence of hemorrhage, infarction, mass, mass effect, or
midline shift. There is no pathologic intracranial enhancement. There are a
few foci of FLAIR hyperintensity scattered in the subcortical and deep white
matter, nonspecific but commonly seen in a patient of this age due to chronic
small vessel ischemic disease. Ventricles and sulci are age-appropriate.
Intracranial flow voids are maintained.
There are 9 mm right parietal (series 13, image 17) and 10 mm left frontal
(series 13, image 19) calvarial lesions. The lesions are T2 hyperintense, not
well characterized on T1 weighted images, and enhancing.
There retention cysts in the maxillary sinuses. The paranasal sinuses are
otherwise clear. The mastoid air cells are clear.
IMPRESSION:
1. No acute intracranial abnormality.
2. Scattered FLAIR hyperintensities in the white matter, nonspecific but
commonly seen due to mild chronic small vessel ischemic disease. Brain volume
appears normal for age.
3. Right parietal and left frontal calvarial lesions, not well characterized
and indeterminate in nature. These lesions may be hemangiomas. Other
etiologies, such as metastatic disease, cannot be excluded. If further
characterization is clinically relevant, noncontrast CT of the head could be
performed for better evaluation of the calvarium.
Radiology Report
INDICATION: ___ year old woman with rapidly progressive dementia, lesions on
MRI ?hemangioma // eval extraparenchymal lesions - ?hemangioma
TECHNIQUE: Helical axial MDCT images were obtained through the brain without
the administration of IV contrast. Reformatted images in coronal and sagittal
axes were generated.
DOSE: DLP: 892 mGy-cm, CTDI: 54 mGy
COMPARISON: MR head ___.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass effect. The
ventricles and sulci are normal in size and configuration. Mild
periventricular white matter hypodensities are nonspecific, but may represent
small vessel disease. The basal cisterns are patent and there is preservation
of gray-white matter differentiation.
Again seen, are 9 mm right parietal (03:31) and 15 mm left frontal hypodense
calvarial lesions, which may represent a hemangiomas. Additionally, there is
hyperostosis of the frontal bones bilaterally left greater than right. The
visualized paranasal sinuses, mastoid air cells, and middle ear cavities are
clear.
IMPRESSION:
1. No acute intracranial abnormality.
2. Unchanged right parietal and left frontal calvarial lesions, that appear
typical of hemangiomas.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Confusion, Hallucinations
Diagnosed with ALTERED MENTAL STATUS , HALLUCINATIONS
temperature: 98.9
heartrate: 86.0
resprate: 16.0
o2sat: 99.0
sbp: 165.0
dbp: 84.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ yo RH F with migraines and possible
prior TIA (L sided weakness at the time) who was referred by Dr.
___ for workup of rapidly progressive cognitive
decline. In fact, the patient's cognitive decline is less
rapidly progresive than initially thought. She has reported
memory loss over the past ___ years, hallucinations of
women/children smaller than true size for the past ___ year, and 3
falls within the past 6 months. The patient's memory problems
include remote and recent memory and word finding difficulty.
The hallucinations do not have an auditory component, do not
interact with the patient, and after the initial surprise of
having hallucinations, do not bother the patient. However, she
has called the police at night because she gets confused and
thinks she is unsafe. The falls are a combination of
unsteadiness and accidents (slipping on ice, etc). EEG showed
diffuse slowing but no epileptiform discharges, and LP was
bland, so this is unlikely to be seizures or
infectious/autoimmune encephalitis. The diagnosis for her memory
loss and hallucinations is ___ Body Dementia, although patient
does not have Parkinsonian symptoms at this time.
NEURO:
- MRI brain with contrast: some atrophy, extraparenchymal masses
possibly hemangiomas. Masses confirmed as hemangiomas on CT
___. Initial concern that these masses could be causing
seizures (manifesting as hallucinations) in this patient, but
this was not corroborated by EEG. cvEEG shows diffuse slowing
but no epileptiform activity.
- LP - traumatic tap but bland. CSF cx neg. A-beta and tau
pending.
- Effexor 75mg daily - will taper off this medication, as per
outpatient psychiatrist Dr. ___ (___), by
reducing dose by 50% for 1 week and then stopping, as this
medication can be worsening the patient's REM sleep behavior
disorder. SSRIs and SNRIs can exacerbate dementia in this
patient. In the future, her psychiatrist would like to consider
seroquel for hallucinations if not well controlled on donepezil.
- Continue donepezil 5 mg for dementia with memory
loss/hallucinations
- Continue trazodone 25 mg qhs to suppress REM sleep in this
patient with REM sleep behavior disorder
- will arrange for outpatient Neuropsychiatric evaluation
- will follow up in cognitive clinic with Dr. ___ and with
neurologist Dr. ___ (___)
HEME/ID: labs show WBC ___, with 40-60% eosinophils. She does
report recent UTI which was treated with an unknown antibiotic
which she believes begins with a "B". If she received Bactrim,
this could be sequellae of having a Sulfa allergy. Can also be
seen in some leukemias and lymphomas (but she has no other sx),
allergies and allergic reactions, and parasitic infections.
Since the eosinophilia has persisted since admission, drug
reaction may be less likely. Last CBC in ___ showed only
3% eosinophils, but there is concern for parasitic infection in
this patient with recent travel to ___ ___ and
3 days of diarrhea in ___ (although self-limited). There is
also concern for HIV, since patient has had new sexual contact.
- WBC count persistently elevated with eosinophilic
predominance.
- ID was consulted and recommended the following tests, which
are pending: ESR pending, CRP 4.6, HIV pending, ANCA pending,
cortisol 9.5, strongyloides pending, HTLV I/II pending, LFTs
elevated and should be followed as outpatient, stool O&P - 3
samples sent and ___ is negative with next 2 pending, CDiff
negative
- Serum tox negative
- UTox negative
- UA bland, urine cx neg
- will refer to ___ clinic as outpatient for continued workup
of eosinophilia, possibly to include bone marrow biopsy since
malignancy is a consideration in a patient of this age,
especially if ID workup results are negative (currently pending)
and AEC>1500
- will need follow up in ___ clinic if infectious workup returns
positive - PCP ___ need to refer patient.
CHRONIC PROBLEMS:
- Hyperlipidemia: continue simvastatin
- h/o TIA: continue clopidogrel
***Transitional Issues***
- taper off effexor in 1 week
- follow up neuropsychiatric evaluation
- may need referral to ___ clinic if infectious workup positive
- may need bone marrow biopsy for evaluation of eosinophilia |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
animals
Attending: ___
Chief Complaint:
chills, jaundice
Major Surgical or Invasive Procedure:
ERCP with sphincterotomy ___
History of Present Illness:
Mr. ___ is an ___ yo male with medical history notable for afib
and tachybrady syndrome s/p PPM on metoprolol and Xarelto, HTN,
aortic stenosis s/p AVR, CAD, nonhodgkin lymphoma on
surveillance
who presents w/x1 week of decreased appetite and po intake,
fatigue, generalized weakness, and chills.
Per patient, around 230AM he woke up with severe shaking chills.
He reports getting up to use the bathroom and losing his balance
due to the chills; he hit his left knee, denied head strike,
LOC.
He also reports x2 episodes of NB/NB vomiting. He checked his
blood pressure and noted it was 98/58 which is low compared to
baseline of BO 120-130/60-70. In addition, per one family member
patient was confused. He denies fever, headache,
lightheadedness/dizziness, CP/palp, SOB, dysuria, changes in BM,
rash. He denies new medications. He denies recent travel. He
endorses dark/orange urine.
In the ED, initial VS were: 97 75 115/60 95% RA.
On arrival to the floor patient is feeling nearly back to normal
save for continuing to have dark brownish urine. He denies
fevers, chills, confusion, abdominal pain, orthopnea, PND, leg
swelling.
ED labs imaging notable for:
13.4>13.4/39.0<156
Na 133 K 4.6 Cl 95 BUN 24 Cr 1.0 Gluc 139
ALT: 428 AST: 370 AP: 480 Tbili: 5.2 Alb: 4.3 Lip: 50
Flu negative
U/A few bacteria
Imaging showed:
-CXR: IMPRESSION: Mild cardiomegaly, hilar congestion.
-CT A/P:
IMPRESSION:
1. The gallbladder is not significantly distended, however the
wall is edematous and enhancing. Early acute cholecystitis
cannot
be excluded. Recommend further evaluation with gallbladder
ultrasound.
2. Retroperitoneal and pelvic sidewall lymphadenopathy,
unchanged
since ___ compatible with history of lymphoma.
3. Borderline splenomegaly.
RECOMMENDATION(S): US of the gallbladder
-RUQ U/S:
IMPRESSION:
Biliary sludge with mild gallbladder wall edema without
sonographic ___ sign. No definite sonographic evidence of
cholecystitis
Past Medical History:
-Atrial fibrillation with tachy brady syndrome
-S/p dual chamber SJM Accent RF on ___ on
rivaroxaban
-AS s/p AVR in ___ complicated by abdominal incisional
hernia.
-Minimal CAD
-Non-Hodgkin Lymphoma - Currently monitoring
Social History:
___
Family History:
Family history reviewed and found to be
noncontributory to this illness
Physical Exam:
DISCHARGE PHYSICAL EXAM:
VS: Afebrile and vital signs stable (reviewed in POE)
General Appearance: pleasant, comfortable, no acute distress
Eyes: PERLL, EOMI, no conjuctival injection, anicteric
ENT: no sinus tenderness, MMM, no JVD
Respiratory: CTA b/l with good air movement throughout
Cardiovascular: RR, S1 and S2 wnl, ___ systolic murmur RUSB
Gastrointestinal: nd, +b/s, soft, nt, -___ sign
Extremities: no cyanosis, clubbing or edema
Skin: warm, no rashes/no jaundice/no skin ulcerations noted
Neurological: Alert, oriented to self, time, date, reason for
hospitalization. Cn II-XII intact. ___ strength throughout.
fluent speech.
Psychiatric: pleasant, appropriate affect
GU: no catheter in place
Pertinent Results:
ADMISSION LABS:
___ 02:10PM BLOOD WBC-13.4*# RBC-4.47* Hgb-13.4* Hct-39.0*
MCV-87 MCH-30.0 MCHC-34.4 RDW-13.3 RDWSD-42.7 Plt ___
___ 02:10PM BLOOD Neuts-85.5* Lymphs-6.6* Monos-7.1
Eos-0.0* Baso-0.2 Im ___ AbsNeut-11.48*# AbsLymp-0.89*
AbsMono-0.95* AbsEos-0.00* AbsBaso-0.03
___ 02:10PM BLOOD Glucose-139* UreaN-24* Creat-1.0 Na-133*
K-4.6 Cl-95* HCO3-24 AnGap-14
___ 02:10PM BLOOD ALT-428* AST-370* AlkPhos-480*
TotBili-5.2*
___ 05:11AM BLOOD Calcium-8.6 Phos-2.7 Mg-2.2
___ 02:10PM BLOOD Albumin-4.3
___ 02:10PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 05:11AM BLOOD Acetmnp-NEG
DISCHARGE LABS:
___ 05:07AM BLOOD WBC-6.3 RBC-3.92* Hgb-11.5* Hct-34.9*
MCV-89 MCH-29.3 MCHC-33.0 RDW-13.2 RDWSD-42.9 Plt ___
___ 05:07AM BLOOD Glucose-74 UreaN-11 Creat-0.9 Na-142
K-4.9 Cl-102 HCO3-28 AnGap-12
___ 05:07AM BLOOD ALT-134* AST-40 AlkPhos-285* TotBili-2.8*
___ 05:07AM BLOOD Albumin-3.7 Calcium-9.0 Mg-2.2
IMAGING:
CT A/P ___:
IMPRESSION:
1. Gallbladder wall thickening with mucosal hyperenhancement
with moderate gallbladder distension. No intra or extrahepatic
biliary ductal dilation. Findings may reflect early acute
cholecystitis. Further evaluation with gallbladder ultrasound is
advised.
2. Prominent lymph nodes and borderline splenomegaly likely
reflect known history of lymphoma.
CXR ___: Mild cardiomegaly, hilar congestion.
RUQ US ___: No evidence of acute cholecystitis. No biliary
dilation.
ERCP ___
Impression: The scout film was normal.
The bile duct was successfully cannulated using a Rx
sphincterotome preloaded with 0.035in guidewire.
Contrast was injected and there was brisk flow through the
ducts.
Contrast extended to the entire biliary tree.
Contrast injection revealed multiple filling defects in the CBD
consistent with stones.
A biliary sphincterotomy was successfully performed with the
sphincterotome.
There was no post-sphincterotomy bleeding.
A biliary sphincteroplasty was successfully performed using a
6-8mm CRE balloon upto 8mm.
The biliary tree was swept with a 9-12mm balloon starting at
the bifurcation.
Multiple stones and sludge were successfully removed.
The CBD and CHD were swept repeatedly until no further stones
were seen.
The final occlusion cholangiogram showed no evidence of filling
defects in the CBD.
Excellent bile and contrast drainage was seen endoscopically
and fluoroscopically.
I supervised the acquisition and interpretation of the
fluoroscopic images.
The quality of the fluoroscopic images was good.
Otherwise normal ercp to third part of the duodenum
Recommendations:
NPO overnight with aggressive IV hydration with LR at 200 cc/hr
If no abdominal pain in the morning, advance diet to clear
liquids and then advance as tolerated
Recommend surgical evaluation for possible cholecystectomy.
If any abdominal pain, fever, jaundice, gastrointestinal
bleeding please call Advanced Endoscopy Fellow on call
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Succinate XL 50 mg PO BID
2. Rivaroxaban 20 mg PO DAILY
3. Simvastatin 10 mg PO 3X/WEEK (___)
4. Valsartan 80 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Ferrous Sulfate 325 mg PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours
Disp #*10 Tablet Refills:*0
2. MetroNIDAZOLE 500 mg PO TID
RX *metronidazole [Flagyl] 500 mg 1 tablet(s) by mouth every 8
hours Disp #*15 Tablet Refills:*0
3. Ferrous Sulfate 325 mg PO DAILY
4. Metoprolol Succinate XL 50 mg PO BID
5. Simvastatin 10 mg PO 3X/WEEK (___)
6. Valsartan 80 mg PO DAILY
7. Vitamin D 1000 UNIT PO DAILY
8. HELD- Rivaroxaban 20 mg PO DAILY This medication was held.
Do not restart Rivaroxaban until ___ or as directed otherwise
by your Cardiologist
Discharge Disposition:
Home
Discharge Diagnosis:
Cholangitis
Afib
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen and pelvis
INDICATION: ___ with a history of SLL with new onset elevated LFTs,
jaundice, increased fatigue // ? cholangitis
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.Oral contrast was not administered.Coronal and
sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 768 mGy-cm.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
LOWER CHEST: There is mild bibasilar atelectasis. There is no evidence of
pleural or pericardial effusion. Patient is status post aortic valve
replacement.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates heterogeneous 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 is borderline enlarged measuring . Stable hypodensities
are again seen in the spleen possibly representing hemangiomas.
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.
Cysts are seen in bilateral kidneys, the largest being a 4.6 cm cyst in the
lower pole of the right kidney. There is no evidence of focal renal lesions
or hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: There is a small hiatal hernia. Small bowel loops
demonstrate normal caliber, wall thickness, and enhancement throughout. The
colon and rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Prostate is mildly enlarged.
LYMPH NODES: Again noted are enlarged retroperitoneal and pelvic sidewall
lymph nodes, the largest measuring 2.4 cm in the right periaortic region
(02:36), unchanged in size. There is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Moderate to severe multilevel degenerative changes of the lower thoracic and
lumbar spine are noted.
SOFT TISSUES: Mesh tacks are seen along the anterior abdominal wall compatible
with prior hernia surgery. Again seen are fat containing supraumbilical
hernias. Fat containing right inguinal hernia is also noted with clips likely
representing prior surgery.
IMPRESSION:
1. Gallbladder wall thickening with mucosal hyperenhancement with moderate
gallbladder distension. No intra or extrahepatic biliary ductal dilation.
Findings may reflect early acute cholecystitis. Further evaluation with
gallbladder ultrasound is advised.
2. Prominent lymph nodes and borderline splenomegaly likely reflect known
history of lymphoma.
RECOMMENDATION(S): US of the gallbladder.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 9:28 pm, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with cough.// ? pneumonia
COMPARISON: Prior chest CT exam dated ___
FINDINGS:
PA and lateral views of the chest provided. A left chest wall pacer device is
again seen with leads extending into the region of the right atrium and right
ventricle. Midline sternotomy wires are again noted. Partially visualized
cervical fusion hardware projects over the lower neck. There is mild
elevation of the right hemidiaphragm, unchanged. The heart is stably
prominent. There is no focal consolidation, large effusion, or pneumothorax.
The appear slightly prominent and mild pulmonary vascular congestion is
suspected. There is no convincing evidence for edema. Aortic knob
calcifications are again noted. Imaged bony structures are intact. No free
air seen below the right hemidiaphragm. Mesh is seen projecting over the
upper abdomen.
IMPRESSION:
Mild cardiomegaly, hilar congestion.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with weakness and leukocytosis, transaminitis,
hyperbilirubinemia.// ? Please evaluate for right upper quadrant pathology,
slight thickening of the gallbladder was seen on the CT scan and recommended
ultrasound
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 5 mm.
GALLBLADDER: No gallstones or sonographic evidence for acute cholecystitis.
The gallbladder is under distended.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
IMPRESSION:
No evidence of acute cholecystitis. No biliary dilation.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Weakness
Diagnosed with Right upper quadrant pain, Epigastric pain, Weakness
temperature: 97.0
heartrate: 75.0
resprate: nan
o2sat: 95.0
sbp: 115.0
dbp: 60.0
level of pain: 0
level of acuity: 2.0 | ___ male with medical history notable for afib and tachybrady
syndrome s/p PPM, HTN, aortic stenosis s/p AVR, CAD, non-hodgkin
lymphoma on surveillance who presents w/x1 week of decreased
appetite and po intake, fatigue, generalized weakness, and
chills found to have choledocholithiasis.
#Choledocholithiasis vs. cholangitis
Pt presented with chills, leukocytosis, and found to have
elevated LFT's, bili. CT a/p showed biliary sludge with mild
gallbladder wall edema. He was started on IV
zosyn->cipro/flagyl x7 day course for presumed cholangitis. He
underwent ERCP on ___ which showed multiple stones and
sludge in the CBD, removed and sphincterotomy performed. Pt
tolerated the procedure well with no post-procedural pain or
nausea. He was counseled to hold his xarelto for 1 week
post-procedure or unless otherwise directed by his Cardiologist.
He ___ also d/w his PCP and ___ prior to deciding on
ccy.
#Afib
#Tachybrady syndrome s/p pacer placement
Xarelto held for procedure and pt got 1x dose of 5mg IV vitamin
K and FFP for elevated INR: 2.9 prior to ERCP. Xarelto also
held for 1 week post-procedure unless otherwise directed by pt's
Cardiologist. Pt's HR controlled with Metoprolol.
#Hyponatremia: Mild. Likely in the setting of poor po intake,
hypovolemia, vomiting. S/p IVF in ED. Now resolved.
#CAD: Continued simvastatin
#HTN: hold valsartan
Billing: greater than 30 minutes spent on discharge counseling
and coordination of care. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
NSAIDS (Non-Steroidal Anti-Inflammatory Drug) / gabapentin
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
In brief, Ms. ___ is a ___ with PMHx of EtOH cirrhosis,
RNY gastric bypass (___), and chronic abdominal pain who
presents with multiple episodes of syncope and stable shortness
of breath x 1 month. She was recently discharged from the
hospital after an episode of intessesuption after which she has
had 5 episodes of syncope all in varying circumstances (some
episodes occurred in sitting and some while standing). The
syncopal episodes are sudden onset with no clear prodrome. LOC
lasts ___ minutes. Regains consciousness without ongoing
confusion or lingering symptoms. No loss of bowel or bladder and
no rhythmic shaking noted by observers. No palpitations or chest
pain and no changes in vision or headache. While in the hospital
last she was started on lyrica and cymbalta and she believes
this is the cause. The patient is on nadol for HTN treatment and
presented with a HR in the ___ but her dose has not been
changed.
Additionally during one of these syncope episodes she hit her
head and injured her left ankle. She reports she saw an
orthopedist who told her she had a stress fracture and would
need an MRI. She was given crutches and told not to bear weight
though she states it is too difficult to use the crutches.
In the ED, initial VS were T98.9 HR 43 BP127/77 RR18 SaO299% RA
Initial labs with AP of 114 and AST of 42, since normalized.
DDimer elevated, but CTA without evidenc of PE (though did not
mild emphysematous changes). CT head and CXR without acute
processes.
Was given 1L NS and addl oxycodone for ankle pain. Since
admission to medicine, has been on tele with alarms x2 for HR of
39. Orthostatics this AM negative by blood pressure criteria,
though HR not recorded. On discussion this AM, patient describes
feeling lightheaded over the course of the last month (not
associated with epsidoes of loss of consciousness, but more
pronounced when rising from a seated position). She reports good
fluid intake, but has difficulty with solids following her
gastric bypass. She has required tube feeding in the past for
nutritional support, most recently in ___.
Past Medical History:
- EtOH cirrhosis
- SMV thrombosis
- Roux-en-Y gastric bypass (___)
- anxiety
- C.section x2 (20+years ago)
- B/l knee surgeries
- tonsillectomy
Social History:
___
Family History:
Family History: Non-contributory, parents living and generally
healthy.
Physical Exam:
ADMISSION PHYSICAL EXAM
=========================
VS - 98.5 ___ 43 ___ 98-99RA
GENERAL: Thin women laying in bed NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: nontender supple neck, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: scattered wheezes in bilateral lung fields, breathing
comfortably without use of accessory muscles
ABDOMEN: nondistended, +BS, tender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, moving all 4 extremities
with purpose. Left ankle with mild erythema and edema
surrounding lateral malleolus, very tender to palpations.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, A and O x3. Good sensation throughout.
Normal strength but testing limited in left ankle due to pain
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM
=========================
VS - 98.8 98.9 ___ 18 98-99RA
GENERAL: Thin women laying in bed not is acute distress
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB
ABD: non-distended abdomen, tinkling bowel sounds, exquisitely
tender to light palpation in LLQ with voluntary guarding. no
rebound tenderness. palpable soft, mobile mass in LLQ localized
to area of pain.
Pertinent Results:
ADMISSION LABS
================
___ 07:50PM BLOOD WBC-6.8 RBC-4.04 Hgb-13.1 Hct-40.1
MCV-99* MCH-32.4* MCHC-32.7 RDW-13.5 RDWSD-49.1* Plt ___
___ 07:50PM BLOOD Neuts-51.1 ___ Monos-9.7 Eos-1.8
Baso-0.9 Im ___ AbsNeut-3.47 AbsLymp-2.45 AbsMono-0.66
AbsEos-0.12 AbsBaso-0.06
___ 07:50PM BLOOD ___ PTT-25.4 ___
___ 07:50PM BLOOD Glucose-114* UreaN-9 Creat-0.6 Na-139
K-4.0 Cl-104 HCO3-24 AnGap-15
___ 07:50PM BLOOD ALT-18 AST-42* AlkPhos-114* TotBili-0.6
___ 07:50PM BLOOD Albumin-3.9 Calcium-9.1 Phos-3.2 Mg-2.2
___ 08:10PM BLOOD D-Dimer-1002*
___ 07:50PM BLOOD HCG-<5
___ 08:10PM BLOOD Lactate-1.3
STUDIES
================
___ CT ABDOMEN AND PELVIS
1. Evidence of gastrogastric fistula in patient who is status
post gastric bypass surgery.
2. No evidence of high-grade bowel obstruction. A functional
partial bowel obstruction cannot be excluded, though the dilated
proximal portion of the jejunum and distal decompressed bowel
loops are similar in appearance compared to prior exam.
3. Stable common bile duct dilation without evidence of
associated obstructive lesion.
4. Right adnexal cyst. Recommend further evaluation with
ultrasound if patient is postmenopausal.
___ MR FOOT ___ CONTRAST ___
1. Undisplaced fracture through the posterior calcaneus not
extending to the articular surface. The appearance suggests
this
may be due to a stress type fracture rather than a traumatic
fracture.
2. Fluid surrounding the flexor hallucis longus tendon distally
consistent with tenosynovitis.
___ MR ANKLE ___ CONTRAST L
1. Undisplaced fracture through the posterior calcaneus not
extending to the articular surface. The appearance suggests
this
may be due to a stress type fracture rather than a traumatic
fracture.
2. Fluid surrounding the flexor hallucis longus tendon distally
consistent with tenosynovitis.
___ CTA
1. No evidence of pulmonary embolism or aortic abnormality.
2. Mild emphysema
___ CT Head
No acute intracranial abnormality. Specifically, no evidence of
hemorrhage.
___ CXR
No evidence of pneumonia.
MICRO
================
None
DISCHARGE LABS
================
___ 05:50AM BLOOD WBC-3.9* RBC-3.82* Hgb-12.4 Hct-38.7
MCV-101* MCH-32.5* MCHC-32.0 RDW-13.4 RDWSD-50.2* Plt ___
___ 05:50AM BLOOD Glucose-91 UreaN-7 Creat-0.6 Na-139 K-3.9
Cl-104 HCO3-24 AnGap-15
___ 05:50AM BLOOD Calcium-8.8 Phos-4.0 Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.5 mg PO BID:PRN anxiety
2. Lactulose 15 mL PO BID
3. Nadolol 20 mg PO DAILY
4. DULoxetine 20 mg PO DAILY
5. Pregabalin 75 mg PO BID
6. Ferrous Sulfate 325 mg PO DAILY
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Omeprazole 40 mg PO DAILY
9. Pancreaze (lipase-protease-amylase) 21,000-37,000 -61,000
unit oral TID W/MEALS
10. Ursodiol 250 mg PO BID
11. Vitamin D ___ UNIT PO 1X/WEEK (TH)
12. Rifaximin 550 mg PO BID
13. Spironolactone 50 mg PO DAILY
14. Lidocaine 5% Ointment 1 Appl TP DAILY
15. FoLIC Acid 1 mg PO DAILY
16. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
Discharge Medications:
1. Psyllium Powder 1 PKT PO DAILY
2. ALPRAZolam 0.5 mg PO BID:PRN anxiety
3. DULoxetine 20 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Lactulose 15 mL PO BID
7. Lidocaine 5% Ointment 1 Appl TP DAILY
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Omeprazole 40 mg PO DAILY
10. OxyCODONE (Immediate Release) 10 mg PO Q4H:PRN Pain -
Moderate
11. Pancreaze (lipase-protease-amylase) 21,000-37,000 -61,000
unit oral TID W/MEALS
12. Pregabalin 75 mg PO BID
13. Rifaximin 550 mg PO BID
14. Ursodiol 250 mg PO BID
15. Vitamin D ___ UNIT PO 1X/WEEK (TH)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: syncope, symptomatic bradycardia
Secondary Diagnoses: ___ fracture, chronic abdominal pain,
etoh cirrhosis, B12 deficiency, HTN, 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
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with repeat falls // Eval for ICH
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: CT head dated ___.
FINDINGS:
There is no evidence of acute territorial infarction, hemorrhage, edema, or
mass. The ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
No acute intracranial abnormality. Specifically, no evidence of hemorrhage.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with difficulty breathing earlier today. // ?
pneumonia
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph dated ___.
FINDINGS:
Heart size is normal. 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:
No evidence of pneumonia.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: History: ___ with difficulty breathing and elevated dimer. // ?
PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Total DLP (Body) = 189 mGy-cm.
COMPARISON: None
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus.
Mild atherosclerotic calcification of the aortic arch. The thoracic aorta is
normal in caliber without evidence of dissection or intramural hematoma. The
heart, pericardium, and great vessels are within normal limits. No pericardial
effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Mild emphysematous changes are seen, predominantly within the
upper lobes bilaterally. Mild dependent atelectasis bilaterally. The
heterogeneity of the lung parenchyma is likely due to air trapping. No focal
consolidations or suspicious lung nodules. The airways are patent to the
level of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES: 2 chronic appearing right rib fractures are demonstrated. No
suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Mild emphysema.
Radiology Report
EXAMINATION: MR FOOT ___ CONTRAST LEFT
INDICATION: ___ year old woman with left foot/ankle pain // fx (?calcaneal
fx) -- dispo pending results
TECHNIQUE: Multiplanar images of the left ankle were performed without the
administration of intravenous contrast using a modified routine ankle protocol
as well as imaging of the forefoot. Images are degraded by motion artifact.
.
COMPARISON: None available.
FINDINGS:
Achilles tendon: Normal.
Posterior tibial tendon: Normal.
Flexor digitorum tendon: Normal.
Flexor hallucis tendon: There is fluid around the distal flexor hallucis
longus tendon in the midfoot consistent with tenosynovitis (06:21)
Peroneal tendons: Normal.
Anterior tibialis tendon: Normal.
Extensor digitorum tendon: Normal.
Extensor hallucis longus: Normal.
Anterior tibiofibular ligament: Normal.
Posterior tibiofibular ligament: Normal.
Anterior talofibular ligament: Visualization is suboptimal due to motion
artifact but this appears to be intact.
Posterior talofibular ligament: Normal.
Calcaneofibular ligament: Normal.
Tibiotalar ligament: Normal.
Tibiospring Ligament: Visualization is suboptimal due to motion artifact, no
definite tear seen.
Spring ligament: Visualization is suboptimal due to motion artifact, no
definite tear seen.
Sinus tarsi: Normal.
Plantar fascia: Normal.
Tibiotalar joint space: There is no joint effusion or osteochondral lesions.
Marrow signal: There is an undisplaced fracture through the posterior inferior
aspect of the calcaneus. This does not extend to the posterior facet of the
subtalar joint and may reflect a stress type fracture rather than traumatic
injury. There is extensive surrounding marrow edema.
Additional images were obtained of the forefoot. These do not demonstrate any
additional fracture. Mild degenerative changes are seen at the first
metatarsophalangeal joint. Visualized muscles and tendons are unremarkable in
appearance except to again noted fluid surrounding the flexor hallucis longus
tendon.
IMPRESSION:
1. Undisplaced fracture through the posterior calcaneus not extending to the
articular surface. The appearance suggests this may be due to a stress type
fracture rather than a traumatic fracture.
2. Fluid surrounding the flexor hallucis longus tendon distally consistent
with tenosynovitis.
NOTIFICATION: Findings discussed with Dr. ___ by telephone by Dr. ___
___ at 09:30 on ___
Radiology Report
EXAMINATION: CT abdomen pelvis with oral and IV contrast.
INDICATION: ___ year old woman with LLQ pain, palpable mass, high pitched
bowel sounds, hx intussusception // ? mass, lead point
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 19.3 mGy (Body) DLP =
9.6 mGy-cm.
2) Spiral Acquisition 4.7 s, 51.9 cm; CTDIvol = 8.8 mGy (Body) DLP = 455.9
mGy-cm.
Total DLP (Body) = 466 mGy-cm.
COMPARISON: ___
FINDINGS:
LOWER CHEST: There is a minimal amount of bibasilar atelectasis. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There are three focal, nonenhancing, hypodense lesions in the inferior right
lobe of the liver that appear stable since prior exam and are consistent with
simple cysts. There is no evidence of intrahepatic bile duct dilation. There
is prominence of the common bile duct measuring up to 10 mm, but stable since
since prior exam. There are no associated obstructive lesions appreciated and
the bile duct tapers appropriately distally suggesting sphincter of Oddi
dysfunction or ampullary stenosis as a cause of dilation. The gallbladder is
within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: Patient is status post gastric bypass procedure. There is
contrast in the excluded stomach, but no contrast in the duodenum suggesting a
gastrogastric fistula. There is a patulous appearance of the portion of the
jejunum in the left upper quadrant presumably at the site of the anastomosis
which is similar, but slightly more distended compared to prior exam.
Downstream loops of bowel appear collapsed. There is a hiatal hernia. The
colon and rectum are within normal limits.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: There is a 1.3 cm right adnexal cyst.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Evidence of gastrogastric fistula in patient who is status post gastric
bypass surgery.
2. No evidence of high-grade bowel obstruction, however noting dilation of
small bowel proximal to the distal Roux anastomosis with decompressed loops
beyond the anastomosis, more prominent than on prior study, suggesting that a
functional/partial bowel obstruction may be present.
3. Stable common bile duct dilation without evidence of associated obstructive
lesion.
4. Right adnexal cyst. Recommend further evaluation with ultrasound if
patient is postmenopausal.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 3:43 ___.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Syncope, Transfer
Diagnosed with Chest pain, unspecified
temperature: 98.9
heartrate: 43.0
resprate: 18.0
o2sat: 99.0
sbp: 127.0
dbp: 77.0
level of pain: 7
level of acuity: 2.0 | Ms. ___ is a ___ with PMHx of EtOH cirrhosis, RNY gastric
bypass (___), and chronic abdominal pain who presented with
multiple episodes of syncope and stable shortness of breath x ___s left ankle injury.
Syncope thought to be due to a combination of bradycardia (on
nadalol for BP control, no evidence of varices on imaging, prior
documentation of HR in ___ and orthostatic hypotension
(history of gastric bypass and chronic abdominal pain, which
limits PO intake). Question remains regarding why LOC episodes
are so prolonged. Patient remained on telemetry for >48 hrs with
no events. Remained asymptomatic during hospitalization, and
heart rate improved to ___ while holding nadolol. Remained
normotensive.
Additionally, had sudden worsening of her chronic abdominal
pain; this was investigated with labs and a CTAP W IV contrast,
which did not show any acute findings. We continued her home
narcotics and ensured bowel regimen titrated to soft BM daily.
Had MRI this admission for ankle to determine disposition, as ___
felt would be safe for home if WB and would need rehab if NWB
LLE. MRI showed calcaneal fx; pt discussed with her outpatient
ortho, who recommended NWB, CAM boot, and outpatient follow up
with him in several weeks.
Re: ETOH cirrhosis, continues on home lactulose and rifaximin.
No hx varices (last EGD ___. D/c'ed nadolol and
spironolactone as above. Needs GI follow-up. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Tachycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo male history of COPD and BPH presented to his PCP's office
today for PFT's. Upon arrival, she noticed his heart rate to be
in the 180's. She sent him for an EKG and labs and then to the
ED.
.
The patient denies palpitations, changed shortness of breath, or
chest pain, throughout any of this. He reports occiasional
lightheadedness and noted that last week he felt as if he might
"fall in traffic while standing at a curb". He denies recent
fevers, chills, or cough, but notes increased daytime urinary
frequency. Patient drank his usual cup of coffee today. He
reports fatigue of unknown timeline that does not limit his
exercises. He is taking daily naps that are not refreshing. He
feels weak and exhausted. No change in weight or appetite. He is
not sleeping well largely due to urinary frequency and wakes up
___. Stream is slow as times. He had recent urologic eval
for hematuria which was negative.
.
In the ED, initial VS were 97.0 112 149/93 18 100% RA. He
received 30 MG PO dilt with rates still in 120s. He received an
additional 10 MG i.v. dilt. Atrius cardiology was consulted who
asked for him to be admitted overnight and started on lovenox
and coumadin with dilt 60 qid. One peripheral line was placed
with 1L of IVF given. Vitals prior to transfer were: T 97.9 hr
74 bp 133/83 sa 02 98% ra.
.
Currently, patient feels well upon arrival to the floor and did
not expect to be admitted today.
Past Medical History:
-COPD
-Asthma
-GERD
-Trochanteric bursitis
-BPH with elevated PSA
-ED
-Colonic polyps
-Hematuria, no malignant cells identified
-Received his pneumovax and influenza vaccines.
Social History:
___
Family History:
Father ___ at ___ from Pneumonia
Mother ___ from EtOH
Paternal Aunt x2 heart disorder
Sister Cancer, still alive at ___
Physical Exam:
PHYSICAL EXAM ON ADMISSION
VS - 98.1 124/87 73 18 98% on RA 74.1kg
GENERAL - well-appearing male 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 - PMI non-displaced, irregularly irregular, no MRG, nl
S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
LYMPH - no cervical LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
.
PHYSICAL EXAM AT DISCHARGE
VSS, afebrile, normotenisve, HR 60-70s
GEN: NAD, A & OX3
HEENT: Supple, JVD flat, no carotid bruits
HEART: RRR, nl S1, S2, no m/r/g
LUNG: CTA bilaterally
ABD: soft, NT/ND
EXT: no pitting edema
Pertinent Results:
ADMISSION LABS
___ 05:00PM BLOOD WBC-7.7 RBC-4.59* Hgb-15.3 Hct-45.1
MCV-98 MCH-33.4* MCHC-33.9 RDW-13.2 Plt ___
___ 05:00PM BLOOD Neuts-58.1 ___ Monos-4.4 Eos-2.5
Baso-0.4
___ 05:00PM BLOOD ___ PTT-31.4 ___
___ 05:00PM BLOOD Glucose-108* UreaN-23* Creat-1.1 Na-138
K-4.2 Cl-103 HCO3-26 AnGap-13
___ 05:00PM BLOOD Calcium-9.7 Phos-3.2 Mg-2.2
.
DISCHARGE LABS
___ 07:05AM BLOOD WBC-6.3 RBC-4.27* Hgb-14.2 Hct-41.5
MCV-97 MCH-33.3* MCHC-34.3 RDW-13.2 Plt ___
___ 07:25AM BLOOD ___ PTT-36.3 ___
.
PERTINENT LABS
___ 05:00PM BLOOD cTropnT-<0.01
___ 07:05AM BLOOD CK-MB-3 cTropnT-<0.01
___ 07:05AM BLOOD CK(CPK)-136
___ 05:00PM BLOOD TSH-1.3
.
PERTINENT STUDIES
# CXR ___
PA AND LATERAL VIEWS OF THE CHEST: The heart size is normal. The
aorta is
tortuous. The pulmonary vascularity is normal. The hilar
contours are within normal limits. Lungs are mildly
hyperinflated, but are clear without focal consolidation. No
pleural effusion or pneumothorax is present. There are
multilevel degenerative changes in the thoracic spine.
IMPRESSION: No acute cardiopulmonary process.
.
# ECHO ___
The left atrium is normal in size. Left ventricular wall
thickness, cavity size and regional/global systolic function are
normal (LVEF >55%). There is no ventricular septal defect. Right
ventricular chamber size and free wall motion are normal. The
aortic root is mildly dilated at the sinus level. The ascending
aorta is mildly dilated. The aortic valve leaflets (3) are
mildly thickened but aortic stenosis is not present. The mitral
valve leaflets are mildly thickened. Physiologic mitral
regurgitation is seen (within normal limits). The estimated
pulmonary artery systolic pressure is normal. There is an
anterior space which most likely represents a prominent fat pad.
IMPRESSION: Normal regional and global biventricular systolic
function. No pathologic valvular abnormalities.
Medications on Admission:
-aspirin 162 mg Daily
-Atrovent HFA 17 mcg/Actuation Aerosol Inhaler Inhalation
4puff HFA Aerosol Inhaler(s) Twice Daily
-finasteride 5 mg daily
-beclomethasone 80mcg Use 1 inhalation by mouth twice daily
Discharge Medications:
1. finasteride 5 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
2. Atrovent HFA 17 mcg/Actuation HFA Aerosol Inhaler Sig: Four
(4) puffs Inhalation twice a day.
3. beclomethasone dipropionate 80 mcg/Actuation Aerosol Sig: One
(1) inhalation Inhalation twice a day.
4. Lovenox ___ mg/mL Syringe Sig: One (1) injection Subcutaneous
once a day.
Disp:*10 injections* Refills:*0*
5. diltiazem HCl 120 mg Tablet Extended Release 24 hr Sig: One
(1) Tablet Extended Release 24 hr PO once a day.
Disp:*30 Tablet Extended Release 24 hr(s)* Refills:*0*
6. Outpatient Lab Work
Please check INR.
Please send the results to Dr ___ at ___
___ Fax: ___
7. warfarin 2.5 mg Tablet Sig: One (1) Tablet PO once a day:
Please take one tablet with dinner daily. You will be notified
for dose changes.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis:
- atrial flutter
Secondary diagnosis:
- 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
INDICATION: New atrial flutter.
COMPARISON: None.
PA AND LATERAL VIEWS OF THE CHEST: The heart size is normal. The aorta is
tortuous. The pulmonary vascularity is normal. The hilar contours are within
normal limits. Lungs are mildly hyperinflated, but are clear without focal
consolidation. No pleural effusion or pneumothorax is present. There are
multilevel degenerative changes in the thoracic spine.
IMPRESSION: No acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: NEW AFLUTTER
Diagnosed with ATRIAL FLUTTER
temperature: 97.0
heartrate: 112.0
resprate: 18.0
o2sat: 100.0
sbp: 149.0
dbp: 93.0
level of pain: 0
level of acuity: 2.0 | ___ yo male with history of COPD who presents with new onset
a-flutter.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ y/o female who presents to ___ after a
fall. She was at her usual job as a ___, left a
meeting and recalls getting to the top of a flight of stairs and
her last memory is waking up in the CT scanner at the hospital,
she estimates that she fell down 10 steps. Report indicated
that she may have had some seizure like activity but detail as
to the description of observed events in not available. Paitient
also incurred a left huumeral head fracture. She was admitted
to the inpatient service for further observation.
Past Medical History:
PMH:
Morbid obesity
PSH:
Laparoscopic cholecystectomy
Tonsillectomy
Family History:
Non-contributory
Physical Exam:
On admission
Temp: 98.2 HR: 96 BP: 135/50 Resp: 18 O(2)Sat: 97
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light, Extraocular muscles intact
Oropharynx within normal limits, no midline tenderness
Cardiovascular: Regular Rate and Rhythm, Normal first and
second heart sounds, no chest wall tenderness
Abdominal: Nontender, Soft, no bruising
GU/Flank: No costovertebral angle tenderness
Extr/Back: ___ upper thoracic paraspinal tenderness, No
cyanosis, clubbing or edema
LUE in splint, 2+ RP, severe pain with any palpation,
compartments soft
Skin: Warm and dry, No rash
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
___: No petechiae
On discharge:
VS: T98.3, 90, 148/86, 14, 95% on room air
Pertinent Results:
___ Radiology:
CXR ___:
No consolidation, no pleural effusion, no pneumothorax, normal
cardiomediastinal silhouette: no acute process
CT Head and Cervical Spine ___:
No mass effect or shift. No evidence of infarction. Small high
left parietal subarachnoid hemorrhage. No evidence of acute
cervical spine fracture
CT Chest ___:
Evidence of a comminuted fracture of the proximal humerus with
impaction of the humeral head and avulsion of the greater
tuberosity
___ Imaging:
___ Left humerus
In comparison with the study of ___, there is again evidence of
a
comminuted fracture of the proximal humerus with impaction of
the humeral head and avulsion of the greater tuberosity.
___ gleno-humeral
In comparison with the study of earlier in this date, there is
again evidence of an impacted fracture of the surgical neck of
the humerus with avulsion of the greater tuberosity. There is a
somewhat low position of the humeral head with respect to the
glenoid fossa.
___ shoulder
Assessment of the patient with known left proximal humerus
fracture with
additional view (axillary view) of the left shoulder required.
AXILLARY VIEW OF THE LEFT SHOULDER
The axillary view re-demonstrates the comminuted fracture with
no evidence of dislocation. The fracture is better assessed on
the prior examinations.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. LeVETiracetam 500 mg PO BID Duration: 7 Days
RX *levetiracetam [Keppra] 500 mg 1 tablet(s) by mouth twice a
day Disp #*14 Tablet Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*25 Tablet Refills:*0
5. Senna 1 TAB PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
- Left small subarachnoid hemorrhage
- Left proximal humoral head fracture.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Evaluate for interval change in small left subarachnoid hemorrhage.
TECHNIQUE: MDCT acquired contiguous axial images were obtained through the
head without contrast. Coronal and sagittal reformats prepared and reviewed.
COMPARISON: CT from ___ dated ___ at 15:30.
FINDINGS:
There is a small subarachnoid hemorrhage in the left frontal vertex, unchanged
from the prior examination. There is no evidence of new or increased
hemorrhage. There is no mass effect or evidence of infarction. The
ventricles and sulci are normal in size and configuration. There is no
fracture. The imaged paranasal sinuses, mastoid air cells, and middle ear
cavities are clear.
IMPRESSION:
Unchanged appearance of small subarachnoid hemorrhage.
Radiology Report
HISTORY: Fracture.
FINDINGS: In comparison with the study of ___, there is again evidence of a
comminuted fracture of the proximal humerus with impaction of the humeral head
and avulsion of the greater tuberosity.
Radiology Report
HISTORY: To assess for fracture.
FINDINGS: In comparison with the study of earlier in this date, there is
again evidence of an impacted fracture of the surgical neck of the humerus
with avulsion of the greater tuberosity. There is a somewhat low position of
the humeral head with respect to the glenoid fossa.
Radiology Report
Assessment of the patient with known left proximal humerus fracture with
additional view (axillary view) of the left shoulder required.
AXILLARY VIEW OF THE LEFT SHOULDER
The axillary view re-demonstrates the comminuted fracture with no evidence of
dislocation. The fracture is better assessed on the prior examinations.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FALL WITH SAH
Diagnosed with FX UP END HUMERUS NOS-CL, FALL ON STAIR/STEP NEC
temperature: 98.2
heartrate: 96.0
resprate: 18.0
o2sat: 97.0
sbp: 135.0
dbp: 50.0
level of pain: 5
level of acuity: 2.0 | Mrs. ___ was admitted to ___ on ___
after you sustained a fall at work. Per medical records, she
was observed to have seizure-like activity after falling down
approximately 10 stairs. She had also lost consciousness for
approximately five minutes. Upon further evaluation, she was
found to have a small left subarachnoid hemorrhage and a left
proximal humerus fracture. She was transferred to ___ for
further evaluation and management.
One at ___, Mrs. ___ was seen by Neurosurgery and
Orthopedics for her injuries. From a neurosurgical standpoint,
the patient did not require a surgical procedure. Her repeat
head CT was stable. She was started on Keppra for seizure
prophylaxis. She will follow-up in their office in one month.
Mrs. ___ did not require an operative procedure for her left
humerus fracture. She was instructed by Orthopedics to keep the
arm in a sling and not bear any weight with that extremity. She
will follow up with that service in approximately two weeks with
an x-ray prior to her appointment.
The patient's pain was managed well with oral narcotic and
non-narcotic analgesics. She was tolerating a regular diet
well. She was hypertensive at times with systolic pressures in
the 150 to 160s and diastolic pressures between 80 and 90. She
was instructed to follow up with her PCP to address this issue,
although the new onset pain could have exacerbated her blood
pressure.
Lastly, Mrs. ___ was seen by Physical and Occupational
therapy. Both services felt that she could be discharged home
with no additional services.
At the time of discharge, the patient was afebrile,
hemodynamically stable and in no acute distress. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Femur fracture
Major Surgical or Invasive Procedure:
Open reduction internal fixation of right femur [Lateral plating
with a 16 hole plate secured with cortical and locking screws.]
History of Present Illness:
___ y/o female with past medical history of DVT on coumadin,
COPD, GERD, dementia, PNA who sufferred from a mechanical fall
at home. Patient stumbled while getting out of a chair and fell
while at home. She was seen at an OSH and was noted to have a R
distal femur fracture and was transferred to ___ for surgery.
Past Medical History:
Moderate dementia requiring assistance with ADL's. H/o prior
delirium with hip repair.
COPD:- based on imaging. She never smoked, does not use
inhalers, denies any wheezing.
h/O DVT:- right lower extremity after hip arthoplasty ___. Son
denies any PE.
H/o swelling of feet, diastolic dysfunction,
shingles,
HTN,
GERD,
R hip hemiarthroplasty
Osteoporosis.
No h/o strokes, heart attacks
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION PHYSICAL EXAM
Temp: 98.6 HR: 102 BP: 155/100 Resp: 16 O(2)Sat: 96
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic
Back: no cspine ttp
Chest: Clear to auscultation, no chest wall ttp
Cardiovascular: Regular Rate and Rhythm
Abdominal: Soft, Nontender
Extr/Back: + distal pulses ___
Skin: Warm and dry
Neuro: wiggles toes
Psych: awake and interactive
DISCHARGE PHYSICAL
T 98.4 HR 74 RR 18 96% RA ___
HEENT: normocephalic, atraumatic
CV: RRR no MRG normal S1 and S2
Lungs: CTAB, no wheezes, rales, rhonchi
Abdomen: soft, nontender to palpation, normal bowel sounds, no
organomegaly
Extremities: 2+ upper extremity pulses, 1+ lower extremity
pulses, symmetric
Skin: large ecchymoses on right lower extremity, dressing over
surgical wound, CDI
Neuro: alert and interactive, CN grossly intact
Pertinent Results:
ADMISSION LABS
___ 06:44PM TSH-0.54
___ 05:30PM URINE BLOOD-MOD NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-SM
___ 05:30PM URINE RBC-29* WBC-6* BACTERIA-NONE YEAST-NONE
EPI-<1
___ 07:55AM GLUCOSE-129* UREA N-25* CREAT-1.2* SODIUM-142
POTASSIUM-4.5 CHLORIDE-107 TOTAL CO2-23 ANION GAP-17
___ 07:55AM WBC-16.2* RBC-3.39* HGB-10.1* HCT-31.3*
MCV-92 MCH-29.9 MCHC-32.3 RDW-12.4
___ 07:55AM NEUTS-87.4* LYMPHS-8.0* MONOS-4.1 EOS-0.1
BASOS-0.4
___ 07:55AM PLT COUNT-193
___ 07:55AM ___ PTT-43.4* ___
CXR ___
AP radiograph of the chest was compared to ___
obtained at 04:33
a.m.
Heart size is normal. Substantial prominence of the ascending
aorta is
re-demonstrated as well as most likely dilated aortic arch.
Chronicity
undetermined. Lungs are essentially clear except for biapical
scarring. No appreciable pleural effusion or pneumothorax is
seen. Hiatal hernia present.
___ FEMUR (AP & LAT) LEFT IN O.R.
FINDINGS: Images from the operating suite show a fixation
device about
fracture of the distal femur. Further information can be
gathered from the
operative report.
___ CXR
No evidence of acute cardiopulmonary process. . Partially
imaged left shoulder demonstrates high riding left humerus and
Preliminary Reportpossible deformity of the left humeral
head/neck junction. ___ consider
Preliminary Reportdedicated left shoulder radiographs for
further evaluation, if clinically
Preliminary Reportindicated.
DISCHARGE LABS
___ 04:59AM BLOOD WBC-9.6 RBC-3.23*# Hgb-9.8*# Hct-28.4*
MCV-88 MCH-30.3 MCHC-34.4 RDW-15.3 Plt ___
___ 04:59AM BLOOD ___
___ 12:45PM BLOOD Ret Man-1.2
___ 04:59AM BLOOD Glucose-94 UreaN-27* Creat-1.1 Na-139
K-4.1 Cl-105 HCO3-27 AnGap-11
___ 04:59AM BLOOD Calcium-8.0* Phos-2.3* Mg-2.1
___ 06:15AM BLOOD LD(LDH)-228 TotBili-0.9
___ 06:15AM BLOOD Hapto-217*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Warfarin 3 mg PO DAILY16
3. Lisinopril 10 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Potassium Chloride 20 mEq PO DAILY
Hold for K >
6. Calcium Carbonate 500 mg PO TID
7. Vitamin D 800 UNIT PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. Warfarin 3 mg PO DAILY16
4. Acetaminophen 1000 mg PO TID
max dose 3g daily
5. Calcium Carbonate 500 mg PO TID
6. Vitamin D 800 UNIT PO DAILY
7. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
8. Docusate Sodium 100 mg PO BID
9. Enoxaparin Sodium 30 mg SC Q24H
use as bridge until INR therapeutic (2.0-3.0)
10. Multivitamins 1 TAB PO DAILY
11. OxycoDONE (Immediate Release) 2.5 mg PO TID:PRN Pain
12. Senna 2 TAB PO HS
13. Potassium Chloride 20 mEq PO DAILY
Hold for K >
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Femur Fracture
blood loss anemia
Discharge Condition:
Patient was alert and interactive. Out of bed with assistance.
With minimal pain adequately controled by PO medication.
Followup Instructions:
___
Radiology Report
REASON FOR EXAMINATION: Right femur fracture, pre-operative.
AP radiograph of the chest was compared to ___ obtained at 04:33
a.m.
Heart size is normal. Substantial prominence of the ascending aorta is
re-demonstrated as well as most likely dilated aortic arch. Chronicity
undetermined. Lungs are essentially clear except for biapical scarring. No
appreciable pleural effusion or pneumothorax is seen. Hiatal hernia present.
Radiology Report
HISTORY: ORIF.
FINDINGS: Images from the operating suite show a fixation device about
fracture of the distal femur. Further information can be gathered from the
operative report.
Radiology Report
INDICATION: Patient with recent fall and femur fracture status post ORIF, now
presents with fever and decreased breath sounds.
COMPARISONS: ___.
FINDINGS:
Frontal view of the chest demonstrates normal lung volumes. Lungs are
essentially clear. Biapical scarring is unchanged. There is minimal blunting
of the left costophrenic angle, suggestive of trace pleural effusion. There
is no appreciable right pleural effusion. No pneumothorax. Hilar and
mediastinal silhouettes are unchanged. Ascending aorta remains prominent.
Heart size is normal. There is no pulmonary edema. Left shoulder is
partially imaged. Left humerus appears high riding, which slight deformity of
the humeral head/neck junction.
IMPRESSION:
1. No evidence of acute cardiopulmonary process.
2. Partially imaged left shoulder demonstrates high riding left humerus and
possible deformity of the left humeral head/neck junction. ___ consider
dedicated left shoulder radiographs for further evaluation, if clinically
indicated.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: R FEMUR FX
Diagnosed with PERI-PROSTHETIC FRACTURE AROUND PROSTHETIC JOINT, ACCIDENT NOS, JOINT REPLACEMENT-HIP
temperature: 98.6
heartrate: 102.0
resprate: 16.0
o2sat: 96.0
sbp: 155.0
dbp: 100.0
level of pain: 0
level of acuity: 2.0 | ___ y/o female with past medical history of DVT on coumadin,
COPD, GERD, dementia, PNA who sufferred from a mechanical fall
at home and is s/p ORIF for a right femur fracture performed on
___.
ACUTE ISSUES
# Femur Fracture - Patient suffered from a mechanical fall on
___ and was transferred to ___ for surgery. Surgery was
postponed until ___ due to elevated INR while on coumadin.
Admission INR was 2.7. Patient received 5 U FFP with appropriate
normalization of her INR. Patient went to the operating suite on
___ for an ORIF of her right femural shaft which included
lateral plating with a 16 hole plate secured with cortical and
locking screws. There were no complications during the
procedure. Patient returned to the floor and was transferred to
the medicine service for management. Pain was adequately managed
with acetminophen 1 g PO TID scheduled, oxycodone 2.5mg po TID
PRN for post op pain, and Morphine ___ mg IV q4 hrs for
breakthrough pain. Ortho monitored the wound daily and felt the
wound was healing appropriately. ___ was consulted on ___.
Lovenox 30 mg subcutaneous daily was given to the patient for
DVT ppx. Patient to be discharge to rehab facility and will
followup with ortho as outpatient.
# Fever, Leukocytosis - Patient had fever and leukocytosis
post-op. Patient denied chills, diaphoresis, cough. Most likely
post-operative findings. Had CXR which was wnl. Increased
pulmonary toilet and pulmonary ___. Patient was not able to
adequately use the incentive spirometry. Patient was afebrile on
discharge. WBC 9.6.
# Dementia - Patient was at risk for delirium given history of
post-op delirium. Patient did not become delirious during
hospitalization. Pain was managed adequately. at risk for
delirium
# Post Op Pain - Pain adequately controlled with the above
regimen. Will continue the acetaminophen 1 g PO TID scheduled
and oxycodone 2.5 mg po TID prn pain. Will not continue morphine
as outpatient.
# DVT history on coumadin - Patient was therapeutic on warfarin
on admission. Required 5 units FFP to normalize INR. Coumadin
was discontinued prior to surgery. Received lovenox 30 mg daily
as prophylaxis. Warfarin was restarted on ___ at 3 mg. Warfarin
was d/c on ___ due to drop in Hct from 27 to 20. Warfarin
restarted on ___ at 3 mg daily with lovenox 30 mg daily bridge.
INR 1.7 at discharge.
# Anemia - Patient required 3 units PRBC on ___ for Hb 6.5. Hb
normalized following transfusion. Received 2 units on ___ for
Hct 20. Post-transfusion Hct 29. Anemia most likely related to
blood loss during surgery and poor bone marrow response. Patient
did not have any signs of overt bleeding. Hemolysis labs (LDH,
Bili, haptoglobin, retic) were wnl. Hb 9.8 and Hct 28.4 on
discharge.
# Oliguria - Urine output declined after surgery. Foley catheter
was in place for UOP monitoring. Received IVF and urine output
increased. Renal function wnl. UOP decreased yesterday. Received
mainteance IVF. F/c was d/c on ___. Required 1 straight cath
was PVR 430cc. Patient was able to void on own at discharge.
CHRONIC ISSUES
# COPD - Patient has a diagnosis of COPD based on imaging. No
smoking history. Received duonebs q8h for post-op wheezing.
Patient was encouraged to use incentive spirometer multiple
times a day. Supplemental O2 was d/c within 12 hours post-op.
Sats >96% RA at discharge.
# HTN - Blood pressure stable during hospitalization. Held home
lasix. Continued home lisinopril.
# Osteoporosis: Ca and vitamin D administered as inpatient.
Continue as outpatient. Recommend outpatient DEXA scan.
# Nutrition - patient was able to eat a regular diet. Ensure
supplementation was given.
TRANSITIONAL ISSUES
- please check daily INR until therapeutic (goal 2.0-3.0)
- please continue lovenox as bridge to therapeutic coumadin at
30mg subcutaneously daily
- please evaluate volume status daily and restart home lasix
dose (20mg daily) if patient develops signs of volume overload
(lower extremity edema, pulmonary rales) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetanus
Attending: ___.
Chief Complaint:
Apnea
Major Surgical or Invasive Procedure:
Exploratory laparoscopy, lysis of adhesions, partial hiatal
hernia reduction with plication to the left crus and
percutaneous gastrostomy tube, endoscopically guided ___
___
___ of Present Illness:
___ with PMH of hypothyroidism, HTN, bipolar disorder, and
breast ca with post-breast radiation BOOP and restrictive lung
disease who originally presented to the hospital about 2 weeks
ago for repair of a large paraesophageal hernia that was thought
to potentially be contributing to her increased WOB and choking,
particularly after eating. Had a lap fundo, gastropexy, and G
tube placed on ___ that was uncomplicated. However,
intermittently had episodes of hypoxia that led to BiPap
initiation and admission to the SICU before returning to the
floor. Had increasing WBC during her admission with a CT chest
revealing LLL and RUL consolidation that was initially covered
with vanc/cefepime before being changed to ceftaz per ID
recommendations. She subsequently was triggered on the floor for
desats requiring a brief period of NRB prompting transfer to the
SICU with request for MICU transfer. At the time of transfer,
patient had been changed to face tent with improvement of her
sats to 98% though with some reports of mild SOB still. Her
breathing was noted to improve after her TFs were clamped and
drained as well as with adequate pain control.
She subsequently triggered again for reports of desats with
patient placed briefly on a NRB before being weaned to 2L NC
before arrival to the ICU. Her stomach was mildly distended on
CXR and KUB. Patient was mildly somnolent but improved at time
of arrival to the ICU. She complained of mild SOB but no other
specific concerns. No other focal complaints at that time
including f/c/s/n/v or CP.
Past Medical History:
Hiatal Hernia
HTN
Restrictive lung disease
BOOP radiation-induced, followed by pulmonology
?TIA
Breast Cancer s/p bilateral mastectomy and XRT
GERD
Bipolar disorder
Papillary thyroid cancer s/p thyroidectomy (___)
Carotid stenosis
HLD
Social History:
___
Family History:
father died ___ CAD CHF
Mother died ___ thrombosis
1 brother DM sister a/w
widow with 6 children daughter with arrythmia
Mother, daughter and son with bipolar disorder
Physical Exam:
ADMISSION EXAM:
===============
VITAL SIGNS: 97.9 131/83 66 18 96RA
GENERAL: elderly woman, no acute distress
HEENT: moist mucosa, anicteric sclerae, PERRL.
CARDIAC: RRR, normal S1, S2, no audible murmurs or rubs
LUNGS: decreased at the bases bilaterally, otherwise CTA
ABDOMEN: soft, nontender, nondistended
EXTREMITIES: warm, nontender, no edema
NEURO: grossly intact and moving all extremities spontaneously,
AOx3, can say DOWB
PSYCH: somewhat flat affect
DISCHARGE EXAM:
===============
General: elderly woman, answering questions appropriately,
lethargic
Rest of physical exam deferred given CMO
Pertinent Results:
ADMISSION LABS:
===============
___ 04:14AM BLOOD WBC-12.8* RBC-3.76* Hgb-11.0* Hct-34.2
MCV-91 MCH-29.3 MCHC-32.2 RDW-13.2 RDWSD-44.2 Plt ___
___ 04:14AM BLOOD Neuts-73.6* Lymphs-11.5* Monos-9.0
Eos-4.3 Baso-0.9 Im ___ AbsNeut-9.41* AbsLymp-1.47
AbsMono-1.15* AbsEos-0.55* AbsBaso-0.11*
___ 04:14AM BLOOD Glucose-124* UreaN-20 Creat-0.8 Na-140
K-4.3 Cl-104 HCO3-24 AnGap-16
___ 05:10AM BLOOD ALT-11 AST-17 LD(LDH)-260* CK(CPK)-19*
AlkPhos-143* TotBili-0.2
MICRO:
======
ALL BLOOD AND URINE CX'S NEGATIVE THROUGHOUT ADMISSION
CDIFF NEGATIVE ___
MRSA SCREEN NEGATIVE ___
RELEVANT IMAGING/STUDIES:
=========================
___ TTE:
IMPRESSION: Small pericardial effusion without echocardiographic
signs of tamponade. Normal biventricular cavity sizes with
preserved regional and global biventricular systolic function.
Mild mitral valve prolapse with mild mitral regurgitation. Mild
pulmonary artery systolic hypertension.
___ CTA chest, CT abdomen:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Consolidation in the right suprahilar region, new since the
prior study, may represent an infectious process.
Consolidation in the left lower lobe may represent a
combination of infectious process and volume loss.
3. The left-sided pleural effusion is increased compared to the
prior study.
The right-sided pleural effusion is new compared to the prior
study.
4. There has been interval placement of a gastrostomy tube.
Large right-sided hiatal hernia persists.
5. Subcutaneous emphysema extending from the axillae down to the
groin
bilaterally and a small amount of pneumoperitoneum are new since
the prior
study, likely postsurgical.
6. Moderate pericardial effusion is again seen, unchanged
compared to the
prior study.
7. Left-sided inguinal hernia contains a nonobstructed loop of
large bowel.
8. A 2.3 cm left renal cyst is mildly hyperattenuating and may
represent a
proteinaceous/hemorrhagic cyst, unchanged since ___.
9. Severe T12 compression deformity is unchanged compared to ___.
___ CXR:
1. Worsening distension, intrathoracic, herniated stomach.
2. No new focal consolidation concerning for pneumonia.
3. Stable left lower lobe collapse with associated small left
pleural
effusion.
4. Minimally improved right perihilar opacities, likely
reflecting
atelectasis.
___ ECHO:
Regional left ventricular wall motion is normal. Overall left
ventricular systolic function is normal (LVEF>55%). with normal
free wall contractility. There is a small pericardial effusion
measuring up to 0.8 cm in greatest dimension, with preferential
fluid deposition inferolateral to the left ventricle. The
effusion is echo dense, consistent with blood, inflammation or
other cellular elements. There are no echocardiographic signs of
tamponade. IMPRESSION: Small pericardial effusion without
echocardiographic evidence of tamponade. Preserved biventricular
systolic function. Left pleural effusion. Compared with the
prior study (images reviewed) of ___, the findings are
simliar.
___ KUB:
G-tube projects over a portion of the stomach and may be
intraluminal however there is no second view to confirm this.
Opacification of the left lung base may represent atelectasis or
developing pneumonia. Elevation of the right hemidiaphragm with
a markedly distended stomach, similar in appearance to ___. Recommend clinical correlation.
___ CXR:
Large air-filled structure in the right lower chest consistent
with a large hiatal hernia. Mediastinal shift to the left side
with associated left basilar atelectasis. Right lung
atelectasis is also noted adjacent to the large hiatal hernia.
Superadded infection cannot be excluded. Findings are without
change from 1 day earlier.
___ CT A/P W/ CONTRAST
1. No acute intra-abdominal pathology.
2. Other unchanged findings as above, including a large hiatal
hernia and
gastrostomy tube in place, stable 0.6 cm probable IPMN in the
pancreatic tail, and severe chronic fracture deformity of the
T12 vertebral body.
___ CT CHEST W/ CONTRAST
Volume of distended stomach traversing the hiatus hernia into
the right lower paramedian chest has decreased.
Previous right upper lobe pneumonia has resolved.
New alveolar opacification superior segment left lower lobe
could be recent aspiration or early pneumonia.
Substantial bibasilar atelectasis unchanged.
___ CT A/P W/ CONTRAST
1. Small amount of free intraperitoneal air, fluid, and a
locule of air in the left rectus muscle, adjacent to the GJ
tube, is likely related to recent tube exchange.
2. New left inguinal hernia containing loops of nondilated
sigmoid colon. No evidence of surrounding inflammatory change,
wall thickening, or obstruction.
3. Persistent bilateral nonhemorrhagic pleural effusions, trace
on the right and small on the left. These have slightly
decreased since the prior study.
4. Persistent large hiatal hernia containing the gastric fundus
and body.
DISCHARGE LABS
==============
no discharge labs given CMO
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN sob, wheeze, cough spell
2. amLODIPine 5 mg PO DAILY
3. FLUoxetine 40 mg PO DAILY
4. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
5. Levothyroxine Sodium 100 mcg PO 6X/WEEK (___)
6. Levothyroxine Sodium 50 mcg PO 1X/WEEK (___)
7. Lithium Carbonate SR (Lithobid) 300 mg PO QHS
8. OLANZapine 5 mg PO DAILY
9. Omeprazole 20 mg PO BID
10. Oxybutynin 5 mg PO QAM
11. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
12. Calcium Carbonate 500 mg PO DAILY
13. Os-Cal 500 + D3 (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral DAILY
14. Loratadine 10 mg PO DAILY:PRN allergies
15. Multivitamins 1 TAB PO DAILY
16. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PR QHS:PRN constipation
3. Docusate Sodium 100 mg PO BID
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H:PRN wheezing
5. Lithium Oral Solution 150 mg PO BID
6. Morphine Sulfate (Oral Solution) 2 mg/mL 2.5 mg PO Q6H:PRN
pain or dyspnea
RX *morphine 10 mg/5 mL 2.5 mg by mouth every 4 hours Disp #*45
Milliliter Milliliter Refills:*0
7. Pantoprazole (Granules for ___ ___ 40 mg PO DAILY
8. Polyethylene Glycol 17 g PO DAILY
9. Senna 8.6 mg PO BID
10. Simethicone 40 mg PO TID:PRN distension
11. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
12. amLODIPine 5 mg PO DAILY
13. Calcium Carbonate 500 mg PO DAILY
14. FLUoxetine 40 mg PO DAILY
15. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
16. Levothyroxine Sodium 100 mcg PO 6X/WEEK (___)
17. Levothyroxine Sodium 50 mcg PO 1X/WEEK (___)
18. Loratadine 10 mg PO DAILY:PRN allergies
19. OLANZapine 5 mg PO DAILY
20. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS
=================
- Paraesophageal hernia
- Recurrent aspiration pneumonia c/b hypoxic respiratory failure
- Severe Malnutrition
SECONDARY DIAGNOSIS
===================
- Right breast cancer s/p lumpectomy, XRT, arimidex
- Radiation pneumonitis/BOOP
- Bipolar disorder
- Hypertension
- Hypothyroidism
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PRE-OP PA AND LAT)
INDICATION: ___ year old woman with large paraesophageal hernia, pleural
effusion, and increasing leukocytosis // r/o consolidation, atelectasis,
increasing pleural effusion Surg: ___ (Lap Hiatal Hernia Repair)
TECHNIQUE: AP upright and lateral views of the chest provided.
COMPARISON: Chest radiographs dated ___.
CT chest with contrast dated ___.
FINDINGS:
Compared to chest radiographs from ___, mild left and minimal
right pleural effusions are unchanged. No pulmonary edema. No focal
consolidation. No pneumothorax. Heart size is difficult to assess the
presence of effusion, though likely top normal and unchanged. Substantial
paraesophageal hernia with rightward displacement of the gastric bubble.
IMPRESSION:
1. Stable moderate left and small right pleural effusions.
2. Stable top-normal heart size.
3. Substantial paraesophageal hernia.
Radiology Report
INDICATION: ___ year old woman with known large hiatal hernia and pleural
effusions, now s/p lap plication of stomach and PEG // r/o ptx, htx
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___ from earlier in the day
FINDINGS:
There has been interval development of extensive subcutaneous gas over the
chest wall. An incompletely evaluated PEG projects over the left upper
quadrant.
Gas within a presumed hiatal hernia projects over the medial right lower
hemithorax. There is a persistent retrocardiac opacity likely reflective of
pleural fluid and atelectasis. No pneumothorax identified.
IMPRESSION:
No discrete pneumothorax identified. Small bilateral pleural effusions,
greater on the left.
Gas within a presumed hiatal hernia projects over the medial right lower
hemithorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman POD1 from lap fundoplication and
gastropexy/g-tube placement w/ new onset SOB, cough // ?PNA, ?Effusion
TECHNIQUE: Chest single view
COMPARISON: ___ chest radiograph, CT chest ___
FINDINGS:
Significant interval improvement in chest wall emphysema. Moderate gastric
distention is new. G-tube in place. Very shallow inspiration. Left basilar
consolidation is similar compared to ___, likely atelectasis, with
adjacent pleural effusion, similar. Consider pneumonia if clinically
appropriate. Mild right basilar atelectasis. No pneumothorax. Arterial
calcifications.
IMPRESSION:
Moderate gastric distention. Stable left basilar consolidation with adjacent
pleural fluid, likely atelectasis, consider pneumonia if clinically
appropriate.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p lap fundoplication, gastropexy, with
increasing work of breathing // ? infection, ? effusion
TECHNIQUE: Chest single view
COMPARISON: ___
FINDINGS:
Significant gastric distention, has worsened since prior. Left basilar
consolidation is similar, likely atelectasis, consider pneumonia if clinically
appropriate. Probable small left pleural effusion, similar. Stable mild
right basilar atelectasis. Chest wall emphysema has mildly improved.
Biapical scarring. No pneumothorax.
IMPRESSION:
Significant gastric distention, worsened since prior
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
volvulus of intrathoracic stomach. No mention in your report (my edit to
Impr). ___ d/w ___ and document.
INDICATION: ___ year old woman with tachypnea // interval change
TECHNIQUE: Single frontal view of the chest.
COMPARISON: Chest radiographs from ___ to ___.
FINDINGS:
Compared to chest radiographs from ___, left lower lobe collapse
and right basilar atelectasis have worsened. Lung volumes remain low. Small
left pleural effusion is unchanged. No large effusion on the right.
Significant gastric distention has worsened since ___, though
minimally changed from ___. Bilateral chest wall subcutaneous
emphysema continues to improve. Biapical scarring is chronic. Heart size,
while difficult to assess in the setting of effusion and atelectasis, is
likely mildly enlarged, unchanged.
IMPRESSION:
1. Worsening left lower lobe collapse and right basilar atelectasis.
2. Persistent small left pleural effusion.
3. Worsening gastric distention since ___, though minimally changed
from ___, raises concern for gastric outlet obstruction or volvulus or
incarceration of the intrathoracic stomach.
4. Stable mild cardiomegaly.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 9:28 AM, 3 minutes after
discovery of findings.
Radiology Report
EXAMINATION:
CTA chest
INDICATION: ___ year old woman with tachypnea - please include abdomen // ?PE
- please include abdomen
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) Stationary Acquisition 2.0 s, 0.5 cm; CTDIvol = 6.1 mGy (Body) DLP = 3.0
mGy-cm.
2) Spiral Acquisition 3.0 s, 23.1 cm; CTDIvol = 7.2 mGy (Body) DLP = 165.6
mGy-cm.
3) Spiral Acquisition 5.2 s, 56.5 cm; CTDIvol = 8.6 mGy (Body) DLP = 482.7
mGy-cm.
Total DLP (Body) = 651 mGy-cm.
COMPARISON: CT abdomen and pelvis ___.
Chest CT ___.
IMPRESSION:
CHEST:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus.
The ascending aorta is mildly aneurysmal measuring up to 3.5 cm. The main
pulmonary artery is prominent consistent with pulmonary artery hypertension.
Thoracic aorta is without evidence of dissection or intramural hematoma.
Moderate pericardial effusion is again seen, unchanged compared to the prior
study.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: The left-sided pleural effusion is increased compared to the
prior study in the right-sided pleural effusion is new compared to the prior
study. There is no pneumothorax.
LUNGS/AIRWAYS: Mild biapical scarring is unchanged compared to the prior
study. Consolidation in the right suprahilar region is new since the prior
study and may represent an infectious process. Consolidation in the left
lower lobe may represent infectious process and volume loss, more prominent
compared to the prior study. There is mild right basilar compressive
atelectasis. Minimal secretions are noted in the right mainstem bronchus.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is 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 adrenal gland is normal in size and shape. There is mild
thickening of the left adrenal gland without evidence of nodularity.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
A 2.3 cm left renal cyst is slightly hyperattenuating and may represent a
proteinaceous/hemorrhagic cyst. Subcentimeter hypodensities in the right
kidney are too small to characterize, likely simple cyst. There is no evidence
of focal renal lesions or hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The esophagus is dilated. A large right-sided hiatal hernia
containing the entire stomach with air-fluid level is present. A gastrostomy
tube is new since the prior study. Small bowel loops demonstrate normal
caliber, wall thickness, and enhancement throughout. Diverticulosis of the
sigmoid colon is noted, without evidence of wall thickening and fat stranding.
The appendix is not visualized. A small amount of pneumoperitoneum is new
since the prior study, likely postsurgical.
PELVIS: The urinary bladder contains air which may be secondary to
instrumentation. There is no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is not visualized.
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 AND SOFT TISSUES: Severe T12 compression deformity is unchanged compared
to ___. There is subcutaneous emphysema bilaterally, new since the
prior study, extending from the axillae down to the groin. A left-sided
inguinal hernia containing a loop of large bowel is noted.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Consolidation in the right suprahilar region, new since the prior study,
may represent an infectious process. Consolidation in the left lower lobe may
represent a combination of infectious process and volume loss.
3. The left-sided pleural effusion is increased compared to the prior study.
The right-sided pleural effusion is new compared to the prior study.
4. There has been interval placement of a gastrostomy tube. Large right-sided
hiatal hernia persists.
5. Subcutaneous emphysema extending from the axillae down to the groin
bilaterally and a small amount of pneumoperitoneum are new since the prior
study, likely postsurgical.
6. Moderate pericardial effusion is again seen, unchanged compared to the
prior study.
7. Left-sided inguinal hernia contains a nonobstructed loop of large bowel.
8. A 2.3 cm left renal cyst is mildly hyperattenuating and may represent a
proteinaceous/hemorrhagic cyst, unchanged since ___.
9. Severe T12 compression deformity is unchanged compared to ___.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p gastropexy, some concern for aspiration
previously // Interval change Interval change
IMPRESSION:
Comparison to ___. Minimally increased lung volumes with stable
perihilar opacity on the right and status post gastropexy. The presence of a
small left pleural effusion cannot be excluded. Bilateral apical thickening.
No other interval changes.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p gastropexy, some concern for aspiration
previously, now with increased oxygen requirement // interval change
interval change
IMPRESSION:
In comparison with the study of ___, there again are extremely low
lung volumes with little overall change in the appearance of the heart and
lungs in this patient with previous gastropexy. Apical pleural thickening
again is seen bilaterally.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with pneumonia now hypoxic // hypoxia, patient
has known pneumonia
TECHNIQUE: Single frontal view of the chest.
COMPARISON: Chest radiographs from ___ to ___.
FINDINGS:
Compared to chest radiographs from ___, lung volumes remain low and
left lower lobe collapse with associated small left pleural effusion persist.
Right perihilar opacities are minimally improved. No new focal consolidation
concerning for pneumonia. Bilateral apical pleural thickening. Severe
distention of the intrathoracic stomach continues to worsen, compared to ___. Heart size, while difficult to assess in the setting of lower
lobe collapse, is likely unchanged.
IMPRESSION:
1. Worsening distension, intrathoracic, herniated stomach.
2. No new focal consolidation concerning for pneumonia.
3. Stable left lower lobe collapse with associated small left pleural
effusion.
4. Minimally improved right perihilar opacities, likely reflecting
atelectasis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with SOB // Eval for interval change Eval
for interval change
IMPRESSION:
Elevation of right hemidiaphragm is unchanged including the gas-filled bowel
in the right upper quadrant. Left retrocardiac atelectasis is unchanged.
Interstitial lung disease is unchanged. No new abnormalities within the lungs
demonstrated.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with PMH of hypothyroidism, HTN, bipolar disorder, and breast
ca with post-breast radiation BOOP and restrictive lung disease who originally
presented to the hospital about 2 weeks ago for repair of a large
paraesophageal hernia, transferred to MICU for SOB/hypoxia. // ? new
intrapulmonary process, aspiration, new effusion
FINDINGS:
Elevated right hemidiaphragm with distended stomach just below 8. Anatomy
years better defined on the CT scan of ___. There is mediastinal
shift to the left side. Increased lung markings bilaterally representing a
combination the known interstitial lung disease and possibly fluid overload/
stir mild CHF. Presumably there is also volume loss in the left lower lobe.
IMPRESSION:
No change from CXR done at 04:33 on ___
Radiology Report
INDICATION: ___ with PMH of hypothyroidism, HTN, bipolar disorder, and breast
ca with post-breast radiation BOOP and restrictive lung disease who originally
presented to the hospital about 2 weeks ago for repair of a large
paraesophageal hernia, transferred to MICU for SOB/hypoxia. // ? distended
bowel loops given new distension, positioning of G/J-tube
TECHNIQUE: Portable supine view the abdomen
COMPARISON: Chest x-ray from ___, CT from ___
FINDINGS:
Multiple loops of large bowel, small bowel, and the stomach are distended with
air, this may represent an ileus. A G-tube projects over a portion of the
stomach and may be intraluminal, however there is no lateral view to confirm
this.
Patient is rotated to the left with opacification at the left lung base, this
may be atelectasis or a developing pneumonia. Recommend correlation with same
day chest radiographs
Elevation of the right hemidiaphragm with a markedly distended stomach in the
right upper quadrant, similar when compared to ___
IMPRESSION:
G-tube projects over a portion of the stomach and may be intraluminal however
there is no second view to confirm this.
Opacification of the left lung base may represent atelectasis or developing
pneumonia
Elevation of the right hemidiaphragm with a markedly distended stomach,
similar in appearance to ___. Recommend clinical correlation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with estrictive lung disease who originally
presented to the hospital about 2 weeks ago for repair of a large
paraesophageal hernia, with ongoing tachypnea // ?new consolidation, change
in hernia
FINDINGS:
Large air-filled structure in the right lower chest consistent with a large
hiatal hernia. Mediastinal shift to the left side with associated left
basilar atelectasis. Right lung atelectasis is also noted adjacent to the
large hiatal hernia. Superadded infection cannot be excluded. Findings are
without change from 1 day earlier.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with aspiration, increased tachypnea // eval
for tachypnea, interval change eval for tachypnea, interval change
IMPRESSION:
In comparison with the study of ___, there again is a huge air-filled
structure in the right lower chest consistent with a large hiatal hernia with
shift of the mediastinum to the left and associated atelectatic changes at
both bases. Again there are extremely low lung volumes.
In view of the extensive changes, it would be extremely difficult in the
appropriate clinical setting to exclude a superimposed pneumonia, especially
in the absence of a lateral view.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with large hiatal hernia and restrictive lung
disease with leukocytosis . // ?PNA ?PNA
IMPRESSION:
Compared to chest radiographs ___ through ___.
Left lower lobe collapse and small left pleural effusion are unchanged,
responsible for severe leftward mediastinal shift. Moderate distension of the
herniated stomach has improved. Right lung clear. Heart severely shifted to
the left by the combination of gastric herniation and left lower lobe collapse
is probably not enlarged. No pneumothorax. Right pleural effusion small if
any.
Radiology Report
EXAMINATION: CT abdomen/pelvis
INDICATION: ___ year old woman with restrictive lung disease, large
paraesophageal hernia ballooning into lung, PEG in place, and recurrent
aspiration with increasing leukocytosis. // ?PNA
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 6.0 s, 0.5 cm; CTDIvol = 28.9 mGy (Body) DLP =
14.4 mGy-cm.
2) Spiral Acquisition 6.2 s, 67.9 cm; CTDIvol = 8.1 mGy (Body) DLP = 552.1
mGy-cm.
Total DLP (Body) = 567 mGy-cm.
COMPARISON: CT of the chest, abdomen and pelvis from ___
FINDINGS:
LOWER CHEST: Please refer to dedicated CT of the chest performed the same day
for intrathoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver is homogeneous in attenuation. A tiny subcapsular
hypodensity in segment 7 (series 601b, image 35), is too small to characterize
but stable since at least ___ and therefore benign. The gallbladder
is within normal limits. There is no intra- or extrahepatic biliary ductal
dilatation.
PANCREAS: There is diffuse fatty atrophy of the pancreas. There is a 0.6 cm
hypodensity in the pancreatic tail, stable since at least ___ and
likely representing a side-branch IPMN. There is no main pancreatic ductal
dilatation.
SPLEEN: The spleen is normal in size and homogeneous in attenuation. There is
a calcified granuloma centrally within the spleen.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are symmetric in size and demonstrate normal bilateral
nephrograms. There is a dominant 2.6 x 2.2 cm cyst in the upper pole of the
left kidney. A 0.6 x 0.4 cm hypodensity in the upper pole of the right kidney
measures higher than of fluid attenuation ___ 57) and is too small to
definitively characterize, but likely represents a hemorrhagic or
proteinaceous cyst. There is no hydronephrosis. Note is made of a small
right extrarenal pelvis. There is no perinephric abnormality.
GASTROINTESTINAL: A gastrostomy tube is in place. Again seen is a large
hiatal hernia containing the gastric fundus and body. Small bowel loops are
normal in caliber. There are scattered colonic diverticula. The rectum is
within normal limits.
PERITONEUM: Previously seen pneumoperitoneum has resolved.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is surgically absent. There is no adnexal
mass.
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. The major mesenteric branch vessels are patent.
BONES: Again seen is a severe chronic fracture deformity of the T12 vertebral
body. There is mild lumbar levoscoliosis and multilevel spinal degenerative
changes. There also degenerative changes of the bilateral sacroiliac joints,
hips and pubic symphysis.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No acute intra-abdominal pathology.
2. Other unchanged findings as above, including a large hiatal hernia and
gastrostomy tube in place, stable 0.6 cm probable IPMN in the pancreatic tail,
and severe chronic fracture deformity of the T12 vertebral body.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ woman with restrictive lung disease and large
paraesophageal hernia. Recurrent aspiration. Increasing leukocytosis.
TECHNIQUE: Multi-detector helical scanning of the chest, coordinated with
intravenous infusion of nonionic, iodinated contrast agent, following oral
administration of contrast agent for selected abdominal studies, was
reconstructed as contiguous 5 mm and 1.0 or 1.25 mm thick axial, 2.5 or 5 mm
thick coronal and parasagittal, and 8 mm MIP axial images. Concurrent scanning
of the abdomen and pelvis and/or neck will be reported separately. All images
of the chest were reviewed. .
DOSE: Acquisition sequence:
1) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 28.9 mGy (Body) DLP =
14.4 mGy-cm.
2) Spiral Acquisition 6.2 s, 67.9 cm; CTDIvol = 8.1 mGy (Body) DLP = 552.1
mGy-cm.
Total DLP (Body) = 567 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: Compared to chest CT ___.
FINDINGS:
Supraclavicular and axillary lymph nodes are not enlarged. Specifically
excluding the breasts which require mammography for evaluation there are no
soft tissue abnormalities in the chest wall suspicious for malignancy.
Atherosclerotic calcification is not apparent in head and neck View vessels
but is present in the left anterior descending coronary artery. The aorta is
normal size. Pulmonary artery dilatation, main 34 mm, is unchanged. Once
again the esophagus is severely distended to the level of the carina. The
very large intrathoracic stomach, traversing the esophageal hiatus to the
right of the midline is smaller today than it was on ___.
Lungs:
Linear scarring at the lung apices, right greater than left, is unchanged.
Previous consolidation posterior segment right upper lobe has improved.
Bibasilar has atelectasis, left greater than right, is unchanged. There is
new ground-glass opacification in the superior segment left lower lobe that
could be recent aspiration, or alternatively atelectasis. Left upper lobe is
largely clear.
Severe compression of the T12 thoracic vertebra with minimal retropulsion is
new since ___, but stable since ___.
IMPRESSION:
Volume of distended stomach traversing the hiatus hernia into the right lower
paramedian chest has decreased.
Previous right upper lobe pneumonia has resolved.
New alveolar opacification superior segment left lower lobe could be recent
aspiration or early pneumonia.
Substantial bibasilar atelectasis unchanged.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with PICC // Pt had a R PICC,42cm ___ ___
Contact name: ___: ___ Pt had a R PICC,42cm ___ ___
IMPRESSION:
Compared to chest radiographs ___ through ___.
Previous left basal atelectasis and perihilar edema have both improved, still
accompanied by small left pleural effusion. There is no longer any pulmonary
edema. No pneumothorax. Moderate cardiomegaly stable. Moderate distension
of the intrathoracic stomach has improved a great deal over the past several
days.
Right subclavian central venous catheter ends in the low SVC.
Radiology Report
INDICATION: ___ year old woman with large paraesophageal hernia, restrictive
lung disease and recurrent aspirations. PEG placed by ACS during gastropexy on
___ (___). // Advancement of G tube to GJ. *Please do not take pt until
___ per gen surg, to allow epithelialization of tract*
COMPARISON: CT OF THE ABDOMEN DATED ___
TECHNIQUE: OPERATORS: Dr. ___ and Dr.
___ and ___, attending radiologists, 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: Analgesia was performed by administrating divided doses of 100
mcg of fentanyl throughout the total intra-service time of 45 minutes during
which the patient's hemodynamic parameters were continuously monitored by an
independent trained radiology nurse. 1% lidocaine was injected in the skin and
subcutaneous tissues overlying the access site.
MEDICATIONS: 1% lidocaine
CONTRAST: 10 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 16.1 min, 45 mGy
PROCEDURE: 1. Exchange of a PEG tube for a MIC gastrojejunostomy tube.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient's 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 tube site was prepped and draped in the usual sterile
fashion.
Scout image demonstrated the PEG tube to overlie the stomach. Contrast
administration outlined the gastric rugae. the existing gastrostomy tube was
used to partially insufflate the stomach. 2 T-fasteners were placed in the
stomach and used to further bolster the existing gastropexy. A 0.035 stiff
glide wire and 5 ___ Kumpe the catheter were used to negotiate the wire
into the small bowel. The catheter was removed over the wire. Using gentle
traction, the existing gastrostomy tube was removed over the wire. A 22
___ peel-away sheath was advanced over the wire into the duodenum. Over
the wire and through the peel-away sheath, an 18 ___ MIC gastrojejunostomy
tube was advanced over the wire into position under fluoroscopy. The
peel-away sheath was removed and the balloon was inflated under fluoroscopic
visualization and brought back against the anterior wall of the stomach.
Contrast was administered through the gastrostomy and jejunostomy lumens to
confirm appropriate positioning. Both lumens were flushed and a tube was
capped. Sterile dressings were applied after the tube was secured. The
patient tolerated the procedure well without any immediate complications.
FINDINGS:
1. Successful conversion of existing PEG tube for an 18 ___ MIC
gastrojejunostomy tube.
IMPRESSION:
Successful placement of a 18 ___ MIC gastrojejunostomy tube with its tip in
the jejunum. The gastric port should not be used for 24 hours.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with hx of hypoxic respiratory failure s/p
procedure for G-tube replacement today and increasing tachypnea. // please
eval for volume load/PNA
TECHNIQUE: Chest single view
COMPARISON: ___ interval increase in gastric distension with
largely intrathoracic stomach within large hernia. Stable left basilar
consolidation, likely atelectasis. Stable small pleural effusions, more
prominent on the left. Stable heart size. Pulmonary vascular congestion and
mild pulmonary edema has worsened. No pneumothorax. Right PICC line.
FINDINGS:
Increased vascular congestion and mild pulmonary edema. Worsened gastric
distension.
Radiology Report
INDICATION: ___ year old woman with hiatal hernia w/ increasing abd distension
and increase in WBC to 24 // assess for SBO
TECHNIQUE: Supine and left lateral decubitus abdominal radiographs were
obtained.
COMPARISON: Abdomen radiograph dated ___.
FINDINGS:
Multiple air-filled non-dilated bowel loops are seen in the lower abdomen.
Contrast in the large bowel is consistent with recent history of percutaneous
gastrojejunostomy tube placement which is in appropriate position.
Significantly dilated stomach is unchanged since ___.
There is no free intraperitoneal air.
Osseous structures are notable for degenerative disease of the lumbar spine.
IMPRESSION:
No radiographic evidence of obstruction.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old woman with PMH of hypothyroidism, HTN, bipolar
disorder, and breast ca with post-breast radiation BOOP and restrictive lung
disease, paraesogheal hernia w/ new onset abdominal pain and hemolysis.
Evaluate for obstructive or acute abdominal process contributing to LLQ pain
and distension.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 415 mGy-cm.
COMPARISON: CT abdomen and pelvis of ___ and ___.
FINDINGS:
LOWER CHEST: Re- demonstration of bilateral nonhemorrhagic pleural effusions,
trace on the right and small on the left, decreased since the prior study.
There is adjacent compressive atelectasis, and a large hiatal hernia
containing the gastric fundus and body.
ABDOMEN:
HEPATOBILIARY: Millimetric hypodensity in segment VII is unchanged and E small
to characterize by CT. No new focal hepatic lesion since the prior study.
There is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within normal limits.
PANCREAS: Diffuse fatty atrophy of the pancreas is unchanged. A 0.5 cm
hypodensity in the pancreatic tail is unchanged since ___. There is
no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
A 2.3 cm simple cyst in the upper pole of the left kidney is unchanged. Right
renal hypodensity is subcentimeter in size and too small to characterize by
CT, but also likely a cyst (2:41). There is a small right extrarenal pelvis.
No evidence of hydronephrosis or perinephric abnormality.
GASTROINTESTINAL: The gastrojejunal tube is appropriately placed with a small
amount of adjacent free intraperitoneal air, fluid, and air in the left rectus
muscle (2:35, 36), likely related to recent G-tube exchange. Small bowel
loops demonstrate normal caliber, wall thickness, and enhancement throughout.
Diverticulosis of the sigmoid colon is noted, without evidence of wall
thickening and fat stranding.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is surgically absent.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate to severe
atherosclerotic disease is noted.
BONES: Severe compression deformity of the T12 vertebral body is unchanged.
There is mild lumbar levoscoliosis and multilevel degenerative changes, most
pronounced at L4-L5.
SOFT TISSUES: Except for postprocedural changes in the region of the
gastrojejunostomy tube, the abdominal and pelvic soft tissues are
unremarkable.
IMPRESSION:
1. Small amount of free intraperitoneal air, fluid, and a locule of air in
the left rectus muscle, adjacent to the GJ tube, is likely related to recent
tube exchange.
2. New left inguinal hernia containing loops of nondilated sigmoid colon. No
evidence of surrounding inflammatory change, wall thickening, or obstruction.
3. Persistent bilateral nonhemorrhagic pleural effusions, trace on the right
and small on the left. These have slightly decreased since the prior study.
4. Persistent large hiatal hernia containing the gastric fundus and body.
Radiology Report
INDICATION: ___ year old woman with hiatal hernia s/p repair, L inguinal
hernia, who continues to have severe abdominal pain of unknown etiology //
please also get one upright, assess for obstruction
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: Abdominal radiograph dated ___.
FINDINGS:
Distended stomach is similar to ___. Bowel gas is seen
throughout the small and large bowels. Portions of small bowel in the mid
abdomen appear to be mildly dilated. Large bowel has normal caliber.
Contrast material is seen in the colon consistent with recent abdominal CT
dated ___.
There is no free intraperitoneal air.
Osseous structures are notable for degenerative disease of the thoracolumbar
spine.
The gastrojejunostomy tube is in unchanged position compared ___.
IMPRESSION:
1. No pneumoperitoneum.
2. Mildly dilated small bowel could represent ileus.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with known BOOP, large hiatal hernia, s/p
partial repair, worsening tachypnea and O2 requirement // cause of worsening
hypoxemia cause of worsening hypoxemia
IMPRESSION:
Compared to chest radiographs ___ through ___.
Moderate to severe distention of the right paramedian portion of the
intrathoracic stomach is unchanged, still displacing the right lower lung.
However leftward mediastinal shift an with a complete collapse of the left
lower lobe have worsened. Upper lungs are grossly clear. No pneumothorax.
Small left pleural effusion is likely.
Right PIC line ends in the mid SVC.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with PMH of hypothyroidism, HTN, bipolar disorder, and breast
ca with post-breast radiation BOOP and restrictive lung disease who originally
presented to the hospital 2 weeks ago for repair of a large paraesophageal
hernia, now s/p MICU course stable on 2L NC after tx of PNA, now s/p GJ tube
modification ___, but having continuing abd pain, worsening tachypnea
evening ___ into ___ // r/o worsening hernia and/or lung compression r/o
worsening hernia and/or lung compression
IMPRESSION:
Compared to chest radiographs ___ through ___.
Severe gaseous distention of the right paramedian intrathoracic stomach is
more pronounced, nearly as large as it was on ___, and further
compromising the volume of the small right lung. Left lower lobe still
collapsed. Left pleural effusion is small. Heart size is indeterminate, but
probably not large.
Right PIC line ends in the low SVC. No pneumothorax.
Radiology Report
INDICATION: ___ with PMH of hypothyroidism, HTN, bipolar disorder, and breast
ca with post-breast radiation BOOP and restrictive lung disease who originally
presented to the hospital 2 weeks ago for repair of a large paraesophageal
hernia, now s/p MICU course stable on 2L NC after tx of PNA, now s/p GJ tube
modification ___, but having continuing abd pain. // r/o obstruction, cause
for acute abdomen (have patient as upright as possible)
TECHNIQUE: Portable supine and upright abdominal radiographs were obtained.
COMPARISON: Abdominal radiograph since ___.
FINDINGS:
The distended stomach is grossly unchanged compared to ___. The
air-filled large and small bowel loops contain contrast material from prior CT
abdomen and pelvis without abnormal dilatation.
There is no free intraperitoneal air.
Osseous structures are notable for degenerative disease of the lumbar spine.
The gastrojejunostomy tube is in unchanged position.
IMPRESSION:
1. Normal bowel gas pattern.
2. No pneumoperitoneum.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Upper abdominal pain, Transfer
Diagnosed with Upper abdominal pain, unspecified
temperature: 97.5
heartrate: 98.0
resprate: 15.0
o2sat: 96.0
sbp: 98.0
dbp: 63.0
level of pain: 0
level of acuity: 3.0 | ___ with PMH of hypothyroidism, HTN, bipolar disorder, and
breast ca with post-breast radiation BOOP and restrictive lung
disease who originally presented to the hospital for repair of a
large paraesophageal hernia, s/p MICU course after tx of PNA,
now s/p modified post-pyloric feeding tube but w/ worsening
abdominal pain and respiratory status despite all interventions.
SURGICAL COURSE
===============
Ms. ___ presented to ___ after an episode of apnea
in the setting of known large paraesophageal hernia with
previous episodes of apnea and planned repair on ___ ___. At ___, she had a CT chest which showed the hiatal
hernia, pleural effusions, and moderate pericardial effusion.
Her apnea resolved spontaneously, without intervention but
previous episodes she has required CPAP. She was transferred to
___ on ___ for interval management and operative
planning.
Medicine was consulted for risk stratification and medical
optimization in light of comorbidities and new pericardial
effusion. She was assigned intermediate risk of <5% for cardiac
complications, but surgery was not contraindicated. A TTE was
performed ___ that found mild mitral valve prolapse, mitral
regurgitation, and mild pulmonary artery systolic hypertension
with a small pericardial effusion and no signs of tamponade
physiology, please see report for further details.
Cardiology was consulted for pericardial effusion, and after
completion of TTE and evaluation of EKGs, recommendations were
made to discharge with ___ of Hearts monitor for one month
for a possible atrial fibrillation versus sinus rhythm with
multiple PACs on an EKG from ___. Also recommended was a one
month follow up TTE to evaluate for expected effusion
resolution, breast cancer follow up and monitoring, TSH
evaluation, and followup with cardiology in 2 months. There was
concern for possible malignant effusion.
In addition to consulting cardiology and medicine, she was
continued to be monitored on telemetry and continuous oxygen
saturation monitoring with surveillance labs. She was tolerating
soft mechanical regular diet, was ambulating with a walker, and
did not have further nausea, vomiting, chest pain, dyspnea, or
apnea episodes while planning for an operation.
On ___, her WBC 16.7, and she had a repeat pre-operative CXR
that found stable pleural effusions (moderate on left, small on
right) with a top normal cardiac size and previously known
hernia. She was taken to the operating room, and had an
exploratory laparoscopy, lysis of adhesions, partial hiatal
hernia reduction with plication to the left crus and
percutaneous, endoscopically guided gastrostomy tube placement.
She tolerated the procedure well, and after her stay in the PACU
was transferred to the floor after prolonged fatigue from
anesthesia. She was continued on telemetry and oxygenation
monitoring.
On ___, patient was transferred to the SICU for increased
work of breathing and found to have a RUL consolidation with WBC
of 24. A CTA was also done to rule out a PE, which was negative,
but was concerning for a RUL consolidation. She completed a
course of cefatzadime. The patient continued to have hypoxic
episodes w/ respiratory distress c/f multiple aspiration events,
went back and forth between the medicine floor and ICU for these
events. The surgery team saw her and felt that she might need
advancement of her G-tube to a G-J tube.
MEDICINE COURSE
===============
# Hypoxic Respiratory Failure
Reported baseline history of tachypnea prior to surgery thought
to be potentially related to large hiatal hernia but also has
known history of BOOP and restrictive lung disease ___ her prior
history of radiation for breast cancer therapy. Had multiple
aspiration events, completed a course of ceftaz for possible PNA
as above. Was seen by speech and swallow multiple times, was
ultimately cleared for just clear liquids for comfort. Patient
had worsening respiratory status every time tube feeds were
started, prompting discontinuation. Patient complained of
difficulty breathing throughout hospitalization w/ interval
CXR's demonstrating worsening paraesophageal hernia causing a
mediastinal shift to the left. Patient placed on low-dose
morphine w/ some improvement in symptoms.
# Abdominal pain/distension
# Hiatal hernia s/p plication and GJ tube placement: Patient
continued to have abdominal pain after the plication procedure.
G tube was modified to a GJ to allow for post-pyloric feeds
while simultaneously allowing for G tube venting, but did not
help symptoms. Tube feeds were attempted 3 times, and even
though they were started at very low rates, her pain and
abdominal distension would worsen w/in 24 hours of starting.
During hospitalization, was noted to have urinary retention, but
no pain relief from straight caths PRN, and retention
self-resolved after home oxybutynin was d/c'd. Patient was also
given aggressive bowel regimen. Despite all interventions,
patient continued to suffer from significant pain. Ultimately
decided to d/c tube feeds. Continued to leave G tube to vent,
morphine as above. Once tube feeds started, patient was placed
on TPN; however, given concerns for volume overload as well as
overall goals of care, this was stopped prior to discharge.
Family wishes to continue ongoing discussions re: TPN at ___
facility.
# Malnutriton: Pt with poor PO intake this admission ___
expansion of hernia with PO and resulting respiratory distress
as described above. Holding TFs as above, can get clear liquids
for comfort per speech and swallow recs. As above, TPN was
stopped prior to discharge.
# GOC: Patient w/ worsening respiratory and nutritional status
despite all interventions over this long hospitalization.
Multiple GOC discussions had w/ patient and family, they are
aware that further medical interventions are limited and likely
not to help. Ultimately decided on transitioning patient to
hospice care and comfort measures only. However, patient's
family not ready to d/c TPN, they are still discussing this
issue amongst themselves. Therefore, the patient was transferred
with a ___ line in place in case they opt for TPN moving
forward. Patient very lethargic during these meetings, and could
not offer much insight into how she would like to be treated.
# HTN: Continued home amlodipine
# Bipolar disorder: Continued home ___ (level 0.5), olanzapine.
# Hypothyroidism: Continued home levothyroxine
TRANSITIONAL ISSUES
===================
[ ] patient has been transitioned to ___, hospice care
[ ] family still undecided on whether to continue TPN, please
continue ongoing ___ discussions, specifically regarding this
issue
[ ] continue to keep G tube to vent, ok to clamp for 30 minutes
if administering meds
# Communication/HCP: ___ (daughter, ___)Phone
number: ___ Cell phone: ___
# Code: DNR/DNI, confirmed with patient and subsequently HCP |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Trauma: fall
nondisplaced Right sided rib fractures ___
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female, s/p fall. Presents with right rib pain
for the past
24 hours. The patient reports that she was walking at home
when she misstepped and fell on top of a chair striking her
right ribs. She was initially okay, however, she later
developed significant pain in the right ribs and presents at
a hospital where she underwent CT scan which demonstrated
for her right-sided rib fractures. She was then transferred
to ___ for trauma evaluation. She denies any
shortness of breath. She denies any fever, chills, abdominal
pain, nausea, vomiting, dysuria, bowel changes. Of note, the
patient is anticoagulated on Coumadin
Past Medical History:
- Atrial fibrillation, rate controlled, on warfarin
- Hypertension on nitro patch, metoprolol
- Right ventricular dysfunction, 3+MR, 2+TR, moderate pulmonary
hypertension on echo ___
- "Threat of glaucoma" on timolol eye drops
- Insomnia, using melatonin
- 11 children
- Struck by motor vehicle in childhood with resulting damage to
right leg, s/p skin grafting, minimal long term motor
complications
- Rotator cuff injury on left
- Septic shoulder joint infected with Group G Streptococcus
___.
- Cervical Spinal Stenosis
- Lumbar Spinal Stenosis
- COPD
- hemorrhoids
Social History:
___
Family History:
Mother died of CVA, 2 sisters died of MI in their ___.
Physical Exam:
PHYSICAL EXAMINATION: upon admission: ___
Temp: 97.5 HR: 88 BP: 105/66 Resp: 18 O(2)Sat: 95 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light
Oropharynx within normal limits
Chest: Right-sided chest wall tenderness
Rectal: Heme Negative
GU/Flank: No costovertebral angle tenderness
Extr/Back: No cyanosis, clubbing or edema
Skin: No rash
Neuro: Speech fluent
Pertinent Results:
___ 05:25AM BLOOD WBC-7.0 RBC-4.16 Hgb-11.6 Hct-36.2 MCV-87
MCH-27.9 MCHC-32.0 RDW-15.9* RDWSD-50.0* Plt ___
___ 05:14AM BLOOD WBC-7.5 RBC-4.21 Hgb-11.5 Hct-36.8 MCV-87
MCH-27.3 MCHC-31.3* RDW-15.7* RDWSD-49.8* Plt ___
___ 08:20AM BLOOD WBC-8.2 RBC-4.43# Hgb-12.1# Hct-38.3
MCV-87# MCH-27.3 MCHC-31.6* RDW-15.9* RDWSD-49.6* Plt ___
___ 08:20AM BLOOD Neuts-67.5 ___ Monos-7.8 Eos-2.0
Baso-0.5 Im ___ AbsNeut-5.53 AbsLymp-1.78 AbsMono-0.64
AbsEos-0.16 AbsBaso-0.04
___ 05:25AM BLOOD Plt ___
___ 05:25AM BLOOD ___
___ 05:14AM BLOOD ___ PTT-41.6* ___
___ 02:45AM BLOOD ___ PTT-36.2 ___
___ 08:20AM BLOOD ___ PTT-37.5* ___
___ 05:25AM BLOOD Glucose-109* UreaN-30* Creat-0.9 Na-136
K-4.1 Cl-103 HCO3-23 AnGap-14
___ 05:25AM BLOOD Glucose-109* UreaN-30* Creat-0.9 Na-136
K-4.1 Cl-103 HCO3-23 AnGap-14
___ 05:14AM BLOOD Glucose-92 UreaN-35* Creat-0.9 Na-137
K-4.5 Cl-103 HCO3-23 AnGap-16
___ 08:20AM BLOOD Glucose-101* UreaN-40* Creat-0.9 Na-132*
K-4.1 Cl-100 HCO3-21* AnGap-15
___ 05:25AM BLOOD Calcium-9.2 Phos-3.0 Mg-2.0
EKG:
Atrial fibrillation with a controlled ventricular response. Left
axis
deviation. Possible left anterior fascicular block. Underlying
artifact.
Compared to the previous tracing of ___ atrial fibrillation
is new.
___: cxr:
Known right lower chest rib fractures not well demonstrated
radiographically.
No pneumothorax detected. Bibasilar atelectasis, minimal on the
right, with possible trace right pleural fluid.
___: chest x-ray:
Lung volumes are lower exaggerating interval engorgement of
pulmonary
vasculature and increase in mild cardiomegaly compared ___. There is no pulmonary edema, pneumothorax or appreciable
pleural effusion.
___: ECHO:
IMPRESSION: Symmetric LVH with normal global and regional
biventricular systolic function. Normally-functioning mitral
valve bioprosthesis. Moderate tricuspid regurgitation. Moderate
pulmonary hypertension.
Time Taken Not Noted Log-In Date/Time: ___ 12:33 am
URINE Site: NOT SPECIFIED
**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. Metoprolol Succinate XL 50 mg PO DAILY
2. Docusate Sodium 100 mg PO DAILY
3. Omeprazole 40 mg PO DAILY
4. Warfarin 2 mg PO DAILY16
5. Aspirin 81 mg PO DAILY
6. Furosemide 40 mg PO DAILY
7. Lisinopril 10 mg PO DAILY
8. Oxybutynin 5 mg PO DAILY
9. Potassium Chloride 20 mEq PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO DAILY
3. Furosemide 40 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. Oxybutynin 2.5 mg PO BID
6. Acetaminophen 650 mg PO TID
7. Senna 8.6 mg PO BID constipation
8. Metoprolol Tartrate 25 mg PO BID
9. Potassium Chloride 20 mEq PO DAILY
10. Fluticasone Propionate 110mcg 2 PUFF IH BID
11. Bisacodyl 10 mg PR QHS:PRN constipation
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Trauma: fall
right ___ rib fractures
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 rib fractures s/p fall // eval for
interval change eval for interval change
COMPARISON: Chest radiographs ___ through ___.
IMPRESSION:
Lung volumes are lower exaggerating interval engorgement of pulmonary
vasculature and increase in mild cardiomegaly compared ___. There is no
pulmonary edema, pneumothorax or appreciable pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with rib fractures, hypotension // eval for
ptx
COMPARISON: Chest x-ray from ___ from ___ at 23:06
FINDINGS:
Compared to the prior study, no definite change is detected.
Again seen are sternotomy wires and the sternotomy closure construct. The
cardiomediastinal silhouette is unchanged.
No overt CHF. Bibasilar atelectasis. Minimal blunting at the right
costophrenic angle, without gross effusion.
The torso CT from ___ describes nondisplaced fractures of the right
___ ribs. These are not readily visible on the current radiograph.
Allowing for lordotic positioning, no pneumothorax is detected. There is only
trace right base atelectasis .
IMPRESSION:
Known right lower chest rib fractures not well demonstrated radiographically.
No pneumothorax detected. Bibasilar atelectasis, minimal on the right, with
possible trace right pleural fluid.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Transfer
Diagnosed with FRACTURE FOUR RIBS-CLOSE, UNSPECIFIED FALL, ATRIAL FIBRILLATION, LONG TERM USE ANTIGOAGULANT
temperature: 97.5
heartrate: 88.0
resprate: 18.0
o2sat: 95.0
sbp: 105.0
dbp: 66.0
level of pain: 2
level of acuity: 2.0 | ___ year old female who was walking at home when she misstepped
and fell on top of a chair striking her right ribs. She did not
strike her head or lose consciousness. She later developed
significant pain in the right ribs and presented to an OSH where
she underwent CT scan which demonstrated right-sided rib
fractures. She was transferred here for management. The patient
was reportedly on coumadin.
Because of her multiple rib fractures, she was admitted to the
intensive care unit for monitoring. Initially she was
hypotensive. Her oxygen saturation was closely monitored and her
hematocrit remained stable. She clinically improved within 24
hours of admission and was transferred to the floor once her Hct
remained stable at ___. Her INR continued to rise following
admission despite holding of coumadin. Max INR was 4.0 on
___. Her only complaint at this time was urgency and
frequency with voids. UA was sent and found to be contaminated,
thus UA obtained via straight cath was resent and found to be
WNL. UCx was pending at the time of discharge, however her
urinary symptoms had already begun to subside at this time. Once
she met the appropriate criteria, Ms. ___ was discharged home
with the understanding that she would follow up with her PCP
___ 24 hours of discharge for INR check as well as per her
appointment scheduled with the cardiology and general surgery
clinics. On the day of discharge (___) her INR was 2.9 and
she received 1mg of coumadin. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Nausea, Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a pleasant ___ w/ HTN, DL, asthma, and
lymphoblastic crisis of CML vs PH (+) ALL, favoring former, s/p
allogeneic SCT RI-MUD, Flu/Bu D+100 (___), LTBI on
INH/B6,
hx of C diff colitis (___) who, per the ED, is p/w one day
onset of N/V/D.
She had bilious vomit x1 and watery diarrhea x1 in the morning.
No abdominal pain, or chest discomfort. No fever, chills, or
malaise. Tacrolimus level checked yesterday 2.4.
In ED: received Zofran and IVF. SBP 120s. Concern for inability
to tolerate PO and was admitted.
On arrival to the ___ service, she had complained of significant
nausea. Even on changing positions for an EKG she started to dry
heave. I ordered 1 mg PO ativan (her home dose for nausea,
confirmed by her on admission). By the time I arrived, she was
quite sedated. She was able to open her eyes and answer
appropriately w/ several words at most. She was able to follow
commands for neuro exam but she wasn't able to provide me much
more history. She does note that she has had nausea for a long
time, that this acute episode is not new and that she's had this
before. She denied any CP/SOB/abd pain. RN ___ confirmed pt
was much more interactive prior to receiving the lorazepam.
Past Medical History:
PAST ONCOLOGIC HISTORY (Per OMR):
Admitted from ___ to ___ to ___. On that admission she
was diagnosed with lymphoblastic crisis of CML vs PH (+) ALL,
favoring the former. Her admission was complicated by prolonged
pancytopenia, Sweet's after GCSF, neutropenic fever, severe
abdominal pain. She lost 30 lbs of weight during this admission,
had severe difficulty with eating and drinking requiring TPN
support. Also admitted from ___ to ___ for C.diff
colitis.
PERIPHERAL BLOOD:
___: BCR ABL1/ABL1 % (IS) 195.993 H
___: BCR ABL1/ABL1 % (IS) 2.493 H
___: BCR ABL1/ABL1 % (IS) 0.261 H
___: BCR ABL1/ABL1 % (IS) 0.000
___: BCR ABL1/ABL1 % (IS) 0.000
___: BCR ABL1/ABL1 % (IS) 0.000
___: BCR ABL1/ABL1 % (IS) 0.000
___: BCR ABL1/ABL1 % (IS) 0.000
___: BCR ABL1/ABL1 % (IS) 0.000
___: BCR ABL1/ABL1 % (IS) 0.000
TREATMENT COURSE (Per ___ clinic note on ___: Hyper C-VAD Part A
___: Desatinib 70 mg bid
___ MTX
___: IT Cytarabine
___: Hyper C-VAD Part B
___: IT MTX
___: Dasatinib 70 mg bid
___: Dasatinib 100 mg daily
___: IT MTX
___: IT MTX
___: IT MTX
___: IT MTX
___: IT MTX
___: IT MTX
___: Screened and consented in protocol ___ A 3-Arm
Randomized Phase II study of Standard-of-Care Vs Bortezomib
based Graft vs Host Disease Regimens for Reduced intensity
conditioning Hematopoietic Stem Cell transplantation Patients
Lacking HLA-matched Related Donors.
___: Day 0: MUD Reduced Intensity Allogeneic Stem Cell
Transplant
___: Consented in protocol# ___: A Phase III Randomized,
Placebo-controlled Clinical Trial to Evaluate the Safety and
Efficacy of ___ (Letemovir) for the Prevention of Clinically
Significant Human Cytomaglovirus (CMV)Infection in Adult,
CMV-Seropositive Allogeneic Hematopoietic Stem Cell Transplant
Recipients. Was randomized to 480 mg of drug versus placebo.
ALLOGENEIC TRANSPLANT
ADMISSION ___
DISCHARGE ___
CONDITIONING REGIMEN: Fludarabine, Busulfan
DAY 0: ___
CELL DOSE: 11.16 X 10(6) CD34/kg
DONOR: Male, CMV pos. AB pos
RECIPIENT: Female, CMV pos, A neg
ABO INCOMPATIBILITY: MAJOR
WBC ENGRAFTMENT: Never dropped ANC to <1000
PLT ENGRAFTMENT: Never dropped platelets to < 100k
# PRBC TRANSFUSIONS DURING TRANSPLANT ADMISSION: 1, last
transfused ___.
# PLT TRANSFUSIONS DURING TRANSPLANT ADMISSION: None
POST TRANSPLANT ADMISSION COMPLICATIONS:
1). Fall- ___ most likely secondary to increase Ativan use. CT
revealed large subgaleal hematoma along right frontal convexity
with no underlining bony or intracranial abnormality.
2) Right posterior vitreous detachment- No intervention
required.
3) Depression. Ongoing on antidepressant. Was present prior to
admission.
4) +PPD- Treatment started during admission with Isoniazid and
Pyridoxine on ___ for total of nine month treatment.
5). HTN- Started on Amlodipine.
6). Reflux- On Zantac and TUMS.
On ___, DAY + 54.
PAST MEDICAL/SURGICAL HISTORY:
Hypertension
Asthma
Positive PPD
Hypercholesterolemia
Anxiety
Uterine fibroid
C.diff colitis ___
s/p surgical extraction of tooth #18 with sectioning of dental
bridge ___
Social History:
___
Family History:
Notable for leukemia in uncle and cousin on mother's side.
Gastric cancer in sister.
Physical Exam:
Admission Physical Exam:
PHYSICAL EXAM: 98 108/62 18 98% RA
General: NAD, Resting in bed comfortably asleep, arousable to
voice but nods off within ___ sec
HEENT: MMM, no OP lesions, no cervical/supraclavicular
adenopathy
CV: RR, NL S1S2 no S3S4, ___ SEM loudes at RICS
PULM: CTAB, No C/W/R, No respiratory distress
ABD: BS+, soft, minimal TTP in lower quadrants b/l, no palpable
masses
LIMBS: WWP, no ___, no tremors
SKIN: No rashes on the extremities
NEURO: Sedated, maintaining airway, pupils b/l 3 mm and
reactive
Discharge Physical Exam:
Vitals: 97.5 ___ 18 99%ra
General: a&o x 3, nad
HEENT: ATNC, MMM
CV: RRR, no MRG
Resp: LCAB, no wheezes, rales, rhonchi
Abd: soft, non-tender, non-distended, +BS
Ext: no edema
Skin: no rash, hickman catheter w/o erythema or tenderness
Pertinent Results:
Admission Labs:
___ 09:30AM BLOOD WBC-3.9* RBC-2.49* Hgb-8.6* Hct-25.1*
MCV-101* MCH-34.5* MCHC-34.3 RDW-13.8 RDWSD-50.4* Plt ___
___ 09:30AM BLOOD Neuts-59.1 ___ Monos-11.7 Eos-1.3
Baso-0.3 Im ___ AbsNeut-2.33 AbsLymp-1.05* AbsMono-0.46
AbsEos-0.05 AbsBaso-0.01
___ 09:30AM BLOOD Plt ___
___ 09:30AM BLOOD UreaN-20 Creat-0.6 Na-143 K-3.7 Cl-110*
HCO3-24 AnGap-13
___ 09:30AM BLOOD ALT-43* AST-25 LD(___)-273* AlkPhos-32*
TotBili-0.2
___ 09:30AM BLOOD TotProt-5.6* Albumin-3.9 Globuln-1.7*
Calcium-8.8 Phos-3.0 Mg-1.9
___ 09:30AM BLOOD TSH-2.5
___ 09:30AM BLOOD tacroFK-2.4*
Notable Interval Labs:
___ 05:45PM BLOOD tacroFK-4.7*
Discharge Labs:
___ 12:00AM BLOOD WBC-2.8* RBC-2.26* Hgb-7.6* Hct-22.9*
MCV-101* MCH-33.6* MCHC-33.2 RDW-13.8 RDWSD-50.6* Plt ___
___ 12:00AM BLOOD Neuts-67.6 Lymphs-18.9* Monos-11.3
Eos-1.5 Baso-0.0 Im ___ AbsNeut-1.86 AbsLymp-0.52*
AbsMono-0.31 AbsEos-0.04 AbsBaso-0.00*
___ 12:00AM BLOOD Plt ___
___ 12:00AM BLOOD Glucose-100 UreaN-12 Creat-0.6 Na-137
K-4.0 Cl-106 HCO3-21* AnGap-14
___ 12:00AM BLOOD ALT-52* AST-35 LD(LDH)-265* AlkPhos-34*
TotBili-0.2
___ 12:00AM BLOOD Calcium-8.5 Phos-2.2* Mg-1.9
___ 06:22AM BLOOD Cortsol-11.7
___ 09:45AM BLOOD tacroFK-4.6___ 05:45PM BLOOD HoldBLu-HOLD
___ 12:13AM BLOOD ___ pH-7.40 Comment-GREEN TOP
___ 12:13AM BLOOD Lactate-0.7
CXR ___
IMPRESSION:
No acute intrathoracic process. Right IJ central venous
catheter in
appropriate position
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q8H
2. Citalopram 20 mg PO DAILY
3. Cyanocobalamin ___ mcg PO DAILY
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Dronabinol 5 mg PO BID:PRN nausea
6. FoLIC Acid 1 mg PO DAILY
7. Isoniazid ___ mg PO DAILY
8. Lorazepam 1 mg PO Q8H:PRN Anxiety
9. Pyridoxine 50 mg PO DAILY
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
11. Budesonide 3 mg PO TID
12. Ranitidine 300 mg PO QHS
13. Magnesium Oxide 400 mg PO DAILY
14. Multivitamins 1 TAB PO DAILY
15. Tacrolimus 2 mg PO Q12H
16. PredniSONE 10 mg PO DAILY
Start: After last tapered dose completes
This is the maintenance dose to follow the last tapered dose
17. DASatinib 100 mg PO QHS
18. Vitamin D 1000 UNIT PO BID
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Budesonide 3 mg PO TID
3. Citalopram 20 mg PO DAILY
4. Cyanocobalamin ___ mcg PO DAILY
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Dronabinol 5 mg PO BID:PRN nausea
7. FoLIC Acid 1 mg PO DAILY
8. Isoniazid ___ mg PO DAILY
9. Lorazepam 1 mg PO Q8H:PRN Anxiety
10. Multivitamins 1 TAB PO DAILY
11. PredniSONE 10 mg PO DAILY
Start: After last tapered dose completes
This is the maintenance dose to follow the last tapered dose
12. Pyridoxine 50 mg PO DAILY
13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
14. Tacrolimus 2 mg PO Q12H
15. Vitamin D 1000 UNIT PO BID
16. DASatinib 100 mg PO QHS
17. Magnesium Oxide 400 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Dehydration
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 BM tx, cancer, pls eval pna and picc placement
COMPARISON: ___
FINDINGS:
PA and lateral views of the chest provided. Right IJ access central venous
catheter seen with its tip in the mid SVC region. The lungs are clear. There
is no focal consolidation, effusion, or pneumothorax. The cardiomediastinal
silhouette is normal. Imaged osseous structures are intact. No free air below
the right hemidiaphragm is seen.
IMPRESSION:
No acute intrathoracic process. Right IJ central venous catheter in
appropriate position.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Diarrhea
Diagnosed with DEHYDRATION
temperature: 98.8
heartrate: 87.0
resprate: 20.0
o2sat: 98.0
sbp: 103.0
dbp: 63.0
level of pain: 0
level of acuity: 2.0 | Ms ___ is a ___ F with CML vs PH+ALL s/p allo matched
unrelated donor SCT who presented to ___ on day +100 with 1
day of inability to tolerate PO, 1 episode of vomiting, and 1
episode of watery non-bloody diarrhea, with notable
post-transplant history of possible mild gvhd of colon and
c.diff colitis.
#) Nausea/Vomiting: Improved following 1 day of bowel rest,
zofran, ranitidine, and IVF. C.diff toxin result was pending at
time of discharge but clinically ruled out given formed stool.
Fecal cultures were pending at time of discharge but as she was
clinically improved, tolerating regular diet, she was cleared
for discharge. This episode was felt to be less likely GVHD or
infection given rapid improvement. She has chronic GI symptoms
of IBS-like complaints since her youth.
#) CML vs PH+ALL: She presented on day ___ s/p allogeneic
matched unrelated donor SCT. She is on dasatinib 100mg qhs at
home and tacrolimus 2mg PO q12h. On a clinic visit the day prior
to admission she was seen at Dr. ___ and had been
doing well with no new complaints. Her tacrolimus had been
increased from 1.5mg q12h to 2mg q12h. During admission, her
tacrolimus was continued at the new dose and trough levels were
monitored daily. Dasatinib was temporarily held as it interacts
with ranitidine. She was continued on prednisone 10mg PO for
history of possible mild GVHD of gut. Upon discharge, ranitidine
was discontinued and she was instructed to resume dasatinib. Her
tacrolimus serum level was 2.4, 4.6, 4.7 during this admission.
# Latent TB Infection: She was continued on isoniazid with
pyridoxine
# Citalopram: She was continued on citalopram 20mg PO daily. She
follows with Dr. ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right ureteral stone
Major Surgical or Invasive Procedure:
Cystoscopy, right ureteroscopy and laser lithotripsy, right
ureteral stent placement
History of Present Illness:
___ with a history of gross hematuria in ___ worked up by
urology and nephrology and felt to likely be due to stones now
with 24 hours of RLQ pain radiating to his right groin. He had
an
episode of pain yesterday that resolved, but this morning had
persistent nausea and emesis. He has recently returned from a 2
week trip to ___ and had an additional similar episode of RLQ
pain prior to leaving for his trip that resolved after a few
hours. He denies any recent illness, fevers, chills. He reports
normal bowel movements. He denies any dysuria, hematuria,
increased frequency or urgency.
Of note, on prior workup for gross hematuria with nephrology, he
was found to have multiple calcium oxalate crystals in the urine
sediment. They recommended hydration with at least 2L of water
per day. He thinks he was able to achieve this while in ___
but
says that since returning 2 weeks ago he has had decreased fluid
intake.
Past Medical History:
PMH/ PSH: none
Social History:
___
Family History:
FH: no history of gu malignancy or other gu disorders
Physical Exam:
NAD
Abdomen soft nt/nd
No CVA tenderness bilaterally
Ext wwp
Pertinent Results:
___ 06:10AM BLOOD WBC-9.9 RBC-4.71 Hgb-13.4* Hct-41.5
MCV-88 MCH-28.4 MCHC-32.3 RDW-12.7 Plt ___
___ 06:10AM BLOOD Glucose-102* UreaN-14 Creat-0.7 Na-140
K-3.8 Cl-104 HCO3-27 AnGap-13
Radiology Report
INDICATION: Right lower quadrant pain and crystals in his urine. Evaluate
for stone.
COMPARISONS: CT of the abdomen and pelvis from ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the abdomen and
pelvis without the administration of IV contrast in the prone position per the
CTU protocol. Sagittal and coronal reformatted images were obtained and
reviewed.
TOTAL DLP: 333 mGy-cm.
FINDINGS:
LUNG BASES: The bases of the lungs are clear without nodules, consolidations
or pleural effusions. The base of the heart is normal in size. There is no
pericardial effusion.
ABDOMEN: The liver is normal in shape and contour. There is mild
hepatosteatosis. Within the limitations of this non-contrast exam, there are
no focal lesions. The gallbladder, spleen, pancreas and adrenal glands are
normal.
There is moderate right hydronephrosis and perinephric stranding. Mild right
hydroureter can be traced to a 7 mm obstructing stone (5B, 30) in the right
mid-distal ureter. In the lower pole of the left kidney, there is a 10 mm
non-obstructing stone (5B, 33). Also, in the lower pole of the left kidney,
there is a 3 mm non-obstructing stone (5B, 31). These stones appear slightly
increased in size since the prior exam in ___. There is no left
hydronephrosis or hydroureter. No renal lesions are identified. There is no
free fluid to suggest a forniceal rupture.
The stomach and small bowel are normal in course and caliber. There is no
evidence of obstruction. There is no free air or free fluid. There is no
mesenteric, periportal or retroperitoneal lymphadenopathy. The abdominal
vasculature is normal in caliber.
Along the right lateral abdominal wall, there is a small fat-containing hernia
with appears to be communicating with the retroperitoneal fat. There is no
surrounding stranding. This is unchanged from the prior exam.
PELVIS: The large bowel is normal without focal inflammatory changes or
evidence of a mass. The appendix is normal. The bladder is unremarkable
without stones. The prostate is normal in size. Several punctate
calcifications are noted. There is no free fluid in the pelvis. Incidentally
noted is a large phlebolith in the left pelvis, unchanged from the prior exam.
OSSEOUS STRUCTURES: There are no concerning lytic or sclerotic osseous
lesions. There are no significant degenerative changes. No fracture is
identified.
IMPRESSION:
1. 7-mm obstructing stone in the mid-to-distal right ureter with moderate
right hydronephrosis and perinephric stranding.
2. Non-obstructing stones in the left kidney, slightly enlarged from the
prior exam, as described above.
3. Mild hepatosteatosis.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with CALCULUS OF KIDNEY, CALCULUS OF URETER, HYDRONEPHPHROSIS
temperature: 97.3
heartrate: 73.0
resprate: 16.0
o2sat: 100.0
sbp: 175.0
dbp: 88.0
level of pain: 7
level of acuity: 3.0 | The patient was admitted to Dr. ___ service from the
___ ED for overnight observation, pain control, and IV fluids.
He was continued on ceftriaxone for a UA with >182 rbc and
nitrite positive. On the morning of HD2 his pain was well
controlled and nausea had resolved. His wbc had declined from 19
to 9 and his creatinine had also declined from 1 to 0.7. Given
stone size and location as well as his UA and admission
leukocytosis and hydronephrosis, the decision was made to go to
the operating room for stent placement. He underwent cystoscopy,
right ureterscopy and laser lithotripsy with right ureteral
stent placement. There were no complications; please see OR
dictation for more detail. Post operatively, his diet was
advanced, pain was controlled on PO medications, and he voided
without difficulted. He was given 5 days of cipro, flomax for
stent discomfort, and nacrotics for pain control. He is given
explicit instructions to call Dr. ___ follow-up for
stent removal in 1 week. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillin G / Phenergan Plain
Attending: ___.
Chief Complaint:
Weakness with hematocrit of 22
Major Surgical or Invasive Procedure:
___ L Femoral Endarterectomy/Fem-AK pop BPG
History of Present Illness:
Mr. ___ is ___ year old gentleman transferred from acute
inpatient rehabilitation for weakness and low hematocrit. He
was discharged the day prior to admission from the hospital to a
rehabilitation facility. Routine labwork done at the
rehabilitation facility demonstrated that he had a hematocrit of
22, which though low is actually not significantly different
from his discharge hematocrit of 23.4. He reports a subjective
feeling of weakness. He denies frank dizziness or
lightheadedness.
ROS: Negative for changes in vision/hearing, nausea/vomiting,
chest pain/shortness of breath, skin changes or rashes,
fevers/chills, new joint pain or swelling. Notably though he is
documented as voiding independently on transfer from the
hospital, he has a foley catheter in place. He does report one
black bowel movement after his surgery, but states that they
have
been brown since. Review of systems is otherwise negative.
Upon further questioning, he noted history of darker stools, but
non-bloody within the past several months. He has not pursued
care for this, and was offered a colonoscopy for screening
purposes, but declined this at the time. He denied a history of
peptic ulcer disease, diverticulosis. He notes his mother had a
history of diverticulitis, but denied a history of colon cancer.
Past Medical History:
PMH: type 2 diabetes mellitus, hypercholesterolemia,
hypertension, PVD s/p L CEA ___, coronary artery disease,
diabetic neuropathy, renal cell carcinoma s/p left radical
nephrectomy, chronic renal insufficiency, left calf melanoma
(s/p excision), basal cell carcinoma, CLL
PSH: right carotid endarterectomy (___), left carotid
endarterectomy (___), left radical nephrectomy, left calf
melanoma excision
Social History:
___
Family History:
Father: potentially had a heart attack at time of his death.
Physical Exam:
Admission:
VS: Tm 98.3 Tc 98.3 HR 73 BP 156/56 RR 20 O2sat 98%RA
General: in no acute distress, non-toxic appearing
HEENT: mucus membranes slightly dry, nares clear, trachea at
midline
CV: regular rate, rhythm
Pulm: diminished at bases, otherwise clear anteriorly
Abd: obese, soft, nontender, nondistended.
MSK: left lower extremity incision with moderate erythema
extended from groin to knee. Minimal sero-sanguinous drainage.
Pulses:
Fem pop DP ___
R palp palp dopp dopp
L palp palp dopp dopp
Discharge:
VS: T 97.6 BP 141/58 HR 54 RR 18 pOx 100 RA Glucose 118-211
General: in no acute distress, non-toxic appearing
HEENT: mucus membranes slightly dry, nares clear, trachea at
midline
CV: regular rate, rhythm
Pulm: diminished at bases, otherwise clear anteriorly
Abd: obese, soft, nontender, nondistended.
MSK: left lower extremity incision with improved erythema
extended from groin to knee. Minimal sero-sanguinous drainage.
Pulses:
Fem pop DP ___
R palp palp dopp dopp
L palp palp dopp dopp
Pertinent Results:
Admission labs:
===============
___ 07:45AM BLOOD WBC-9.2 RBC-2.42* Hgb-7.4* Hct-23.4*
MCV-97 MCH-30.7 MCHC-31.7 RDW-16.7* Plt ___
___ 11:20AM BLOOD WBC-12.2* RBC-2.88* Hgb-9.0* Hct-27.4*
MCV-95 MCH-31.3 MCHC-32.9 RDW-17.1* Plt ___
___ 11:20AM BLOOD ___ PTT-28.3 ___
___ 07:45AM BLOOD Glucose-95 UreaN-86* Creat-3.6* Na-135
K-3.6 Cl-103 HCO3-20* AnGap-16
___: ECG:
=============
Sinus rhythm. Modest intraventricular conduction delay. Compared
to the
previous tracing of ___ there is no significant diagnostic
change
Discharge labs:
===============
___ 06:10AM BLOOD WBC-13.3* RBC-2.72* Hgb-8.6* Hct-25.7*
MCV-95 MCH-31.6 MCHC-33.4 RDW-16.8* Plt ___
___ 06:10AM BLOOD Glucose-121* UreaN-79* Creat-4.1* Na-135
K-4.2 Cl-103 HCO3-22 AnGap-14
___ 06:10AM BLOOD Calcium-7.8* Phos-4.7* Mg-2.6
___ 06:10AM BLOOD Hapto-211*
___ 06:10AM BLOOD Vanco-9.5*
Imaging:
========
CT head without contrast ___:
IMPRESSION:
1. No acute intracranial process.
2. Chronic small vessel ischemic disease and age-related
involutional
changes.
Medications on Admission:
1. oxycodone 5 mg Tablet Sig: ___ Tablets PO Q6H (every 6 hours)
as needed for pain. Disp:*30 Tablet(s)* Refills:*0*
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO TID (3
times a day).
3. aspirin 325 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
4. carvedilol 6.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
5. valsartan 160 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
6. nifedipine 30 mg Tablet Extended Release Sig: Two (2) Tablet
Extended Release PO DAILY (Daily).
7. alprazolam 0.25 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day) as needed for anxiety.
8. calcitriol 0.25 mcg Capsule Sig: One (1) Capsule PO DAILY
(Daily).
9. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily). Disp:*30 Tablet(s)* Refills:*0*
10. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
11. NPH insulin human recomb 100 unit/mL Suspension Sig: Twenty
Six (26) units Subcutaneous at bedtime.
12. hydrochlorothiazide 25 mg Tablet Sig: One (1) Tablet PO once
a day.
13. glimepiride 4 mg Tablet Sig: One (1) Tablet PO once a day.
14. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
15. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
16. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation for 2 weeks.
17. epoetin alfa 20,000 unit/mL Solution Sig: 30.000 units
Injection q 2 weeks: last injection on ___.
18. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO BID (2 times a day) for 10 days. Disp:*20 Tablet(s)*
Refills:*0*
19. torsemide 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
20. Crestor 40 mg Tablet Sig: One (1) Tablet PO once a day.
Discharge Medications:
1. ALPRAZolam 0.25 mg PO BID:PRN anxiety
2. Aspirin 325 mg PO DAILY
3. Calcitriol 0.25 mcg PO DAILY
4. Carvedilol 6.25 mg PO BID
5. Clopidogrel 75 mg PO DAILY
6. Docusate Sodium 100 mg PO TID
7. Ferrous Sulfate 325 mg PO DAILY
8. FoLIC Acid 1 mg PO DAILY
9. glimepiride *NF* 4 mg ORAL DAILY
10. Omeprazole 40 mg PO DAILY
11. Rosuvastatin Calcium 40 mg PO DAILY
12. Senna 1 TAB PO BID:PRN constipation
13. Valsartan 320 mg PO DAILY
14. Epoetin Alfa 8000 UNIT SC QMOWEFR Start: ___
30,000units SC every two weeks. Next injection due ___
15. Hydrochlorothiazide 25 mg PO DAILY
16. Torsemide 60 mg PO DAILY
17. NIFEdipine CR 90 mg PO DAILY
please hold for SBP < 100
18. Vancomycin 1000 mg IV Q48H
next doses are ___ and ___ for wound
drainage/infection. End date ___.
19. Outpatient Lab Work
ICD-9 280.0 (anemia, iron deficient), please check CBC and
chemistry 7 on ___.
- If Hgb < 7 , please consider transfusion vs. ER evaluation at
___
- If K > 5, (non-hemolyzed), Cr > 4.5, or urine output is
sluggish, consider ER evaluation at ___
20. NPH 12 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Anemia
Chronic kidney Disease
___ cellulitis
Type II Diabetes
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires some assistance
Followup Instructions:
___
Radiology Report
INDICATION: Status post fall. On aspirin and Plavix.
COMPARISONS: CT head ___.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without the administration of IV contrast. Sagittal, coronal, and thin-slice
bone image reformats were obtained and reviewed.
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or
infarction. The ventricles and sulci are prominent, consistent with
age-related involutional changes. Mild periventricular confluent white matter
hypodensities are consistent with chronic small vessel ischemic disease.
Atherosclerotic calcifications are noted within the vertebral and carotid
arteries.
No fracture is identified. The visualized paranasal sinuses, mastoid air
cells, and middle ear cavities are clear. The soft tissues are unremarkable
without evidence of large subgaleal hematoma.
IMPRESSION:
1. No acute intracranial process.
2. Chronic small vessel ischemic disease and age-related involutional
changes.
Results were discussed with Dr. ___ at 4:50 p.m. on ___ via
telephone by Dr. ___.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: HCT 22/FATIGUE
Diagnosed with GASTROINTEST HEMORR NOS, ANEMIA NOS, CAD UNSPEC VESSEL, NATIVE OR GRAFT, DIABETES UNCOMPL JUVEN, HYPERTENSION NOS
temperature: 98.9
heartrate: 64.0
resprate: 16.0
o2sat: 100.0
sbp: 144.0
dbp: 63.0
level of pain: 6
level of acuity: 2.0 | ___ year old gentleman with DM2 complicated by neuropathy, HL,
HTN, PVD s/p L CEA in ___, CAD, CKD, CLL among other conditions
presenting with fatigue and low hematocrit (Hct 22, recent
discharge Hct 23.4). He was re-admitted to the ___ vascular
surgery service after recent discharge the previous day after an
uncomplicated left common femoral endarterectomy and left
femoral to above-knee popliteal bypass with Dacron graft on
___ for continued left lower extremity rest pain and
non-healing arterial ulcer. The patient is s/p radical
nephrectomy for renal cancer, has CLL with anemia of chronic
disease with biweekly injections of procrit. He had been
transfused 5 units of packed red blood cells prior to discharge,
with hematocrit upon discharge of ~23. He was discharged to a
rehabilitation facility in the interim; the facility had drew a
CBC without clear reason, with hematocrit noted to be 22. This,
in context of the feelings of weakness and fatigue, prompted
transfer of the patient back to ___ for further evaluation.
# Anemia: The patient presented with a hematocrit of 22 from
discharge of 23; he received one unit of packed red blood cells
as the patient was symptomatic. Hemolysis labs were not
suggestive of hemolysis. His reticulocyte index was 1.8
suggestive of hypoproliferation. Recent nutritional studies
including iron and B12 were within normal limits. His stools
were hemoccult positive on testing, but this is unclear if a
false positive in the setting of iron therapy. There were no
signs or symptoms of an occult or frank GIB. Overall, it was
favored that the patient's anemia was likely secondary to
hypoproduction related to chronic kidney disease among other
factors. His symptoms of fatigue are likely multifactorial and
not solely related to anemia. He had no active chest pain or
other disconcerting signs while hospitalization suggestive of
poor tissue oxygenation. He should have a repeat CBC and
chemistry panel on ___. If his Hgb is less than 7, chest
pain or other concerning symptoms, or evidence of frank blood or
dark stools, he should return to ___ for further evaluation.
His Hgb on discharge was stable at 8.6. In addition, he should
have updated healthcare maintenance including colonoscopy and
perhaps EGD to explore if a slow GIB could be contributing
factor. He should continue Epo injections as well. The patient
has a history of CLL and chronic anemia requiring intermittent
blood transfusions while taking Procrit once every two weeks. He
received 5 units total of blood during his admission for
hematocrits of ___. His procrit was resumed at 24,000 prior to
discharge, and increased to 30,000 units per recommendations by
his nephrologist; his hemoglobin was improved as above with his
last unit of blood transfused on ___. His last procrit
injection was on ___, Next ___.
# CAD/PVD:
The patient has a history of hypertension, hyperlipidemia in
addition to extensive peripheral vascular disease and was
resumed on his statin, beta-blocker and aspirin. He was started
on plavix for 30 days for anti-coagulation for his new left
lower extremity graft (end date: ___. The patient was
otherwise stable from a cardiovascular standpoint; vital signs
were routinely monitored. ASA 325 mg to be continued lifelong.
The patient is s/p left femoral endarterectomy and femoral-above
knee popliteal bypass with PTFE graft. Throughout his
hospitalization, he had good dopplerable signals bilaterally,
with a dopperable graft, and was weight-bearing as tolerated on
both extremities.
# ___ cellulitis: He developed some serous drainage
from his incision with mild erythema, for which he was placed on
bactrim in his previous admission, which was continued early in
his re-admission course, then switched to IV vancomycin for a
recommended one week course through ___. He also had a ?
surgical site infection at his graft site for which he was given
initially bactrim and changed to vancomycin. His vancomycin
level was drawn at the incorrect dose but the level is
suggestive that with another dose that his level will be
correct. He will receive two more doses as noted ___ and
___. His wound appearance has improved as documented in the
physical exam section.
# Hypertension: It was noted during his hospital to be
hypertensive. He is already on valsartan 320 mg daily in
addition to nifedipine 60 mg daily. In addition, he is on
carvedilol 6.25 mg twice daily. We did not uptitrate carvedilol
given HR 50-60's most of the time. Nifedipine CR was increased
to 90 mg daily. Change might be needed based on BP readings.
Hydrochlorothiazide was initially held given the increase in Cr
however this was restarted in the last 2 days of his hospital
stay.
# CKD, Stage 4: The patient has a history of renal insufficiency
s/p left radical nephrectomy, CLL with subsequent anemia of
chronic disease. The patient is also reliant on torsemide daily
for renal insufficiency; this was held in his previous admission
in light of a rising creatinine from his baseline of 3 to 3.7 at
its peak and was 3.6 prior to discharge, and was held again
during his current admission for similar reasons. Routine
electrolytes were followed, and his urine output remained
marginal ~25cc/hr in the absence of diuretics. Intake and output
were closely monitored. At discharge, he will continue his home
diuretics and regimen. His labs are stable with no acute
indications for dialysis. Of note, at this creatinine level, his
fluctuation is likely trivial given that eGFR remains the same.
He will follow-up with nephrology as scheduled for continued
planning for hemodialysis initiation.
# Diabetes type 2 complicated by neuropathy and nephropathy: The
patient has history of diabetes, with blood glucose levels
between 104-400 within his previous hospitalization. He was
restarted on his home dose of NPH in addition to an adjusted
insulin sliding scale. Due to hypoglycemia, his NPH was
decreased to 12 units with SSI.
# Fall: ___ ~ 4:30 pm patient had a fall in the bathroom
which seems mechanical per patient's description. He hit the
posterior portion of his skull. He denied palpitations, chest
pain, light-headedness, syncope or any other symptoms. He was
able to get up afterwards without any issue. His neuro exam was
non-focal. CT head without contrast didn't show intracranial
bleed (he is on aspirin and plavix). He remained asymptomatic
after the fall. He remained alert and oriented x3 with normal
vital signs. No apparent trauma. Telemetry did not reveal acute
events.
# Prophylaxis: The patient received subcutaneous heparin during
this stay, and was encouraged to get up and ambulate as early as
possible.
# CODE STATUS: Full
# CONTACT/ HCP: ___ SPOUSE Phone number: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Hypotension, GIB
Major Surgical or Invasive Procedure:
___ EGD
___ intubation
___ extubation
History of Present Illness:
Mr. ___ is an ___ year old man with a history of CAD s/p
CABG
(___), severe TR s/p tricuspid valve clip (___) with
residual
mod 3+ TR, HFpEF, AF on eliquis, who is presenting as a transfer
from ___ with hypotension and c/f GIB.
Of note, he was recently admitted at ___ for enterococcal
bacteremia. There was c/f endocarditis iso recent tricuspid
clipping (although TEE ___ w/out sign of cardiac infxn), so he
was planned for 6wk abx course (through ___. He was discharged
on ___ to rehab with a PICC line in place. At rehab he was
noticed to be weak and hypotensive. He presented to ___ where he was noted to have melena and hypotension. He
was given 2uPRBCs (1 at ___, 1 on transfer), vanc and cefepime,
and started on levophed. He was transferred to ___ for further
evaluation.
On arrival in the ED his BP was 101/61, he was mentating well so
levophed was discontinued. He denied abdominal pain. Also denied
cough, chest pain or SOB, fevers, chills, n/v, dysuria or
hematuria. GI was consulted and agreed with ICU transfer for
more
likely brisk UGIB (LGI less likely given severity of anemia and
dark stools). Recommended intubating in the ICU for urgent EGD
tomorrow. He was started on IV PPI, and given flagyl.
In the ED,
- Initial Vitals: T 97.9, HR 88, BP 101/61, RR 24, SpO2 98%
- Exam: CTAB, RRR, abd NTND, oriented x 3, guaiac positive
stool
- Labs:
INR 2.0, ___ 21.5
Hgb 6.5, Hct 20.5
ALT 126, AST 211
K 5.6
Cr 2.3, BUN 107, AG19
VBG ___, lactate 3.9
Trop 0.09
- Imaging:
CXR: PICC line terminating in the lower superior vena cava. No
definite recent change since ___.
- Consults: GI
- Interventions: 2uPRBCs (OSH), IV PPI, Flagyl
On arrival in the FICU he is on 0.04 levophed and endorses the
above history. Is also complaining of b/l ___ pain that started
one hour ago, and which he describes as excruciating. Denies any
chest pain.
Past Medical History:
-CAD status post CABG in ___
-severe tricuspid insufficiency turned down for TVR at ___
-s/p TV clip ___
-hyperlipidemia
-atrial fibrillation on Eliquis s/p DCCV ___
-hypothyroidism
-HFpEF (EF 48% now 55%) with right-sided symptoms and admission
to ___ ___
-PH mild on echo
-falls
-depression
-Anemia
Social History:
___
Family History:
Mother deceased at ___, diabetes mellitus
Father at ___
Sister and brother have a history of colon cancer
Physical Exam:
GENERAL: NAD
EYES: Anicteric
HENT: oral mucosa moist
CV: Heart regular, holosystolic murmur ___, no S3, no S4. JVD
around 11 cm but suspect ___ TR
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic tenderness.
MSK: Moves all extremities, muscle wasting.
SKIN: No rashes
NEURO: AO x 4 today, moves all 4 extremities symmetrically and
with purpose
PSYCH: calm
DISCHARGE PHYSICAL EXAM:
GENERAL: NAD
EYES: Anicteric
HENT: oral mucosa moist
CV: Heart regular, holosystolic murmur ___, no S3, no S4. JVD
around 11 cm but suspect ___ TR. Trace ___ edema, no sacral
edema.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic tenderness.
MSK: Moves all extremities, muscle wasting.
SKIN: No rashes
NEURO: AO x 4 today, moves all 4 extremities symmetrically and
with purpose
PSYCH: calm
Pertinent Results:
LAB RESULTS ON ADMISSION:
====================
___ 08:51PM BLOOD WBC-11.0* RBC-2.18* Hgb-6.5* Hct-20.5*
MCV-94 MCH-29.8 MCHC-31.7* RDW-16.8* RDWSD-55.4* Plt ___
___ 04:15AM BLOOD WBC-15.5* RBC-2.54* Hgb-7.7* Hct-22.8*
MCV-90 MCH-30.3 MCHC-33.8 RDW-16.3* RDWSD-50.8* Plt ___
RELEVANT IMAGING
====================
___ BILATERAL LOWER EXTREMITY U/S:
1. No evidence of deep venous thrombosis in the right or left
lower extremity veins.
2. Nonspecific subcutaneous edema within the bilateral lower
extremities.
___ EGD:
In the upper esophagus, there was an area of trauma with no
active bleeding. In the stomach there was hematin on all the
walls and was washed thoroughly. There were multiple small
nonbleeding erosions throughout the body and antrum. There were
no lesions that required any intervention. Normal mucosa in the
whole examined duodenum.
___ TTE:
CONCLUSION:
The left atrium is mildly dilated. The right atrium is
moderately enlarged. 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 45-50%. There is
no resting left ventricular outflow tract gradient.
Moderately dilated right ventricular cavity with moderate global
free wall hypokinesis. The aortic sinus diameter is normal for
gender. The aortic valve leaflets (3) appear structurally
normal. There is no aortic valve
stenosis. There is trace 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. MitraClip prosthesis is present. There is
moderate to severe [3+] tricuspid regurgitation. Due to acoustic
shadowing, the severity of tricuspid regurgitation may be
UNDERestimated. There is mild pulmonary artery systolic
hypertension. In the setting of at least moderate to severe
tricuspid regurgitation, the pulmonary artery systolic pressure
may
be UNDERestimated. There is no pericardial effusion.
IMPRESSION: Mild LVH with mild LV systolic dysfunction.
Moderately dilated RV with probable moderate dysfunction. Mitral
clip on TV, does not appear fully attached, moderate to severe
TR. At least mild pulmonary hypertension. Mild mitral
regurgitation.
Compared with the prior TTE ___ (focused) HR is faster.
Findings are probably similar, LV and RV function probably
overestimated on prior study.
LAB RESULTS ON DISCHARGE:
==========================
___ 04:23AM BLOOD WBC-4.6 RBC-2.42* Hgb-7.2* Hct-23.3*
MCV-96 MCH-29.8 MCHC-30.9* RDW-17.0* RDWSD-57.1* Plt ___
___ 04:23AM BLOOD ___ PTT-28.6 ___
___ 04:23AM BLOOD Glucose-103* UreaN-42* Creat-1.4* Na-134*
K-4.2 Cl-94* HCO3-25 AnGap-15
___ 08:32AM BLOOD ALT-75* AST-47* LD(LDH)-395* AlkPhos-108
TotBili-0.4
___ 09:29AM BLOOD cTropnT-0.10*
___ 04:23AM BLOOD Calcium-8.0* Phos-2.9 Mg-2.3
___ 04:15AM BLOOD VitB___-___*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ampicillin 2 g IV Q6H
2. CefTRIAXone 2 gm IV Q12H
3. Heparin Flush (10 units/ml) 2 mL IV PRN and PRN, line flush
4. MetOLazone 2.5 mg PO EVREY OTHER DAY
5. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
6. Allopurinol ___ mg PO DAILY
7. Apixaban 2.5 mg PO BID
8. Aspirin 81 mg PO DAILY
9. Atorvastatin 80 mg PO QPM
10. Digoxin 0.125 mg PO DAILY
11. Ferrous Sulfate 325 mg PO DAILY
12. Finasteride 5 mg PO DAILY
13. Levothyroxine Sodium 75 mcg PO DAILY
14. multiv-min-FA-lycopene-lutein 1.25-2.5-7 mg oral DAILY
15. Pantoprazole 40 mg PO Q24H
16. Potassium Chloride 20 mEq PO DAILY
17. Potassium Chloride 20 mEq PO PRN WITH METOLAZONE with
metolazone
18. QUEtiapine Fumarate 12.5 mg PO QHS
19. Spironolactone 25 mg PO DAILY
20. Tamsulosin 0.4 mg PO QHS
21. Torsemide 120 mg PO BID
22. Tranylcypromine Sulfate 10 mg PO BID
23. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP TID:PRN itch
24. Metoprolol Succinate XL 12.5 mg PO DAILY
Discharge Medications:
1. Metoprolol Tartrate 6.25 mg PO BID
Hold for SBP <90, HR<55
2. Atorvastatin 20 mg PO QPM
3. QUEtiapine Fumarate 6.25 mg PO QHS
4. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
5. Allopurinol ___ mg PO DAILY
6. Ampicillin 2 g IV Q6H
7. CefTRIAXone 2 gm IV Q12H
8. Digoxin 0.125 mg PO DAILY
9. Ferrous Sulfate 325 mg PO DAILY
10. Finasteride 5 mg PO DAILY
11. Heparin Flush (10 units/ml) 2 mL IV PRN and PRN, line flush
12. Levothyroxine Sodium 75 mcg PO DAILY
13. multiv-min-FA-lycopene-lutein 1.25-2.5-7 mg oral DAILY
14. Pantoprazole 40 mg PO Q24H
15. Potassium Chloride 20 mEq PO DAILY
16. Potassium Chloride 20 mEq PO PRN WITH METOLAZONE with
metolazone
Hold for K >
17. Tamsulosin 0.4 mg PO QHS
18. Tranylcypromine Sulfate 10 mg PO BID
19. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP TID:PRN
itch
20. HELD- MetOLazone 2.5 mg PO EVREY OTHER DAY This medication
was held. Do not restart MetOLazone until your doctor tells you
to
21. HELD- Metoprolol Succinate XL 12.5 mg PO DAILY This
medication was held. Do not restart Metoprolol Succinate XL
until your doctor tells you to
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Hemorrhagic shock, likely UGIB from stomach erosions
Atrial fibrillation
___
Delirium
Acute kidney injury
History of Enterococcal Bacteremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph, AP portable upright.
INDICATION: Neck line placement. Hypotension.
COMPARISON: ___.
FINDINGS:
Right-sided PICC line terminates in the lower superior vena cava. Otherwise,
there has been no definite recent change since ___.
IMPRESSION:
PICC line terminating in the lower superior vena cava.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with patchy infiltrates on CXR // interval
changes interval changes
IMPRESSION:
Comparison to ___. No relevant change is seen. Moderate
cardiomegaly. Stable alignment of the sternal wires. Stable position of the
right PICC line. No pulmonary edema. No pleural effusions. No pneumonia.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with HFpEF, AF, presenting with hypotension and
concern for GIB, now s/p intubation and OG tube placement. // Confirm ET and
OG tube placement, any post-procedure complications Confirm ET and OG tube
placement, any post-procedure complications
IMPRESSION:
Comparison to ___, 5:16 a.m.. The tip of the endotracheal tube
projects 4.5 cm above the carinal. The course of the feeding tube is
unremarkable, the tip projects over the central parts of the stomach. Stable
moderate cardiomegaly. Mild retrocardiac atelectasis. No pneumonia, no
pulmonary edema, no pleural effusions. Correct position of the right PICC
line.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with UGIB, CAD, AF on eliquis with b/l ___ pain x
1 hour // DVT?
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
There is normal compressibility, color flow, and spectral doppler of the
bilateral common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is extensive atherosclerotic disease within the bilateral visualized
arteries. The left common femoral artery appears borderline dilated measuring
1.4 cm, similar to the CT performed 5 days prior.
Pulsatile venous waveforms are again seen.
No evidence of medial popliteal fossa (___) cyst.
There is moderate subcutaneous edema without focal fluid collection within the
bilateral lower extremities.
IMPRESSION:
1. No evidence of deep venous thrombosis in the right or left lower extremity
veins.
2. Nonspecific subcutaneous edema within the bilateral lower extremities.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hypotension, Transfer
Diagnosed with Gastrointestinal hemorrhage, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: uta
level of acuity: 1.0 | Mr. ___ is an ___ year old man with a history of recent
admission for enterococcal bacteremia, CAD s/p CABG, severe TR
s/p TV clipping (___), AF on eliquis, who presented from an
OSH with melena and hemorrhagic shock. The patient was
transfused total 4U pRBC. EGD revealed multiple non-bleeding
erosions of stomach. Home aspirin and Eliquis were discontinued.
Father ___ unfortunately had ongoing episodes of melena, and in
the setting of his advanced heart failure as well as ongoing
GIB, we held family meetings with regard to goals of care. At
the time of discharge, Father ___ expressed wish for no further
escalation of care, as well as no transfer to hospital. His goal
was to stay at ___ for as long as possible, surrounded by
his community, and to be comfortable. At the same time, he
continued to be interested in continuation of his current
medications, including antibiotics and cardiac medications. He
welcomed involvement of palliative care team and ___ and
further discussions regarding transition to hospice.
# Goals of care
Multiple family meetings were held with Father ___, his HCP
___, as well as niece ___. Father ___ expressed sadness
and frustration with his repeated hospitalizations. He shared
that he was tired of being in and out of the hospital, and that
his goal would really be to stay at ___ for as long as
possible, surrounded by his community. He would like to focus
his care on comfort at this time, and would not want further
invasive procedures; he also would not want to be back in the
hospital (even if this means that he should pass away sooner).
He notes that previously hospice had been mentioned, and he is
interested in hearing more- although isn't quite ready for this
yet. He remains interested in his current oral medications as
well as IV antibiotics.
Specifically, with regard to his GIB, he is not interested in
repeated endoscopies or transfusions. He would also like to
limit blood draws. We discussed his anticoagulation, and given
that he has ongoing bleed with no plan for intervention, this
will be held, understanding the risk of clots/stroke given
atrial fibrillation.
He is confirmed to be DNR/DNI, no invasive procedures, no
transfer to hospital. He would be interested in further
discussion with the palliative care team at ___, with
potential for eventual transition to hospice. MOLST form was
filled out with these wishes.
# Hemorrhagic shock
# Likely UGIB from erosions in stomach
Presented with most likely UGIB with multiple small nonbleeding
erosions seen in the stomach on EGD ___ which is most likely
source. S/p 4u pRBC total per prior notes, including total of 2u
pRBC here. Family meeting was held, during which we discussed
best way forward for management of his GIB. As above, he was not
interested in repeated endoscopies, blood transfusions, and
wished to limit blood draws. After discussion of risks/benefits,
home apixaban was held, understanding risk of stroke given
underlying atrial fibrillation. Last Hgb was 7.2.
# Atrial Fibrillation
Patient was frequently tachycardic. Home metoprolol and digoxin
were initially held due to hemorrhagic shock, restarted once BP
stabilized. Apixaban held due to GI bleed. He was sent home on
fractionated metoprolol 6.25 mg BID with holding parameters,
would continue to discuss need for this medication.
# Delirium
Patient noted to have mild hyperactive delirium post-extubation
with agitation. Resolved. He was maintained on half of home
quetiapine.
# ___
Creatinine 2.3 on admission from baseline ~1.6. Likely pre-renal
in setting of hemorrhagic shock. Improved to 1.4 at time of last
check.
# HFpEF
Home torsemide and Metolazone were initially held in setting of
hemorrhagic shock. When restarted at 120 mg torsemide BID,
patient was net negative ___. Hence this was restarted at
lower dose of 120 mg daily, on which weight was stable and net
negative 300 mL. Discharge weight is 123.9 lbs.
# Enterococcal bacteremia
# C/f new infectious source
Recent admission for enterococcus faecalis bacteremia (blood cx
+ @ BI-N on ___, negative since ___. Etiology unclear at last
admission given CT A/P unremarkable and no obvious GI/GU source
and TEE without obvious endocarditis/vegetation. Given recent TV
clipping, ID plan to treat for endocarditis/clip involvement and
OPAT orders for IV ampicillin 2g q6h and CTX 2g q6h through
___.
- Continue ampicillin and ceftriaxone till ___ to complete 6
week course (he is still interested in this)
# Type II NSTEMI
# CAD s/p CABG (___)
# Transaminitis
Trop on admission to 0.09 although denies any chest pain. Likely
Type II NSTEMI in setting of hemorrhagic shock and demand
ischemia also with elevated LFTs (now downtrending) likely
related to hypotension. TTE reassuring. trops stable. Restarted
atorvastatin at low dose of 20 mg, but ongoing discussion wrt
medications given overall goals of care. Aspirin discontinued
(discussed with cardiology).
# B/l ___ pain
Reported some b/l thigh pain x ___ year with weakness. Also
endorsing b/l calf pain. B/l LEs are warm with 2+ pulses. LENIs
negative for DVT. B12 normal. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Left Intraparenchymal Hemorrhage.
Major Surgical or Invasive Procedure:
___ - Left decompressive hemicraniectomy
___ - Trach/PEG
History of Present Illness:
Eu Critical, ___, aka ___, was last seen normal by
her daughter at ___ on ___. She had been complaining of a
headache for the past day, after being hit in the head with a
box while at work at ___. She told her daughter that she
could not go to work as she did not feel well and was dizzy, and
laid on the ground where she was noted to have a facial droop
and started to slur her speech. Her daughter called ___ where
EMS noted to her to be flaccid on the right and a decreasing
mental status en route. She was brought to ___
where she was intubated and a CT head showed a large left sided
intraparenchymal hemorrhage. She was then sent to ___ for
further neurosurgical management. Upon arrival at ___, her
pupils were non-reactive and anisocoric and she had extensor
posturing in all four extremities. She was given 100g Mannitol
and 1000mg Keppra. A Nicardipine gtt was initiated to maintain
SBP<140.
Past Medical History:
Hypertension
Social History:
___
Family History:
Family Hx:
Non contributory.
Physical Exam:
ON ADMISSION:
=============
O: BP: 114/76 HR: 92 R:22 O2Sats: 100% intubated
HEENT: Pupils: Anisorcoric Left 5mm, non-reactive, Right 3mm
non-reactive
Extrem: Warm and well-perfused.
___ Coma Scale:
[x]Intubated
Eye Opening:
[x]1 Does not open eyes
[ ]2 Opens eyes to painful stimuli
[ ]3 Opens eyes to voice
[ ]4 Opens eyes spontaneously
Verbal:
[x]1 Makes no sounds
[ ]2 Incomprehensible sounds
[ ]3 Inappropriate words
[ ]4 Confused, disoriented
[ ]5 Oriented
Motor:
[ ]1 No movement
[x]2 Extension to painful stimuli (decerebrate response)
[ ]3 Abnormal flexion to painful stimuli (decorticate response)
[ ___ Flexion/ withdrawal to painful stimuli
[ ]5 Localizes to painful stimuli
[ ]6 Obeys commands
_4T_ Total
ICH Score:
GCS
[x]2 GCS ___
[ ]1 GCS ___
[ ]0 GCS ___
ICH Volume
[x]1 30 mL or Greater
[ ]0 Less than 30 mL
Intraventricular Hemorrhage
[ ]1 Present
[x]0 Absent
Infratentorial ICH
[ ___ Yes
[x]0 No
Age
[ ]1 ___ years old or greater
[x]0 Less than ___ years old
Total Score: __3__
Neuro:
Mental status: Intubated, sedation was held for exam - no EO to
noxious
Cranial Nerves:
I: Not tested
II: Pupils: Anisorcoric Left 5mm, non-reactive, Right 3mm
non-reactive
III-XII: +corneal reflexes bilaterally, +Gag, +cough
Motor: Extensor posturing to noxious stimuli in all four
extremities
ON DISCHARGE:
=============
Opens eyes: [ ]spontaneous [ ]to voice [x]to noxious
Follows commands: [ ]Simple [ ]Complex [x]None
Pupils: PERRL ___
Speech Fluent: [ ]Yes [x]No verbal output
Comprehension intact [ ]Yes [x]No
Motor:
Withdraws to noxious stimulus in all four extremities. Increased
resting muscle tone throughout.
Wound:
Left hemicraniectomy incision
[x]Clean, dry, intact, wound edges well approximated
PEG
[x]2x2 gauze bumper under PEG site, redness evaluated by ACS, 2
sutures removed by ACS and bumper rotated
Pertinent Results:
Please see OMR for pertinent lab and imaging studies.
___ 04:15AM BLOOD WBC-5.5 RBC-3.17* Hgb-10.7* Hct-33.9*
MCV-107* MCH-33.8* MCHC-31.6* RDW-15.4 RDWSD-60.8* Plt ___
___ 04:25AM BLOOD ___ PTT-25.9 ___
___ 04:15AM BLOOD Glucose-116* UreaN-18 Creat-0.6 Na-141
K-4.6 Cl-97 HCO3-34* AnGap-10
___ 02:50PM BLOOD ALT-85* AST-39 LD(LDH)-304* AlkPhos-101
TotBili-0.3
___ 09:21AM BLOOD CK-MB-1 cTropnT-<0.01
___ 04:15AM BLOOD Calcium-10.8* Phos-3.4 Mg-1.9
___ 04:45PM BLOOD HCV Ab-NEG
___ 11:05PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:45PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
___ 04:40AM BLOOD PTH-27
___ 04:45PM BLOOD Free T4-1.3
___ 04:45PM BLOOD TSH-1.3
___ 04:40AM BLOOD 25VitD-26*
Pertinent recent imaging:
Bilateral ___ US ___
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
CTA Chest ___
IMPRESSION:
1. There is a re-demonstrated nonocclusive pulmonary embolism in
the segmental branches of the left upper lobe as seen on the
head and neck CTA performed earlier today. No additional
pulmonary emboli are visualized. No imaging evidence of right
heart strain.
2. Emphysema.
3. Additional findings above.
CTA Head and Neck ___
IMPRESSION:
1. Acute pulmonary embolus left upper lobe.
2. Multifocal areas of intracranial arterial narrowing, may
represent
vasospasm,, differential diagnosis is vasculopathy.
3. Grossly stable appearance following left craniotomy and
decompression with persistent extracranial brain herniation.
Minimal interval decreased size of rim enhancing left
parenchymal subacute hematoma. Follow-up recommended to
document resolution.
4. Stable mass effect, hydrocephalus.
5. Multiple punctate infarcts are stable.
6. Transverse sinuses better evaluated on prior MRI.
7. No significant narrowing CTA neck.
8. Diffusely enlarged thyroid gland, consider thyroiditis.
MRI Head ___
IMPRESSION:
Multiple punctate areas of restricted diffusion in the right
temporal,
parietal and frontal lobes in keeping with acute embolic
infarcts.
Filling defect in the left transverse sinus suggestive of dural
venous sinus thrombosis, which is new compared to prior.
The patient is status post left frontotemporoparietal
decompressive surgery. The hematoma is decreased in size and
there is decreased mass effect. The amount of transcranial
herniated brain tissue is slightly increased compared to prior.
There is two small rim enhancing extracranial collections
anterior to the
transcranial herniated brain tissue as described above. These
are nonspecific and may represent rim enhancing hematomas, but
infection/abscesses should be considered in the differential
diagnosis.
Abominal US ___
IMPRESSION:
Normal abdominal ultrasound.
Medications on Admission:
Medications prior to admission:
Hydrochlorothiazide 25mg PO daily
Folic Acid 1mg PO Daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
Do not exceed 4GM acetaminophen in 24 hours.
2. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
3. Docusate Sodium 100 mg PO BID
4. Famotidine 20 mg PO BID
5. Glycopyrrolate 1 mg PO BID
6. Heparin 5000 UNIT SC BID
7. LevETIRAcetam 1250 mg PO BID
8. Metoprolol Tartrate 50 mg PO Q6H
9. Multivitamins W/minerals Liquid 15 mL PO DAILY
10. Nystatin Oral Suspension 5 mL PO QID
11. Senna 8.6 mg PO BID constipation
12. Thiamine 100 mg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. FoLIC Acid 1 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Intraparenchymal Hemorrhage
Seizure
Nonocclusive Pulmonary Embolism
Multiple Embolic Strokes
Venous Sinus Thrombosis
Tachycardia
Hypertension
Pneumonia, H. Flu
Thrombocytopenia
Respiratory Failure
Transaminitis
Discharge Condition:
Mental Status: Nonverbal
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with IPH// remained intubated post-op. please
eval lung fields
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
IMPRESSION:
Lungs are low volume with bibasilar atelectasis. Support lines and tubes
unchanged. Cardiomediastinal silhouette is stable. There is no pleural
effusion. No pneumothorax is seen
Radiology Report
EXAMINATION: PORTABLE HEAD CT W/O CONTRAST Q151 CT HEAD
INDICATION: ___ year old woman with large left IPH s/p craniectomy// post op
scan
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Found no primary dose record and no dose record stored with the sibling
of a split exam.
!If this Fluency report was activated before the completion of the dose
transmission, please reinsert the token called CT DLP Dose to load new data.
COMPARISON: Head CT ___
FINDINGS:
There is large acute intraparenchymal hematoma centered on left frontal lobe,
involving centrum semiovale, corona radiata, extending into basal ganglia, sub
insula, upper left temporal lobe. Dominant component of hematoma measures 8.6
cm x 4.8 cm, similar compared with ___ at 23:28. Along the upper
margin at the vertex, hematoma has mildly increased, measuring 8.5 cm x 4.3
cm, compared with 8.1 cm x 3.7 cm on prior. There is mild surrounding edema.
There has been interval left frontoparietal craniectomy. There is
intraventricular extension of hemorrhage, with volume of intraventricular
hemorrhage worsened since prior.
Small area of hypodensity within upper margin of hematoma may be related to
hyperacute bleed.
The midline shift is 1.7 cm to the right, compared with 1.9 cm on prior. Left
uncal herniation is improved. Hydrocephalus is again seen, left atrium is
more dilated, right atrium, temporal horn is minimally improved. Partially
preserved suprasellar cistern. Effaced perimesencephalic cistern. Partially
effaced pre pontine cistern. Patent foramen magnum. Mild edema surrounding
hematoma is stable. No evidence of PCA infarct.
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:
Interval craniectomy. Large acute hematoma centered on left frontal lobe has
mildly increased along its upper extent, and contains small area of hyperacute
component of bleed along the upper margin.
Improved left uncal herniation. Improved midline shift, measuring 1.7 on
current study. Worsened intraventricular component of hemorrhage, with mildly
improved hydrocephalus.
Remainder as above
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with PICC// Pt had a L PICC,45cm ___ ___
Contact name: ___: ___
TECHNIQUE: Portable AP chest
COMPARISON: There is made to most recent chest radiograph performed 5 hours
prior.
FINDINGS:
Interval placement of a left PICC line terminating in the distal SVC. All
other monitoring support devices appear in stable and unchanged position.
There is no pleural effusion or pneumothorax. The cardiomediastinal
silhouette is stable and unchanged.
IMPRESSION:
Left PICC line terminating in the distal SVC.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with left intraparenchymal hemorrhage status
post decompressive craniectomy. Evaluate for underlying lesion.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 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 ___.
CTA from outside institution ___.
FINDINGS:
Patient is status post left frontoparietal decompressive craniectomy with
postsurgical changes. As demonstrated on prior CT examinations, there is a
large left hemispheric intraparenchymal hemorrhage with varying chronicity of
blood products in surrounding vasogenic edema occupying almost the entirety of
the left frontal lobe. There is similar intraventricular extension with blood
products layering in the bilateral lateral ventricle occipital horns. No
evidence of new areas of hemorrhage or hyperacute bleed. A band of restricted
diffusion medial to the area of hemorrhage involving left cingulate gyrus and
adjacent left frontal lobe is noted (see 5, 6: 21). Suggested areas of
superimposed blood products are also noted (see 10:17).
There is slightly decreased rightward midline shift measuring 13 mm,
previously 17 mm. There is similar near complete effacement of the left
lateral ventricle and mild left uncal herniation.
The major intracranial flow voids are preserved. The dural venous sinuses are
patent post-contrast MPRAGE sequences..
There is mild mucosal thickening of the left sphenoid sinus. Otherwise, the
remaining paranasal sinuses, middle ear cavities and mastoid air cells are
clear. The orbits do not demonstrate any acute abnormalities bilaterally.
There is no abnormal enhancement after contrast administration.
IMPRESSION:
1. Postsurgical changes status post left decompressive hemicraniectomy.
2. Grossly stable sized large left frontal intraparenchymal hemorrhage with
varying chronicity of blood products and intraventricular extension, with no
evidence of definitive underlying lesion.
3. Slight interval decrease in rightward midline shift, now 13 mm, previously
17 mm.
4. Similar degree of left ventricular effacement and mild left uncal
herniation, with grossly stable intraventricular hemorrhage.
5. No evidence of enhancing parenchymal lesions or new areas of hemorrhage.
6. Findings concerning for acute to subacute left cingulate gyrus adjacent
frontal lobe infarct medial to area of intraparenchymal hemorrhage, with
questioned associated areas of hemorrhage.
Radiology Report
INDICATION: ___ year old woman with left BG IPH, evaluate for underlying
malignancy// CT torso with and without contrast to evaluate for underlying
malignancy
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were
acquired through the chest, abdomen and pelvis following intravenous contrast
administration with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 965 mGy-cm.
COMPARISON: None.
FINDINGS:
CHEST:
An endotracheal tube is appropriately positioned. An enteric tube terminates
in the stomach. Left-sided PICC terminates in the upper SVC.
The thyroid gland enhances homogeneously. There is no axillary, mediastinal,
or hilar lymphadenopathy by CT size criteria.
Heart is normal size. There is no pericardial effusion. The thoracic aorta
is normal in caliber. The central pulmonary arteries are well opacified.
There is a small amount of secretions in the central airways. The airways are
patent to subsegmental level. There is moderate biapical emphysema, right
worse than left. There is a punctate calcified nodule in the right middle
lobe (series 302, image 171). There is mild dependent atelectasis. No
consolidation. There is no pleural 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.
High-density material within the gallbladder likely represents vicarious
excretion of contrast.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no hydronephrosis. Multiple millimetric hypodensities in the kidneys
are too small to characterize but is statistically likely represent cysts.
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. There is a substantial amount of stool in
the colon and rectum, most severe within the rectum and sigmoid colon.
PELVIS: The urinary bladder and distal ureters are unremarkable. The bladder
is decompressed around a Foley catheter and contains a small amount of air.
Small amount of dependent pelvic free fluid could be physiologic.
REPRODUCTIVE ORGANS: Heterogeneous appearance of the uterus containing
multiple rounded hypoenhancing foci is likely due to multiple fibroids.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
No evidence of malignancy in the chest, abdomen, or pelvis.
Substantial stool burden in the distal colon and rectum.
Radiology Report
INDICATION: ___ year old woman with left BG IPH, evaluate for underlying
malignancy// CT torso with and without contrast to evaluate for underlying
malignancy
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were
acquired through the chest, abdomen and pelvis following intravenous contrast
administration with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 965 mGy-cm.
COMPARISON: None.
FINDINGS:
CHEST:
An endotracheal tube is appropriately positioned. An enteric tube terminates
in the stomach. Left-sided PICC terminates in the upper SVC.
The thyroid gland enhances homogeneously. There is no axillary, mediastinal,
or hilar lymphadenopathy by CT size criteria.
Heart is normal size. There is no pericardial effusion. The thoracic aorta
is normal in caliber. The central pulmonary arteries are well opacified.
There is a small amount of secretions in the central airways. The airways are
patent to subsegmental level. There is moderate biapical emphysema, right
worse than left. There is a punctate calcified nodule in the right middle
lobe (series 302, image 171). There is mild dependent atelectasis. No
consolidation. There is no pleural 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.
High-density material within the gallbladder likely represents vicarious
excretion of contrast.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no hydronephrosis. Multiple millimetric hypodensities in the kidneys
are too small to characterize but is statistically likely represent cysts.
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. There is a substantial amount of stool in
the colon and rectum, most severe within the rectum and sigmoid colon.
PELVIS: The urinary bladder and distal ureters are unremarkable. The bladder
is decompressed around a Foley catheter and contains a small amount of air.
Small amount of dependent pelvic free fluid could be physiologic.
REPRODUCTIVE ORGANS: Heterogeneous appearance of the uterus containing
multiple rounded hypoenhancing foci is likely due to multiple fibroids.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
No evidence of malignancy in the chest, abdomen, or pelvis.
Substantial stool burden in the distal colon and rectum.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with IPH// Assess ETT position and for any
pulmonary congestion Assess ETT position and for any pulmonary congestion
IMPRESSION:
Compared to a chest radiographs ___.
Tip of the endotracheal tube is now at the upper margin of the clavicles,
approximately 6 cm from the carina. This is standard position if the chin,
not in the field of view, is elevated. Nasogastric drainage tube ends in the
upper stomach.
Lungs clear. Normal cardiomediastinal and hilar silhouettes and pleural
surfaces.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with L frontal IPH s/p hemicrani// intubated to
eval ETT intubated to eval ETT
IMPRESSION:
Compared to chest radiographs ___ through ___.
ET tube, nasogastric tube, left PIC line in standard placements. Lungs clear.
Heart size normal. No pleural abnormality.
Radiology Report
EXAMINATION: PORTABLE HEAD CT W/O CONTRAST Q151 CT HEAD
INDICATION: ___ year old woman with left IPH. Please perform portable CT, s/p
craniectomy.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Found no primary dose record and no dose record stored with the sibling
of a split exam.
!If this Fluency report was activated before the completion of the dose
transmission, please reinsert the token called CT DLP Dose to load new data.
COMPARISON: Portable head CT from ___. CTA from ___.
MR from ___.
FINDINGS:
Again noted is a large intraparenchymal mixed density hematoma involving the
left cerebral hemisphere with the center in the left frontal lobe, associated
with significant effacement of the left lateral ventricle and sulci and
causing a left to right shift of normally midline structures of approximately
1 cm, comparable to the prior exam from ___. The
irregularly-shaped high-density component of the hematoma measures
approximately 8.5 x 5.1 cm (series 2; image 19), similar to the prior exam.
This is surrounded by a hypodense component and edema, spanning an area
approximately 9.4 x 6.7 cm. Again noted is intraventricular extension of the
hemorrhage involving the posterior horns of lateral ventricles, increased from
the prior study. Focus of subarachnoid hemorrhage dependently in the right
sylvian fissure (series 2, image 15) appears new from prior examination,
presumably secondary to redistribution. Visualization of the pontine cistern
is limited due to artifact but the partial effacement of the pontine cistern
appears unchanged. The pneumocephalus is slightly decreased. There remains a
ventriculomegaly, overall similar in size from prior exam.
Temporoparietal bone defects associated with the left craniectomy are again
noted. Otherwise, there is no evidence of fracture. The visualized portion
of the paranasal sinuses demonstrate mild mucosal thickening in the ethmoid
sinus. The mastoid air cells and middle ear cavities are clear. The
visualized portion of the orbits are unremarkable.
IMPRESSION:
1. Evolution of the large intraparenchymal frontal lobe hemorrhage with
interval increase in the intraventricular extent, without significant change
in mass effect.
2. Trace subarachnoid hemorrhage layering in the right sylvian fissure,
presumably secondary to redistribution. No evidence of new areas of
hemorrhage or large territory infarction.
3. Additional findings as described above, including unchanged
ventriculomegaly and 1 cm rightward midline shift.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with Left frontal IPH// Remains intubated,
please evaluate lung fields
IMPRESSION:
In comparison with the study of ___, the monitoring and support devices
are stable. No evidence of pneumonia, vascular congestion, or pleural
effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with IPH, s/p intubation// interval change
IMPRESSION:
In comparison with the study of ___, the monitoring and support devices
are unchanged. No evidence of pneumonia, vascular congestion, or pleural
effusion.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with IPH// interval change
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 10.0 s, 17.0 cm; CTDIvol = 48.8 mGy (Head) DLP =
829.0 mGy-cm.
Total DLP (Head) = 843 mGy-cm.
COMPARISON: Head CT of ___. Brain MRI of ___.
FINDINGS:
Patient is status post left hemicraniectomy for decompression in the setting
of a large, mixed density intraparenchymal hematoma centered in the left
frontal lobe, which continues to evolve and now measures approximately 8.5 x
6.0 cm including surrounding vasogenic edema. The overall, this appears
unchanged given differences in measurement technique (03:23). Few fluid fluid
levels within hematoma may represent liquefaction or coagulopathy. There
remains a similar degree of the effacement left lateral ventricle, with a
grossly unchanged 10 mm of rightward midline shift. Intraventricular
hemorrhage in layering in posterior horns of the lateral ventricles is grossly
unchanged. Mild dilation of the right lateral ventricle is similar to prior.
Interval reduction in subarachnoid blood products layering in the right
sylvian fissure. Effacement of the perimesencephalic, prepontine cistern
appears unchanged. No new/increasing hemorrhage. No evidence of superimposed
acute large territorial infarct.
Left hemi craniectomy changes are again demonstrated. Partial paranasal sinus
opacification is mildly worsened with more fluid in this left sphenoid sinus.
The visualized portion of the orbits are unremarkable.
IMPRESSION:
1. Similar appearance of an evolving large left frontal lobe intraparenchymal
hemorrhage with surrounding edema. Few fluid fluid levels within hematoma may
be from liquefaction or coagulopathy. Hemicraniectomy. Approximately 10 mm
of rightward midline shift is similar. No evidence of new or increasing
hemorrhage.
2. Stable dilatation of the right lateral ventricle.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with PNA, intubated// PNA PNA
IMPRESSION:
Compared to chest radiographs ___ through ___.
Lungs are clear. Heart size normal. No pleural abnormality.
ET tube ends at the thoracic inlet with the chin down; a should not be
withdrawn any further. Left PIC line ends in the low SVC. Nasogastric
drainage tube ends in the upper portion of a nondistended stomach.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with ETT advancement// eval for ETT placement
IMPRESSION:
In comparison with the study of ___, the monitoring support devices
are unchanged. Cardiac silhouette remains within normal limits and there is
no vascular congestion, pleural effusion, or acute focal pneumonia.
Specifically, the tip of the endotracheal tube lies approximately 3 cm above
the carina.
Radiology Report
INDICATION: ___ year old woman- intubated// confirm placement
TECHNIQUE: Portable AP chest radiograph.
COMPARISON: Chest radiograph dated ___ and ___.
FINDINGS:
The endotracheal tube terminates approximately 4.6 cm above the carina,
unchanged. Left PICC line terminates in the cavoatrial junction. The enteric
tube extends into the stomach and out of view. The lungs are clear. The
pulmonary vascular is unremarkable. No pleural effusion or pneumothorax. The
cardiomediastinal silhouette is unremarkable. No acute osseous abnormalities.
IMPRESSION:
1. The endotracheal tube terminates in approximately 4.6 cm above the carina,
unchanged.
2. No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with IPH, s/p trach// pna, please eval
pna, please eval
IMPRESSION:
Comparison to ___. The endotracheal tube has been removed, new
tracheostomy tube is in correct position. No pneumothorax or
pneumomediastinum. Minimal right basal atelectasis. Normal size of the
heart. No pleural effusions.
Radiology Report
INDICATION: ___ year old woman with left IPH s/p left decompressive
craniectomy// Evaluate for pneumonia
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
A tracheostomy tube is present. The tip of a left PICC line projects over the
cavoatrial junction.
There is no focal consolidation, pleural effusion or pneumothorax identified.
Minimal bibasilar atelectasis is again noted..
IMPRESSION:
No significant interval change since the prior chest radiograph.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with lengthy immobilization, febrile to 102.7//
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 compressibility is
demonstrated in the posterior tibial and peroneal veins bilaterally.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Radiology Report
INDICATION: ___ year old woman with large left ICH with large midline shift
s/p craniectomy ___, s/p trach/PEG ___// Febrile and tachycardic and
febrile r/o PE
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.7 s, 35.2 cm; CTDIvol = 9.6 mGy (Body) DLP = 336.8
mGy-cm.
2) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 16.6 mGy (Body) DLP =
8.3 mGy-cm.
Total DLP (Body) = 345 mGy-cm.
COMPARISON: CT of the chest ___
FINDINGS:
The heart is normal in size and there is no pericardial effusion. No
appreciable atherosclerotic calcifications in the coronaries or major vessels.
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no
evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main and right pulmonary arteries are
normal in caliber, and there is no evidence of right heart strain.
0.6 cm lymph node in the left supraclavicular station is unchanged node not
pathologically enlarged. There is no axillary, mediastinal, or hilar
lymphadenopathy. The thyroid gland appears unremarkable.
There are no pleural space abnormalities.
Tracheostomy terminates in good position. Moderate quantity of secretions in
both lower lobes airways, left greater than right. There are no confluent
consolidations concerning for pneumonia with mild dependent bibasilar
atelectasis. There is a new a dilated subsegmental bronchus seen in the right
lower lobe (2:75 with a nodular opacity seen distal to this dilated airway.
There is surrounding ground-glass changes in the adjacent lung and findings
may reflect focal bronchial dilatation secondary to distal mucous plugging.
Centrilobular and paraseptal emphysema is mild and predominantly of the upper
lobes.
Limited images of the upper abdomen show minimal free air, possibly related to
the PEG performed 5 days ago. For clinical correlation.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
IMPRESSION:
-No evidence of pulmonary embolism.
-Moderate quantity of secretions in both lower lobes airways but no evidence
of pneumonia.
-New focally dilated subsegmental bronchus in the right lower lobe with distal
nodular opacification possibly reflecting mucous plugging within the distal
airway and upstream dilatation. Attention on follow-up imaging is
recommended.
-Limited images of the upper abdomen show minimal quantity of free air,
possibly related to the recent PEG, for clinical correlation.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with +increase oral secretions and ? mucous
plugging on CT// ? interval changes of secretions
TECHNIQUE: Portable AP chest
COMPARISON: Comparison is made to chest radiograph performed ___.
FINDINGS:
There has been interval removal of the left PICC line. Tracheostomy tube is
midline. There is no effusion, consolidation, or pneumothorax. No definitive
evidence of mucous plugging is identified. The cardiomediastinal silhouette
is normal.
IMPRESSION:
The lungs are clear without evidence of effusion or consolidation. There is
no definitive evidence of mucous plugging.
Radiology Report
INDICATION: ___ year old woman with tracheostomy, has had intermittent fevers
and productive cough.// evaluate for pneumonia vs atelectasis
TECHNIQUE: AP chest radiograph.
COMPARISON: Chest radiograph dated ___.
FINDINGS:
The lungs are clear. The pulmonary vasculature is unremarkable. No pleural
effusion or pneumothorax. The cardiomediastinal silhouette is normal. No
acute osseous abnormalities.
IMPRESSION:
No evidence of pneumonia or atelectasis.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman febrile with elevated LFTs.// Please evaluate
for hepatobilliary cause of fever/elevated LFT
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: ___ CT abdomen and pelvis with and without IV
contrast.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 3 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 7.9 cm.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Normal abdominal ultrasound.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with intermittent fevers, tracheostomy with
productive cough.// evaluate for pneumonia evaluate for pneumonia
IMPRESSION:
Compared to chest radiographs ___ through ___.
Lung volumes are low but there is no focal pulmonary abnormality. Heart size
normal. No pneumothorax or pleural effusion. Tracheostomy tube midline.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p Left decompressive hemicraniectomy now with
continued fevers. CXR to evaluate for etiology of fevers.// CXR to evaluate
for etiology of fevers. CXR to evaluate for etiology of fevers.
IMPRESSION:
Comparison to ___. Tracheostomy tube in situ. Normal size of
the heart. No pleural effusions. No pulmonary edema, no pneumonia. Normal
hilar and mediastinal contours.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST ___ MR HEAD
INDICATION: ___ year old woman with IPH s/p hemicraniectomy for decompression,
now with persistent fevers, no identified source// please eval for any
possible source of infection
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of Gadavist intravenous contrast, axial imaging was performed
with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE
imaging was performed and re-formatted in axial and coronal orientations.
COMPARISON: Prior MR done ___.
FINDINGS:
The patient is status post left frontotemporoparietal decompressive surgery.
Large left frontal intraparenchymal hematoma is once again noted and is
decreased in size compared to prior imaging currently measuring 93 x 44 mm in
the axial plane (previously 100 x 58 mm). Amount of blood in the ventricular
occipital horns also improved. There is interval decrease in mass effect and
midline shift currently 5 mm (previously 10 mm). Transcranial herniation of
the left frontal temporal and parietal lobes are slightly increased compared
to prior.
Multiple punctate areas of restricted diffusion in the right temporal,
parietal and frontal lobes in keeping with acute infarcts.
There is a small extra-axial collection anterior to the transcranial
herniating left frontal lobe (series 101, image 79) measuring 12 x 9 mm which
demonstrates rim enhancement and mild restricted diffusion (this may also be
pseudo restricted diffusion due to blood products) which may represent rim
enhancement surrounding blood products, but infection/abscess should be
considered in the differential.
There is a small extra-axial fluid collection anterior to the herniated left
temporal lobe measuring 16 x 14 mm in diameter which demonstrates mild rim
enhancement, but does not demonstrate restricted diffusion. Again this may
represent liquified blood products or infection/abscess.
There is mild reactive enhancement of the extracranial soft tissues
surrounding the herniated brain tissue.
Filling defect present in the left transverse sinus suggestive of dural venous
sinus thrombosis.
Wallerian degeneration extending along the left corticospinal tract.
Retained fluid present in the nasopharynx. Moderate mucosal thickening
involving the left posterior ethmoid air cells and sphenoid sinus. The orbits
appear normal. The intracranial arteries demonstrate normal T2 flow voids.
Fluid present in the mastoid air cells bilateral.
IMPRESSION:
Multiple punctate areas of restricted diffusion in the right temporal,
parietal and frontal lobes in keeping with acute embolic infarcts.
Filling defect in the left transverse sinus suggestive of dural venous sinus
thrombosis, which is new compared to prior.
The patient is status post left frontotemporoparietal decompressive surgery.
The hematoma is decreased in size and there is decreased mass effect. The
amount of transcranial herniated brain tissue is slightly increased compared
to prior.
There is two small rim enhancing extracranial collections anterior to the
transcranial herniated brain tissue as described above. These are nonspecific
and may represent rim enhancing hematomas, but infection/abscesses should be
considered in the differential diagnosis.
NOTIFICATION: The findings were discussed by Dr. ___ with
Dr. ___ on the ___ ___ at 9:35 am, 10 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ year old woman with large left IPH, s/p L decompressive
craniectomy on ___, now with left VST and embolic infarcts// Evaluate for
embolic stroke etiology
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of Omnipaque intravenous contrast material. Three-dimensional
angiographic volume rendered, curved reformatted and segmented images were
generated on a dedicated workstation. This report is based on interpretation
of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.5 mGy-cm.
2) Spiral Acquisition 4.8 s, 38.0 cm; CTDIvol = 13.3 mGy (Body) DLP = 504.0
mGy-cm.
3) Stationary Acquisition 4.1 s, 0.5 cm; CTDIvol = 23.8 mGy (Body) DLP =
11.9 mGy-cm.
Total DLP (Body) = 516 mGy-cm.
Total DLP (Head) = 748 mGy-cm.
COMPARISON: MR head ___, CT head ___, MR head ___.
FINDINGS:
CT HEAD:
The patient is again seen status post left craniotomy and decompression with
extensive postsurgical changes. Overall, the degree of local edema, mass
effect, and 6 mm of rightward midline shift appears similar to the most recent
prior brain MRI examination. The extent of extracranial brain herniation
appears similar. The ventricular system is dilated but unchanged from the
previous examination.
As compared to the most recent prior CT examination, the extent of
intraventricular hemorrhage has decreased. Numerous focal hypodensities
within the right frontal, parietal, and temporal lobes correspond with areas
of known infarct as seen on recent MRI examination.
Rim enhancing fluid collections anterior to the herniated left frontal lobe
measure 7 x 6 mm, previously 12 x 9 mm (3:268), and anterior to the herniated
left temporal lobe measuring 15 x 7 mm, previously 16 x 14 mm (3:245).
Mucosal thickening and secretions are seen in the left sphenoid sinus. The
right frontal sinus is underpneumatized. The remainder of the paranasal
sinuses, middle ear cavities, and mastoid air cells are clear. The orbits are
grossly unremarkable bilaterally.
CTA HEAD AND NECK:
There is a 2 vessel aortic arch. The vertebral arteries are patent
bilaterally. The common carotid arteries are also patent bilaterally, with
mild noncalcified atherosclerotic plaque seen at the bilateral carotid bulbs.
There is no evidence of internal carotid stenosis by NASCET criteria.
Mild atherosclerotic disease is seen involving the right greater than left
cavernous internal carotid arteries. Moderate narrowing of both paraclinoid
and supraclinoid ICA. Areas of moderate narrowing right M1, medial left M1,
moderate narrowing right M2 M3, mild narrowing left M2 M3, moderate narrowing
right A2, mild narrowing right M1, mild narrowing A3 segments findings are
largely new or worsened since prior, may represent vasospasm if there is been
subarachnoid hemorrhage, or underlying arteriopathy.
Moderate narrowing right P 2, P3 segments. Mild narrowing left P2 segment.
Long segment small caliber basilar artery, similar to prior.
Dural venous sinuses were better evaluated on MRI ___.
OTHER:
Acute subsegmental pulmonary embolus is seen in the left upper lobe. Chest CT
recommended further evaluation.
A tracheostomy is noted with endotracheal tube terminating in the lower
thoracic trachea. The visualized lung apices demonstrate some frontal lower
and paraseptal emphysematous changes. A calcified granuloma is seen in the
left upper lobe. Diffusely enlarged thyroid gland, consider thyroiditis.
There is no cervical lymphadenopathy by CT size criteria.
IMPRESSION:
1. Acute pulmonary embolus left upper lobe.
2. Multifocal areas of intracranial arterial narrowing, may represent
vasospasm,, differential diagnosis is vasculopathy.
3. Grossly stable appearance following left craniotomy and decompression with
persistent extracranial brain herniation. Minimal interval decreased size of
rim enhancing left parenchymal subacute hematoma. Follow-up recommended to
document resolution.
4. Stable mass effect, hydrocephalus.
5. Multiple punctate infarcts are stable.
6. Transverse sinuses better evaluated on prior MRI.
7. No significant narrowing CTA neck.
8. Diffusely enlarged thyroid gland, consider thyroiditis.
RECOMMENDATION(S): Consider CTA chest with contrast, pulmonary embolus
protocol.
Follow-up brain MRI to document resolution.
NOTIFICATION: The findings were discussed with ___ , M.D. by
___, M.D. on the telephone on ___ at 2:19 pm, 5 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with left IPH s/p left decompressive
hemicraniectomy, trach, peg, now with increasing respiratory rate// Evaluate
for etiology of increased respiratory rate
IMPRESSION:
In comparison with the study of ___, the the tracheostomy tube remains
in good position. Cardiac silhouette is within normal limits and there is no
vascular congestion or acute focal pneumonia. Mild atelectatic changes are
seen at both bases, more prominent on the left.
Radiology Report
EXAMINATION: CTA CHEST WITH AND WITHOUT CONTRAST
INDICATION: ___ year old woman with large left IPH s/p decompressive
hemicraniectomy, had a CTA head/neck, PE visualized in left upper lobe.//
Please evaluate 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) Spiral Acquisition 2.8 s, 36.9 cm; CTDIvol = 4.9 mGy (Body) DLP = 180.7
mGy-cm.
2) Stationary Acquisition 2.4 s, 0.5 cm; CTDIvol = 6.2 mGy (Body) DLP = 3.1
mGy-cm.
Total DLP (Body) = 184 mGy-cm.
COMPARISON: CTA head and neck ___. CT chest ___
and ___
FINDINGS:
BASE OF NECK: Tracheostomy is in place. Visualized thyroid is within normal
limits.
AXILLA, HILA, AND MEDIASTINUM: No adenopathy.
HEART AND VASCULATURE:
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.
There is a filling defect at the bifurcation at the level of the segmental
branches in the left upper lobe consistent with a pulmonary embolism as seen
on the comparison head and neck CTA. There are no additional pulmonary
emboli. The main and right pulmonary arteries are normal in caliber, and
there is no evidence of right heart strain.
Mildly prominent left ventricle which is unchanged. No pericardial effusion.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There are mild secretions within the airways. Right greater
left apical bulla. Moderate centrilobular and paraseptal emphysema. Similar
mild basilar atelectasis bilaterally.
ABDOMEN: Visualized upper abdomen is unremarkable.
BONES: No suspicious osseous lesions.
IMPRESSION:
1. There is a re-demonstrated nonocclusive pulmonary embolism in the segmental
branches of the left upper lobe as seen on the head and neck CTA performed
earlier today. No additional pulmonary emboli are visualized. No imaging
evidence of right heart strain.
2. Emphysema.
3. Additional findings above.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ woman with large L IPH s/p decompressive
hemicraniectomy, has PE seen on CTA Neck, read on CTA Chest pending.// Please
evaluate bilateral lower extremities for 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 is
demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Gender: F
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: ICH, Transfer
Diagnosed with Other nontraumatic intracerebral hemorrhage
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | ___ is a ___ year-old woman with HTN who presents
with acute onset dizziness followed by fall found to have large
left temporoparietal ICH at OSH that increased on repeat imaging
here at ___ with rightward midline shift and subfalcine
herniation, s/p decompressive craniectomy on the left ___.
#Left Intraparenchymal Hemorrhage
The patient was transferred intubated from OSH with a left sided
intraparenchymal hemorrhage with surrounding edema. A repeat
head CT was obtained upon arrival to ___ that showed worsening
hemorrhage with increasing midline shift and herniation. A
meeting was had with the family offering a surgical
decompressive craniectomy as well as discussing her poor
prognosis. It was decided to proceed with surgical intervention.
She underwent an emergent left sided decompressive
hemicraniectomy on ___ and was admitted to the Neuro ICU
post-operatively for close neurologic monitoring. She was
started on Keppra x7 days postop for seizure prophylaxis. Postop
head CT showed minimal increase in IPH, with improved uncal
herniation and MLS. She was started on 3% hypertonic saline for
cerebral edema. She was maintained on hypertonic saline.
Hypertonic saline d/c'd ___. CT torso was done to look for
underlying malignancy, which was negative. MRI performed to look
for underlying etiology of bleed, but was unrevealing. On ___,
the patient underwent a NCHCT and a family meeting was held in
the afternoon, in which patient's prognosis at this point was
discussed. Repeat CT on ___ was stable. On ___, the staples
from the incision were removed. On ___ patient was noted to
have left arm, left shoulder twitching and was restarted on
Keppra 1gm BID. She was placed on continuous EEG for 24 hours
which showed continuous focal slowing over entire left
hemisphere, no seizure activity. On ___, she was again noted
to have facial twitching and left shoulder twitching, concerning
for seizure activity. Keppra was increased to 1250mg BID and
restarted on continuous EEG, which was negative for seizure
activity. EEG was again DC'd on ___ and she was maintained on
Keppra 1250mg BID. Patient's neurologic exam remained stable.
#Embolic Infarcts /Dural venous sinus thrombosis
Neurology was consulted for new right MCA territory
embolic-appearing infarcts and developing venous sinus
thrombosis on MRI ___. Neurology recommended TTE with bubble,
which identified no cardiac source of embolism. Left transverse
sinus VST is small and now flow limiting, thought to be related
to pressure due to IPH and swelling. Anticoagulation was
deferred. CTA Head/Neck from ___ showed multifocal cerebral
arterial narrowing concerning for vasospasm vs vasculopathy.
Cardiology was contacted regarding optimality of TTE study, who
recommended obtaining a TEE, which would be a better study to
further evaluate for possible source of emboli. Family
discussion determined to not proceed with further workup of
infarcts.
#PE
The same CTA head/neck on ___ discussed above also showed a
small PE in the left upper lobe. A CTA chest confirmed
non-occlusive PE in left upper lobe, for which anticoagulation
was deferred because of the IPH and the patient's respiratory
status remained stable. LENIs were negative for DVT. She was
closely monitored for physiologic signs of worsening of PE.
#Hypertension /Intermittent SVT
SBP into the 170s, requiring nicardipine drip intermittently.
Intermittently tachycardic, so given fentanyl boluses for
discomfort and started on metoprolol 25mg Q8H for both blood
pressure control and intermittent SVT. Lopressor was increased
on ___ due to persistent tachycardia. Cardiology was consulted
for recommendations regarding rate control; metoprolol was
adjusted.
#Respiratory Failure
The patient was intubated on arrival and remained intubated
during her ICU stay. Mini BAL was performed on ___ gram stain
grew GNR's. Cultures grew H flu, antibiotics narrowed to
ceftriaxone completed on ___. She failed to be weaned from the
ventilator and tracheostomy was placed on ___ and weaned off
vent. On ___ patient required increased in secretions and
required frequent suctioning. She was started on Glycopyrrolate
with much improvement in secretions. She was noted to have
yellow secretions on ___, sputum culture was collected. Final
results were still pending on discharge however the patient's
respiratory status was stable, WBC WNL, and patient afebrile.
Repeat cultures may be followed-up on as an outpatient if
needed.
#Thrombocytopenia
Per PMD documentation, patient had recent weight loss; could not
obtain recent bloodwork from PCP. Some hematologic abnormalities
were noted, including thrombocytopenia. On admission platelets
100, trended down to ___. She did not require transfusion and
platelet count improved. Outpatient heme records received, show
mild baseline elevation of MCV and thrombocytopenia which was
being monitored outpatient.
#Nutrition
OGT was placed. Tube feeds were at goal, and on ___ she was
noted to have hypophosphatemia; concern for refeeding syndrome
so decreased rate of tube feeds and repleted electrolytes,
contact dietary for tube feeding recommendations. They
recommended titrating up on tube feeds very slowly and repleting
electrolytes as needed. Thiamine and folate were added. On
___, the patient underwent placement of a PEG tube. Tube feeds
were restarted Jevity 1.2 cal. Due to an uptrending serum
calcium level, tube feeds were changed to Glucerna 1.2 cal on
___. She was noted to have skin breakdown at the PEG site with
ulceration and ACS was made aware on ___ and they placed a 2x2
gauze under the bumper. ACS was paged again to re-evaluate the
PEG site as 2 sutures remained in place on ___ and patient
continued with skin breakdown despite 2x2 gauze. 2 sutures were
removed and the bumper to the PEG was rotated. It was
recommended to leave open to air or use a thin gauze if a
dressing was indicated.
#Fever
The patient was febrile intermittently during her ICU stay and
was pancultured. Mini BAL on ___ with GNR's on gram stain. She
was started empirically on vanc/cefepime on ___. Patient with
sputum cultures grew H.influenzae and completed course of
ceftriaxone on ___. On ___ patient was febrile up to 102.4,
urinalysis, chest xray and LENIs were negative. Obtained blood
cultures, PICC line removed and tip of catheter was cultured. On
___ patient persisted with fevers up to 101.9. Infectious
disease was consulted for further management, Vancomycin and
cefepime was started. Two Sputum cultures was obtained, which
were both contaminated with respiratory flora. An induced sputum
culture, suctioned from trach site was obtained, which... She
was febrile again on ___, and UA/CXR were ordered, both
negative for acute process. On ___ ID recommended
discontinuation of antibiotics with close monitoring, for
possible drug fever. She continued to be febrile after
antibiotics discontinued. MRI was obtained ___ which was
negative for infection but showed right embolic infarcts and a
developing dural venous sinus thrombosis. Once PE identified, it
was determined that is the likely cause of her intermittent
fevers. No further fever workup obtained.
#Mucous Plug
Patient underwent a CTA Chest to rule out pulmonary embolism on
___ which revealed no evidence of pulmonary embolism and new
focally dilated subsegmental bronchus in the right lower lobe
with distal nodular opacification possibly reflecting mucous
plugging within the distal airway and upstream dilatation. Chest
physiotherapy and aggressive suctioning ordered, the patients
respiratory status remained stable on discharge.
#Elevated LFTs
Medicine was consulted for elevated ALT/Lipase/Amylase in the
setting of fever on ___, who recommended Hepatitis B/C
serology, Fe/Ferritin/TIBC, TSH/Free T4, and a RUQ ultrasound as
workup. Aside from a slightly elevated Ferritin, this workup was
overall negative for any acute/subacute hepatic process, and the
elevated LFTs were stable on ___. This was attributed to a
medication effect, likely either beta-blocker or cephalosporin.
#Dispo
Patient was evaluated by ___ and OT who recommended rehab. |
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, concern for HD line infection
Major Surgical or Invasive Procedure:
___ - ___ removed TdC
History of Present Illness:
Mr. ___ is a ___ year old man with ESRD ___ FSGS on HD ___
by cath, MI in setting of cocaine use, and OSA who presents with
fever concerning for HD line infection.
On the day prior to presentation (on ___, he began to feel
unwell. He endorsed weakness with fevers, chills, and sweats. He
reports dry cough, but denies any chest pain, abd pain, nausea,
vomiting. He does make urine but denies dysuria. He does report
some frequency/urgency.
He was seen at his facility clinic as well as ___ clinic. At HD,
he was noted to have T102. He was only able to tolerate a short
HD session given his symptoms and was given vancomycin 1g after
HD as well as acetaminophen. His vancomycin was dosed at 1030AM
on ___. He was then transferred to our ED for further
evaluation on ___. Prior blood culture was drawn resulted in
Klebsiella.
The patient had previously had LUE fistula that had failed. He
was since seen by transplant surgery with RUE fistula put in
place in ___. The patient started HD in ___ but was only
able to use his RUE fistula once as there was concern for a
branch with steal, which was subsequently occluded. Since then,
he has had a temp HD line placed, which he has been using for
HD. He was seen for a fistulogram on ___.
In the ED:
- Initial vital signs were notable for:
T 103 HR 80 BP 160/63 RR 20 O2 Sat 100% RA
- Exam notable for:
Chest: R HD tunnel line insertion site w/o edema or erythema or
drainage.
Ext: LUE and RUE fistula with palpable thrill.
- Labs were notable for:
-- Chem panel: Na 138, K 3.5, Cl 96, CO2 28, BUN 38, Cr 7.1,
Glc
102, AG 14
-- CBC: WBC 8, Hgb 8.6 with MCV 101, Plt 179
-- Coags: ___ 15.3, PTT 31.8, INR 1.4
-- LFTs: AP 39; otherwise normal
-- Lactate 1.2
-- Blood cultures pending
---- ___: GNRs (___)
---- ___: No growth so far
---- ___: No growth so far
-- Urine culture no evidence of infection
- Studies performed include:
-- CXR ___
No consolidation or edema.
Right chest wall central venous catheter tip in the low SVC.
A TTE was ordered due to heart murmur on exam.
- Patient was given:
-- IV Cefepime 500mg
-- Home medications
- Consults:
-- ___ was consulted and did not think that exchange of the
catheter was needed since the fistula was functioning. They
planned to remove the HD line if fistula access is successful.
-- Renal: Completed 3 hour HD via R fistula on ___
Vitals on transfer:
T 99.85 HR 73 BP 137/81 RR 18 O2 Sat 99% RA
Upon arrival to the floor, the patient reports that he has been
feeling much better over the last few days with IV antibiotics
and that he tolerated his 3-hour HD session today via his right
fistula without issue. He is excited to be on the floor. He is
awaiting his dinner. He had poor appetite a few days ago but has
improved appetite today.
He still has intermittent dry cough (present since ___ but
it has improved. His R HD line set is "tender" but not quite
painful. He reports it has been tender since it was placed in
___.
REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise
negative.
Past Medical History:
ESRD
Hypertension
Hypercholesterolemia
Cocaine-induced MI in ___
Obstructive sleep apnea
BPH
Hemorrhoids
Social History:
___
Family History:
He knows his father is on hemodialysis. He is not in touch with
his father so there is no additional information. Mother passed
away of breast cancer in her ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: T 98.8 BP 148 / 75 HR 75 RR 18 O2 Sat 100 RA
GENERAL: Alert and interactive. In no acute distress. Laying in
bed.
EYES: + Conjunctival pallor. No icterus. PERRL. EOMI.
ENT: MMM. Thyroid is normal in size and texture, no nodules. No
cervical lymphadenopathy.
CHEST: R tunneled line in place: non erythematous, nontender.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs appreciated on my exam.
RESP: Clear to auscultation bilaterally. No wheezes, rhonchi or
rales. No increased work of breathing.
ABDOMEN: Normal bowels sounds, non distended, non-tender to deep
palpation in all four quadrants. No organomegaly.
MSK: No spinous process tenderness. No CVA tenderness. No lower
extremity edema.
EXT: Right arm fistula with palpable thrill. Good distal radial
pulses. Bandages over a couple of sites from HD. Bandage over
fistulogram site from ___.
SKIN: Warm. Cap refill <2s. No rash.
NEUROLOGIC: AOx3. CN2-12 intact. ___ strength throughout. Normal
sensation.
PSYCH: Appropriate mood and affect
DISCHARGE PHYSICAL EXAM:
Temp: 98.5 PO BP: 114 / 71 HR: 62 RR: 18 on 97 RA
GEN: alert, interactive, sitting up in bed in NAD
CHEST: R tunneled CVL out, dressing c/d/i, no TTP
___: RRR nl s1/s2 no murmur
PULM: CTABL no increased WOB
ABD: soft, NTND, +BS
EXT: RUE fistula with palpable thrill, (+)bruit.
SKIN: WWP, no edema over BLE
NEURO: CNI grossly, MAEx4
Pertinent Results:
ADMISSION LABS:
===============
___ 01:21PM BLOOD WBC-8.0 RBC-2.70* Hgb-8.6* Hct-27.3*
MCV-101* MCH-31.9 MCHC-31.5* RDW-14.0 RDWSD-52.2* Plt ___
___ 01:21PM BLOOD Neuts-88.9* Lymphs-5.1* Monos-5.3
Eos-0.0* Baso-0.1 Im ___ AbsNeut-7.10* AbsLymp-0.41*
AbsMono-0.42 AbsEos-0.00* AbsBaso-0.01
___ 01:21PM BLOOD Plt ___
___ 01:21PM BLOOD Glucose-102* UreaN-38* Creat-7.1* Na-138
K-3.5 Cl-96 HCO3-28 AnGap-14
___ 01:21PM BLOOD estGFR-Using this
___ 01:21PM BLOOD ALT-14 AST-17 AlkPhos-39* TotBili-0.4
___ 01:21PM BLOOD Albumin-3.5
___ 02:10PM BLOOD Lactate-1.2
___ 07:05PM URINE Blood-SM* Nitrite-NEG Protein-100*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.5 Leuks-NEG
___ 07:05PM URINE RBC-1 WBC-<1 Bacteri-NONE Yeast-NONE
Epi-<1
PERTINENT LABS:
===============
___ 09:17AM BLOOD VitB12-853 Folate-12
DISCHARGE LABS:
===============
___ 06:50AM BLOOD WBC-4.7 RBC-2.96* Hgb-9.3* Hct-29.8*
MCV-101* MCH-31.4 MCHC-31.2* RDW-14.0 RDWSD-51.5* Plt ___
___ 06:50AM BLOOD Plt ___
___ 06:50AM BLOOD Glucose-81 UreaN-45* Creat-7.2*# Na-140
K-4.4 Cl-98 HCO3-26 AnGap-16
___ 06:50AM BLOOD Calcium-9.2 Phos-6.4* Mg-2.2
IMAGING:
========
___ CXR Portable
FINDINGS:
- Lung volumes are low with secondary bronchovascular crowding.
There is no consolidation or evidence of edema. No
pneumothorax. Right chest wall
central venous catheter identified with tip in the low SVC.
Cardiomediastinal silhouette is within normal limits. No acute
osseous abnormalities.
IMPRESSION:
Right chest wall central venous catheter tip in the low SVC.
___ TTE
The left atrial volume index is SEVERELY increased. The right
atrium is mildly enlarged. There is an intermittent
left-to-right color flow Doppler signal across the interatrial
septum most c/w a small secundum-type atrial septal defect. The
estimated right atrial pressure is ___ mmHg. There is mild
symmetric left ventricular hypertrophy with a normal cavity
size. There is normal regional and global left ventricular
systolic function. Quantitative biplane left ventricular
ejection fraction is 68 % (normal 54-73%). Left ventricular
cardiac index is normal (>2.5 L/min/m2). There is no resting
left ventricular outflow tract gradient. Tissue Doppler suggests
an increased left ventricular filling pressure (PCWP greater
than 18 mmHg). Normal right ventricular cavity size with normal
free wall motion. Tricuspid annular plane systolic excursion
(TAPSE) is normal. The aortic sinus diameter is normal for
gender with a normal ascending aorta diameter for gender. The
aortic arch diameter is normal with a mildly dilated descending
aorta. There is no evidence for an aortic arch coarctation. 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 trace aortic regurgitation. The mitral
valve leaflets appear structurally normal with no mitral valve
prolapse. No masses or vegetations are seen on the mitral valve.
There is trivial mitral regurgitation. The pulmonic valve
leaflets are not well seen. The tricuspid valve leaflets appear
structurally normal. No mass/vegetation are seen on the
tricuspid valve. There is physiologic tricuspid regurgitation.
The pulmonary artery systolic pressure could not be estimated.
There is a trivial pericardial effusion.
IMPRESSION: No valvular pathology or pathologic valvular flow
identified. Mild symmetric left ventricular hypertrophy with
normal cavity size and regional/global biventricular systolic
function. Small secundum type atrial septal defect with
intermittent left-to-right flow. No prior study available for
comparison.
MICROBIOLOGY:
=============
___ 6:50 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 1:30 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 10:10 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 9:17 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
__________________________________________________________
___ 12:35 pm BLOOD CULTURE
Blood Culture, Routine (Final ___:
KLEBSIELLA OXYTOCA.
Identification and susceptibility testing performed on
culture #
___-___ ___.
Aerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
__________________________________________________________
___ 4:10 am BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 4:10 am BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 7:05 pm URINE
URINE CULTURE (Final ___: NO GROWTH.
__________________________________________________________
___ 2:50 pm BLOOD CULTURE
SOURCE: HD LINE ( ADDED PER REQUESTION ___.
Blood Culture, Routine (Final ___:
KLEBSIELLA OXYTOCA
|
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- 16 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM NEGATIVE ROD(S).
Aerobic Bottle Gram Stain (Final ___: GRAM NEGATIVE
ROD(S).
__________________________________________________________
___ 2:19 pm BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 1:21 pm BLOOD CULTURE
Blood Culture, Routine (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. Docusate Sodium 100 mg PO BID
4. Metoprolol Tartrate 50 mg PO BID
5. NutriSure Plus (food supplemt, lactose-reduced) 0.05-1.5
gram-kcal/mL oral 3X/WEEK
6. sevelamer CARBONATE 1600 mg PO TID W/MEALS
7. Tamsulosin 0.4 mg PO QHS
8. Vitamin B Complex w/C 1 TAB PO DAILY
9. Vitamin D ___ UNIT PO EVERY 4 WEEKS (___)
10. Oxybutynin 5 mg PO QHS
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q24H Duration: 12 Days
2. Ramelteon 8 mg PO QHS:PRN Insomia
3. Metoprolol Tartrate 37.5 mg PO BID
4. amLODIPine 10 mg PO DAILY
5. Atorvastatin 10 mg PO QPM
6. Docusate Sodium 100 mg PO BID
7. NutriSure Plus (food supplemt, lactose-reduced) 0.05-1.5
gram-kcal/mL oral 3X/WEEK
8. Oxybutynin 5 mg PO QHS
9. sevelamer CARBONATE 1600 mg PO TID W/MEALS
10. Tamsulosin 0.4 mg PO QHS
11. Vitamin B Complex w/C 1 TAB PO DAILY
12. Vitamin D ___ UNIT PO EVERY 4 WEEKS (___)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Klebsiella oxytoca bacteremia
HD line infection
End State Renal Disease secondary to Focal Segmental Glomerular
Sclerosis
Macrocytic anemia
SECONDARY DIAGNOSES:
History of myocardial infarction related to cocaine
Hypertension
Benign prostatic hyperplasia
Obstructive sleep apnea
Consipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Hi ___ with HD line, dry cough, and fever eval for HD line
location, PNA
TECHNIQUE: Single portable view of the chest
COMPARISON: None
FINDINGS:
Lung volumes are low with secondary bronchovascular crowding. There is no
consolidation or evidence of edema. No pneumothorax. Right chest wall
central venous catheter identified with tip in the low SVC. Cardiomediastinal
silhouette is within normal limits. No acute osseous abnormalities.
IMPRESSION:
Right chest wall central venous catheter tip in the low SVC.
Radiology Report
INDICATION: ESRD ___ FSGS on HD ___ by cath, MI in setting of cocaine use,
and OSA who presents with fever and Klebsiella bacteremia. Underwent HD
successfully via R fistula on ___// Please remove HD line due to concern
that it is a source of infection. Tolerated HD via R fistula on ___.
COMPARISON: none
TECHNIQUE: OPERATORS: Dr. ___ the procedure.
ANESTHESIA: None
MEDICATIONS: None
CONTRAST: None
FLUOROSCOPY TIME AND DOSE: None
PROCEDURE: 1. Right chest tunneled dialysis catheter removal.
PROCEDURE DETAILS: The procedure was performed at bedside. The Right chest
tunneled line site was cleaned and draped in standard sterile fashion. 1%
lidocaine was administered around the tube track. The cuff was loosened with a
bent forceps. The catheter was removed with gentle traction while manual
pressure was held at the venotomy site. Hemostasis was achieved after 5 min of
manual pressure. A clean sterile dressing was applied. The patient tolerated
the procedure well. There were no immediate postprocedural complications.
FINDINGS:
Expected appearance after tunneled line removal.
IMPRESSION:
Successful removal of a right chest tunneled line.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by OTHER
Chief complaint: Fever, Wound eval
Diagnosed with Fever, unspecified
temperature: 103.0
heartrate: 80.0
resprate: 20.0
o2sat: 100.0
sbp: 160.0
dbp: 63.0
level of pain: 0
level of acuity: 2.0 | This is a ___ year old incarcerated male with past medical
history of ESRD secondary to FSGS, cocaine-induced MI, OSA,
admitted ___ with sepsis and klebsiella bacteremia,
thought to be secondary to his tunneled line, treated with
antibiotics and tunneled line removal, tolerating HD via AV
fistula, able to be discharged back to custody ___
# Klebsiella oxytoca sepsis secondary to acute blood stream
infection
# Complication of indwelling tunneled HD catheter
Patient presented with fever and malaise from his ___ clinic.
Blood cultures from admission on ___ grew Klebsiella oxytoca,
as did blood cultures from ___. He was started on broad
spectrum antibiotics, subsequently narrowing based on
sensitivities. On ___ he underwent removal of his tunneled HD
line. Source of infection thought to be his line. Workup did
not reveal other potential pulmonary, GI, GU sources. TTE was
obtained given concern from one provider for ___ possible murmur,
however no valvular pathology was identified. Subsequent blood
cultures remained without growth at time of his discharge.
Discharged with plan to complete total 2 week course (from last
negative blood culture) of PO Ciprofloxacin.
# ESRD ___ FSGS on HD MWF:
Presenting weight 92kg. Discharge weight 90kg. No evidence of
volume overload on exam. His HD line as pulled as above, but he
was able to be dialyzed via RUE AVF. Continued sevelamer 1600
TID. Continued Vitamin B complex supplementation.
# Hx of MI related to cocaine: Decreased metoprolol tartrate
50mg BID to 37.5 BID as occasional heart rates in ___,
asymptomatic. Continued atorvastatin 10mg daily.
# Hypertension: Continue amlodipine 10mg daily
# Constipation: Continue docusate, senna
# BPH: Still making urine, Continue Tamsulosin, Continue
oxybutynin which was changed from daily to twice daily for
better control.
# Obstructive sleep apnea: Not on cpap. Consider evaluation for
CPAP
====================
TRANSITIONAL ISSUES:
====================
[ ] Please continue Ciprofloxacin 500 daily for EOT date
___.
[ ] Decreased Metoprolol from 50 BID to 37.5 BID as heart rates
were in ___.
[ ] Consider evaluation for CPAP given prior diagnosis of sleep
apnea
[ ] Of note, TTE incidentally showed small secundum type atrial
septal defect with intermittent left-to-right flow. EF of 68%.
Consider outpatient cardiology referral.
#CODE: FULL CODE presumed
#CONTACT: ___
> 30 minutes spent 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:
Abdominal pain, nausea/vomiting, dark stool,
weakness
Major Surgical or Invasive Procedure:
EGD ___
History of Present Illness:
HPI: ___ male ___ man h/o ETOH dependence
and possible suicide attempts (last hospitalized in ___ for
detox treated per Valium detox protocol; at that time was also
found to have BRBPR thought to be iso hemorrhoids; hgb 9.7) who
presents with persistent weakness x 7 days with intermittent
abdominal pain with some epigastric pain, nausea, and fevers for
the past 4 days.
In the ED:
Patient stated that his abdominal pain and epigastric pain has
since resolved, although patient felt feverish over the past
couple of days and felt somewhat weak in his legs. Patient
states
that he becomes very tired on ambulation now. Patient has
continued to drink at home over the past ___ days and frequently
drinks. Patient describes frequent black stools and a history of
profuse BRBPR ___ years prior without any subsequent hematochezia.
Patient notes repeated falls, but states they are because he is
usually drunk. Patient states that although he hasn't eaten
anything in 4 days, he is now quite hungry and denies any
abdominal pain at this time.
Intermittent back pain, no b/b incontinence, no saddle
anesthesia, no numbness, no urinary retention.
In the ED, initial vital signs were: 37.7 60 146/82 16
- Labs were notable for Hgb 10.9 at 0420 WBC 6.8, PLT 136, Trop
negative, lactate 2.4, UA w/ few bacteria, neg nitr, neg leuk,
3WBC,
ALT 93, AST 223, AP 259, Lipase 300, Tbili 1.2, Alb 4.4
repeat Hgb at 1211 was 9.3 (after 3L IVF), WBC 6.9, PLT 113,
Lactate 1.6
Studies performed include:
Liver and GB U/S
IMPRESSION:
1. Echogenic liver consistent with steatosis. Other forms of
liver disease and
more advanced liver disease including steatohepatitis or
significant hepatic
fibrosis/cirrhosis cannot be excluded on this study.
2. No focal hepatic mass.
3. Normal gallbladder and no biliary ductal dilation.
4. No obvious pleural effusions.
CXR
IMPRESSION:
No pleural effusion or focal pneumonia.
Patient was given:
- Pantoprazole 40mg PO
- Thiamine 100 mg PO
- Folic Acid 1mg PO
- Zofran 4mg IV
- LR 1L x3
- Vitals on transfer: 2 98.4 87 116/81 18 99% RA
Upon arrival to the floor, the patient confirms the above
history. He states that he started having acute onset abdominal
pain radiating to both sides of his back 7 days ago (pain was
constant, not associated with food intake or bowel movements, up
to 10 out of 10, and only responded to 2 pills he got from his
brother who allegedly prompted from his home country-unknown
ingredients). At the same time he started having nausea
nonbloody nonbilious non-coffee ground emesis several times per
day. For the past 4 days he has not been tolerating any p.o.
intake. 7 days ago he started having dark loose bowel
movements,
Initially several times per day but yesterday only once per day
and today none. He also endorses subjective fevers and chills 7
days and a feeling of generalized weakness and dizziness when he
gets up to walk.
No loss of consciousness, no recent chest pain (history of
stabbing chest pain longtime ago), no recent shortness of breath
(has a history of shortness of breath associated with drinking
prior to onset of current symptoms).
Regarding his history of depression, he denies current SI.
Review of Systems:
(+) per HPI
Past Medical History:
Hemorrhoids
s/p L leg surgery ___ peds vs auto
h/o Head trauma
Chronic LBP
Past Psychiatric History:
Depression and EtOH dependence s/p multiple detox admissions but
no psychiatric. Endorses "multiple" suicide attempts, all by
cutting, including a stab wound to his L axilla (he shows the
scar). Denies previous hospitalizations and med trials. No
psychiatrist or therapist. Denies self-injurious behavior aside
from suicide attempts.
Social History:
___
Family History:
Mother died from complications of alcoholism
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals- 97.6 PO 133 / 87 81 20 97 Ra
GENERAL: AOx3, restless
HEENT: NCAT, OP, MMM
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
ABDOMEN: Normal bowels sounds, non distended. Tenderness to
palpation in RUQ and LUQ. No guarding / rebound
EXTREMITIES: No clubbing, cyanosis, or edema, no sign of
atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally.
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy
NEUROLOGIC: Gait unsteady. ___ strength througout.
DISCHARGE PHYSICAL EXAM
Vitals- reviewed in POE
GENERAL: AOx3, NAD
HEENT: NCAT, OP, MMM
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
ABDOMEN: Normal bowels sounds, non distended. non-tender. No
guarding / rebound
EXTREMITIES: No clubbing, cyanosis, or edema, no sign of
atrophy/hypertrophy.
NEUROLOGIC: AAOx3, moving all extremities with purpose.
Pertinent Results:
ADMISSION LABS
___ 04:20AM BLOOD WBC-6.8 RBC-4.15* Hgb-10.9* Hct-33.6*
MCV-81* MCH-26.3 MCHC-32.4 RDW-20.8* RDWSD-58.5* Plt ___
___ 04:20AM BLOOD Neuts-63.5 ___ Monos-14.5*
Eos-0.6* Baso-1.0 Im ___ AbsNeut-4.34 AbsLymp-1.31
AbsMono-0.99* AbsEos-0.04 AbsBaso-0.07
___ 04:20AM BLOOD Glucose-118* UreaN-13 Creat-0.8 Na-133
K-3.3 Cl-87* HCO3-30 AnGap-16
___ 04:20AM BLOOD ALT-93* AST-223* AlkPhos-259* TotBili-1.2
___ 04:20AM BLOOD Lipase-300*
___ 04:20AM BLOOD cTropnT-<0.01 proBNP-45
___ 09:44AM BLOOD cTropnT-<0.01
___ 09:20PM BLOOD Calcium-9.4 Phos-4.2 Mg-1.1* Iron-34*
___ 09:20PM BLOOD calTIBC-233* VitB12-703 Ferritn-123
TRF-179*
___ 04:20AM BLOOD Triglyc-93
PERTINENT INTERVAL LABS
___ 09:20PM BLOOD ALT-68* AST-163* AlkPhos-191* TotBili-0.8
___ 07:20AM BLOOD ALT-81* AST-201* AlkPhos-214* TotBili-0.8
___ 07:00AM BLOOD ALT-109* AST-276* AlkPhos-204*
TotBili-0.8
___ 07:25AM BLOOD ALT-151* AST-310* AlkPhos-217*
TotBili-0.8
___ 09:20PM BLOOD calTIBC-233* VitB12-703 Ferritn-123
TRF-179*
___ 09:20PM BLOOD HBsAg-NEG HBsAb-POS HBcAb-POS* HAV
Ab-POS*
___ 07:00AM BLOOD AMA-NEGATIVE Smooth-PND ANCA-NEGATIVE B
___ 07:00AM BLOOD ___ Titer-1:40*
___ 07:20AM BLOOD AFP-3.0
___ 07:00AM BLOOD IgG-1242 IgM-153
___ 07:00AM BLOOD HIV Ab-NEG
___ 09:20PM BLOOD HCV Ab-POS*
___ 09:20PM BLOOD HCV VL-7.1*
DISCHARGE LABS
___ 07:25AM BLOOD WBC-6.4 RBC-3.92* Hgb-10.6* Hct-32.6*
MCV-83 MCH-27.0 MCHC-32.5 RDW-22.1* RDWSD-65.8* Plt ___
___ 07:25AM BLOOD Glucose-158* UreaN-9 Creat-0.7 Na-136
K-3.6 Cl-92* HCO3-23 AnGap-21*
___ 07:25AM BLOOD ALT-151* AST-310* AlkPhos-217*
TotBili-0.8
___ 07:25AM BLOOD Calcium-10.0 Phos-3.2 Mg-1.7
URINE STUDIES
___ 10:05AM URINE Color-Yellow Appear-Hazy* Sp ___
___ 10:05AM URINE Blood-NEG Nitrite-NEG Protein-30*
Glucose-NEG Ketone-NEG Bilirub-SM* Urobiln->12 pH-8.0 Leuks-NEG
___ 10:05AM URINE RBC-4* WBC-3 Bacteri-FEW* Yeast-NONE
Epi-<1
___ 10:05AM URINE CastHy-3*
MICROBIOLOGY
___ 10:05 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: < 10,000 CFU/mL.
IMAGING
RUQUS ___
IMPRESSION:
1. Echogenic liver consistent with steatosis. Other forms of
liver disease and
more advanced liver disease including steatohepatitis or
significant hepatic
fibrosis/cirrhosis cannot be excluded on this study.
2. No focal hepatic mass.
3. Normal gallbladder and no biliary ductal dilation.
4. No obvious pleural effusions.
CXR ___
IMPRESSION:
No pleural effusion or focal pneumonia.
Medications on Admission:
None.
Discharge Medications:
1. Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 500 mg 1 tablet(s) by mouth every 6 hours as
needed Disp #*100 Tablet Refills:*0
2. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*12
3. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*12
4. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*12
Discharge Disposition:
Home
Discharge Diagnosis:
# acute pancreatitis
# liver cirrhosis
# hypertensive gastropathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man with chest pain. Evaluate for pleural effusion.
TECHNIQUE: Chest PA and lateral
COMPARISON: No prior imaging is available on PACS at the time of this
dictation.
FINDINGS:
Lung volumes are slightly low. No focal consolidation, edema, effusion, or
pneumothorax. The heart is normal in size. Biapical pleural thickening
and/or scarring is minimal. Right curvature of the mid thoracic spine is
mild. Vertebral body heights appear preserved.
IMPRESSION:
No pleural effusion or focal pneumonia.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ man with chest pain. Evaluate for pleural effusion
or increased common bile duct.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: No prior imaging is available on PACS at the time of this
dictation.
FINDINGS:
LIVER: The liver is diffusely echogenic. The contour of the liver is smooth.
No focal liver mass. The main portal vein is patent with hepatopetal flow. No
ascites.
BILE DUCTS: No intrahepatic biliary dilation. The CHD measures 2 mm.
GALLBLADDER: The gallbladder is not distended. No evidence of stones or
gallbladder wall thickening. No pericholecystic fluid.
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 8.9 cm.
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
OTHER: No obvious pleural effusions. Please note that ultrasound is not the
modality typically used to assess effusions.
IMPRESSION:
1. Echogenic liver consistent with steatosis. Other forms of liver disease and
more advanced liver disease including steatohepatitis or significant hepatic
fibrosis/cirrhosis cannot be excluded on this study.
2. No focal hepatic mass.
3. Normal gallbladder and no biliary ductal dilation.
4. No obvious pleural effusions.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: N/V
Diagnosed with Acute pancreatitis without necrosis or infection, unsp
temperature: 96.7
heartrate: 108.0
resprate: 16.0
o2sat: 100.0
sbp: 142.0
dbp: 112.0
level of pain: 0
level of acuity: 3.0 | ___ male ___ man h/o ETOH dependence and
possible suicide attempts (last hospitalized in ___ for
detox
treated per Valium detox protocol; at that time was also found
to
have BRBPR thought to be iso hemorrhoids; hgb 9.7) who presents
with persistent weakness x 7 days with intermittent abdominal
pain with some epigastric pain, nausea, and fevers for the past
4
days.
# acute pancreatitis
Lipase on admission was 300. In combination with this upper
abdominal pain treatment diagnostic criteria for acute
pancreatitis, most likely in the setting of this history of
significant alcohol consumption. Right upper quadrant abdominal
ultrasound did not show any signs of gallstones or biliary duct
dilatation and a T bili was normal. There were no signs of
endorgan damage. He was aggressively resuscitated with IV
fluids. His pain was well controlled on minimal doses of IV
Dilaudid and quickly subsided with supportive treatment. The
patient was initially kept n.p.o. pending a gastroscopy as
below. Following his procedure, his diet could be advanced with
good tolerance. On discharge, the patient was asymptomatic,
eating normally, and without abdominal pain.
# Upper GI bleed
# hypertensive gastropathy
The patient has chronic anemia with a hemoglobin of ___. This
current presentation with dark stools and an initial drop in his
hemoglobin was consistent with an upper GI bleed. He underwent
an EGD ___, which demonstrated hypertensive gastropathy,
likely secondary to his hepatic cirrhosis as below, as the
source of his upper GI bleed. Hepatology was consulted for
further management and recommended antibiotic treatment with
ceftriaxone until discharge. No need to treat with octreotide
or a prophylactic beta-blocker. No need to treat with PPIs.
Outpatient follow-up with hepatology is recommended (see below).
# liver cirrhosis
Patient found to have positive HCV Ab with elevated viral load
of
7.1 log 10 IU/mL. Unknown transmission without significant risk
factors including no prior history of past transfusions (other
than one ___ years ago), tattoos, or hospitalizations. Likely with
cirrhosis with evidence of portal hypertension with portal
hypertensive gastropathy. ETOH may be playing a component as
well. Outpatient follow up with hepatology is recommended.
Work-up including ___, ANCA, immunoglobulins, Ferritin,
TIBC, Fe, viral hepatitis panel, and HCV genotype was ordered.
The patient was seen by nutrition and social work. The patient
was counseled on the necessity to abstain from alcohol.
MEDICATION CHANGES
==================
*** NEW Medications/Orders ***
Acetaminophen 500 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen 500 mg 1 tablet(s) by mouth every 6 hours
as needed Disp #*100 Tablet Refills:*0 This is a new medication
for pain
FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*12 This is a new vitamin
Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*12 This is a new vitamin
Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*12 This is a new vitamin |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Bactrim / Penicillins / Sulfa (Sulfonamide Antibiotics) /
Xanthines / aminophylline hydrate / theophylline
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Laparoscopic cholecystectomy
History of Present Illness:
Mr. ___ is a ___ year old man with history of coronary
stents who presents with fevers and abdominal pain. He underwent
upper endoscopy for GERD and screening colonoscopy on ___
which demonstrated gastritis, esophagitis, and two colonic
polyps
which were removed. That evening he felt fatigued and took his
temperature which was 101. Over the following two days he
continued to check his temperature which ranged from 99-101. On
___ he developed Right sided back pain which progressed to RUQ
and epigastric pain. He has had some small loose bowel movements
since his colonoscopy. He has no nausea.
Past Medical History:
PMH: cardiac stents, HTN
PSH: vocal cord biopsy
Social History:
___
Family History:
noncontributory
Physical Exam:
Admission Physical Exam:
Vitals: 99.2 86 147/95 18 97RA
GEN: A&O, NAD
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended. TTP RUQ. ___
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: 99.2, 126/82, 91, 18, 94 RA
Gen: A&O x3. Sitting up in chair in NAD
CV: HRR
Pulm: LS with faint wheeze
Abd: soft NT/ND. Lap sites CDI closed with dermabond
Ext: WWP no edema
Pertinent Results:
___ 06:22AM BLOOD WBC-10.0 RBC-4.32* Hgb-13.7 Hct-41.0
MCV-95 MCH-31.7 MCHC-33.4 RDW-11.7 RDWSD-40.6 Plt ___
___ 06:31AM BLOOD WBC-12.1* RBC-4.47* Hgb-14.4 Hct-42.4
MCV-95 MCH-32.2* MCHC-34.0 RDW-11.8 RDWSD-40.8 Plt ___
___ 10:00PM BLOOD WBC-21.7* RBC-5.03 Hgb-16.1 Hct-47.5
MCV-94 MCH-32.0 MCHC-33.9 RDW-11.9 RDWSD-41.2 Plt ___
___ 06:22AM BLOOD Glucose-79 UreaN-20 Creat-1.1 Na-144
K-4.0 Cl-106 HCO3-26 AnGap-12
___ 06:31AM BLOOD Glucose-79 UreaN-19 Creat-1.1 Na-147
K-3.9 Cl-107 HCO3-23 AnGap-17
___ 10:00PM BLOOD Glucose-96 UreaN-16 Creat-1.4* Na-143
K-3.6 Cl-102 HCO3-26 AnGap-15
___ 10:00PM BLOOD ALT-23 AST-19 AlkPhos-69 TotBili-0.7
___ 06:22AM BLOOD Calcium-8.6 Phos-3.7 Mg-2.1
___ 06:31AM BLOOD Calcium-9.1 Phos-3.7 Mg-1.8
Imaging:
CT Chest/Abdomen/Pelvis: IMPRESSION:
1. Findings are concerning for acute cholecystitis. No free
intraperitoneal air.
2. Mild bronchial wall thickening.
3. Mild paraseptal emphysema.
US abdomen:
IMPRESSION:
Diffusely thickened gallbladder wall without distension or
pericholecystic edema is likely due to chronic cholecystitis.
Possible tiny
cholelithiasis.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Metoprolol Succinate XL 50 mg PO DAILY
2. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Dexilant (dexlansoprazole) 60 mg oral DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*30 Tablet Refills:*0
2. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram 17 g by mouth once a day
Disp #*14 Packet Refills:*0
4. Aspirin 81 mg PO DAILY
5. Atorvastatin 40 mg PO QPM
6. Dexilant (dexlansoprazole) 60 mg oral DAILY
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Triamterene-HCTZ (37.5/25) 1 CAP PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with recent endoscopy/colonoscopy now presenting
with chest pain/abdominal pain, fevers in the // Without pneumonia,
pneumomediastinum, or other acute abnormalities. Rule out appendicitis,
pneumo peritoneum
TECHNIQUE: Chest PA and lateral
COMPARISON: None
FINDINGS:
Lungs are well expanded. Bilateral hila are ill-defined without clear masses.
There is no pulmonary edema or focal consolidations. Cardiac size is normal.
No pleural effusion or pneumothorax.
IMPRESSION:
Ill-defined bilateral hila could represent bronchial disease.
Radiology Report
EXAMINATION: CT CHEST/ABD/PELVIS W/ CONTRAST
INDICATION: History: ___ with s/p EGD, fever // r/o ___
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 12.0 mGy (Body) DLP =
6.0 mGy-cm.
2) Spiral Acquisition 9.4 s, 74.1 cm; CTDIvol = 23.7 mGy (Body) DLP =
1,752.9 mGy-cm.
Total DLP (Body) = 1,759 mGy-cm.
COMPARISON: None.
FINDINGS:
CHEST:
No supraclavicular or axillary lymphadenopathy. No mediastinal or hilar
adenopathy.
No pneumomediastinum. Esophagus is unremarkable.
Cardiac size is normal. Moderate calcifications in the aortic valve and
coronary arteries are noted. No pericardial effusion. Normal size of the
pulmonary artery and thoracic aorta.
Mild paraseptal emphysema is upper lobe predominant. Subsegmental atelectasis
are noted in the right lower lobe. No other parenchymal abnormalities.
Airways are patent to subsegmental level bilaterally.
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. Partly full gallbladder with wall
thickening. Gallbladder is partly full. Minimal partly dependent hyperdense
material suggests there may be tiny stones within the gallbladder. There is
no free intraperitoneal air.
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: An indeterminate isoattenuating left adrenal nodule measures 16 mm
in diameter (2:60).
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of solid renal lesions or hydronephrosis. Possible tiny
stone measuring 2 mm along the left lower pole. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: Prostate is mild to moderately enlarged with central
hypertrophy. Seminal vesicles appear normal.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Liver steatosis.
2. Diffuse gallbladder wall thickening and a partly full gall bladder. This
is nonspecific but could be seen with acute cholecystitis in the appropriate
setting, among other possible causes of gallbladder wall thickening and edema
such as fluid overload or liver disease. Probable cholelithiasis.
Correlation with clinical findings is recommended.
3. No free intraperitoneal air or splenic injury.
4. Mild bronchial wall thickening.
5. Mild paraseptal emphysema.
6. Left adrenal nodule, indeterminate by imaging criteria although likely to
represent an adenoma. Follow-up MR or CT with adrenal protocol is recommended
to reassess in ___ year. Biochemical correlation may also be appropriate.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with acute chole // sonographic evidenc
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Same-day CT abdomen pelvis
FINDINGS:
LIVER: The liver is diffusely echogenic. The contour of the liver is smooth.
There is no focal liver mass. The main portal vein is patent with hepatopetal
flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 2 mm
GALLBLADDER: There is no gallbladder distension, however the gallbladder wall
is diffusely thickened. A hyperechoic tiny focus could represent a very small
adherent stone measuring less than 5 mm. There is no pericholecystic edema.
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.
Spleen length: 9.6 cm
KIDNEYS: Limited views of the kidneys show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Echogenic liver and diffusely thickened gallbladder wall without distension or
pericholecystic edema. Findings could be secondary to liver disease or fluid
overload. Acute cholecystitis seems unlikely in the absence of oral and a
clinical findings.
RECOMMENDATION(S): Correlation of gallbladder resolved with clinical findings
is recommended.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Fever
Diagnosed with Acute cholecystitis
temperature: 99.6
heartrate: 110.0
resprate: 16.0
o2sat: 97.0
sbp: 174.0
dbp: 102.0
level of pain: 4
level of acuity: 3.0 | The patient was admitted to the General Surgical Service on ___
for evaluation and treatment of abdominal pain. Admission RUQ
ultra-sound showed diffusely thickened gallbladder wall and
abdominal/pelvic CT also revealed gallbladder wall thickening
and probable cholelithiasis. The patient underwent laparoscopic
cholecystectomy, which went well without complication (reader
referred to the Operative Note for details). After a brief,
uneventful stay in the PACU, the patient arrived on the floor
tolerating clears, on IV fluids, and oral analgesia for pain
control. The patient was hemodynamically stable.
Pain was well controlled. Diet was progressively advanced as
tolerated to a regular diet with good tolerability. The patient
voided without problem. During this hospitalization, the patient
ambulated early and frequently, was adherent with respiratory
toilet and incentive spirometry, and actively participated in
the plan of care. The patient received subcutaneous heparin and
venodyne boots were used during this stay.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient was discharged home without services.
The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Ascites
Major Surgical or Invasive Procedure:
Diagnostic and US-guided therapeutic paracentesis.
No PMNs in ascites.
3.8L of ascitic fluid removed.
History of Present Illness:
___ HIV/HCV cirrhosis, decompensated with HE and variceal
bleeding p/w new ascites and ___ edema. He has not had ascites
previously and has been compliant with his spironolactone. He
denies abdominal pain, fevers, or chills. Since his recent car
accident, he has been eating more packaged food. He denies SOB,
orthopnea or chest pain. He has not noted dyspnea with exertion.
In the ED, initial vitals were 98.8 92 118/73 24 94%. Labs were
significant for hct 35.1 and plts 81 (both approximately at
baseline). His Na was 132, which is down from recent labs. His
MELD on admission was 21. A diagnostic para was performed which
was negative for SBP. Vitals prior to transfer were 97.8 88
128/75 18 96% RA.
Currently, the patient reports feeling well. He is lying flat
without difficulties. He has some soreness at the site of para,
but denies abdominal pain.
Past Medical History:
# HCV (genotype 1) cirrhosis, complications: HE, variceal bleed
s/p banding. Previously treated with interferon and ribarin but
stopped due to variceal bleed. Reactivated on transplant list
___
# HIV on HAART. CD4 nadir: 25. No history of OI.
# Depression
# GERD
# Colonic adenoma- removed in colonoscopy ___
# Diabetes type 2
# Maxillary sinus mass: Seen by ENT ___
Social History:
___
Family History:
Sister with DM and steatosis of the liver, mother with CAD.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.3, 129/87, 93, 18, 99% RA
General: Well appearing, NAD, lying flat. Pleasant/interactive.
Mood/affect wnl
HEENT: EOMI, PERRL, MMM, OP clear
Neck: Supple
CV: RRR, nl s1s2, no m/r/g
Lungs: CTAB, no w/ra/rh, good air entry throughout, no accessory
mm use.
Abdomen: S/non tender, moderate distension. No rebound/guarding.
Unable to assess fully for liver edge
Ext: WWP, ___ edema, DP 2+ b/l
Neuro: AAOx3, motor ___, sensation intact to light touch. Gait
not assessed.
Skin: Slightly jaundiced
DISCHARGE PHYSICAL EXAM:
VS: T98-98.5, 95-110/42-65, p92-101, RR16, 96RA ___-202
General: well appearing male in no acute distress
HEENT: no scleral icterus
CV: regular rate and rhythm, normal S1 S2, no murmurs
Lungs: clear bilaterally, no wheezing
Abdomen: Large, nontense, much softer than yesterday, no fluid
wave, nondistended
Ext: peripheral edema +2 to mid-calves bilaterally
Neuro: moves all extremities, ambulatory
Skin: Slightly jaundiced
Pertinent Results:
ADMISSION LABS:
___ 02:10PM BLOOD WBC-6.2 RBC-3.25* Hgb-11.6* Hct-35.1*
MCV-108* MCH-35.7* MCHC-33.1 RDW-15.8* Plt Ct-81*
___ 02:10PM BLOOD Neuts-68.6 Lymphs-17.2* Monos-8.9
Eos-4.3* Baso-0.9
___ 02:10PM BLOOD ___ PTT-37.9* ___
___ 02:10PM BLOOD Glucose-130* UreaN-13 Creat-0.8 Na-132*
K-4.5 Cl-102 HCO3-25 AnGap-10
___ 02:10PM BLOOD ALT-40 AST-156* AlkPhos-229* TotBili-8.3*
___ 02:10PM BLOOD Albumin-2.8*
___ 02:28PM BLOOD Lactate-2.2*
DISCHARGE LABS:
___ 05:35AM BLOOD WBC-3.2* RBC-2.95* Hgb-10.3* Hct-31.7*
MCV-108* MCH-35.1* MCHC-32.6 RDW-14.6 Plt Ct-53*
___ 05:35AM BLOOD ___ PTT-138.4* ___
___ 05:35AM BLOOD Glucose-107* UreaN-9 Creat-0.7 Na-136
K-3.6 Cl-105 HCO3-26 AnGap-9
___ 05:35AM BLOOD TotBili-9.5*
___ 05:35AM BLOOD Albumin-2.4* Calcium-8.1* Phos-2.5*
Mg-2.0
ASCITES
ASCITES ANALYSIS WBC RBC Polys Lymphs Monos Mesothe Macroph
___ 18:16 285* 3325* 0 54* 0 1* 45*
PERITONEAL FLUID
ASCITES CHEMISTRY TotPro Albumin
___ 18:16 0.3 <1.0
PERITONEAL FLUID
___ peritoneal fluid
NEGATIVE FOR MALIGNANT CELLS.
Mesothelial cells and lymphocytes.
___ RUQ ultrasound
1. Small, coarse nodular liver compatible with given diagnosis
of cirrhosis.
2. Patent main portal vein with hepatopetal flow without
evidence of
thrombosis.
3. New large ascites.
4. Splenomegaly.
___ paracentesis
Uneventful ultrasound-guided therapeutic paracentesis with
extraction of 3.8 L of fluid.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 800 mg PO DAILY
2. BuPROPion 75 mg PO BID
3. Duloxetine 20 mg PO DAILY
4. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
5. Lactulose ___ mL PO TID
6. Metoclopramide 5 mg PO BID
7. Nadolol 60 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. Raltegravir 400 mg PO BID
10. Rifaximin 550 mg PO BID
11. Senna ___ TAB PO BID:PRN constipation
12. Spironolactone 50 mg PO DAILY
13. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
14. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN sob
Discharge Medications:
1. Albuterol-Ipratropium ___ PUFF IH Q6H:PRN sob
2. Acyclovir 800 mg PO DAILY
3. BuPROPion 75 mg PO BID
4. Duloxetine 20 mg PO DAILY
5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
6. Lactulose ___ mL PO TID
7. Metoclopramide 5 mg PO BID
8. Pantoprazole 40 mg PO Q24H
9. Rifaximin 550 mg PO BID
10. Senna ___ TAB PO BID:PRN constipation
11. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
12. Raltegravir 400 mg PO BID
13. Spironolactone 50 mg PO BID
RX *spironolactone 50 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*3
14. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*3
15. Nadolol 60 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
1) Ascites
Secondary diagnoses:
1) Hepatitis C cirrhosis
2) Hepatic encephalopathy
3) HIV on HAART medications
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Cirrhosis and new ascites.
COMPARISON: Abdominal ultrasound ___.
TECHNIQUE: Grayscale and Doppler ultrasound images were obtained of the
abdomen.
FINDINGS: The liver again is small demonstrating a coarse echotexture with
nodular contour compatible with given diagnosis of cirrhosis. There is no
focal intrahepatic lesion. The main portal vein is patent with hepatopetal
flow. The anterior right, posterior right and left portal veins are patent
with normal forward flow. There is no evidence of portal vein thrombosis.
There is no intra- or extra-hepatic biliary duct dilatation, and the common
bile duct measures 3 mm in diameter. The spleen is stably enlarged measuring
16.8 cm in largest axis. Large ascites is prominently increased compared to
prior examination. Patient is status post cholecystectomy. The pancreas is
not well visualized due to overlying bowel gas and ascites.
IMPRESSION:
1. Small, coarse nodular liver compatible with given diagnosis of cirrhosis.
2. Patent main portal vein with hepatopetal flow without evidence of
thrombosis.
3. New large ascites.
4. Splenomegaly.
Radiology Report
INDICATION: ___ yo M with HIV/HCV cirrhosis with new ascites. Please perform US
guided paracentesis.
TECHNIQUE: US guided therapeutic paracentesis.
ULTRASOUND GUIDED THERAPEUTIC PARACENTESIS: Following brief review of the
steps, benefits, risks, and alternatives a written consent was acquired. A
preprocedural timeout was performed using three independent patient
identifiers as per ___ protocol.
Ultrasound was performed in all four quadrants of the abdomen and a large
pocket of fluid in the right lower quadrant was chosen as the target site of
intervention. The skin was marked, prepped, and draped in the usual sterile
fashion. Following administration of 1% buffered lidocaine into the
subcutaneous tissues, a 5 ___ ___ catheter was inserted, yielding 3.8
liters of blood-tinged yellow ascitic fluid.
The attending physician, ___, was present during the critical steps of the
procedure. The patient tolerated the procedure well without immediate
complications.
IMPRESSION: Uneventful ultrasound-guided therapeutic paracentesis with
extraction of 3.8 L of fluid.
Gender: M
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: BILATERAL LE EDEMA
Diagnosed with CIRRHOSIS OF LIVER NOS
temperature: 98.8
heartrate: 92.0
resprate: 24.0
o2sat: 94.0
sbp: 118.0
dbp: 73.0
level of pain: 0
level of acuity: 2.0 | Dr. ___ is a ___ with HIV and HCV cirrhosis complicated by
hepatic encephalopathy, variceal bleeding s/p banding, who was
admitted to the hospital with new-onset ascites, most likely due
to increased sodium intake in recent weeks.
ACTIVE PROBLEMS
# Ascites and ___ edema. This is most likely from increased
sodium intake since he has been eating more packaged meals in
past few weeks due to recent car accident. It could also
represent progression of liver disease. Diagnostic paracentesis
revealed no PMNs. US-guided therapeutic paracentesis removed
3.8L of fluid. He received 25g of 25% albumin IV. UA showed no
UTI. His spironolactone was increased from 50mg daily to 50mg
BID. We have added furosemide 40mg daily.
CHRONIC PROBLEMS
# HCV Cirrhosis, complicated by hepatic encephalopathy and now
ascites. Patient is listed for Liver Transplant. We continued
his lactulose and rifaximin, aiming for ___ bowel movements per
day.
# GIB/varices. No esophageal varices in last EGD ___.
Patient's HR was in 80-100 range during admission. We did not
adjust his nadolol since he is already at a high dose of 60mg
and higher dose could cause kidney dysfunction.
# HIV. Patient was continued on HAART medications. No history of
opportunistic infections.
# Maxillary sinus mass. Evaluated by ENT on ___ and felt to
be right maxillary mucopyocele. Recommended removal, but will
need approval from Transplant and ID services and correction of
coagulopathy prior to surgery.
### TRANSITIONAL ISSUES ###
1) Spironolactone increased to 50mg BID. We added furosemide
40mg daily.
2) Please monitor electrolytes.
3) Encouraged low salt diet.
4) Follow up with Dr. ___ Dr. ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Lower abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M with a history of HTN presenting with five days of
intermittent left lower abdominal pain refered by his PCP.
In the ED, initial vitals were: 97.1 66 136/86 16 100% RA. In
the ED, labs were notable for normal CBC, chemistry, and lactate
of 1.6. U/A was negative. CT scan showed sigmoid diverticulitis.
He was given Cipro IV and admitted to medicine for further
management.
On the floor, the patient notes that he has left lower quadrant
pain that began 5 days ago. He describes the pain as an
intermittent sharp pain that comes and goes. He notes that this
morning the pain became so severe that he was unable to walk. He
denies any nausea, vomiting, diarrhea, or constipation. He notes
he has been eating and drinking normally without difficulty. He
has tried ibuprofen with codeine for the pain intermittently. He
denies fever, chills, dysuria, cough, chest pain, or headaches.
He does note that about 1 month ago he was evaluated for similar
abdominal pain in the right lower qudrant that was attributed to
a possible nephrolithiasis. He was given tylenol with codeine at
that time. He currently denies any right lower quadrant pain.
Of note he does mention hematuria in the past thought to be due
to UTI for which he was given amoxicillin with resolution of his
symptoms. He has since stopped taking 81 mg aspirin daily.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
HTN
Colonscopy ___ with diverticulitis and multiple polyps plan for
repeat in ___ years
Hematuria resolved with amoxicillin per patient's report and
cessation of aspirin
GERD
High cholesterol
Social History:
___
Family History:
No known family history of colon cancer. Father with
hypertension and diabetes.
Physical Exam:
EXAM ON ADMISSION:
==================
Vitals: T: 98.2 BP: 113/81 P: 64 R:18 O2: 95% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, tender to palpation in mid lower quadrant and
left lower quadrant with guarding though no rebound. Non-tender
to palpation in RLQ. Negative rovsig sign. Negative psoas sign.
No evidence of hernia
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rash
Neuro: CN II-XII intact, ___ strength in upper and lower
extremities.
EXAM ON DISCHARGE:
==================
Vitals: T: 98.1, BP 115/71, HR 68,RR 18, 97% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, tender to palpation in left lower quadrant with
guarding though no rebound. Non-tender to palpation in RLQ.
Negative rovsig sign. Negative psoas sign. No evidence of hernia
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rash
Neuro: CN II-XII intact, ___ strength in upper and lower
extremities.
Pertinent Results:
LABS ON ADMISSION:
==================
___ 01:50PM BLOOD WBC-7.6 RBC-4.97 Hgb-15.6 Hct-44.2 MCV-89
MCH-31.3 MCHC-35.2* RDW-12.8 Plt ___
___ 01:50PM BLOOD Glucose-107* UreaN-16 Creat-1.2 Na-136
K-4.1 Cl-99 HCO3-27 AnGap-14
___ 01:54PM BLOOD Lactate-1.6
STUDIES:
========
CT ABD ___:
IMPRESSION:
1. Acute sigmoid diverticulitis. Extensive surrounding fat
stranding and
phlegmonous changes without evidence of macroperforation or
drainable abscess formation.
2. Cholelithiasis without evidence of acute cholecystitis.
EKG:
====
QTc of 418
PRIOR Colonscopy ___:
==========================
Findings:
Protruding Lesions A single sessile 5 mm polyp of benign
appearance was found in the transverse colon. A single-piece
polypectomy was performed using a cold snare in the transverse
colon. The polyp was completely removed. A single sessile 4 mm
polyp of benign appearance was found in the hepatic flexure. A
single-piece polypectomy was performed using a cold snare in the
hepatic flexure. The polyp was completely removed. Three sessile
polyps of benign appearance and ranging in size from 4 mm to 5
mm were found in the splenic flexure, descending colon and
rectum. Single-piece polypectomies were performed using a cold
snare in the splenic flexure, descending colon and rectum. The
polyps were completely removed.
Excavated Lesions A few diverticula were seen in the right and
left colon. Diverticulosis appeared to be of mild severity.
Impression: Polyp in the transverse colon (polypectomy)
Polyp in the hepatic flexure (polypectomy)
Polyps in the splenic flexure, descending colon and rectum
(polypectomy)
Diverticulosis of the right and left colon
Otherwise normal colonoscopy to cecum
Recommendations: We will follow up polyp pathology
Repeat screening colonoscopy in ___ years pending polyp
pathology
Additional notes: The procedure was performed by the attending
and the GI fellow. The attending was personally present during
the entire procedure and collaborated with the Fellow on the
findings of this report. The patient's reconciled home
medication list is appended to this report. FINAL DIAGNOSES are
listed in the impression section above. Estimated blood loss =
zero. Specimens were taken for pathology as listed above.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Naproxen 250 mg PO Q8H:PRN pain
2. Atenolol 25 mg PO DAILY
3. Tamsulosin 0.4 mg PO QHS
4. Acetaminophen w/Codeine ___ TAB PO Frequency is Unknown
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. Tamsulosin 0.4 mg PO QHS
3. Acetaminophen 325-650 mg PO Q6H:PRN pain
RX *acetaminophen 325 mg ___ tablet(s) by mouth every 6 hours
Disp #*40 Tablet Refills:*0
4. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth every
12 hours Disp #*19 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 #*28 Tablet Refills:*0
6. Ondansetron 4 mg PO Q8H:PRN nausea/vomiting Duration: 5 Days
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*15 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Uncomplicated diverticulitis
Cholelithiasis without evidence of acute cholecystitis
Secondary:
Hypertension
Benign prostatic hypertrophy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Left lower quadrant pain, evaluate for diverticulitis
TECHNIQUE: Axial helical MDCT scan of the abdomen and pelvis following the
administration of IV contrast . Coronal and sagittal reformatted images were
also generated for review.
DOSE: 920 mGy-cm
COMPARISON: CT abdomen pelvis from ___
FINDINGS:
LOWER CHEST: There is mild bibasilar dependent atelectasis. The visualized
portions of the heart and pericardium are unremarkable. There is no pleural
effusion.
LIVER: The liver enhances homogeneously, with no focal lesions or
intrahepatic biliary duct dilatation. The gallbladder contains small
radiopaque gallstones without evidence of wall thickening or pericholecystic
fluid. The portal vein is patent.
PANCREAS: The pancreas does not demonstrate focal lesions or peripancreatic
stranding or fluid collection.
SPLEEN The spleen is homogeneous and normal in size. Note is made of a small
splenule.
ADRENALS: The adrenal glands are unremarkable.
KIDNEYS: The kidneys do not show solid or cystic lesions and demonstrate
symmetric nephrograms and excretion of contrast. No pelvicaliceal dilatation
or perinephric abnormalities are present.
GI TRACT: The stomach, duodenum, and small bowel show no evidence of wall
thickening or obstruction. There is extensive colonic diverticulosis. There is
wall thickening and extensive surrounding fat stranding and phlegmonous
changes involving a segment of the sigmoid colon compatible with acute
diverticulitis. There is no evidence of macroperforation or abscess formation.
The remaining colon is non-dilated without obstructive lesions. The appendix
is visualized and normal.
VASCULAR: The aorta contains moderate atherosclerotic calcification but is
normal in caliber without aneurysmal dilatation. The origins of the celiac
axis, SMA, bilateral renal arteries, and ___ are patent.
RETROPERITONEUM AND ABDOMEN: There is no retroperitoneal or mesenteric lymph
node enlargement. No ascites, free air, or abdominal wall hernias are noted.
PELVIC CT: The urinary bladder and distal ureters are unremarkable. No
pelvic wall or inguinal lymph node enlargement is seen. There is no pelvic
free fluid.
OSSEOUS STRUCTURES: No blastic or lytic lesions suspicious for malignancy is
present.
IMPRESSION:
1. Acute sigmoid diverticulitis. Extensive surrounding fat stranding and
phlegmonous changes without evidence of macroperforation or drainable abscess
formation.
2. Cholelithiasis without evidence of acute cholecystitis.
Gender: M
Race: HISPANIC/LATINO - GUATEMALAN
Arrive by WALK IN
Chief complaint: Lower abdominal pain
Diagnosed with DIVERTICULITIS OF COLON
temperature: 97.1
heartrate: 66.0
resprate: 16.0
o2sat: 100.0
sbp: 136.0
dbp: 86.0
level of pain: 1
level of acuity: 3.0 | ___ M with a history of HTN presenting with five days of
intermittent lower abdominal pain found to have uncomplicated
sigmoid diverticulitis.
# Uncomplicated Diverticulitis:
Mr. ___ presented to the hospital with left lower quadrant
pain found to have uncomplicated diverticulitis with CT abdomen
showing localized localized diverticular inflammation and is
without evidence of abscess, obstruction, or perforation. He is
also without evidence of leukocytosis though exam was notable
for left lower quadrant tenderness with guarding though no
rebound. Patient's last colonscopy in ___ showed evidence of
sigmoid diverticulitis with polyps with need for repeat in ___
years. Mr. ___ was admitted to the hospital placed on clear
liquid diet, started on PO ciprofloxacin/flagyl with improvement
of his abdominal pain and ability to ambulate easily prior to
discharge. He was discharged with 10 day course of PO
cipro/flagyl, tylenol for pain, and zofran for nausea (Qtc of
418). He was instructed to continue clear liquid diet for ___
days and if tolerating without issue could transition to regular
diet.
# HTN:
Blood pressure remained well controlled and he was continued on
atenolol.
# BPH:
Continued on home tamsulosin QHS
#History of hematuria
Patient with prior history of hematuria that per his report had
resolved after treatement with amoxicillin possible secondary to
nephrolithiasis vs. hemorrhagic UTI. UA currently without
evidence of blood. Follow up with primary care doctor
#Cholelithiasis without cholecystitis
CT abdomen showing diverticulitis above noted cholelithiasis
though no cholecystitis |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypercarbic respiratory failure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ history of COPD on 2L O2, HFpEF, CKD
III, CAD, DM II, HTN, bullous pemphigoid on prednisone, beta
thalassemia trait, hard of hearing, recent admission to ___ for
COPD exacerbation and hypercarbic respiratory failure requiring
BiPAP, presenting from rehab facility with BRBPR and respiratory
distress.
Patient is a long-term resident of ___,
presenting with worsening shortness of breath, tachypnea, and
BRBPR. Nursing facility initially noted blood in her diaper on
___, which has increased over the last several days with
significant amount of bright red blood. She also states that she
has been feeling more fatigued over last several days. Rehab
staff had noted inflamed hemorrhoids and was treated with
preparation H. However noted to have down-trending Hb from 9.2
in ___ to 8.3. Also with some worsening shortness of breath,
CXR was obtained per report there with no e/o consolidation.
Night prior to admission, patient was also found on the floor
next to her bed, had an un-witnessed fall, was unable to answer
if she had a head strike. Was referred to ED for possible LGIB.
Regarding her recent admission from ___, presented to
___ after presenting with AMS. ABG at the time was 7.17/112. Was
a confirmed DNR/DNI, had improvement in hypercarbic respiratory
failure with BIPAP.
In the ED here,
Initial Vitals: T 97.8 HR 88 BP 144/70, RR 36, O2 99% 2L NC
Exam: Patient is tachypneic and grunting. Abdomen is soft. She
has bilateral lower extremity edema.
Labs:
- WBC 10.4, Hb 7.1, PLT 273
- Na 145, K 5.6, bicarb 34, BUN 38, Cr 1.2, glucose 238
- Troponin 0.03
- VBG ___
- proBNP 351
ED Course: Initial VBG ___, was started on BiPAP ___
FiO2 30% with slight improvement in VBG to ___. With Hb
7.1 however given maroon guaiac positive stool in ED, was given
1U PRBC with repeat Hb 7.7. Attempted to get NCHCT given recent
fall however patient was unable to lie flat to tolerate CT.
Imaging:
CXR: IMPRESSION: Essentially nondiagnostic exam due to patient
positioning.
Interventions:
___ 14:19 IH Albuterol 0.083% Neb Soln
___ 14:19 IH Ipratropium Bromide Neb
___ 14:34 IV MethylPREDNISolone Sodium Succ 125 mg
___ 17:45 IH Albuterol 0.083% Neb Soln 1 Neb
___ 17:45 IH Ipratropium Bromide Neb 1 Neb ___
Past Medical History:
- COPD
- HFpEF
- CAD
- HTN
- T2DM
- OA
- Bullous Pemphigoid
- OA
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
GEN: Eyes shut, uncomfortable appearing, labored breathing
EYES: Unable to open eyes, with some serous dicharge
CV: Regular rate and rhythm, no m/r/g
RESP: Decreased air movement throughout, no wheezes, rales, or
rhonchi
GI: Distended, otherwise soft, non-tender throughout
MSK: L hip ecchymoses and TTP. 2+ peripheral pulses. 1+ pitting
edema to mid-shin.
NEURO: Unable to adequately assess.
DISCHARGE PHYSICAL EXAM
24 HR Data (last updated ___ @ 907)
Temp: 98.5 (Tm 98.7), BP: 160/67 (107-160/57-67), HR: 80
(79-87), RR: 18 (___), O2 sat: 100% (97-100), O2 delivery: 2L
General: Lying in bed, NAD
HEENT: NCAT, MMM, EOMI
CV: RRR, nl S1/S2, II/VI early systolic murmur best heard at
RUSB
Lungs: Breathing comfortably, no accessory muscle use. Coarse
breath sounds b/l.
Abdomen: Soft, non-tender, non-distended.
Ext: WWP, no CCE.
Neuro: Moving all extremities, face symmetric.
Pertinent Results:
ADMISSION LABS
================
___ 12:25PM BLOOD WBC-10.4* RBC-3.37* Hgb-7.1* Hct-26.6*
MCV-79* MCH-21.1* MCHC-26.7* RDW-20.5* RDWSD-57.6* Plt ___
___ 12:25PM BLOOD Neuts-72.9* ___ Monos-5.0
Eos-0.3* Baso-0.1 Im ___ AbsNeut-7.59* AbsLymp-2.21
AbsMono-0.52 AbsEos-0.03* AbsBaso-0.01
___ 12:25PM BLOOD ___ PTT-25.0 ___
___ 12:25PM BLOOD Glucose-238* UreaN-38* Creat-1.2* Na-145
K-5.6* Cl-99 HCO3-34* AnGap-12
___ 12:25PM BLOOD ALT-11 AST-29 LD(LDH)-327* AlkPhos-51
TotBili-<0.2
___ 12:25PM BLOOD proBNP-351
___ 12:25PM BLOOD cTropnT-0.03*
___ 08:03PM BLOOD Calcium-9.3 Phos-3.5 Mg-2.3
___ 03:00AM BLOOD calTIBC-287 Ferritn-37 TRF-221
___ 12:55PM BLOOD ___ pO2-39* pCO2-93* pH-7.23*
calTCO2-41* Base XS-6
___ 08:12PM BLOOD Lactate-0.9
PERTINENT INTERVAL LABS
==========================
___ 12:25PM BLOOD cTropnT-0.03*
___ 08:03PM BLOOD CK-MB-5 cTropnT-0.02*
___ 11:20AM BLOOD CK-MB-3 cTropnT-0.03*
___ 01:46PM BLOOD CK-MB-3 cTropnT-0.02*
___ 03:00AM BLOOD calTIBC-287 Ferritn-37 TRF-221
DISCHARGE LABS
===============
___ 06:02AM BLOOD WBC-8.7 RBC-3.33* Hgb-7.2* Hct-26.4*
MCV-79* MCH-21.6* MCHC-27.3* RDW-20.4* RDWSD-58.8* Plt ___
___ 06:02AM BLOOD Glucose-159* UreaN-19 Creat-0.9 Na-141
K-4.4 Cl-99 HCO3-33* AnGap-9*
___ 06:02AM BLOOD Calcium-8.5 Phos-3.1 Mg-2.1
MICROBIOLOGY
=============
Blood cultures ___
Urine culture ___ - no growth
Respiratory viral screen and culture ___
Influenza A and B - negative
IMAGING STUDIES
=================
Hip XR ___
No acute fracture or dislocation is identified on these frontal
views. There are moderate degenerative changes of the right hip
and mild degenerative changes of the left hip.
CT head and c-spine w/o contrast ___. Please note that significant motion artifact limits
evaluation of the
cervical spine. Evaluation for subtle fractures limited. Within
this
confines, no obvious displaced fracture or traumatic
subluxation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO BID:PRN Pain - Mild/Fever
2. Senna 17.2 mg PO BID
3. Potassium Chloride 10 mEq PO DAILY
4. ___ 22 Units Breakfast
___ 4 Units Dinner
Insulin SC Sliding Scale using REG Insulin
5. amLODIPine 10 mg PO DAILY
6. PredniSONE 7 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Albuterol 0.083% Neb Soln 1 NEB IH Q8H:PRN shortness of
breath
9. Gabapentin 100 mg PO BID
10. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
11. Arnuity Ellipta (fluticasone furoate) 100 mcg/actuation
inhalation DAILY
12. Ferrous GLUCONATE 324 mg PO DAILY
13. Polyethylene Glycol 17 g PO DAILY
14. Omeprazole 20 mg PO DAILY
15. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO BID:PRN gas
16. Furosemide 80 mg PO BID
17. Aranesp (in polysorbate) (darbepoetin alfa in polysorbat) 40
mcg/mL injection 1X/WEEK
Discharge Medications:
1. Chlorthalidone 12.5 mg PO DAILY
RX *chlorthalidone 25 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*0
3. ___ 22 Units Breakfast
___ 4 Units Dinner
Insulin SC Sliding Scale using REG Insulin
4. Acetaminophen 650 mg PO BID:PRN Pain - Mild/Fever
5. Albuterol 0.083% Neb Soln 1 NEB IH Q8H:PRN shortness of
breath
6. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO BID:PRN gas
7. amLODIPine 10 mg PO DAILY
8. Aranesp (in polysorbate) (darbepoetin alfa in polysorbat) 40
mcg/mL injection 1X/WEEK
9. Arnuity Ellipta (fluticasone furoate) 100 mcg/actuation
inhalation DAILY
10. Aspirin 81 mg PO DAILY
11. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
12. Gabapentin 100 mg PO BID
13. Omeprazole 20 mg PO DAILY
14. Polyethylene Glycol 17 g PO DAILY
15. PredniSONE 7 mg PO DAILY
16. Senna 17.2 mg PO BID
17. HELD- Potassium Chloride 10 mEq PO DAILY This medication
was held. Do not restart Potassium Chloride until your
electrolytes are checked.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
HYPOXIC RESPIRATORY FAILURE
COPD EXACERBATION
PNEUMONIA
SECONDARY DIAGNOSES
===================
Altered Mental status
Lower gastrointestinal bleed
Hypernatremia
Type II Diabetes Mellitus
Hypertension
Chronic Kidney Disease
Heart failure with preserved ejection fraction
Elevated troponin
Chronic pain
Bullous pemphigoid
Coronary Artery Disease
Hyperkalemia
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 sob resp distress// ?PNA ?CHF
COMPARISON: None
FINDINGS:
AP portable semi upright view of the chest. Low lung volumes markedly limit
the evaluation as well as the patient is head projecting over the upper chest.
Imaged portion of the right lung appears clear. The left lung is not
assessed.
IMPRESSION:
Essentially nondiagnostic exam due to patient positioning.
Radiology Report
EXAMINATION: CR - CHEST PORTABLE AP
INDICATION: ___ year old woman with history of COPD, HFpEF, presenting with
respiratory distress, hematochezia, admitted for COPD exacerbation and
possible LGIB// Eval for etiology of hypercarbic respiratory failure. Also
eval for PNA
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___.
IMPRESSION:
The lungs appear hyperinflated which may represent chronic emphysematous
changes. There is mild blunting of the left costophrenic angle which may
represent a small pleural effusion or atelectasis. There is no focal
consolidation or pneumothorax. The cardiac silhouette is mildly enlarged.
There is central pulmonary vascular congestion without overt pulmonary edema.
No acute osseous abnormalities are identified.
Radiology Report
EXAMINATION: DX PELVIS AND HIP UNILATERAL
INDICATION: ___ year old woman with history of dementia s/p fall// Eval for fx
TECHNIQUE: Frontal view radiograph of the pelvis with an additional frontal
view of the left hip.
COMPARISON: None.
FINDINGS:
No acute fracture or dislocation is identified on these frontal views. There
are moderate degenerative changes of the right hip and mild degenerative
changes of the left hip.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with history of COPD, dementia, presenting s/p
fall unclear if head strike, admitted with COPD exacerbation and BRBPR. Also
with bilateral eye lid swelling eval for orbital fx// EVal for bleed/stroke,
fracture
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.7 mGy-cm.
2) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.7 mGy-cm.
3) Sequenced Acquisition 2.0 s, 8.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
373.8 mGy-cm.
4) Sequenced Acquisition 2.0 s, 8.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
373.9 mGy-cm.
Total DLP (Head) = 2,243 mGy-cm.
COMPARISON: None.
FINDINGS:
The examination is at least moderately motion degraded despite multiple repeat
acquisitions. Within this confines, there is no obvious intracranial
hemorrhage or midline shift. No intra or extra-axial mass effect. There is
prominence of the ventricles and sulci suggestive of involutional changes.
Evaluation for fracture is limited due to extensive motion artifact, however,
no obvious displaced fracture is seen. The right mastoids may be partially
opacified. The visualized portion of the paranasal sinuses and left mastoid
appear grossly clear. The visualized portion of the orbits are unremarkable.
IMPRESSION:
1. Please note that the exam is significantly limited by extensive motion
artifact. Within these limitations, no obvious intracranial hemorrhage or
midline shift.
2. Evaluation for fractures limited, however, no obvious displaced fracture
identified.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: ___ year old woman with history of COPD, dementia, presenting s/p
fall unclear if head strike, admitted with COPD exacerbation and BRBPR// Eval
for fx Eval for fx
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 4.7 s, 18.4 cm; CTDIvol = 25.1 mGy (Body) DLP = 462.1
mGy-cm.
2) Spiral Acquisition 4.7 s, 18.4 cm; CTDIvol = 25.1 mGy (Body) DLP = 462.1
mGy-cm.
Total DLP (Body) = 924 mGy-cm.
COMPARISON: None.
FINDINGS:
Please note that significant motion artifact limits evaluation of the cervical
spine. Within these limitations, there is no traumatic subluxation or obvious
displaced fracture. There is no definite prevertebral swelling.
There is moderate cervical spondylosis with disc space narrowing and bridging
osteophyte formation. There is mild multilevel vertebral canal narrowing and
moderate right C4-C5 and C5-C6 neural foraminal stenosis due to uncovertebral
hypertrophy and facet joint arthropathy. No focal consolidations seen in the
lung apices.
Re-identified is complete opacification of the right mastoid air cells,
without definitive underlying fracture.
IMPRESSION:
1. Please note that significant motion artifact limits evaluation of the
cervical spine. Evaluation for subtle fractures limited. Within this
confines, no obvious displaced fracture or traumatic subluxation.
2. Additional findings described above.
RECOMMENDATION(S): If there is high clinical concern of fracture, the study
should be repeated with CT or MRI.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with hx COPD on home 2L O2 with shortness of
breath.// evaluate for pulmonary edema/cause of respiratory distress
TECHNIQUE: Chest AP
COMPARISON: ___
IMPRESSION:
Lungs are low volume with small bilateral effusions and bibasilar atelectasis.
Interstitial abnormality in both lower lobes is unchanged. Overall
constellation Findings related to congestive heart failure. Cardiomediastinal
silhouette is stable. No pneumothorax is seen.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: Ms. ___ is a ___ history of COPD on 2L O2, HFpEF, CKD
III,CAD, DM II, HTN, bullous pemphigoid on prednisone, betathalassemia trait,
hard of hearing, recent admission to BWF forCOPD exacerbation and hypercarbic
respiratory failure requiringBiPAP, presenting from rehab facility with BRBPR
and respiratorydistress admitted with possible LGIB and COPD exacerbation,
inthe MICU on BIPAP since yesterday, now off BIPAP, no acute GIB// Please
assess bilateral pleural effusions (simple vs. complicated?) and amount for
possible thoracentesisPlease assess PNA vs. pulmonary edema?
TECHNIQUE: MDCT axial images were acquired through the chest without
intravenous contrast administration.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 1.9 s, 29.7 cm; CTDIvol = 19.2 mGy (Body) DLP = 568.2
mGy-cm.
Total DLP (Body) = 568 mGy-cm.
COMPARISON: None.
FINDINGS:
The lack of intravenous contrast administration limits the evaluation of the
lung parenchyma and mediastinum.
The thyroid is unremarkable.
There is no size significant supraclavicular, axillary, mediastinal, or hilar
lymphadenopathy.
There are moderate atherosclerotic calcifications of the thoracic aorta.
Trace bilateral simple pleural effusions are seen, with associated
subsegmental atelectasis. There is no evidence of pericardial effusion.
Focal areas of airspace opacification are seen in both lower lobes, as well as
in the right upper lobe along the major fissure, likely infectious
representing multifocal pneumonia. The airways are patent to the subsegmental
level.
Limited images of the upper abdomen are unremarkable, except for a tiny
hyperdense structure in the upper pole of the left kidney, with Hounsfield
units of 95. This most likely represents a proteinaceous or hemorrhagic cyst.
There is mild uniform thickening of the left adrenal gland, likely
hyperplasia.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
IMPRESSION:
1. Focal airspace opacifications are seen in both lower lobes and right upper
lobe, suggestive of multifocal pneumonia. Recommend re-imaging after treatment
to ensure resolution.
2. Trace bilateral simple pleural effusions are seen, with associated
subsegmental atelectasis. They are too small for thoracentesis.
RECOMMENDATION(S): Recommend follow up imaging after treatment to ensure
resolution of the multifocal opacities.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: BRBPR, Dyspnea
Diagnosed with Gastrointestinal hemorrhage, unspecified
temperature: 97.8
heartrate: 88.0
resprate: 36.0
o2sat: 99.0
sbp: 144.0
dbp: 70.0
level of pain: 2
level of acuity: 1.0 | Ms. ___ is a ___ history of COPD on 2L O2, HFpEF, CKD
III, CAD, DM II, HTN, bullous pemphigoid on prednisone, beta
thalassemia trait, hard of hearing, recent admission to ___ for
COPD exacerbation and hypercarbic respiratory failure requiring
BiPAP, presenting from rehab facility with BRBPR and respiratory
distress admitted with possible LGIB and COPD exacerbation. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / morphine / Macrobid / Biaxin
Attending: ___.
Chief Complaint:
Abd pain, hematemesis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ year old female with a history of gastric bypass
(___), gastrojejunal anastomotic ulcer, H. pylori,
polysubstance abuse, who presents with an episode of
hematemesis. She had some nausea upon waking up this morning,
which is her baseline before she eats. She took her morning dose
of Wellbutrin with some water, and had a single episode of
clear/mucus emesis
about 20 minutes after the same. She had another two episodes
following the initial one, the second of which was bloody. Per
patient, she noticed blood on her lips and teeth, and bright red
blood in the toilet bowl. Did have some transient dizziness upon
seeing the blood, but denies any palpitations, shortness of
breath or loss of consciousness. Shortly after the episode of
hematemesis, she began to have ___ stabbing epigastric pain
that radiated towards her back; similar to prior episodes of
pain that have prompted hospitalization in the past. She went to
___ ER for evaluation and was transferred here for
further evaluation after she was found to be hemodynamically
stable and given Protonix 80mg IV. She has not had any episodes
of emesis after 9am.
Of note, patient was last admitted at ___ from ___ to
___ for a suicide attempt and severe epigastric pain.
Workup at that time was significant for a gastrojejunal ulcer
and gastrogastric fistula seen on EGD. She was also found to
have H. pylori and treated for the same, although per patient
treatment was not completed. Patient was discharged to an
extended care psychiatric facility, where she was until
recently. Since her discharge, she has continued to have nausea
upon awakening, and intermittent stabbing epigastric abdominal
pain, exacerbated by acidic and spicy foods. She does report
that any food that "makes her chew" causes abdominal discomfort,
and her diet has consisted of fluids, yoghurt and soup for the
most part. She has not
consumed any alcohol since ___. She has not taken Zofran and
sucralfate (which do provide symptomatic relief) because she did
not have prescriptions for the same when discharged from the
ECF. Over the past two weeks, she has had laryngitis, cough and
a cold. Cough is productive of clear-yellow sputum, accompanied
by fever initially. However, denies any vigorous coughing this
morning. She has not seen any healthcare provider since her
discharge.
At this time, patient denies any nausea or further episodes of
emesis. She continues to have epigastric pain that is controlled
with Dilaudid. Review of systems is negative for
lightheadedness, palpitations, dysphagia, constipation, melena
or bloody stool.
Past Medical History:
PMH:
1) polysubstance abuse including alcohol
2) suicide attempt recently with clonodine and alcohol
3) anxiety/depression
4) history of SVT
5) asthma
6) colonic polyps - per patient c-scope for mild bleeding in
___, improved after polypectomy-at ___
7) neuropathy ___ to accident
8) idiopathic intermitent abdominal pain
9) ADD
Past Surgical Hx:
1) Roux en y gastric bypass + chole ___ at ___.
Incisions consistent with Lap-assisted procedure.
2) Multiple ortho surgeries - left shoulder, upper spine, lower
back, left knee.
3) Patient recalls appendectomy "long time ago"
4) desmoid tumor resection in thoracic spine X3
Social History:
___
Family History:
Mother: positive for DM
Father: positive for gout, gastric ulcers
Brother:healthy
Physical ___:
PHYSICAL EXAM
Gen: NAD, comfortable
CV: RRR, nl s1/s2
Lungs: CTAB
Abd: soft, ND, +BS, tender to palpation in epigastrium without
rebound/guarding
Ext: no edema
Pertinent Results:
___ 02:15PM BLOOD WBC-9.7# RBC-4.88 Hgb-13.8 Hct-42.2
MCV-87 MCH-28.2 MCHC-32.6 RDW-15.2 Plt ___ Neuts-63.3
___ Monos-5.1 Eos-1.6 Baso-0.5 ___ PTT-31.1
___ UreaN-10 Creat-0.6 ALT-8 AST-17 AlkPhos-96
TotBili-0.5 Lipase-19 Albumin-3.7 Iron-94 calTIBC-378 VitB12-574
___ Ferritn-15 TRF-291
___ 02:22PM BLOOD Glucose-80 Na-141 K-4.4 Cl-104 calHCO3-21
___ 02:22PM BLOOD O2 Sat-92 COHgb-7*
___ CT ABD & PELVIS WITH CONTRAST:
IMPRESSION:
1. Post-surgical changes related to Roux-en-Y gastric bypass
surgery. Oral contrast is not seen in the excluded stomach and
pancreaticobiliary limb of the small bowel, as was seen on
___ and ___ CT exams. However, this may in part
relate to timing of the study, as oral contrast is more distal
in the bowel and any oral contrast through a gastro-gastric
fistula may have passed more distal than the afferent limb. No
bowel obstruction.
2. Persistent dilation of the common bile duct, likely related
to prior
cholecystectomy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion (Sustained Release) 150 mg PO QAM
2. BuPROPion (Sustained Release) 150 mg PO QPM
3. Ferrous Sulfate 325 mg PO DAILY
4. Gabapentin 400 mg PO TID
5. Thiamine 100 mg PO DAILY
6. Vitamin D 400 UNIT PO DAILY
7. Calcium Carbonate 1250 mg PO DAILY
8. Acetaminophen 1000 mg PO Q8H
9. Lorazepam 0.5 mg PO DAILY:PRN anxiety
10. Multivitamins 1 CAP PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. BuPROPion (Sustained Release) 150 mg PO QAM
3. BuPROPion (Sustained Release) 150 mg PO QPM
4. Calcium Carbonate 1250 mg PO DAILY
5. Ferrous Sulfate 325 mg PO DAILY
6. Gabapentin 400 mg PO TID
7. Lorazepam 0.5 mg PO DAILY:PRN anxiety
8. Multivitamins 1 CAP PO DAILY
9. Thiamine 100 mg PO DAILY
10. Vitamin D 400 UNIT PO DAILY
11. Bismuth Subsalicylate 30 mL PO QID Duration: 14 Days
RX *bismuth subsalicylate [Bismuth] 262 mg 2 Tablets by mouth
four times a day Disp #*112 Tablet Refills:*0
12. Doxycycline Hyclate 100 mg PO Q12H Duration: 14 Days
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*28 Tablet Refills:*0
13. MetRONIDAZOLE (FLagyl) 250 mg PO Q6H Duration: 14 Days
RX *metronidazole [Flagyl] 250 mg 1 tablet(s) by mouth every six
(6) hours Disp #*112 Tablet Refills:*0
14. Nicotine Patch 14 mg TD DAILY:PRN Tobacco withdrawal
RX *nicotine 14 mg/24 hour 1 patch Daily Disp #*30 Each
Refills:*0
15. Omeprazole 40 mg PO BID
RX *omeprazole 40 mg 1 capsule(s) by mouth twice a day Disp #*60
Capsule Refills:*0
16. Sucralfate 1 gm PO QID
RX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp
#*120 Tablet Refills:*0
17. ZOFRAN ODT *NF* (ondansetron) 4 mg Oral q8h prn nausea
RX *ondansetron [ZOFRAN ODT] 4 mg 1 tablet(s) by mouth every 6
to 8 hours Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Marginal ulcer
H. pylori infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Patient with history of gastric bypass surgery, now presents with
epigastric pain, tenderness and one episode of hematemesis.
COMPARISONS: CT abdomen and pelvis of ___.
TECHNIQUE: MDCT-acquired contiguous images of the abdomen and pelvis were
obtained with intravenous and oral contrast at 5-mm slice thickness.
Coronally and sagittally reformatted images are provided.
FINDINGS:
CT OF THE ABDOMEN:
Imaged lung bases are clear. No pleural effusion is seen. Heart is normal in
size without pericardial effusion.
The liver demonstrates homogeneous enhancement. No suspicious hepatic lesion
is identified. There is no intrahepatic biliary ductal dilatation. The
portal vein is patent. The gallbladder is surgically absent. Multiple
surgical clips are seen within the gallbladder fossa. The common bile duct
remains dilated measuring up to 16 mm, which may relate to prior
cholecystectomy, unchanged. The spleen is unremarkable. There is no
splenomegaly. The pancreas is normal in attenuation. No pancreatic ductal
dilatation or peripancreatic fluid collection is seen.
The patient is status post gastric bypass surgery. No oral contrast material
is seen within the excluded portion of the stomach. Similarly, no oral
contrast is seen within the pancreaticobiliary limb of the small bowel. The
fistulous communication between the Roux limb and excluded stomach seen on
___ exam is no longer visualized on today's study. Jejunojejunostomy
site in the left mid abdomen is unremarkable. The bowel loops are normal in
caliber. There is no bowel wall thickening or obstruction.
The adrenal glands are normal. The kidneys enhance and excrete contrast
symmetrically without hydronephrosis or renal masses.
No pathologically enlarged mesenteric or retroperitoneal lymph nodes are seen.
There is no free air or free fluid within the abdomen.
CT OF THE PELVIS:
The bladder, distal ureters, the uterus, rectum and sigmoid colon are
unremarkable. There is no pelvic lymphadenopathy. There is no free air or
free fluid within the pelvis.
OSSEOUS STRUCTURES: No suspicious lytic or sclerotic bony lesion is seen.
Degenerative joint changes at L4-L5 are noted.
IMPRESSION:
1. Post-surgical changes related to Roux-en-Y gastric bypass surgery. Oral
contrast is not seen in the excluded stomach and pancreaticobiliary limb of
the small bowel, as was seen on ___ and ___ CT exams. However,
this may in part relate to timing of the study, as oral contrast is more
distal in the bowel and any oral contrast through a gastro-gastric fistula may
have passed more distal than the afferent limb. No bowel obstruction.
2. Persistent dilation of the common bile duct, likely related to prior
cholecystectomy.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: HEMATEMESIS
Diagnosed with HEMATEMESIS, ABDOMINAL PAIN EPIGASTRIC, BARIATRIC SURGERY STATUS
temperature: 97.8
heartrate: 74.0
resprate: 16.0
o2sat: 98.0
sbp: 136.0
dbp: 83.0
level of pain: 7
level of acuity: 2.0 | Ms. ___ was transferred from an OSH with complaints of abd
pain, nausea and emesis x 3, one of which contained blood. Upon
arrival, the patient's vital signs and hematocrit were stable
(Hct 44.2); Abd/pelvic CT was unrevealing. The patient was
subsequently admitted to the ___ Surgical Service for
administration of PPIs, carafate, re-initiation of H. pylori
treatment with intravenous levofloxacin and metronidazole.
On HD2, the patient's diet was advanced to stage 3 and well
tolerated. Her H. pylori regimen was transitioned to oral
bismuth, omeprazole, metronidazole and doxycycline (pt w/ PCN
allergy). Gastroenterology was in agreement with these
recommendations, and added that she should get a follow-up EGD 6
weeks after initiation of treatment. Vital signs remained stable
and the patient did not experience any further vomiting. Her
primary care provider was contacted, and he reported that
patient had not followed up with him following her previous
discharge, and that he would be happy to follow her. He also
noted that she had a history of being adherent with only
narcotic pain medication.
At the time of discharge, patient was hemodynamically stable, no
emesis since the unwitnessed episodes at home, with improved
pain and ability to tolerate a diet. She was discharged home on
a 2-week course of h. pylori treatment with follow-up with her
PCP and gastroenterology. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Cholera Vaccine / fluorescein
Attending: ___
Chief Complaint:
Ostomy Bleed
Major Surgical or Invasive Procedure:
EGD and colonscopy (___)
Paracentesis with removal of 4 L (___)
TIPS, IVC filter placement, stomal varices embolization (___)
History of Present Illness:
___ yo M with PMH of HCV cirrhosis and colon cancer s/p resection
and colostomy ___ years ago who was transferred from ___
___ for anemia and bleeding at colostomy site.
This is his third episode of bleeding in past 2 weeks. Presented
to ___ ED every time. Last week had bleeding from
ostomy. It was a large amount, filling his ostomy bag, and he
reportedly syncopized at home. Pressure was applied and
hemostasis achieved. Two days ago he had recurrent bleeding and
received 4 units pRBCs, and 1 unit platelets. Yesterday he had
brisk bleeding from stoma filling two bags and he was unable to
stop it by applying pressure. He again received a blood
transfusion and was transferred to ___ for evaluation for
possible variceal bleed and TIPS procedure. Denies dizziness,
lightheadedness, LOC, chest pain, SOB, and N/V/D. He says stool
looks at baseline at this time.
At ___ Hct was 22. On presentation to the ED vital
signs were within normal limits. Labs were remarkable for a Hct
of 25. Stools were dark green and guaiac negative (twice).
Paracentesis was performed and negative for SBP. Given
ceftriaxone, 2 units pRBCs, and IVF. Liver consulted and
recommended admission to ___. Colorectal Surgery was
consulted and given no active bleeding they declined to
intervene urgently.
Past Medical History:
- HCV cirrhosis with no h/o varices, HE, or SBP
- Colon cancer s/p colostomy and chemotherapy ___ years ago
- Gout
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM
VS: 98.8, 88, 103/62, 20, 98% RA
General: AAOx3, NAD, lying in bed with colostomy exposed
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD, right port-a-cath
CV: RRR, nl S1/S2, no MRG
Lungs: CTAB, no wheezes/rales/rhonchi
Abdomen: Soft, distended, ostomy draining light brown stool
GU: Deferred
Ext: Warm, well-perfused, 1+ pitting edema bilaterally
Neuro: CN II-XII grossly intact
Skin: No jaundice, no concerning lesions
DISCHARGE EXAM
VS: 98.7, 89, 100/48, 20, 100% RA
General: AAOx3, NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
CV: RRR, nl S1/S2, no MRG
Lungs: CTAB, no wheezes/rales/rhonchi
Abdomen: Soft, NTND, ostomy draining brown stool
GU: Deferred
Ext: Warm, well-perfused, 2+ pitting edema bilaterally
Neuro: CN II-XII grossly intact, mild asterixis
Skin: No jaundice, no concerning lesions
Pertinent Results:
ADMISSION LABS
___ 02:15PM BLOOD WBC-5.3 RBC-2.71* Hgb-8.4* Hct-25.3*
MCV-94 MCH-31.0 MCHC-33.1 RDW-20.1* Plt Ct-88*
___ 02:15PM BLOOD Neuts-93.2* Lymphs-4.6* Monos-1.3*
Eos-0.7 Baso-0.3
___ 02:15PM BLOOD ___ PTT-29.9 ___
___ 02:15PM BLOOD Glucose-136* UreaN-27* Creat-1.3* Na-134
K-4.6 Cl-110* HCO3-16* AnGap-13
___ 02:15PM BLOOD ALT-13 AST-33 AlkPhos-100 TotBili-4.1*
___ 02:15PM BLOOD Lipase-62*
___ 02:15PM BLOOD cTropnT-<0.01
___ 02:15PM BLOOD Albumin-2.9*
___ 02:38PM BLOOD Lactate-2.4*
___ 07:02PM BLOOD Lactate-1.5
___ 07:58PM URINE Color-Yellow Appear-Clear Sp ___
___ 07:58PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 07:58PM URINE RBC-0 WBC-1 Bacteri-NONE Yeast-NONE
Epi-<1
___ 03:30PM ASCITES WBC-168* RBC-214* Polys-21* Lymphs-66*
Monos-5* Macroph-8*
PERTINENT LABS
___ 05:55AM BLOOD Hapto-34
___ 03:39PM BLOOD Hgb-8.2* calcHCT-25
___ 01:03PM BLOOD Hgb-11.9* calcHCT-36
DISCHARGE LABS
___ 08:55AM BLOOD WBC-6.0 RBC-2.86* Hgb-8.9* Hct-26.8*
MCV-94 MCH-31.1 MCHC-33.2 RDW-21.9* Plt Ct-66*
___ 08:55AM BLOOD ___ PTT-31.8 ___
___ 08:55AM BLOOD Glucose-150* UreaN-16 Creat-1.3* Na-134
K-3.6 Cl-112* HCO3-13* AnGap-13
___ 08:55AM BLOOD ALT-332* AST-361* AlkPhos-269*
TotBili-2.8*
___ 08:55AM BLOOD Calcium-7.8* Phos-1.9* Mg-1.9
MICROBIOLOGY: Blood and urine cultures negative.
IMAGING
TIPS (___): Successful TIPS placement and embolization of
stomal varices. Infrarenal IVC filter placement. Temporary right
internal jugular vein triple-lumen catheter placed.
Ultrasound-guided paracentesis removing 7 L.
TTE (___): The left atrium is moderately dilated. No atrial
septal defect or patent foramen ovale is seen by 2D, color
Doppler or saline contrast with maneuvers. Left ventricular wall
thicknesses are normal. The left ventricular cavity is mildly
dilated. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. There is mild
global left ventricular hypokinesis (LVEF = 45-50 %). Tissue
Doppler imaging suggests a normal left ventricular filling
pressure (PCWP<12mmHg). Right ventricular chamber size and free
wall motion are normal. The aortic valve leaflets are mildly
thickened (?#). There is no aortic valve stenosis. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. Trivial mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mildly dilated left
ventricle with mild global hypokinesis
Bilateral ___ study (___): No evidence of deep vein
thrombosis in bilateral lower extremity.
CTA abdomen/pelvis (___): Cirrhotic liver with stigmata of
portal hypertension including large volume ascites,
splenomegaly, and extensive varices, including esophageal,
periesophageal, perigastric, and peristomal. The peristomal
varices are a potential source of bleeding, though there is no
evidence of active extravasation. Two incompletely characterized
hypodensities in the liver are likely cysts, or possibly
regenerative nodules. Given the history of colon cancer, this
could be confirmed with ultrasound or short-term ___ as
metastases cannot be completely excluded. No evidence of HCC.
Ascitic fluid under the abdominal wall hernia, parastomal
hernia, and bilateral inguinal hernias. A loop of small bowel is
present in the abdominal wall hernia, though there is no
evidence of obstruction or strangulation. Filling defect in
right lower lobe pulmonary artery, best identified on the venous
phase, consistent with pulmonary embolism. Dedicated CTA of the
chest is suggested to assess the extent of emboli.
Diverticulosis without evidence of diverticulitis. Moderate body
wall edema, including skin thickening at the ostomy sites,
without discrete fluid collections to suggest an abscess.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 20 mg PO DAILY
2. Furosemide 40 mg PO DAILY
3. Spironolactone 50 mg PO DAILY
4. Allopurinol ___ mg PO DAILY
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Nadolol 20 mg PO DAILY
7. Rifaximin 550 mg PO BID
8. Ferrous Sulfate 65 mg PO BID
9. Multivitamins 1 TAB PO DAILY
10. Dorzolamide 2% Ophth. Soln. 1 DROP RIGHT EYE BID
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Dorzolamide 2% Ophth. Soln. 1 DROP RIGHT EYE BID
3. Ferrous Sulfate 325 mg PO BID
RX *ferrous sulfate 325 mg (65 mg iron) 1 tablet(s) by mouth
twice a day Disp #*60 Tablet Refills:*1
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Rifaximin 550 mg PO BID
7. Lactulose 30 mL PO Q4H hepatic encephalopathy
RX *lactulose 10 gram/15 mL 15 mL by mouth three times a day
Disp #*1000 Milliliter Refills:*1
8. Furosemide 40 mg PO DAILY
9. Nadolol 20 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Spironolactone 50 mg PO DAILY
12. Outpatient Lab Work
Please draw blood for CBC, electrolytes, BUN/Cr, ALT, AST, AP,
and TBili on ___ with PCP. ICD 571.5 Cirrhosis.
Please fax results to Dr. ___ at ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
- ___ varices
- Acute blood loss anemia
Secondary diagnoses:
- Pulmonary embolism
- Contrast-induced nephropathy
- HCV cirrhosis
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: Bleeding from ostomy site. Assess for periostomy varices.
COMPARISONS: None.
TECHNIQUE: Contiguous axial MDCT images were obtained through the abdomen and
pelvis before and after the administration of IV contrast per the mesenteric
CTA protocol. Sagittal and coronal reformatted images were obtained and
reviewed.
TOTAL DLP: 2721.11 mGy-cm.
FINDINGS:
LUNG BASES: There is an filling defect in a right lower lobe pulmonary
artery, best demonstrated on the venous phase (3B, 204). This finding is
equivocal on the arterial phase, as less of the lung bases included in the
field of view, though may be apparent (3A, 3), consistent with a pulmonary
embolism. There is mild atelectasis. There is no nodule, consolidation, or
pleural effusion. The base of the heart is normal in size. There is a coarse
calcification in the left ventricular papillary muscle (2, 6), which is
nonspecific and may be from prior infarct. There are moderate-to-severe
coronary artery calcifications in the imaged portions of the coronary
arteries. Coarse calcifications are noted along the mitral annulus. There is
no pericardial effusion.
ABDOMEN: The liver is shrunken and nodular, in keeping with a history of
cirrhosis. There are no definite arterially enhancing lesions to suggest a
hepatoma or dysplastic nodule. An ill-defined band-like hypodensity on the
venous phase in the right lobe is likely fibrotic. A second low-density
lesion centrally is more rounded and measures 11 mm (3b, 231). This is more
likely a cyst or regenerative nodule, though is incompletely characterized by
this CT. Finally, an 8 mm hypodensity in the periphery of the inferior right
lobe is also likely a cyst, but incompletely evaluated (3b, 271). The portal
vein, SMV, and splenic vein are patent. There is a patent paraumbilical vein.
There is no intra- or extra-hepatic biliary duct dilation. The gallbladder is
normal. There is no CT evidence of cholecystitis. The spleen is enlarged,
measuring up to 19.2 cm (3B, 255). No focal splenic lesions. The pancreas
and adrenal glands are normal. The kidneys are slightly atrophic, though
enhance and excrete contrast symmetrically. In the left kidney, there is a 33
mm simple cyst. Several subcentimeter hypodensities in the right kidney are
too small to fully characterize, though also likely represent cysts. There
are no concerning renal lesions. There is no hydronephrosis.
There is a large amount of nonhemorrhagic ascites throughout the abdomen.
Extensive esophageal, periesophageal, perigastric, abdominal, and peristomal
varices are present. The peristomal varices may be from venous collaterals
from the greater saphenous veins bilaterally. The stomach and small bowel are
normal in course and caliber without evidence of obstruction. Incidentally
noted is a small duodenal diverticulum. There is no free air. In the
abdominal wall, just left of midline, there is a 5 cm abdominal wall hernia
(3B, 328), which includes a partial loop of small bowel. Moderate-to-large
amount of ascitic fluid is noted within the hernia. There is no evidence of
obstruction or strangulation. Small periportal and retroperitoneal lymph
nodes do not meet criteria for pathologic enlargement. There are no
pathologically enlarged lymph nodes in the abdomen. Calcifications in the
right upper quadrant and right lower quadrant may reflect torsed epiploic
appendages, under unlikely of clinical significance.
PELVIS: The patient is status post a resection of the rectum and distal
sigmoid colon. There is mild soft tissue thickening around the stoma on the
left lower quadrant, which is likely post-surgical. There is no evidence of
obstruction. Again, there are extensive varices around the stoma and a small
amount of ascitic fluid through a parastomal hernia. There is diverticulosis
without evidence of diverticula throughout the remainder of the colon. A clip
is noted in ascending colon near the terminal ileum. There are no focal
inflammatory changes or evidence of a mass. The bladder and prostate are
unremarkable. There is no pelvic or inguinal lymphadenopathy. There are
bilateral inguinal hernias containing a moderate amount of ascitic fluid.
There is significant anasarca and moderate body wall edema throughout without
discrete fluid collections.
CTA: There is no evidence of active intraluminal bleeding within the small or
large bowel. There is a replaced left hepatic artery. The abdominal
vasculature is otherwise normal in course and caliber. Moderate-to-severe
atherosclerotic disease is noted along the course of the abdominal aorta,
bilateral common iliac arteries, internal iliac arteries, and bilateral
femoral arteries. There is no severe stenosis. Atherosclerotic
calcifications at the takeoff of the celiac artery and SMA and bilateral renal
arteries are causing mild narrowing without severe stenosis. There is no
evidence of aneurysm or dissection.
OSSEOUS STRUCTURES: There are no concerning lytic or sclerotic osseous
lesions. No fractures are identified. Mild degenerative changes are noted in
the lumbar spine.
IMPRESSION:
1. Cirrhotic liver with stigmata of portal hypertension including large
volume ascites, splenomegaly, and extensive varices, including esophageal,
periesophageal, perigastric, and peristomal. The peristomal varices are a
potential source of bleeding, though there is no evidence of active
extravasation.
2. Two incompletely characterized hypodensities in the liver are likely
cysts, or possibly regenerative nodules. Given the history of colon cancer,
this could be confirmed with ultrasound or short-term follow-up as metastases
cannot be completely excluded. No evidence of HCC.
3. Ascitic fluid under the abdominal wall hernia, parastomal hernia, and
bilateral inguinal hernias. A loop of small bowel is present in the abdominal
wall hernia, though there is no evidence of obstruction or strangulation.
4. Filling defect in right lower lobe pulmonary artery, best identified on
the venous phase, consistent with pulmonary embolism. Dedicated CTA of the
chest is suggested to assess the extent of emboli.
5. Diverticulosis without evidence of diverticulitis.
6. Moderate body wall edema, including skin thickening at the ostomy sites,
without discrete fluid collections to suggest an abscess.
Results were discussed with Dr. ___ on ___ at 20:50 via telephone by
Dr. ___ at the time of the findings were discovered.
Radiology Report
HISTORY: Male with pulmonary embolism on CTA.
COMPARISON: None.
TECHNIQUE: Grayscale, color and spectral Doppler evaluation was performed on
bilateral lower extremity veins.
FINDINGS:
There is normal compressibility, flow and augmentation of the bilateral common
femoral, proximal femoral, mid femoral, distal femoral and popliteal veins.
Normal color flow and compressibility are demonstrated in the right posterior
tibial veins. Normal color flow in the left posterior tibial veins. Normal
respiratory variation in the common femoral veins bilaterally. Multiple
normal appearing lymph nodes in the right groin. Moderate sized plaque in the
left common femoral artery. Mild subcutaneous edema bilaterally.
IMPRESSION:
No evidence of deep vein thrombosis in bilateral lower extremity.
Radiology Report
INDICATION: ___ male with stomal varices and sudden onset bleeding,
for emergent TIPS and embolization. Additionally, has DVT, requiring IVC
filter placement.
PHYSICIANS: Dr. ___, the attending radiologist, performed the
procedure. Dr. ___, fellow, and Dr. ___ (resident),
assisted.
PROCEDURE LIST:
1. Right internal jugular vein temporary triple-lumen line placement.
2. Ultrasound-guided paracentesis.
3. Hepatic venogram and pressure measurements.
4. CO2 portogram.
5. Portal venogram and pressure measurements.
6. TIPS placement (Viatorr 10 mm x 6 cm x 2 cm plus 12 mm x 6 cm Luminexx).
7. Inferior mesenteric venogram.
8. Embolization of stomal varices (alcohol and coil embolization).
9. Post-embolization inferior mesenteric venogram.
10. Post TIPS portal venogram and pressure measurements.
11. IVC venogram.
12. IVC filter placement (Option filter).
SEDATION: Sedation for procedure was provided by general anesthesia.
Specific details regarding medications use can be found in the
anesthesiologist note.
CONTRAST: 150 mL Optiray.
FLUOROSCOPY: 85 minutes fluoro time, 1.6 mGy.
PROCEDURE DETAILS: Prior to initiation of procedure, written informed consent
was obtained and a preprocedure timeout was performed. The patient was placed
supine on the angiographic table and general anesthesia was induced. The
right neck, upper abdomen, and left groin were prepped and draped in sterile
manner.
As requested by the anesthesiologist, a triple-lumen central access line was
placed. Initially, ultrasound was performed of the right internal jugular
vein which demonstrated its patency. Under direct ultrasound visualization, a
micropuncture needle was advanced into the internal jugular vein and a
micropuncture sheath was placed. Following placement, ultrasound demonstrated
patency of the right internal jugular vein. Pre- and post-hard copy images
were obtained. Under fluoroscopic guidance, wire was advanced into the right
atrium, and over ___ wire a MAC triple-lumen line was placed, with the tip
in the distal SVC. All the ports were flushed and aspirated. The catheter
was secured to the skin with suture and the anesthesiologist was provided
access to the ports for use.
Next, an ultrasound-guided paracentesis was also performed. Under ultrasound,
a ___ needle was advanced into the perihepatic space and through the ___
needle, ___ wire was positioned followed by placement of a 6 ___
___ drain in the perihepatic space. Approximately 7 liters of fluid was
removed, which remain nonbloody throughout the procedure. At the end of the
procedure, the catheter was cut and removed and a Tegaderm applied.
Next, under ultrasound guidance, a second separate access was again obtained
through internal jugular vein using a micropuncture access set, and over a
___ wire, a TIPS sheath was placed in the IVC. Using this, a 5 ___ MPA
was used to access the right hepatic vein, and a venogram was performed.
Right atrial pressures were also measured at this time. Following this, over
___ wire, an occlusion balloon was placed into the distal right hepatic
vein, and the balloon was inflated. A CO2 portogram was done in an AP view.
Following this, the sheath was advanced into the right hepatic vein, and the
catheter was exchanged for the cannula of the TIPS sheath. A ___
needle was then advanced and used to stick the liver targeting the portal
vein. Initial access to the portal vein was obtained in a very distal branch,
and despite multiple attempts and success at getting wires into the portal
vein, the catheter and the sheath could not be advanced due to an acute angle.
Given this, the sheath and catheter and wire were removed from the portal
vein, and using ___ needle, the liver was stuck more proximally to
obtain a favorable angle of access into the portal vein. Again access was
obtained into the portal vein, and a Glidewire was used to access the main
portal vein followed by dilatation of the hepatic vein tract with a 6 mm x 4
cm Mustang balloon, and advancement of the sheath in the main portal vein.
Next, direct portal venography was performed including pressure measurements.
The sheath was positioned within the main portal vein, and then a 10 x 6 x 2
cm Viatorr stent was advanced into the sheath, and uncovered and positioned
within the tract. The stent was deployed, and dilated to 10 mm using a 10 mm
x 4 cm Mustang balloon. Given the location of the proximal end of the stent
within the hepatic vein, this was extended using a 12 mm x 6 cm Luminexx
stent, and both stents were then dilated to 12 mm using a 12 mm x 4 cm Mustang
balloon.
Following this, the sheath was positioned in the main portal vein, and a 6
___ guide catheter and Glidewire were used to access the IMV and an IMV
venogram was performed. This demonstrated flow distally towards stomal
varices. The guiding catheter was advanced distally near the IMV, and then a
4 ___ catheter and Glidewire were advanced even more distally, followed by
use of a ___ microcatheter and Headliner wire to get very distally within the
branch feeding the stomal varices. Contrast injection confirmed good
location, and demonstrated approximately 3 cc of contrast was required to fill
the stomal varices. Following this, 3 cc of 100% dehydrated alcohol was
injected into the stomal varices. Contrast injection demonstrated complete
stasis of flow suggesting thrombosis. Additional coil embolization of the
main vein feeding the stomal varices was performed using two 10 mm x 20 cm
Interlock coils. Following this, the microcatheter was removed and contrast
injection under DSA angiography from the superior aspect of the IMV
demonstrated stasis of flow and complete obliteration of the stomal varices.
The guiding catheter was then exchanged for a straight flush catheter, and
pressure measurements within the right atrium and portal vein were obtained.
Portal venography demonstrated good flow through the TIPS stent into the right
atrium.
Next, the sheath was pulled back to the right atrium, and a wire was used to
advance the straight flush catheter into the IVC. An IVC venogram was
performed identifying the level at which the renal veins enter the IVC. A
Options filter sheath was then positioned over the wire through our ___ Fr tip
sheath into the IVC, and an Option filter was deployed in the infrarenal
location with the tip medially inferior to the entry of the renal veins.
Contrast injection following this demonstrated good flow through the filter.
The sheath was removed and pressure was then applied to the neck access site.
Pressure was held until manual compression.
The patient tolerated the procedure well and there were no immediate
complications. He was transferred to the ICU for monitoring.
FINDINGS:
1. Patent right internal jugular vein pre- and post placement of a
triple-lumen catheter. The tip is in distal SVC and the line is ready to use.
2. Ultrasound-guided paracentesis demonstrated clear, straw-colored fluid
throughout the procedure. Approximately 7 liters was removed (albumin was
given at approximately 6 g per liter).
3. Hepatic venogram and pressure measurements demonstrated initial
portosystemic gradient of ___ mmHg.
4. Successful TIPS placement from the right hepatic vein to the right portal
vein using a Viatorr stent (10 mm x 6 cm x 2 cm), with extension on the
hepatic venous side using a Luminexx stent (12 mm x 6 cm). The stent was
dilated to 12 mm in its mid portion and 10 mm in its proximal portal side.
Portosystemic gradient after successful TIPS placement was 3 mmHg.
5. Inferior mesenteric venography demonstrated prominent persistent flow and
filling of the feeding vein supplying stomal varices (despite TIPS placement).
This was successfully embolized very close to the stoma using a combination of
dehydrated alcohol injection (3 cc) and coil embolization. Post-embolization
venography demonstrated good obliteration of varices and no further flow into
stoma varices.
6. IVC venography demonstrated normal caliber single IVC (less than 30 mm)
and single renal veins, as was seen on recent CT. Successful placement of
infrarenal Option type retrievable filter.
IMPRESSION:
1. Successful TIPS placement and embolization of stomal varices.
2. Infrarenal IVC filter placement (Option retrievable filter).
3. Temporary right internal jugular vein triple-lumen catheter placed.
4. Ultrasound-guided paracentesis.
Radiology Report
REASON FOR EXAMINATION: Evaluation of the patient with central venous line
placement and known gastrointestinal bleeding.
AP radiograph of the chest was reviewed with comparison to ___ CT
abdomen.
The central venous line tip is at the level of low SVC. Heart size and
mediastinum are stable. Mild vascular engorgement cannot be excluded, but no
overt pulmonary edema is seen. No pneumothorax is present.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: BLEEDING AT COLOSTOMY SITE
Diagnosed with ANEMIA NOS, OTHER COLOSTOMY COMP, MALIGNANT NEO COLON NOS, CIRRHOSIS OF LIVER NOS, UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA, HYPERTENSION NOS
temperature: 97.6
heartrate: 80.0
resprate: 16.0
o2sat: 100.0
sbp: 108.0
dbp: 54.0
level of pain: 0
level of acuity: 2.0 | ___ yo M with PMH of HCV cirrhosis and colon cancer s/p resection
and colostomy ___ years ago who presents on transfer from OSH with
anemia and bleeding concerning for variceal bleed.
ACTIVE ISSUES
# ___ variceal bleeding: Unclear etiology on admission.
EGD and colonoscopy were unremarkable. CTA showed ___
varices which were thought to be the most likely source. Patient
was managed with pantoprazole and octreotide drips and
ceftriaxone for SBP prophylaxis. Frank blood from ostomy on
___ with hypotension. Resuscitated and taken for TIPS on
___. The ___ varices were embolized. Low
post-procedure portosystemic gradient. Observed in MICU
overnight no events. Patient had no further issues with
bleeding. Patient received total of 6 units pRBCs and 2 units of
platelets from ___ to ___. He Hct remained stable after TIPS
and embolization of varices.
# Acute kidney injury: Cr 1.6 on admission. Unclear baseline.
Likely pre-renal azotemia in the setting of acute bleed on
admission. Cr remained elevated after patient was taken for TIPS
and was slow to improve with IV fluids. This was attributed to
contrast-induced nephropathy in the setting of TIPS. Patient was
given more IV fluids and Cr had begun to trend down on
discharge. Home diuretics were held on admission and were
restarted on discharge.
# Pulmonary embolism: RLL pulmonary artery filling defect that
was incidentally found on CTA abdomen/pelvis. Unable to
anticogulate in setting of GI bleed. Bilateral ___ studies
negative for DVT. TTE as part of pre-transplant workup showed no
PFO. Patient had retrievable IVC filter placed with TIPS on
___.
# Hepatic encephalopathy: Patient with mild encephalopathy may
be his baseline. There was no evidence of exacerbation of
encephalopathy after TIPS with the exception of mild asterixis.
CHRONIC ISSUES
# HCV cirrhosis: Reportedly there is no history of SBP or HE;
however, he is on rifaxamin, nadolol, diuretics chronically.
Diagnostic paracentesis was with no SBP. CTA on ___ notable
for ___ varices. Patient underwent TIPS which resulted
in an improved gradient as above. Continued home rifaximin.
Continued nadolol initially but was held in MICU given soft
blood pressures. Restarted on discharge. Diuretics were held in
the setting of unstable blood volume but were also restarted on
discharge. Nutrition was consulted.
# Thrombocytopenia: Likely due to chronic liver disease.
Transfused to Plt > 50. Given 2 units of platelets in the
setting of TIPS.
# Colon cancer: Patient s/p surgery and chemotherapy ___ years
ago. Not being actively treated for this.
TRANSITIONAL ISSUES
- Patient successfully underwent TIPS
- Will need abdominal US every 6 months for ___ screening
- Given Rx for outpatient lab work
- Monitor mental status given risk of hepatic encephalopathy
- PCP ___ scheduled
- ___ Liver Clinic ___ scheduled
- ___ gastroenterologist ___ scheduled |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
lorazepam
Attending: ___.
Chief Complaint:
Abdominal Pain
Major Surgical or Invasive Procedure:
laparoscopic converted to open appendectomy
History of Present Illness:
___ with background of developmental delay and HTN,
presented with symptoms of nausea, vomiting, abdominal
distension
and food intolerance for 48 hours. He is unable to provide a
history and information is provided by mother. She noted him
becoming increasingly uncomfortable and rememebered he last had
a
normal bowel movement on ___. She also noted that he was
expressing tenderness in his left scrotum which started at
around
the same time. He has never experienced a similar episode in the
past and she thinks he had a temperature prior to presentation.
Past Medical History:
PMH:
HTN, developmental delay
PSH: None
Social History:
___
Family History:
Non contributory
Physical Exam:
GEN: Alert, baseline mental function according to mum
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Mild distention, no rebound or guarding,
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 11:11PM PLT COUNT-172
___ 11:11PM NEUTS-89.9* LYMPHS-4.9* MONOS-4.9 EOS-0.2
BASOS-0.1
___ 11:11PM WBC-16.7* RBC-6.17 HGB-17.8 HCT-53.6* MCV-87
MCH-28.8 MCHC-33.2 RDW-13.9
___ 11:11PM ALBUMIN-4.7
___ 11:11PM LIPASE-13
___ 11:11PM estGFR-Using this
___ 11:11PM GLUCOSE-182* UREA N-26* CREAT-1.1 SODIUM-137
POTASSIUM-3.5 CHLORIDE-94* TOTAL CO2-26 ANION GAP-21*
___ 01:58AM LACTATE-1.9
___ 01:58AM LACTATE-1.9
___ 01:58AM COMMENTS-GREEN TOP
___ 07:10PM WBC-8.2# RBC-4.80 HGB-14.1# HCT-42.8# MCV-89
MCH-29.5 MCHC-33.1 RDW-13.3
___ 07:10PM WBC-8.2# RBC-4.80 HGB-14.1# HCT-42.8# MCV-89
MCH-29.5 MCHC-33.1 RDW-13.3
___ 07:10PM CALCIUM-7.6* PHOSPHATE-2.4* MAGNESIUM-1.7
___ 07:10PM GLUCOSE-128* UREA N-17 CREAT-0.7 SODIUM-137
POTASSIUM-3.6 CHLORIDE-103 TOTAL CO2-24 ANION GAP-14
CT abd/pelvis:
___:
LOWER CHEST: Moderate-sized bilateral pleural effusions are new
since ___ with adjacent lung base consolidation most
consistent with
atelectasis. The heart size is top normal. No pericardial
effusion.
ABDOMEN:
HEPATOBILIARY: The liver, gallbladder, and bile ducts are
normal.
PANCREAS: The pancreas is normal.
SPLEEN: The spleen is normal.
ADRENALS: The adrenal glands are normal.
URINARY: The kidneys and ureters are normal.
GASTROINTESTINAL: The patient is status post recent
appendectomy. Irregular
fluid-density collection in the right lower quadrant has
multiple components,
the largest of which measures 2.8 x 1.6 x 2.3 cm (2:58, 601b:
28).
Non-organized fluid was present in a similar location on the
prior exam of ___, but there has been an interval increase in size
and development
of enhancing walls. There is no extraluminal oral contrast or
pneumoperitoneum. There is mild cecal inflammation with moderate
adjacent soft
tissue stranding involving the lateral conal fascia, as expected
after
appendiceal inflammation and surgery. Normal distal esophagus.
The stomach
and small bowel are normal. Oral contrast is present to the
level of the
rectum.
RETROPERITONEUM: Several prominent mesenteric nodes in the
right lower
quadrant are likely reactive. Otherwise no intra-abdominal
lymphadenopathy.
VASCULAR: Normal systemic vasculature. Normal portal
vasculature.
PELVIS: A small amount of gas within the bladder is consistent
with known
recent Foley catheter removal. The bladder is otherwise
unremarkable without
wall thickening. No inguinal or pelvic sidewall lymphadenopathy.
No free
pelvic fluid.
REPRODUCTIVE ORGANS: Normal prostate.
BONES AND SOFT TISSUES: No worrisome osseous lesion. Fluid in
the right lower
quadrant subcutaneous tissues immediately deep to surgical
staples is
consistent with postoperative seroma but mild soft tissue
enhancement is seen
along its lateral margin (2:53).
IMPRESSION:
1. Irregular intra-abdominal fluid collection with enhancing
walls in the
right lower quadrant with largest pocket measuring 2.8 x 1.6 x
2.3 cm. No
extraluminal oral contrast or pneumoperitoneum.
2. Subcutaneous fluid immediately deep to right lower quadrant
abdominal wall
surgical staples likely represents postoperative seroma but
given enhancement
along its lateral margin, a developing abscess cannot be
excluded.
3. New moderate bilateral pleural effusions with adjacent
bibasilar
atelectasis, incompletely imaged.
Medications on Admission:
Atenolol 50mg once daily
Sertraline 100mg once daily
Cyproheptadine 4mg once daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth Twice
a day Disp #*50 Capsule Refills:*0
3. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth three times a day
Disp #*30 Tablet Refills:*0
4. OxycoDONE (Immediate Release) 2.5-5 mg PO Q4H pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every ___ hours Disp
#*50 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 #*50
Capsule Refills:*0
6. Polyethylene Glycol 17 g PO DAILY
7. Atenolol 50 mg PO DAILY
8. Cyproheptadine 4 mg PO DAILY
9. Sertraline 100 mg PO DAILY
10. ciprofloxacin 500 mg/5 mL oral BID Duration: 10 Days
RX *ciprofloxacin 500 mg/5 mL 5 ml by mouth twice a day
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Perforated appendicitis
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: SCROTAL U.S.
INDICATION: Left scrotal tenderness to palpation. Evaluate for torsion.
TECHNIQUE: Grey scale with color and spectral Doppler ultrasound of the
scrotum was performed with linear transducer.
COMPARISON: None.
FINDINGS:
The right testicle measures: 4.2 x 1.8 x 2.2 cm.
The left testicle measures: 3.9 x 1.8 x 2.4 cm.
The testicular echogenicity is normal, without focal abnormalities. A small
right hydrocele is present. A 4 mm extratesticular echogenicity within the
right hydrocele demonstrate shadowing, and is consistent with a scrotal pearl.
The epididymis is normal bilaterally. There is a 4 mm left epididymal head
cyst.
Vascularity is normal and symmetric in the testes and epididymis.
IMPRESSION:
1. No evidence of testicular torsion.
2. Small right hydrocele.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: Diffuse abdominal pain, distention, and guarding.
TECHNIQUE: Helical axial MDCT images were obtained from the bases of the
lungs through the pubic symphysis, after the administration of IV and oral
contrast. Reformatted images in coronal and sagittal axes were generated.
DLP: 332.8 mGy-cm.
COMPARISON: None available.
FINDINGS:
The bases of the lungs are clear. There is no pleural or pericardial effusion.
LIVER: The liver enhances homogeneously without focal lesion or intrahepatic
biliary duct dilation. The portal vein is patent.The nondistended gallbladder
is within normal limits, without wall thickening or pericholecystic fluid.
SPLEEN: The spleen is homogeneous and normal in size.
PANCREAS: The pancreas is without focal lesion or peripancreatic stranding or
fluid collection.
ADRENALS: The adrenal glands are unremarkable.
KIDNEYS: The kidneys demonstrate symmetric nephrograms and excrete contrast
promptly. There is no focal lesion or hydronephrosis.
GI:The stomach is decompressed, but there is no obvious intraluminal mass or
wall thickening.There is mild dilation of the distal small bowel, with a
transition point seen within the right pelvis (2:67). The bowel wall enhances
normally. There is a small amount of free fluid within the mesenteries,
measuring 2.7 x 3.3 cm (02:54). Air and stool are seen within the colon.An
appendicolith is noted, measuring up to 8 mm in diameter. The appendix distal
to the at appendicolith is fluid filled and dilated, measuring 1.0 cm.
Although there is no wall thickening, hyperenhancement of the wall and mild
adjacent fat stranding is suggestive of early appendicitis. The terminal
ileum demonstrates mild wall thickening and hyperenhancement.
RETROPERITONEUM: The aorta is normal in caliber, without atherosclerotic
calcifications.There is no retroperitoneal or mesenteric lymph node
enlargement by CT size criteria.
CT PELVIS: The urinary bladder appears normal.No pelvic wall or inguinal lymph
node enlargement by CT size criteria is seen.There is no pelvic free fluid.
OSSEOUS STRUCTURES:No focal lesion suspicious for malignancy present.
IMPRESSION:
1. Appendicolith, with mild dilation of the distal appendix. Although there is
no wall thickening, hyperenhancement of the wall of the appendix and mild
surrounding stranding are suggestive of appendicitis.
2. Wall thickening and hyperenhancement of the terminal ileum are likely
ileitis reactive to the appendicitis rather than inflammatory bowel disease.
3. Fluid collection in the cecal mesentery is also likely reactive.
4. Mild dilation of the distal small bowel, with a transition point seen
within the right pelvis, consistent with a partial small bowel obstruction,
possibly secondary to 1 & 2 above. Air and stool are seen within the distal
colon.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with s/p open appy, intubated // endotracheal
tube position, any cardiopulomonary process
TECHNIQUE: Single frontal view of the chest
COMPARISON: None
IMPRESSION:
Cardiac size is top normal, accentuated by low lung volumes. ET tube is in
standard position. NG tube tip is in the stomach. There is crowding of the
bronchovascular structures. opacities in the lower lobes left greater than
right could be atelectasis and or aspiration. There is no pneumothorax or
pleural effusion. Partially visualized oral contrast from prior CT within the
abdomen.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man s/p lap converted to open appendectomy. Emesis
when extubated, failed to extubate -> reintubated // eval interv change.
Please complete exam on ___ by 5am.
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
IMPRESSION:
Cardiac size is top-normal accentuated by the low lung volumes. Worsening
bibasilar opacities larger on the left side are worrisome for aspiration.
Opacities in the upper lungs right greater than left have nodular appearance.
These could be part of aspiration but septic embolism is not excluded given
the nodular appearance, CT is advised. There is no pneumothorax. If any there
is a small left effusion. NG tube tip is in the stomach, the side port is
probably at the GE junction and should be advanced for more standard position
NOTIFICATION: The findings were discussed by Dr. ___ with ___ on the
telephone on ___ at 10:00 AM, 40 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with perfed appy // eval pneumonia eval
pneumonia
IMPRESSION:
In comparison with the study of ___, there are even lower lung
volumes, which accentuates the transverse diameter of the heart. Bilateral
areas of increased opacification processed, so they appear less prominent than
on the previous study. This could reflect some improving vascular congestion
superimposed on underlying multifocal pneumonia.
Radiology Report
EXAMINATION: Abdomen
INDICATION: ___ acute appendicitis w/reactive ileus now s/p lap converted to
open appendectomy // Assess placement of NGT
TECHNIQUE: Single portable supine view of abdomen
COMPARISON: None
FINDINGS:
NG tube tip is in the stomach. There are air filled nondistended small bowel
loops. There is no evidence of obstruction. Residual Contrast is seen in the
sigmoid and rectum.
IMPRESSION:
NG tube tip is in the stomach.
Radiology Report
INDICATION: ___ year old man w/ perf appendicitis ___ s/p open appy now w/
rising leukocytosis // eval for abscess
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis
following intravenous contrast administration with split bolus technique.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was administered.
DOSE: DLP: 339 mGy-cm (abdomen and pelvis.
IV Contrast: 100 mL Omnipaque
COMPARISON: None.
FINDINGS:
LOWER CHEST: Moderate-sized bilateral pleural effusions are new since ___ with adjacent lung base consolidation most consistent with
atelectasis. The heart size is top normal. No pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver, gallbladder, and bile ducts are normal.
PANCREAS: The pancreas is normal.
SPLEEN: The spleen is normal.
ADRENALS: The adrenal glands are normal.
URINARY: The kidneys and ureters are normal.
GASTROINTESTINAL: The patient is status post recent appendectomy. Irregular
fluid-density collection in the right lower quadrant has multiple components,
the largest of which measures 2.8 x 1.6 x 2.3 cm (2:58, 601b: 28).
Non-organized fluid was present in a similar location on the prior exam of ___, but there has been an interval increase in size and development
of enhancing walls. There is no extraluminal oral contrast or
pneumoperitoneum. There is mild cecal inflammation with moderate adjacent soft
tissue stranding involving the lateral conal fascia, as expected after
appendiceal inflammation and surgery. Normal distal esophagus. The stomach
and small bowel are normal. Oral contrast is present to the level of the
rectum.
RETROPERITONEUM: Several prominent mesenteric nodes in the right lower
quadrant are likely reactive. Otherwise no intra-abdominal lymphadenopathy.
VASCULAR: Normal systemic vasculature. Normal portal vasculature.
PELVIS: A small amount of gas within the bladder is consistent with known
recent Foley catheter removal. The bladder is otherwise unremarkable without
wall thickening. No inguinal or pelvic sidewall lymphadenopathy. No free
pelvic fluid.
REPRODUCTIVE ORGANS: Normal prostate.
BONES AND SOFT TISSUES: No worrisome osseous lesion. Fluid in the right lower
quadrant subcutaneous tissues immediately deep to surgical staples is
consistent with postoperative seroma but mild soft tissue enhancement is seen
along its lateral margin (2:53).
IMPRESSION:
1. Irregular intra-abdominal fluid collection with enhancing walls in the
right lower quadrant with largest pocket measuring 2.8 x 1.6 x 2.3 cm. No
extraluminal oral contrast or pneumoperitoneum.
2. Subcutaneous fluid immediately deep to right lower quadrant abdominal wall
surgical staples likely represents postoperative seroma but given enhancement
along its lateral margin, a developing abscess cannot be excluded.
3. New moderate bilateral pleural effusions with adjacent bibasilar
atelectasis, incompletely imaged.
NOTIFICATION: The findings were discussed via telephone by Dr. ___ with
___, surgical resident, on ___ at 3:49 ___, 10 minutes after discovery
of the findings.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: Abd pain, Vomiting
Diagnosed with INTESTINAL OBSTRUCT NOS
temperature: 100.4
heartrate: 110.0
resprate: 16.0
o2sat: 98.0
sbp: 137.0
dbp: 89.0
level of pain: 13
level of acuity: 3.0 | Mr. ___ was admitted to ___ after having nausea and
vomiting. He was found to have appendicitis. He was taken to the
OR and had a lap to open appendectomy. However, pre op he
developed a-fib with RVR. He was treated pre op and this
continued through out the operation. However, he tolerated the
procedure well. He was admitted to the ICU post op for
management of his a-fib. He was transferred to the floor after
his rate was controlled. He was evaluated by cardiology and he
was continued on IV to PO metoprolol. He had another episode of
A-fib while he was on the floor. He was transferred to a
cardiac floor for a dilt drip. HE was hemodynamiclly stable
during this episode. He continued to have abdominal distention
during his stay and had constipation. He had a repeat CT scan
which showed an abscess. He was continued on antibiotics. He was
discharged with follow up and will follow up with his own
cardiologist. He was tolerating PO, ambulating and doing well at
the time of discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
clindamycin / levofloxacin / acetaminophen
Attending: ___.
Chief Complaint:
Dyspnea, chest pain
Major Surgical or Invasive Procedure:
___ placement ___
History of Present Illness:
___ with COPD not on home O2, CAD s/p CABG, HTN, HL, pAF, h/o
CVA, alcohol abuse, presents with fever, cough, and chest pain
concerning for community-acquired pneumonia.
Of note, he had complaints of chest pain in ___ and was
ruled out in ED for ACS with two sets of negative troponins and
negative nuclear stress test. He was intoxicated with alcohol at
the time, observed overnight, and sent home. He has history of
alcoholic gastritis.
This time, his symptoms of chest pain and dyspnea occured over
last two days. They usually resolve but today has been constant
since noon and worse in severity. He drinks 0.5 pint of vodka
every 2 days, last drink ___ AM, no history of DTs or
withdrawal seizures.
In the ED initial vitals were: 98.6 88 96/57 18 100% RA. He
became febrile to 100.8 in ED. Labs with WBC 7.1, Hgb 11.4, Na
132, bicarb 11 with anion gap of 30, BUN 17, Cr 0.8. Lactate
2.8->2.3. TnT neg. CXR with questionable pneumonia. EKG with
very mild TWI V2-V3. UA negative. RUQ US without cholecystitis.
He was given 2L NS, thiamine, folic acid, APAP 1g PO,
azithromycin and ceftriaxone 1g IV.
On the floor, patient has mild dyspnea but otherwise no
complaints.
ROS: Recent chest pain, cough, dyspnea, fever. He has mild
orthopnea without PND, uses 1 pillow. Denies any nausea,
vomiting, abdominal pain, diarrhea, constipation, dysuria,
frequency.
Past Medical History:
- Cerebrovascular Disease (right ICA occlusion posterior
parietal stroke in ___, right brain strokes in ___, cerebellar
strokes/atrophy complicated by gait disturbance and left
hemiparesis)
- Restrictive Lung (uncharacterized
- COPD not on home O2
- EtOH Abuse/Dependence complicated by Alcoholic Hepatitis
- Alcoholic Cerebellar Degeneration with postural and action
tremors and gait disturbance
- Brachiocephalic Artery Ischemia status-post Aorto-Innominate
Artery Bypass
- Paroxysmal Atrial Flutter/Fibrillation not on warfarin due to
history of UGIB and recurrent falls, on diltiazem due to
beta-blocker intolerance
- CAD with prior NSTEMI s/p CABG
- Acetaminophen/Ethanol Acute Liver Failure in ___
- Pneumothorax ___ internal jugular line placement ___
- HTN
- HLD
- Aspiration Pneumonia
- Question of Dementia
- Esophagitis s/p esophageal stricture dilation status-post
G-tube placement and removal in ___
- Unspecified Upper GI Bleeding
- Dizziness
- Hypothyroidism
- Occipital neuralgia
- Tobacco abuse
- Urinary Retention
- Anemia
- Abdominal pain
- Advance care planning -- has HCP, and discussed goals of care
during office visit ___: He affirmed that he is full code,
favors aggressive treatment.
Social History:
___
Family History:
Father - died of MI at age ___
Mother - had DM and died at age ___
No family history of liver disease. Several brothers with CAD in
late ___ and early ___.
Physical Exam:
Initial physical exam:
VS: T97.9 135/42 73 28 98 2L NC-> 98 RA
GEN: Elderly appearing male in no acute distress
HEENT: Sclera anicteric, MMM
HEART: RRR, normal S1 S2, no murmurs
LUNGS: Faint expiratory wheezing, few crackles at R base, no
use of accessory muscles, speaking in full sentences
ABD: Soft, NT ND, normal BS
EXT: No ___ edema
NEURO: Oriented to name, place, not date
Discharge physical exam:
Physical exam:
VS: 98.2 94/44, 61, 18, 99% on RA
GEN: Elderly gentleman lying in bed very comfortable appearing
in NAD
HEENT: EOMI, Sclera anicteric, MMM
Chest: RRR, systolic murmur II/VI at RUSB
LUNGS: RLL crackles, no wheezes or rhonchi
ABD: soft, non-distended, +BS. Obese abdomen. non tender, no
rebound/guarding.
EXT: PICC in R arm without evidence of swelling, erythema,
warmth. Calves nontender, symmetric. No edema.
NEURO: AOx3 (not day of month). No focal neurologic deficits
appreciated.
Pertinent Results:
===================
ADMISSION LABS:
===================
___ 04:52PM BLOOD WBC-7.1 RBC-3.38* Hgb-11.4* Hct-34.2*
MCV-101* MCH-33.7* MCHC-33.3 RDW-15.1 RDWSD-56.5* Plt ___
___ 04:52PM BLOOD Neuts-62.8 ___ Monos-4.6*
Eos-0.6* Baso-1.1* Im ___ AbsNeut-4.47# AbsLymp-2.17
AbsMono-0.33 AbsEos-0.04 AbsBaso-0.08
___ 04:52PM BLOOD Plt ___
___ 04:52PM BLOOD ALT-31 AST-78* AlkPhos-110 TotBili-0.8
___ 04:52PM BLOOD Lipase-35
___ 04:52PM BLOOD cTropnT-<0.01
___ 10:53PM BLOOD cTropnT-<0.01
___ 06:25AM BLOOD cTropnT-<0.01
___ 04:52PM BLOOD Albumin-4.0
___ 10:53PM BLOOD ASA-NEG Ethanol-20* Acetmnp-22
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 04:55PM BLOOD Comment-GREEN TOP
___ 04:55PM BLOOD Lactate-2.8*
======================
DISCHARGE LABS:
======================
___ 06:59AM BLOOD WBC-5.9 RBC-2.45* Hgb-8.1* Hct-24.2*
MCV-99* MCH-33.1* MCHC-33.5 RDW-13.4 RDWSD-48.0* Plt ___
___ 06:59AM BLOOD Plt ___
___ 06:59AM BLOOD Glucose-99 UreaN-4* Creat-0.5 Na-129*
K-4.2 Cl-99 HCO3-23 AnGap-11
___ 12:28PM BLOOD ALT-28 AST-49* TotBili-0.8
___ 06:59AM BLOOD Calcium-8.0* Phos-2.9 Mg-1.5*
___ 03:38PM BLOOD calTIBC-148* Ferritn-299 TRF-114*
==========
Imaging:
==========
CXR ___: Continued chronic changes within the right upper and
mid lung fields as well the left lung base. Slightly increased
opacification in the retrocardiac region could reflect worsening
left lower lobe atelectasis though infection cannot be
completely excluded.
EKG ___: Normal sinus rhythm. Abnormal R wave progression.
Cannot rule out
anterolateral myocardial infarction of indeterminate age.
Diffuse non-specific ST-T wave abnormalities. Compared to the
previous tracing of ___ the ST segment abnormalities have
increased.
RUQUS ___:
1. Cholelithiasis, without sonographic evidence of acute
cholecystitis.
2. Echogenic liver consistent with steatosis. Other forms of
liver disease and more advanced liver disease including
steatohepatitis or significant hepatic fibrosis/cirrhosis cannot
be excluded on this study.
EKG ___: Normal sinus rhythm with intra-atrial conduction
abnormality. Low voltage throughout. Compared to the previous
tracing the R wave progression has normalized (probably due to
lead placement) and the ST segment abnormalities are much less
marked.
CT abd pelvis ___:
1. Likely pneumonia in the left lung base.
2. Mild SMA ostial stenosis.
3. Gastroesophageal reflux.
4. Persistent smooth thickening of the pylorus.
5. Rectal stool ball without colitis.
6. Cholelithiasis.
Left upper extremity ultra sound ___
IMPRESSION:
1. No evidence of deep vein thrombosis in the left upper
extremity. The
cephalic vein was not visualized.
2. Slow flow was seen throughout the venous structures in the
left upper
extremity.
3. Diminutive/diffusely stenotic left internal jugular vein
similar in
appearance to prior CT.
EGD ___
Ulcer in the gastroesophageal junction
Patulous esophagus.
Deformity of the pylorus (biopsy)
Normal mucosa in the duodenum
Otherwise normal EGD to third part of the duodenum
Right Upper Extremity US: ___:
1. No evidence of deep vein thrombosis in the left upper
extremity. The cephalic vein was not visualized.
2. Slow flow was seen throughout the venous structures in the
left upper extremity.
3. Diminutive/diffusely stenotic left internal jugular vein
similar in appearance to prior CT.
CXR ___:
Status post median sternotomy with stable cardiac and
mediastinal contours given differences in patient rotation.
Stab;e widened right paratracheal stripe consistent with known
lymphadenopathy. There continue be scattered patchy ill-defined
opacities at the left lung base as well as throughout the right
lung with no definite change to suggest an acute infectious
process. The patient's mandible obscures the apices. No
obvious pneumothorax.
CXR ___:
Heterogeneous opacities throughout the right lung and left lung
base have worsened. Given waxing and waning over serial
radiographs, there is concern for recurrent
aspiration/aspiration pneumonia.
Video swallow ___: Aspiration of thin liquid.
CXR ___:
Radiographs and chest CT scans since at least ___
documente asymmetric
pulmonary abnormality consisting of fibrosis and intermittent
consolidation in large parts of the right lung and left lung
base, with relative sparing of the left upper lobe. Most
recently, since ___ and ___, a component of mild
pulmonary edema has improved and lung volumes have increased.
There is no pneumothorax or appreciable pleural effusion. The
chronic abnormality in the right lung is more abnormal now than
it was in ___.
The alignment of sternal wires, some which are fractured, has
not changed since at least ___.
=========
MICRO:
=========
Blood cxs: ___ Negative
Blood culture: ___ x2 negative
Blood culture: ___ x2 NGTD
Urine culture ___ negative
C diff ___ negative
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Ferrous Sulfate 325 mg PO DAILY
4. Finasteride 5 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Levothyroxine Sodium 112 mcg PO DAILY
7. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
8. Gabapentin 100 mg PO QHS
9. Lidocaine 5% Patch 1 PTCH TD QAM
10. Multivitamins 1 TAB PO DAILY
11. Tamsulosin 0.4 mg PO QHS
12. Thiamine 100 mg PO DAILY
13. Tiotropium Bromide 1 CAP IH DAILY
14. TraMADOL (Ultram) 25 mg PO Frequency is Unknown TID:PRN pain
15. TraZODone 150 mg PO QHS
16. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea
17. Diltiazem Extended-Release 120 mg PO DAILY
18. esomeprazole magnesium 40 mg oral BID
19. Rosuvastatin Calcium 10 mg PO QPM
Discharge Medications:
1. Ascorbic Acid ___ mg PO DAILY
RX *ascorbic acid ___ mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Finasteride 5 mg PO DAILY
RX *finasteride 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Gabapentin 100 mg PO QHS
RX *gabapentin 100 mg 1 capsule(s) by mouth at night Disp #*30
Capsule Refills:*0
6. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % (700 mg/patch) apply to affected area once a
day Disp #*30 Patch Refills:*0
7. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 capsule(s) by mouth daily Disp #*30 Capsule
Refills:*0
8. Rosuvastatin Calcium 10 mg PO QPM
RX *rosuvastatin [Crestor] 10 mg 1 tablet(s) by mouth every
evening Disp #*30 Tablet Refills:*0
9. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at night Disp #*30
Capsule Refills:*0
10. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
11. TraMADOL (Ultram) 25 mg PO TID TID:PRN pain
12. TraZODone 150 mg PO QHS
RX *trazodone 150 mg 1 tablet(s) by mouth every night Disp #*30
Tablet Refills:*0
13. Albuterol Inhaler ___ PUFF IH Q4H:PRN dyspnea
RX *albuterol sulfate [ProAir HFA] 90 mcg 2 puff IH every 4
hours Disp #*1 Inhaler Refills:*0
14. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
RX *calcium carbonate-vitamin D3 [Calcium 500 + D] 500 mg
calcium (1,250 mg)-400 unit 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
15. esomeprazole magnesium 40 mg oral BID
RX *esomeprazole magnesium 40 mg 1 capsule(s) by mouth twice a
day Disp #*60 Capsule Refills:*0
16. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg 1
capsule IH daily Disp #*30 Capsule Refills:*0
17. Docusate Sodium 200 mg PO BID
Hold if having diarrhea
RX *docusate sodium 100 mg 2 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
18. Polyethylene Glycol 17 g PO DAILY
Hold if having diarrhea
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth once a
day Disp #*60 Packet Refills:*1
19. Levothyroxine Sodium 150 mcg PO DAILY
take in the morning, ___ min apart from all other medicines
RX *levothyroxine 150 mcg 1 tablet(s) by mouth once a day Disp
#*30 Tablet Refills:*1
20. Sodium Chloride 1 gm PO TID
RX *sodium chloride 1 gram 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
21. Outpatient Lab Work
CHEM 10 twice a week ___ and ___ and fax results to
Dr. ___ at ___
ICD10: ___.1
22. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN
heartburn
RX *alum-mag hydroxide-simeth 200 mg-200 mg-20 mg/5 mL 15 mL by
mouth four times a day Refills:*0
23. Magnesium Oxide 400 mg PO BID
Do not take at same time as levothyroxine
RX *magnesium oxide 400 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Community acquired pneumonia
Chronic alcohol abuse
Constipation
Gastric ulceration and edema of the pylorus.
Poor nutritional status
Hyponatremia
Recurrent aspirations
SECONDARY DIAGNOSIS:
Anemia
Atrial fibrillation
COPD
BPH
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Mental Status: Confused - sometimes.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with chest pain and cough
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: Chest radiograph ___, CT torso ___.
FINDINGS:
Patient is status post median sternotomy and CABG. Lung volumes remain low.
Heart size is normal. The mediastinal and hilar contours are unchanged with
mild widening of the right paratracheal stripe suggestive of underlying
lymphadenopathy, as seen previously. Pulmonary vasculature is not engorged.
There are continued ill-defined patchy opacities within the left lung base as
well as within the right upper and mid lung fields, reflective of chronic
changes. Slightly increased patchy opacification in the retrocardiac region
could reflect superimposed left lower lobe atelectasis, but infection is not
excluded. No large pleural effusion or pneumothorax is demonstrated.
IMPRESSION:
Continued chronic changes within the right upper and mid lung fields as well
the left lung base. Slightly increased opacification in the retrocardiac
region could reflect worsening left lower lobe atelectasis though infection
cannot be completely excluded.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with right upper quadrant pain
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: Right upper quadrant ultrasound ___.
FINDINGS:
LIVER: The liver is diffusely echogenic, suggestive of hepatic steatosis. The
contour of the liver is smooth. There is no focal liver mass, of though
assessment is limited. The main portal vein is patent with hepatopetal flow.
There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 2 mm.
GALLBLADDER: Sludge and several stones are seen within the lumen, measuring up
to 1 cm. No evidence of gallbladder wall thickening, gallbladder distention,
or pericholecystic fluid.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity, measuring 7.8 cm.
KIDNEYS: Limited images of the right kidney demonstrate no gross
abnormalities.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cholelithiasis, without sonographic evidence of acute cholecystitis.
2. Echogenic liver consistent with steatosis. Other forms of liver disease
and more advanced liver disease including steatohepatitis or significant
hepatic fibrosis/cirrhosis cannot be excluded on this study.
Radiology Report
EXAMINATION: CT abdomen pelvis with contrast
INDICATION: ___ year old man with h/o diffuse abdominal pain, SMA mesenteric
ischemia, with worsening abdom pain // r/o acute process
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique. IV Contrast: 130 mL Omnipaque.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was administered.
DOSE: Acquisition sequence: 1) CT Localizer Radiograph 2) CT Localizer
Radiograph 3) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 1.1 mGy (Body)
DLP = 1.1 mGy-cm. 4) Stationary Acquisition 8.5 s, 1.0 cm; CTDIvol = 19.2 mGy
(Body) DLP = 19.2 mGy-cm. 5) Spiral Acquisition 13.3 s, 45.6 cm; CTDIvol = 8.9
mGy (Body) DLP = 391.4 mGy-cm. Total DLP (Body) = 425 mGy-cm.
COMPARISON: CT abdomen pelvis ___, ___, plain chest
radiograph ___.
FINDINGS:
LOWER CHEST: New left lung base patchy density consistent with airspace
disease. Bilateral subpleural septal thickening with right lung base pleural
thickening consistent with fibrotic changes, no significant change. No
pleural effusions.
Slightly patulous thickened esophagus with contrast and fluid consistent with
reflux, unchanged. Small hiatal hernia. No pericardial effusion.
ABDOMEN:
HEPATOBILIARY: Heterogeneous hepatic enhancement without a discrete lesion or
ductal dilation. Cholelithiasis.
PANCREAS: No discrete lesion or ductal dilation.
SPLEEN: No splenomegaly.
ADRENALS: Unremarkable.
URINARY: Simple bilateral renal cysts. No hydronephrosis or hydroureter.
GASTROINTESTINAL: Stomach is distended with fluid and contrast. Persistent
thickening of the pylorus measuring up to 9 mm, suggesting chronic
inflammation/ edema is noted by the prior EGD. No discernible ulceration,
adjacent adenopathy, or fat stranding. No discernible mass.
Left hemi colonic diverticulosis. 70 mm rectal stool ball. No adjacent
inflammatory changes. No intestinal obstruction. Nonvisualized appendix. No
pneumoperitoneum.
PELVIS: Unremarkable prostate, seminal vesicles, and bladder.
LYMPH NODES: No adenopathy.
VASCULAR: Advanced arteriosclerosis. Mild SMA ostial stenosis. Moderate
bilateral renal arterial stenosis. Patent ___. Occluded bilateral proximal
SFA, chronic.
BONES AND SOFT TISSUES: Thoracolumbar spine degenerative changes. No soft
tissue mass.
IMPRESSION:
1. Likely pneumonia in the left lung base.
2. Mild SMA ostial stenosis.
3. Gastroesophageal reflux.
4. Persistent smooth thickening of the pylorus.
5. Rectal stool ball without colitis.
6. Cholelithiasis.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US LEFT
INDICATION: ___ year old man with CAD s/p CABG, HTN, CVA, with new pitting L
arm/had edema // r/o DVT
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: Chest CT, ___
FINDINGS:
There is normal flow with respiratory variation in the bilateral subclavian
vein.
The left internal jugular vein is diminutive which may be due to chronic
stenosis or atrophy. The axillary veins are patent, show normal color flow
and compressibility. The left brachial, basilic veins are patent, compressible
and show normal color flow and augmentation. The left cephalic vein is not
visualized.
Note that while no DVT is visualized, slow flow is seen throughout the venous
structures in the left upper extremity.
IMPRESSION:
1. No evidence of deep vein thrombosis in the left upper extremity. The
cephalic vein was not visualized.
2. Slow flow was seen throughout the venous structures in the left upper
extremity.
3. Diminutive/diffusely stenotic left internal jugular vein similar in
appearance to prior CT.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with recent CAP, still with diffuse
rhonchi/wheezes, low grade fever // interval change, ?acute process
interval change, ?acute process
COMPARISON: Comparison to ___ at 16:09
FINDINGS:
Portable semi-erect chest radiograph ___ at 09:30 is submitted.
IMPRESSION:
Status post median sternotomy with stable cardiac and mediastinal contours
given differences in patient rotation. Stab;e widened right paratracheal
stripe consistent with known lymphadenopathy. There continue be scattered
patchy ill-defined opacities at the left lung base as well as throughout the
right lung with no definite change to suggest an acute infectious process.
The patient's mandible obscures the apices. No obvious pneumothorax.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with picc // r picc 45cm iv ___ ___ Contact
name: ___: ___ r picc 45cm iv ___ ___
COMPARISON: Comparison to prior study dated ___ at 09:30
FINDINGS:
Portable AP upright chest radiograph ___ at 15:08 is submitted.
IMPRESSION:
Interval placement of a right subclavian PICC line which courses cephalad in
the neck and the tip is not visualized on the image. Repositioning is
recommended. Status post median sternotomy with stable cardiac and
mediastinal contours. Stable slightly widened right paratracheal soft tissue
consistent with known lymphadenopathy. Scattered patchy ill-defined opacities
in the left lung base and throughout the right lung are stable. No
pneumothorax. No pleural effusions.
NOTIFICATION: Results were communicated by phone to the IV nurse, ___, on ___ at 16:25 at the time of discovery.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with right PICC reposition. ___ ___ // Right
PICC reposition. ___ ___ Contact name: ___: ___ Right PICC
reposition. ___ ___
COMPARISON: Comparison to ___ at 15:08
FINDINGS:
Portable upright chest radiograph ___ at 17:59 is submitted.
IMPRESSION:
The right subclavian PICC line again courses cephalad with the tip now
identified within the right internal jugular vein. Repositioning is
recommended. Right paratracheal soft tissue is stable consistent with known
lymphadenopathy. Ill-defined patchy opacities the left base and throughout
the right lung are stable. Status post median sternotomy with stable cardiac
and mediastinal contours. No pneumothorax.
Radiology Report
EXAMINATION: , though
INDICATION: ___ year old man with COPD not on home O2, CAD s/p CABG, HTN, HL,
pAF, h/o CVA, alcohol abuse, here for CAP. s/p full course treatment for CAP,
off abx, with new fever. Working up new or progressive infection. // evidence
of worsening infiltrate
TECHNIQUE: CHEST (PORTABLE AP)
COMPARISON: Portable AP view of the chest dated ___, PA and
lateral views of the chest dated ___, CT chest dated
___
FINDINGS:
Lung volumes are low. Midline sternotomy wires are well aligned. Right sided
PICC now terminates in right axilla. The cardiac silhouette and pulmonary
vasculature unremarkable. Again noted is right paratracheal soft tissue,
consistent with known lymphadenopathy. Diffuse, patchy, right-sided opacity
is progressed since the most recent examination. Left basilar opacity is more
prominent as well. No definite pleural effusion or pneumothorax.
IMPRESSION:
Heterogeneous opacities throughout the right lung and left lung base have
worsened. Given waxing and waning over serial radiographs, there is concern
for recurrent aspiration/aspiration pneumonia.
Radiology Report
INDICATION: ___ with COPD not on home O2, CAD s/p CABG, HTN, HL, pAF, h/o
CVA, alcohol abuse, presents with fever, cough, and chest pain concerning for
community-acquired pneumonia, then here for abdominal pain now improved; now
here for SIADH/hyponatremia, concern for recurrent aspiration pneumonia. //
recurrent aspiration pneumonia
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the speech and swallow division. Multiple consistencies of
barium were administered.
DOSE: Fluoro time: 1 min 42 sec min.
COMPARISON: None.
FINDINGS:
Barium passes freely through the oropharynx and esophagus without evidence of
obstruction. There is aspiration of thin liquid.
IMPRESSION:
Aspiration of thin liquid.
Please refer to the speech and swallow division note in OMR for full details,
assessment, and recommendations.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with recurrent aspiration pneumonia. //
worsening of infiltration worsening of infiltration
COMPARISON: Chest radiographs ___ through ___. What is
IMPRESSION:
Radiographs and chest CT scans since at least ___ documente asymmetric
pulmonary abnormality consisting of fibrosis and intermittent consolidation in
large parts of the right lung and left lung base, with relative sparing of the
left upper lobe. Most recently, since ___ and ___, a component
of mild pulmonary edema has improved and lung volumes have increased. There
is no pneumothorax or appreciable pleural effusion. The chronic abnormality
in the right lung is more abnormal now than it was in ___.
The alignment of sternal wires, some which are fractured, has not changed
since at least ___.
Radiology Report
INDICATION: ___ year old man with COPD not on home O2, CAD s/p CABG, HTN, HL,
pAF, h/o CVA, alcohol abuse, has been here since ___ for pneumonia,
treated with abx. Complicated by hyponatremia and aspiration. Has Midline, but
need labs multiple times a day. Need Midline replaced to PICC today because no
IV nurses can get blood and need lab draws. // Please replace midline with
PICC
COMPARISON: None.
TECHNIQUE: OPERATORS: Dr. ___, Interventional Radiology Fellow and Dr.
___, attending radiologist performed the procedure. Dr. ___
___ and Dr. ___ personally 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: None
CONTRAST: None
FLUOROSCOPY TIME AND DOSE: 0.2 min, 1 mGy
PROCEDURE: 1. Repositioning of right PICC.
PROCEDURE DETAILS: Using sterile technique and local anesthesia, the existing
PICC line was aspirated and flushed and a Nitinol guidewire was introduced
into the superior vena cava (SVC). A peel-away sheath was then placed over a
guidewire. The guidewire was then advanced into the superior vena cava. A
single lumen PIC line measuring 40 cm in length was then placed through the
peel-away sheath with its tip positioned in the distal SVC under fluoroscopic
guidance. Position of the catheter was confirmed by a fluoroscopic spot film
of the chest. The peel-away sheath and guidewire were then removed. The
catheter was secured to the skin, flushed, and a sterile dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. Existing right arm approach PICC with tip in the midline replaced with a
new single lumen PIC line with tip in the distal SVC.
IMPRESSION:
Successful placement of a 40 cm right arm approach single lumen PowerPICC with
tip in the distal SVC. The line is ready to use.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Pneumonia, unspecified organism
temperature: 98.6
heartrate: 88.0
resprate: 18.0
o2sat: 100.0
sbp: 96.0
dbp: 57.0
level of pain: ?
level of acuity: 2.0 | ___ with COPD not on home O2, CAD s/p CABG, HTN, HL, pAF, h/o
CVA, alcohol abuse, presents with fever, cough, and chest pain
concerning for community-acquired pneumonia, which improved with
CAP treatment; he was then kept for constipation/diffuse
abdominal pain which improved; he then developed SIADH in the
setting of recent PNA and hypothyroidism.
# Hyponatremia/SIADH: initially did not improve despite 1L IVF
challenge initially; Ulytes afterwards were suggestive of SIADH,
likely in setting of hypothyroidism (TSH ~20) and recent CAP;
fluid restriction was started. Pt was euvolemeic. Likely
exacerbated by poor PO intake and alcoholism/poor solute intake.
Renal followed and recommended salt tabs 1g TID with 1L fluid
restriction. Na stabilized to 129 at time of discharge.
# Hypothyroidism: TSH checked ___ given lower BP's and
hyponatremia was 20. Pt's levothyroxine was increased to
150mcg/day; may not have been dosed appropriately at home. Will
need repeat TSH in ___ weeks post discharge.
# PNEUMONIA, community-acquired vs ?aspiration in the setting
of alcohol abuse. His CXR on admission was not entirely
definitive. Presumed CAP given fever, mild tachypnea, and
dyspnea. Note that he has longstanding dyspnea and chest pain
which has been worked up in past without clear cause. Finished
7 day course of oral cefpodox and azithromycin, last day
___.
# Fever, recurrent aspiration: Patient developed temperature to
101.2 in am ___, afebrile afterwards, and 101.3 on ___.
Panculture was unremarkable. Initial fever on ___ resolved
without any intervention. There was concern for recurrent
aspiration and speech and swallow evaluated. Patient aspirating
significantly on video swallow. Isolated fevers thought to be
secondary to aspiration events. Decision made not to treat with
antibiotics as patient was always hemodynamically stable and
events resolved on their own. Felt that adding antibiotics when
he wasn't decompensating, would be putting him at risk for c
diff and resistance. Speech and swallow recommended nectar thick
liquids and soft dysphagia diet. They also recommended SLP ___
and further evaluation and treatment as an outpatient (pt should
call ___. The patient was given packets of information
and individual counseling regarding his diet and how to prevent
further aspiration.
# CHEST PAIN. Tenderness to palpation of ribs/sternum suggests
MSK etiology. ACS ruled out with nonspecific EKG changes,
negative tropx3. Pt has presented with similar complaints in the
past.
# Abdominal discomfort: diffuse and migrating abdominal pain,
most likely due to severe constipation. Had many small bowel
movements during hospitalization but still large stool burden on
CT. CT also showed thickened duodenum and pylorus so EGD was
performed that showed a gastric ulcer and a deformity of the
pylorus (biopsied). Pylors biopsy results were wnl. Ferrous
sulfate stopped as thought to contribute to constipation. Iron
>100.
# Electrolyte abnormalities (hypophos, hyperkalemia, hypomag):
likely due to a "refeeding syndrome" in the setting of chronic
poor nutrition and alcohol abuse. Repleted often during
hospitalization. Encourage nutrition (with ensures) on
discharge. Discharged on magnesium 400mg BID.
#Left arm edema: diagnosed on HD 5. Unclear etiology, upper
extremity US was negative other than for slow flow, so this is
likely a result of blood draw trauma.
# Anemia: Patient with 10 pt hct drop in 36 hours at beginning
of hospitalization. No evidence of bleeding. Most likely due
dilution with underlying bone marrow suppression from chronic
alcohol use + dilutional effect. Retic index was 0.8, Hgb
remained stable. Iron stopped as thought to be contributing to
abdominal pain. Hgb on discharge 8.1. Would consider outpatient
iron infusions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Remicade
Attending: ___
___ Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ male with a history of Crohn's disease
presenting with abdominal pain and free air after a colonoscopy.
The patient had a colonoscopy this morning at 8 AM for
surveillance of his Crohn's disease. He was noted to have
pseudopolyps as well as sigmoid diverticulitis but no active
inflammatory Crohn's disease on colonoscopy. Segmental biopsies
were taken. After the colonoscopy patient had his usual gas
pains. However in the afternoon he had worsening pain which did
not feel normal to him and he presented to the emergency
department. He denies any fevers. He was able to tolerate
lunch. He did however have some emesis. He also had a bowel
movement. Of note, the patient has had Crohn's disease since
the
___ and has been in remission since ___ until ___
when he tried to wean off of Humira, this prompted a Crohn's
flare. He was then restarted on his Humira. He otherwise was
feeling well prior to his colonoscopy.
Past Medical History:
Mesalamine 4 g enema nightly, mesalamine 1.___ tabs
every morning, atorvastatin 10', lisinopril 0', , Humira 40 mg
subcu q. 2 weeks (last dose ___,
Entocort 1 every other day
Social History:
___
Family History:
non-contributory
Physical Exam:
Physical examination upon discharge:
Vital signs: 99.4, 73, 118/68, 18, 95% on room air
PE:
Alert and oriented x3, no acute distress, conversant, pleasant
No respiratory distress
Abdomen nondistended, minimally tender over upper abdomen
No lower extremity edema
Physical examination upon discharge: ___:
vital signs: 98.8, bp=112/68, hr=50, rr-18, oxygen saturation
95 % room air
GENERAL: NAD
CV: ns1,s2
LUNGS: clear
ABDOMEN: hypoactive BS, soft, mild distention, non-tender, no
guarding, no rebound
EXT: no pedal edema bil., no calf tenderness bil
NEURO: alert and oriented x 3, speech clear
Pertinent Results:
___ 06:30AM BLOOD WBC-10.5* RBC-4.16* Hgb-12.4* Hct-38.7*
MCV-93 MCH-29.8 MCHC-32.0 RDW-14.6 RDWSD-50.3* Plt ___
___ 04:19AM BLOOD WBC-20.3* RBC-3.75* Hgb-11.2* Hct-34.4*
MCV-92 MCH-29.9 MCHC-32.6 RDW-14.4 RDWSD-48.4* Plt ___
___ 04:15PM BLOOD WBC-16.1* RBC-4.84 Hgb-14.4 Hct-44.2
MCV-91 MCH-29.8 MCHC-32.6 RDW-14.3 RDWSD-48.2* Plt ___
___ 04:15PM BLOOD Neuts-89.0* Lymphs-5.8* Monos-4.2*
Eos-0.4* Baso-0.2 Im ___ AbsNeut-14.34* AbsLymp-0.93*
AbsMono-0.68 AbsEos-0.06 AbsBaso-0.03
___ 06:30AM BLOOD Plt ___
___ 06:30AM BLOOD Glucose-91 UreaN-9 Creat-1.1 Na-140 K-4.1
Cl-103 HCO3-25 AnGap-12
___ 04:15PM BLOOD Glucose-100 UreaN-17 Creat-1.1 Na-144
K-4.1 Cl-102 HCO3-27 AnGap-15
___ 06:30AM BLOOD Calcium-8.5 Phos-2.3* Mg-2.1
___ 04:33AM BLOOD Lactate-1.0
___: CXR:
1. Pneumo-peritoneum, large quantity.
2. No acute intra-thoracic process.
___: ct abd.
Large volume pneumoperitoneum without extraluminal contrast leak
or pooling identified. No abnormal colonic wall thickening or
site of bowel perforation identified
Medications on Admission:
Mesalamine 4 g enema nightly, mesalamine 1.___ tabs
every morning, atorvastatin 10', lisinopril 0', , Humira 40 mg
subcu q. 2 weeks (last dose ___,
Entocort 1 every other day
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H Duration: 14 Days
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*28 Tablet Refills:*0
2. Atorvastatin 10 mg PO QPM
3. Budesonide 9 mg PO DAILY
4. Lisinopril 10 mg PO DAILY
5. Mesalamine ___ 1200 mg PO QAM
6. Mesalamine Enema 4 gm PR QHS
Discharge Disposition:
Home
Discharge Diagnosis:
pneumoperitoneum
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 s/p colonoscopy w/ abd pain// upright ?free air
TECHNIQUE: Portable AP chest
COMPARISON: None.
FINDINGS:
Free air is seen below the bilateral hemidiaphragms, consistent with a large
quantity of pneumoperitoneum. Minor volume loss at the left lung base.
Lung volumes are low. The cardiomediastinal silhouettes are within normal
limits. No focal consolidations are seen. There is no pulmonary edema or
pleural abnormality.
IMPRESSION:
1. Pneumoperitoneum, large quantity.
2. No acute intrathoracic process.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 5:11 pm, 2 minutes after
discovery of the findings by the attending physician. Earlier a wet reading
had been provided with flagging for urgent attention.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: +PO contrast; pneumoperitoneum s/p colonoscopy. Please also
include rectal contrast+PO contrast// Please also include rectal contrast
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Water-soluble oral and rectal contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 26.5 mGy (Body) DLP =
13.2 mGy-cm.
2) Spiral Acquisition 6.5 s, 51.1 cm; CTDIvol = 14.3 mGy (Body) DLP = 730.7
mGy-cm.
Total DLP (Body) = 744 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: There is mild dependent atelectasis in the imaged lung bases. No
pleural or pericardial effusion is seen.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. Periportal edema is noted. There is
no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: There is large volume pneumoperitoneum seen throughout the
abdomen. The stomach is unremarkable. Small and large bowel loops are normal
in caliber. Rectal contrast is seen to the cecum. No extraluminal contrast
leak or pooling is identified. No abnormal colonic wall thickening is seen.
PELVIS: The urinary bladder is 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. Mild atherosclerotic disease
is noted. Left-sided retroaortic renal vein is noted incidentally.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
There is severe S-shaped scoliosis of the thoracolumbar spine.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
Large volume pneumoperitoneum without extraluminal contrast leak or pooling
identified. No abnormal colonic wall thickening or site of bowel perforation
identified.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, N/V
Diagnosed with Oth postprocedural complications and disorders of dgstv sys, Oth surgical procedures cause abn react/compl, w/o misadvnt, Oth places as the place of occurrence of the external cause
temperature: 99.4
heartrate: 80.0
resprate: 20.0
o2sat: 99.0
sbp: 124.0
dbp: 105.0
level of pain: 8
level of acuity: 2.0 | ___ year old male who was admitted to the hospital with abdominal
pain after having a colonoscopy. Upon admission, the patient
was made NPO, given intravenous fluids, and underwent imaging.
A cat scan of the abdomen was done which showed pneumoperitoneum
which was concerning for a bowel perforation.
The patient was placed on bowel rest and started on a course of
ceftazadime and flagyl. After his abdominal pain decreased, he
resumed a regular diet. He was transitioned to a 14 day course
of augmentin. He was ambulatory and voiding without difficulty.
He resumed his home medications.
The patient was discharged on HD #3 with stable vital signs and
a stable hematocrit. He was instructed to follow-up with his
primary care provider and his ___. The patient
was provided with the telephone number to the acute care clinic
with any questions or concerns. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
___ s/p fall transferred from ___ with left scapular
fracture, left rib fractures, and T11 fracture with
retropulsion.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ h/o HTN, HLD, DVT (a few years ago, unclear if provoked, not
currently anticoagulated) who presents as polytrauma after a
mechanical fall.
She woke up around 8am this morning and had difficulty opening
her left eye. Her eye felt a bit sore and swollen so she got up
and called her PCP. Her PCP asked her to come to the ED.
Unfortunately, at the OSH ED, she had a mechanical fall while
walking with her cane on the way into the entrance (states she
normally walks with her walker but did not have it with her at
the time. She was then transferred to ___ ED for trauma
evaluation.
On evaluation here, patient states she fell onto the left side
of
her head. She does not think she lost consciousness. She
complains of neck pain, left shoulder pain, and right knee pain.
She denies numbness/tingling in her upper or lower extremities.
She also denies bowel/bladder incontinence or saddle anesthesia.
___ was placed by the ED. Of note, patient has had mid to
lower back pain for several weeks since she was in a car
accident
about a month ago. She has had a right foot drop for about the
same period of time, for which she has been seeing home ___ and
wearing an AFO brace. She denies pain in other areas or other
injuries.
Past Medical History:
PMH: hypertension, hyperlipidemia, chronic back pain, h/o DVT
s/p fall, dementia, constipation
PSH: none
Social History:
___
Family History:
noncontributory
Physical Exam:
Afebrile, VSS
General: Awake.
Neurologic: grossly intact
HEENT: Abrasion and ecchymosis to right forehead. No proptosis
or conjunctival injection.
Neck: In hard collar
Pulmonary: Lungs CTA
Cardiac: RRR,
Extremities: right knee abrasion
Pertinent Results:
MRI T Spine ___. Severely limited examination of the axial reformats for the
cervical and
thoracic spine secondary to patient motion artifact.
2. No evidence of acute cervical spine fracture or acute
ligamentous injury.
3. Stable T11 vertebral body burst fracture with probable edema.
4. Mild T11 spinal canal stenosis secondary to 8 mm retropulsion
of the
superior posterior fracture fragment.
5. Stable T8 and T9 vertebral body chronic compression
fractures.
6. Stable L2 on L3 vertebral body compression deformities.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Duloxetine 60 mg PO DAILY
4. Gabapentin 100 mg PO DAILY
5. Mirtazapine 7.5 mg PO QHS
6. Multivitamins 1 TAB PO DAILY
7. Polyethylene Glycol 17 g PO DAILY:PRN constipation
8. Simvastatin 20 mg PO DAILY
9. Donepezil 10 mg PO HS
10. Senna 8.6 mg PO BID:PRN constipation
11. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
3. Donepezil 10 mg PO HS
4. Duloxetine 60 mg PO DAILY
5. Mirtazapine 7.5 mg PO QHS
6. Multivitamins 1 TAB PO DAILY
7. OxycoDONE (Immediate Release) 2.5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q4H PRN Disp #*30
Tablet Refills:*0
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Senna 8.6 mg PO BID:PRN constipation
10. Simvastatin 20 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Fall
Rib fractures
Left scapular fracture
T1 retropulsion
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: Status post fall.
TECHNIQUE: Portable frontal view of the chest.
COMPARISON: Same-day CT torso.
FINDINGS:
Heart is moderately enlarged. There is unfolding of thoracic aorta. Hilar
contours are unremarkable. There is a small left-sided pleural effusion with
adjacent atelectasis. Lungs are otherwise grossly clear. There is no
pneumothorax. There is end-stage degenerative change of the right
glenohumeral joint. Numerous bilateral acute and chronic rib fractures and
left scapular fracture are better assessed on same-day CT examination.
IMPRESSION:
1. Small left-sided pleural effusion and adjacent atelectasis. Lungs are
otherwise grossly clear.
2. Multiple rib fractures and left scapular fracture are better assessed on
same-day CT.
Radiology Report
EXAMINATION: CT abdomen and pelvis with contrast
INDICATION: Status post fall with positive FAST scan, T11 spine fracture with
retropulsion, left scapular fracture, bilateral chronic and acute rib
fractures.
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 3.0 s, 0.5 cm; CTDIvol = 14.4 mGy (Body) DLP =
7.2 mGy-cm.
2) Spiral Acquisition 6.1 s, 47.6 cm; CTDIvol = 8.2 mGy (Body) DLP = 390.2
mGy-cm.
Total DLP (Body) = 397 mGy-cm.
COMPARISON: CT torso without contrast ___. CT torso ___.
FINDINGS:
Heart size is moderately enlarged with trace physiologic pericardial fluid.
There is a moderate simple density left-sided pleural effusion with adjacent
compressive atelectasis. There is additional moderate inferior lingular
atelectasis and mild right base atelectasis. There is a trace right-sided
pleural effusion.
CT abdomen with contrast: Liver enhances homogeneously without focal lesion
or biliary dilatation. There is no liver laceration. Portal vein is patent.
Gallbladder sits low, however is grossly unremarkable.
Spleen is unremarkable without laceration. A 5 mm cystic lesion is seen
within the anterior pancreatic body, likely an IPMN (02:52). Pancreas adrenal
glands are otherwise unremarkable. There are several bilateral renal cysts
measuring up to 4.9 cm in the left upper pole kidney. Some of the adjacent
cysts show dense coarse rim calcifications. Kidneys are otherwise
unremarkable without focal solid lesion or hydronephrosis.
Stomach is collapsed and unremarkable. Duodenum and small bowel loops are
normal caliber without evidence of obstruction. There is sigmoid predominant
diverticulosis without evidence of diverticulitis. Large bowel is otherwise
grossly unremarkable.
There is severe atherosclerotic calcifications along a normal caliber
abdominal aorta. There is no mesenteric or retroperitoneal lymphadenopathy.
There is small volume nonhemorrhagic ascites. There is no pneumoperitoneum or
ventral abdominal hernia.
CT pelvis with contrast: Bladder, uterus, adnexa and rectum are grossly
unremarkable. Pelvic floor descent is noted.
Bones and soft tissues: Again demonstrated is an acute burst fracture of the
T11 vertebral body with 4 mm of retropulsion. Severe compression deformities
of T8 and T9 are unchanged. Moderate superior endplate compression of L2, L3
and L5 are unchanged. There is grade 1 anterolisthesis of L5 on S1. There
are deformities from a healed fractures of the left superior and inferior
pubic ramus. The pelvic ring is otherwise intact. Several chronic and
subacute bilateral rib fractures are better characterized on these same-day CT
torso exam. Superficial soft tissues appear diffusely edematous.
IMPRESSION:
1. No acute intra-abdominal or pelvic findings.
2. Moderate left and trace right nonhemorrhagic pleural effusions, small
volume nonhemorrhagic ascites and diffuse superficial soft tissue edema, may
be reflective of anasarca.
3. Acute burst fracture of the T11 vertebral body with 4 mm retropulsion.
4. Chronic compression deformities of T8, T9, L2, L3 and L5 vertebral bodies
with partial visualization of several subacute and chronic lower rib
fractures.
5. Pelvic floor descent.
6. 5 mm cystic pancreatic lesion, statistically likely to represent IPMN.
Radiology Report
EXAMINATION: MRI CERVICAL AND THORACIC PT21 MR SPINE
INDICATION: ___ s/p fall transferred from ___ with left scapular
fracture, left rib fractures, and T11 fracture. Rule out ligamentous injury.
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..
COMPARISON: Cervical spine CT and CT torso from ___, torso CT from
___ and chest CT from ___.
FINDINGS:
CERVICAL:
Limited evaluation of the axial reformats and GRE sequences of the cervical
spine secondary to patient motion artifact.
Cervical lordosis appears exaggerated due to severe thoracic kyphosis. There
is minimal anterolisthesis of C3 on C4 and C7 on T1. Small foci of high signal
on T2, low signal on T1 along the endplates of C2-C3 could reflect type 1 bone
marrow changes. There is intervertebral disc space height loss at the C4-C5
and the C6-C7 levels. There is generalized loss of intervertebral disc signal
on the T2 weighted images due to degenerative disease. No other vertebral
body lesions are detected in the cervical spine. The spinal cord appears
normal in caliber and configuration. There is no evidence of infection or
neoplasm.The anterior and posterior longitudinal ligaments appear grossly
intact with no evidence of ligamentous injury.
Limited evaluation of a of the cervical spine in the GRE sequences secondary
to patient motion artifact. The sagittal images suggest disc bulges,
ligamentum flavum thickening and intervertebral osteophyte formation producing
mild spinal canal narrowing without cord compression. However, if these are
areas of clinical concern, a repeat study is recommended.
At the C2-C3 level, there is a small central disc protrusion causing mild
effacement of the anterior thecal sac. There is no spinal canal or neural
foraminal narrowing.
At the C3-C4 level, there is minimal disc bulge. There is no spinal canal
stenosis or neural foraminal narrowing.
At the C4-C5 level, there is minimal disc bulge. There is no spinal canal
stenosis or neural foraminal narrowing.
At the C5-C6 level, there is mild central disc protrusion causing mass less
than mild narrowing of the spinal canal. Evaluation of the neural foramen at
this level is degraded secondary to patient motion artifact.
At the C6-C7 level there is a small central disc protrusion causing effacement
of the anterior thecal sac. There is no spinal canal stenosis. Evaluation of
the neural foramen is limited at this level.
THORACIC:
Limited evaluation of the axial reformats of the thoracic spine secondary to
patient motion artifact.
There is moderate thoracic kyphosis.
There are chronic compression fractures at the T8-T9 level, stable as compared
to prior chest CT from ___, allowing for differences in modality.
There is no associated increased STIR signal intensity of the fractures to
suggest an acute component.
There is redemonstration of a T11 comminuted compression fracture it extends
through the superior endplate, with associated are it vertebral body height
loss and an 8 mm retropulsion of a superior and posterior fracture fragment
causing mild spinal canal stenosis. There is associated T2/ STIR signal
hyperintensity of the T11 vertebral body suggesting underlying bone marrow
edema.
There is a focus of high T2 and STIR signal intensity with corresponding low
T1 signal at the posterior aspect of the T12 vertebral body which is felt to
reflect a vertebral hemangioma as seen on prior CT examination. Compression
deformities of the L2 and L3 vertebral bodies appear stable since at least
prior CT examination from ___.
Small foci of high signal on T2, low signal on T1 along the endplates of T2-T3
and T3-T4 could reflect type 1 bone marrow changes. There is no evidence of
infection or neoplasm.
Allowing for limited examination of the axial reformats of the thoracic spine,
there is no spinal canal or neural foraminal stenosis at the T1-T2, T2-T3,
T3-T4, T4-T5, T5-T6 or T6-T7 levels.
There is at least moderate spinal canal stenosis at the T8-T9 and T9-T10
levels secondary to chronic compression deformities of the T8 and T9 vertebral
bodies.
At the T10-T11 level, there is no significant spinal canal stenosis.
8 mm retropulsion of a superior and posterior fracture fragment is causing
mild compression the spinal canal at this level.
At the T11-T12 level, there is no spinal canal stenosis.
At the T12-L1 level, there is a small disc bulge which is causing mild
effacement of the anterior thecal sac.
OTHER: Evaluation of the known comminuted fracture of the left scapula is
difficult to assess on this examination. Known bilateral pleural effusions
are better assessed on prior dedicated CT examinations. There is a 4.3 cm T2
bright lesion with linear T2 hypointensities in the upper pole of the left
kidney which corresponds to the previously identified partially calcified
cyst, better assessed on prior CT examination.
IMPRESSION:
1. Severely limited examination of the axial reformats for the cervical and
thoracic spine secondary to patient motion artifact.
2. No evidence of acute cervical spine fracture or acute ligamentous injury.
3. Stable T11 vertebral body burst fracture with probable edema.
4. Mild T11 spinal canal stenosis secondary to 8 mm retropulsion of the
superior posterior fracture fragment.
5. Stable T8 and T9 vertebral body chronic compression fractures.
6. Stable L2 on L3 vertebral body compression deformities.
Radiology Report
EXAMINATION: SHOULDER (AP, NEUTRAL AND AXILLARY) TRAUMA RIGHT
INDICATION: ___ year old woman with trauma s/p fall // injury?
injury?
TECHNIQUE: Three views of the right shoulder
COMPARISON: ___
FINDINGS:
Bones are diffusely demineralized. There is no evidence of acute fracture or
dislocation involving the glenohumeral or AC joint. Severe degenerative
changes again demonstrated at the glenohumeral joint which has progressed
since the prior study, with joint space narrowing, subchondral sclerosis,
cystic change, as well as deformity of the right humeral head. Again noted is
high riding position of right humeral head, suggestive of chronic rotator cuff
injury.
IMPRESSION:
Severe degenerative changes at the right glenohumeral joint as detailed above.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: MULT RIB FX, s/p Fall
Diagnosed with Multiple fractures of ribs, left side, init for clos fx, Fracture of unsp part of scapula, left shoulder, init, Stable burst fracture of T11-T12 vertebra, init for clos fx, Fall on same level, unspecified, initial encounter
temperature: 98.5
heartrate: 78.0
resprate: 12.0
o2sat: 100.0
sbp: 104.0
dbp: 64.0
level of pain: 4
level of acuity: 1.0 | The patient was admitted to ___ as a Basic trauma from ___
___. Appropriate primary and secondary survey were performed
per trauma protocol. She was found have the following injuries:
Left scapular fracture
T11 burst fracture with 8mm retropulsion
multiple Rib fractures
chronic T8 & T9 compression fractures.
Orthopedic surgery was consulted for spinal injury and for
scapular fracture. They recommended activity as tolerated and
did not recommend a brace. C spine was cleared with MRI which
was negative for Cspine injury, thus hard collar was removed. IS
was encouraged and pain was controlled with oral pain medication
due to her rib fractures. She was successfully weaned off oxygen
on the day of discharge. Physical therapy and occupational
therapy were consulted and they recommended rehabilitation. Her
diet was advanced and she tolerated a regular diet without
difficulty. The patient was discharged on ___ to rehab. At
the time of discharge, she was off oxygen, pain was controlled
with oral pain medication, and she was tolerating a regular diet
and urinating and stooling normally. She was discharged to rehab
with plan to remain in rehab for less than 30 days, and plan to
follow up with ACS, Ortho spine, and ortho trauma in ___ weeks
after discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pancreaticocutaneous fistula
Major Surgical or Invasive Procedure:
___: CT-guided replacement of an 8 ___ catheter inside
the
peripancreatic collection.
History of Present Illness:
___ w/ prior external and internal drainage of pancreatic
fistula both ___ ___, and OR I&D of abdominal wall abscess ___
___ coming to the ED today because of new abdominal wall
drainage from his incision since 4am this morning. The patient
notes that he has felt general malaise and fatigue since 1 week
ago when he had a drinking binge (approx ___ drinks). He has
had some worsening epigastric abdominal pain radiating to the
back since that episode. The patient was admitted for further
evaluation.
Past Medical History:
HTN
Cirrhosis
Esophagitis
Alcoholism
Melanoma
Chronic Pancreatitis
Anxiety
PSH:
___ External open drainage of pancreatic fistula.
___ Internal drainage of pancreatic fistula (pancreatic
fistula tract jejunostomy).
Social History:
___
Family History:
non-contributory
Physical Exam:
Physical Exam on admission:
Vitals: Temp 96.7, HR 84, BP 110/76, RR 16, 98% Room air
GEN: A&Ox3, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l
ABD: Erythema over prior upper abdominal incision. Small
pinpoint
hole exuding purulent output. No fluctuance. Below this
incision
at the prior I&D site there are two openings with thinned skin.
These two areas do not appear to be connecting to the superior
hole draining fluid
Ext: ___ warm and well perfused
Prior Discharge:
VS: 98.3, 64, 105/67, 18, 100% RA
GEN: AAOx3, NAD
CV: RRR, no m/r/g
PULM: CTAB
ABD: Superior part of midline incision covered with ostomy bag
with thick purulent drainage. Inferior part of the wound open
with dry gauze packing, the wound divided on two sections by
small skin bridge. LUQ drainage catheter to bulb suction with
sanguineous drainage, site c/d/i.
EXTR: Warm, no c/c/e
Pertinent Results:
___ 07:20AM BLOOD WBC-10.4 RBC-4.07* Hgb-10.2* Hct-33.7*
MCV-83 MCH-25.1* MCHC-30.3* RDW-16.7* Plt ___
___ 08:10AM BLOOD ALT-28 AST-29 AlkPhos-130 Amylase-51
TotBili-0.3
___ 08:10AM BLOOD Calcium-8.8 Phos-4.1 Mg-2.3
___ 12:02PM ASCITES ___
___ 4:30 pm ABSCESS PERIPANCREATIC.
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Final ___:
HAEMOPHILUS SPECIES NOT INFLUENZAE. SPARSE GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # ___
(___).
STREPTOCOCCUS ANGINOSUS (MILLERI) GROUP. SPARSE GROWTH.
IDENTIFICATION PERFORMED ON CULTURE # ___
(___).
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
___ 9:35 pm SWAB Source: Abd midline wound.
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
1+ (<1 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Preliminary):
STREPTOCOCCUS ANGINOSUS (___) GROUP. MODERATE
GROWTH.
SENSI PER ___. ___ ___.
HAEMOPHILUS SPECIES NOT INFLUENZAE. SPARSE GROWTH.
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
___ ABD CT:
IMPRESSION:
Multiloculated collection between the pancreas and the posterior
wall of the stomach, which measures 4.4 x 6 x 3.3 cm and has a
slightly thick enhancing rim. This is new compared to the prior
study of ___, where only phlegmonous changes without
discrete collections.
Apparent track from this new collection traversing into the
anterior abdominal wall and also into a very small subfascial
collection with predominantly gas. The previously seen anterior
abdominal wall collection is resolved post drainage.
There are mild inflammatory changes surrounding the inferior
aspect of the
pancreas with a small area of hypoenhancement within the medial
aspect of the tail without necrosis.
Medications on Admission:
atenolol 25 mg daily
Discharge Medications:
1. Atenolol 25 mg PO DAILY
2. moxifloxacin *NF* 400 mg Oral qd Duration: 9 Days Reason for
Ordering: per ID recommendation
RX *moxifloxacin [Avelox] 400 mg 1 tablet(s) by mouth once a day
Disp #*10 Tablet Refills:*0
3. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*15 Tablet Refills:*0
4. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pancreaticocutaneous fistula
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
TYPE OF THE EXAM: CT of the abdomen and pelvis without and with intravenous
contrast.
TECHNIQUE: Multiple axial MDCT of the abdomen and pelvis were obtained pre and
post administration or intravenous and oral contrast.
COMPARISON EXAM: Multiple prior CT's performed in our institution, the
latest one was dated ___ and a CT of the abdomen and pelvis performed
at another institution dated ___.
FINDINGS:
The lung bases demonstrate no evidence of pleural effusion. There are no
consolidations.
Examination of the abdomen and pelvis demonstrates presence of a
multiloculated collection between the anterior aspect of the pancreatic body
/tail and the lesser curvature of the stomach. This is new from the prior CT
and measures 4.3 cm in the AP dimension in the axial plane and 6 x 3.3 cm
measured in the coronal plane (series 400: image 25). Originating from this
collection, there is fat stranding and also what appears to be a fistulous
tract that goes anteriorly towards the anterior abdominal wall with a
bifurcated morphology with one fistulous tract connecting to an anterior
collection beneath the fascia, which measures 2.2 x 1.8 cm and an additional
tract that goes to anterior abdominal wall where some superficial stranding is
noted with defect in the overlying skin. There is a linear hyperdense
structure which was on the prior study of unclear etiology. There are
surgical sutures in the anterior abdomen with a loop of bowel near the
anterior abdominal wall, is consistent with a pancreaticojejunostomy. The
anterior wall collection that was seen on the prior study is not seen on
today's study. At the area of previously seen anterior abdominal wall
collection, there is a skin defect with overlying packing material with no
residual collection. Pancreas otherwise enhances homogeneously with the
exception of a small region at the medial tail (3:21). There is a stable
collection without rim enhancement at the posterior aspect of the stomach.
Liver demonstrates no evidence of focal lesions. The spleen is upper level of
norm. Bilateral kidneys and adrenal glands are unchanged and are
unremarkable. There are no complicating features of pancreatitis. The splenic
vein, portal confluence and intrahepatic portal veins are patent. The
arterial structures are patent without evidence of aneurysmal dilatation.
There are some inflammatory changes below the level of the pancreas. Small
lymph nodes regional, without lymphadenopathy are noted. The small and
colonic loops of bowel within the abdomen and pelvis are well opacified
without abnormal dilatation. There are scattered sigmoid diverticula without
diverticulitis. There is an incisional right abdominal wall fat-containing
small hernia.
Osseous structures demonstrate again anterolisthesis of L4 on L5 with
bilateral pars defects and degenerative changes, unchanged from the prior
studies. There are no acute fractures or destructive lesions.
IMPRESSION:
Multiloculated collection between the pancreas and the posterior wall of the
stomach, which measures 4.4 x 6 x 3.3 cm and has a slightly thick enhancing
rim. This is new compared to the prior study of ___, where only
phlegmonous changes without discrete collections.
Apparent track from this new collection traversing into the anterior abdominal
wall and also into a very small subfascial collection with predominantly gas.
The previously seen anterior abdominal wall collection is resolved post
drainage.
There are mild inflammatory changes surrounding the inferior aspect of the
pancreas with a small area of hypoenhancement within the medial aspect of the
tail without necrosis.
Radiology Report
INDICATION: Patient with pancreaticocutaneous fistula, leukocytosis, purulent
drainage, peripancreatic fluid collection.
COMPARISON: Abdominal CT done yesterday.
PHYSICIANS: ___ and ___.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained. A preprocedure
timeout was performed, discussing the planned procedure, confirming the
patient's identity with three identifiers, and reviewing a checklist per ___
protocol.
The patient was placed on his back on the CT table to access the
peripancreatic collection. Under CT guidance, an entrance site was selected
and the skin was prepped and draped in the usual sterile fashion. 10 cc of
lidocaine 1% was instilled for local anesthesia. An 18-gauge ___ needle
was first inserted into the collection. 50 cc of pus was removed from the
collection and sent to microbiology, then over ___ wire, an 8 ___
catheter was placed inside the collection.
Moderate sedation was provided by administering divided doses of 150 mcg of
fentanyl and 3 mg of Versed throughout the total intraservice time of 38
minutes during which the patient's hemodynamic parameters were continuously
monitored by radiology nursing personnel. There was no complication after the
procedure.
IMPRESSION: CT-guided replacement of an 8 ___ catheter inside the
peripancreatic collection. Material was removed from the collection and sent
to microbiology.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABDOMINAL WOUND DRAINAGE
Diagnosed with OTHER POST-OP INFECTION, ABN REACT-SURG PROC NEC
temperature: 96.7
heartrate: 84.0
resprate: 16.0
o2sat: 98.0
sbp: 110.0
dbp: 76.0
level of pain: 0
level of acuity: 3.0 | The patient well known for Dr. ___ was admitted to
the HPB Surgical Service for evaluation of his new abdominal
wall drainage. On ___, the patient underwent abdominal CT
scan, which demonstrated multiloculated collection between the
pancreas and the posterior wall of the stomach with apparent
track from this new collection traversing into the anterior
abdominal wall (please see Radiology report for details). The
patient was started on IV Zosyn, made NPO and ___ was called for
consult. On ___ patient underwent CT-guided placement of an 8
___ catheter inside the peripancreatic collection. Midline
fistula was covered with ostomy bag for drainage. The patient's
peripancreatic fluid was sent to microbiology for analysis.
Fluid was positive for Streptococcus Milleri group and
Haemophilus species, ID was called for consult. Patient's wound
was packed with dry gauze daily. The patient's WBC started to
downward and he was afebrile. Diet was advanced to clears on
___ and diet was well tolerated. The patient underwent wound,
ostomy and drain care while ___ hospital, and he demonstrated
understanding. Prior discharge on ___, patient's WBC returned
within normal limits, he remained afebrile and fistula/drain
output subsided. The patient was hemodynamically stable.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ibuprofen
Attending: ___
Chief Complaint:
weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ year old female with recently diagnosed
Stage IVB ovarian adenocarcinoma who presents to the ED with leg
weakness and difficulty ambulating 5 days after starting
treatment with carboplatin/paclitaxel.
The patient was in her usual state of health until 3 days ago
when she noticed the gradual onset of lower extremity heaviness
and thigh pain. Over the next three days her pain worsened. She
was without fevers or chills. She had no back pain or
bowel/bladder incontinence. No Paresthesia. She then called her
oncologist's office who recommended she present to the ED for
further evaluation.
The patient went to an OSH where she underwent ___ which was
negative for DVT. She was then transferred to ___ for further
care.
In the ED, the initial vital signs were: T 97.0 Hr 65 BP 128/93
R 16 SpO2 985
Laboratory data was notable for: Normal Chem7, CK and CBC
The patient received: ___ 08:50 PO/NG Docusate Sodium 100
mg
Upon arrival to 11R, the patient states she feels much improved
after receiving IVF at the OSH. She states her strength and pain
is significantly improved.
She has no headache or vision changes. No chest pain or dyspnea.
No abd pain. No n/v/d. No back pain. No bowel or bladder
incontinence.
ROS: 10 point review of systems discussed with patient and
negative unless noted above
Past Medical History:
PAST ONCOLOGIC HISTORY:
Due to abdominal pain, she had a pelvic ultrasound on ___
showing uterus measuring 8.8 x 4.8 x 4.4 cm with an endometrial
stripe up to 0.9 cm. A complex cyst was seen measuring 5.8 x 6.9
x 8.3 cm with multiple septations, one of which is thick. The
left ovary measured 5.1 x 3.2 x 3.7 cm without a mass or cyst
noted. A moderate amount of free pelvic fluid was noted. CT A/P
showed no free fluid in the peritoneal cavity and the right
adnexal mass was measured to be 8.1 x 8.4 x 7.4 cm. Her lymph
nodes were normal and there were no inflammatory changes in the
mesentery. CA 125 was 106.
On ___ she underwent total abdominal hysterectomy,
bilateral salpingo-ooprectomy, right ureterolysis, removal of
anterior abdominal wall mass, cystotomy repair, total infracolic
omentectomy, bilateral pelvic lymph node sampling, plasma jet
ablation of diaphragmatic and peritoneal nodules. Intraoperative
findings were notable for an 8 to 9 cm white smooth walled right
ovarian cyst that was adherent to the right pelvic sidewall with
question of invasion into the right pelvic peritoneum adjacent
to the ureter deep to the pelvis. The right fallopian tube had a
cystic appearing bulge and was adherent to the round ligament
and anterior abdominal wall in the lower pelvic area. A 4 cm
anterior abdominal wall bulge was noted to contain tumor and the
peritoneum overlying this mass was adherent to the right cornea.
The left ovary was enlarged and cystic measuring 4-5 cm. Surface
excrencences were noted on the left diaphragm and omentum and
the anterior pelvic peritoneum and presacral space, all
approximately 2-3 mm in size. There was no evidence of disease
at the conclusion of the surgery. Cystoscopy showed a bladder
repair evident, and normal-appearing bladder mucosa.
Final pathology showed high-grade ovarian serous adenocarcinoma,
and right anterior abdominal wall mass revealed metastatic
serous adenocarcinoma. Lymph nodes, omentum, and bladder wall
biopsy were negative for malignancy. Cytology of pelvic washings
was negative.
OTHER PMH:
Ovarian CA, as above
Gastric bypass (___)
HTN (resolved after bypass)
Hyperlipidemia (resolved after bypass)
Pre-DM2 (resolved after bypass)
h/o kidney stones
laparoscopic tubal ligation
laparoscopic cholecystectomy
"varicose vein" surgery, unclear procedure
Social History:
___
Family History:
Mother possibly died of ovarian cancer in her ___
Physical Exam:
ADMISSION:
==========
VITALS: T 98.0 BP 93/69 HR 106 R 20 SpO2 96 Ra
GENERAL: NAD, lying comfortably in bed
HEENT: Clear OP without lesions. Moist membranes
EYES: PERRL, anicteric
NECK: supple
RESP: No increased WOB, no wheezing, rhonchi or crackles
___: RRR no MRG
GI: soft, NTND no rebound or guarding
EXT: warm, no edema
SKIN: dry, no rashes
NEURO: CN II-XII intact. Sensation intact. Strength ___ UE and
___ b/l
MSK: Normal muscle bulk of ___. No pain on palpation. No pain on
palpation of spine
ACCESS: PIV
DISCHARGE:
=========
T98.3, BP 106/71, HR 75, RR 18, 100% RA
Orthos:
Lying 106/71, HR 75 -> Sitting 109/74, HR 85 -> Standing 127/69,
HR 117
GENERAL: NAD, lying comfortably in bed
HEENT: Clear OP without lesions. Moist membranes
EYES: PERRL, anicteric, EOMI
RESP: No increased WOB, no wheezing, rhonchi or crackles
___: RRR no MRG
GI: +BS, soft, NTND no rebound or guarding
EXT: lower ext warm, no edema
SKIN: dry, no rashes
NEURO: CN II-XII intact. Sensation intact. Strength ___ UE and
___ b/l
MSK: Normal muscle bulk of ___. No pain on palpation. No pain on
palpation of spine
ACCESS: PIV
Pertinent Results:
ADMISSION/SIGNIFICANT LABS:
==========================
___ 08:39PM BLOOD WBC-9.0 RBC-4.22 Hgb-12.1 Hct-37.9 MCV-90
MCH-28.7 MCHC-31.9* RDW-12.9 RDWSD-42.5 Plt ___
___ 08:39PM BLOOD Glucose-109* UreaN-19 Creat-0.6 Na-139
K-4.4 Cl-107 HCO3-23 AnGap-9*
___ 06:15AM BLOOD ALT-12 AST-13 AlkPhos-89 TotBili-0.4
___ 06:23AM BLOOD TSH-1.8
MICRO:
======
URINE CULTURE (Final ___:
STAPHYLOCOCCUS EPIDERMIDIS. 10,000-100,000 CFU/mL.
COAG NEG STAPH does NOT require contact precautions,
regardless of
resistance.
_________________________________________________________
STAPHYLOCOCCUS EPIDERMIDIS
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
NITROFURANTOIN-------- <=16 S
OXACILLIN------------- =>4 R
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ 1 S
IMAGING/OTHER STUDIES:
======================
MRI Brain ___. Small area of T1 hypointense signal in the dens, could
represent a bone island, but a marrow replacing process,
including metastatic disease can't be excluded. Diffuse
intermediate T1 signal throughout the calvarium, likely
represents red marrow reconversion, although this could obscure
an underlying metastatic calvarial lesion. These findings could
be further evaluated with a CT of the head, extending through
the
C2 vertebral body if clinically indicated.
2. No intracranial evidence of metastatic disease or abnormal
enhancement after contrast administration.
LABS AT DISCHARGE:
=================
___ 06:23AM BLOOD WBC-5.7 RBC-3.68* Hgb-10.7* Hct-33.5*
MCV-91 MCH-29.1 MCHC-31.9* RDW-12.4 RDWSD-41.2 Plt ___
___ 06:23AM BLOOD Glucose-91 UreaN-20 Creat-0.7 Na-140
K-4.7 Cl-103 HCO3-28 AnGap-9*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LORazepam 0.5 mg PO Q6H:PRN nausea/anxiety
2. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
3. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
4. Docusate Sodium 100 mg PO BID
5. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. LORazepam 0.5 mg PO Q6H:PRN nausea/anxiety
3. Multivitamins 1 TAB PO DAILY
4. Ondansetron 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
5. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
6. Calcium Carbonate Dose is Unknown PO Frequency is Unknown
Discharge Disposition:
Home
Discharge Diagnosis:
# Fatigue secondary to recent chemotherapy and
# stage IVB Ovarian Adenocarcinoma
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: ___ with recently diagnosed Stage IVB ovarian adenocarcinoma who
presents to the ED with leg weakness and difficulty ambulating 5 days after
starting treatment with carboplatin/paclitaxel. Leg weakness has resolved but
now having new headaches.// please eval for intracranial mass lesion.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 8 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: None available.
FINDINGS:
T1 hypointense signal within the dens (series 3, image 11) could represent a
prominent bone island, but can't exclude metastatic lesion. Intermediate T1
signal throughout the calvarium, likely represents red marrow, but can't
exclude a marrow replacing process, including metastatic disease.
There is no evidence of acute intracranial process or hemorrhage. Ventricles
are normal in morphology. No suspicious intra-axial lesions.
The orbits are unremarkable. There is mild mucosal thickening in the
maxillary and ethmoid sinuses. Mastoid air cells are clear.
IMPRESSION:
1. Small area of T1 hypointense signal in the dens, could represent a bone
island, but a marrow replacing process, including metastatic disease can't be
excluded. Diffuse intermediate T1 signal throughout the calvarium, likely
represents red marrow reconversion, although this could obscure an underlying
metastatic calvarial lesion. These findings could be further evaluated with a
CT of the head, extending through the C2 vertebral body if clinically
indicated.
2. No intracranial evidence of metastatic disease or abnormal enhancement
after contrast administration.
RECOMMENDATION(S): Diffuse intermediate T1 signal throughout the calvarium,
likely represents red marrow reconversion, although this could obscure an
underlying metastatic calvarial lesion. These findings could be further
evaluated with a CT of the head, extending through the C2 vertebral body if
clinically indicated.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: B Leg pain
Diagnosed with Weakness
temperature: 97.0
heartrate: 65.0
resprate: 16.0
o2sat: 98.0
sbp: 128.0
dbp: 93.0
level of pain: 0
level of acuity: 2.0 | ___ with recently diagnosed Stage IVB ovarian adenocarcinoma who
presented to the ED with bilateral leg weakness and difficulty
ambulating 5 days after starting treatment with
carboplatin/paclitaxel.
# Lethargy/generalized weakness:
Patient presented with progressive fatigue and subjective leg
weakness. ___ at OSH prior to admission negative for DVT. Her
exam was reassuring against cord compression and therefore did
not warrant dedicated spine imaging. No major lab abnormalities.
TSH normal. Case discussed with outpatient oncologist who agreed
that symptoms most likely related to her recent chemotherapy,
particularly paclitaxel (initiated 5d prior to admission).
Orthostatics were negative by blood pressure criteria
(borderline
by HR criteria), and her initial symptoms resolved completely
with IVFs. She was asymptomatic with a normal neurologic exam at
discharge, tolerating a regular diet. Followup in ___
clinic
already scheduled for ___.
# Headache:
Endorsed new HAs ___. No other red flag symptoms, but given
known diagnosis of stage IV cancer, MRI obtained to exclude
brain
metastasis that did not identify parenchymal brain mets. There
was a question of an abnormal signal in the skull calvarium of
unclear significance. Per discussion with Dr. ___
imaging either with bone scan or dedicated CT will be determined
on follow up with Dr. ___ as outpatient.
# Ovarian Cancer:
Recently diagnosed and s/p total lap hysterectomy and b/l
salpingo-oophorectomy on ___. Started C1 of ___ 5
days prior to admission. As above, outpatient oncologist (Dr.
___ followed closely, and Ms. ___ will f/u in clinic ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Knee Pain
Major Surgical or Invasive Procedure:
Joint Arthrocentesis (___)
Ortho Joint Washout (___)
History of Present Illness:
___ male with ESRD ___ Alport's Syndrome s/p living
related renal transplant (___), atrial fibrillation on
apixaban, s/p multiple left knee replacements (last at
___ with recurrent MRSA left knee arthritis who is
transferred from ___ with right knee pain/edema
and elevated creatinine.
The patient was riding a moped on ___ when his
knee began to ache. Since that time he has been unable to bear
weight on the extremity and developed NBNB emesis, subjective
fevers and chills. He presented to ___ ED on ___.
Patient was seen at ___ and found to have elevated
creatinine at 2.1 (baseline normally is 1.8). X-rays performed
were reportedly negative for fracture.
In the ED, initial vitals were: 98.6 82 118/69 16 98%. Shortly
thereafter was febrile to 103.2 and was reportedly rigoring.
- Labs were significant for WBC 16.8, hemoglobin 12.4, platelets
149. INR 1.3. Chem panel notable for bicarb 21 (gap 13),
creatinine 2.1 from baseline 1.8.
- Urine studies showed urine sodium 10, FeNa 0.09%, urine
osmolality 509. UPC 0.6.
- Urinalysis showed 7 RBCs, 5 WBCs, 100 proteins and no
bacteria.
- Left knee arthrocentesis was performed and showed 152K WBC
with 94% polys. No crystals.
-- Renal Transplant U/S: Normal renal transplant ultrasound. A
few small simple cysts in the transplant kidney, measure up to
1.4 cm.
-- X-rays of left femur/tib/fib: no evidence of fracture, or
periprosthetic loosening.
- The patient was given 1g vancomcyin, 1g tylenol and 2L NS.
Vitals prior to transfer were: 98.5 72 128/68 18 99% RA
Upon arrival to the floor, the patient repoted severe pain in
his left lower extremity.
He denies any change in urinary frequency, dysuria or increased
pain over his graft.
REVIEW OF SYSTEMS:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
-ESRD ___ Alport Syndrome now s/p Renal Transplant ___
-Atrial fibrillation on apixaban
-Pacemaker placement, indication unclear; may be for bradycardia
-Left total knee replacement x4
-Multiple knee revisions (TKR > removal with spacer > removal
-with a new spacer > TKR)
-MRSA bacteremia with PICC line infection; treated with
vancomcyin
-T6 spinal tumor, benign, s/p removal (present since birth, per
patient) and spinal fusion surgery
-OSA on CPAP
-Anal carcinoma s/p XRT now in remission
Social History:
___
Family History:
Mother carrier of ___ syndrome.
Brother with ESRD secondary to HTN, also s/p LRRT (mother).
Sister without medical problems.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T 98.4, BP 112/80, HR 96, RR 18, 100%RA.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding; no tenderness over
graft
GU: No foley
Ext: left knee is edematous and warm to the touch; no erythemal
decreased range of motion; 2+ DP pulses
Neuro: CNII-XII intact, moves all extremities
DISCHARGE PHYSICAL EXAM:
Vitals: Tm 98.0, 114-139/81-91, 60-67, 18, 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: Supple, JVP not elevated, no LAD
CV: RRR, 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; no tenderness over
graft
Back: no spinal tenderness
Ext: left knee wrapped. Dec tenderness, Inc range of motion; 2+
DP pulses
Pertinent Results:
ADMISSION LABS:
___ 05:30PM BLOOD WBC-16.8* RBC-4.14* Hgb-12.4* Hct-37.6*
MCV-91 MCH-30.0 MCHC-33.0 RDW-14.1 RDWSD-47.4* Plt ___
___ 05:30PM BLOOD ___ PTT-32.0 ___
___ 05:30PM BLOOD Glucose-95 UreaN-28* Creat-2.1* Na-135
K-3.7 Cl-101 HCO3-21* AnGap-17
___ 05:30PM BLOOD CK-MB-<1 cTropnT-<0.01
___ 05:30PM BLOOD rapmycn-4.1*
___ 05:35PM URINE Blood-TR Nitrite-NEG Protein-100
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 05:35PM URINE RBC-7* WBC-5 Bacteri-NONE Yeast-NONE
Epi-<1
___ 05:35PM URINE Hours-RANDOM Creat-182 Na-10 K-42 Cl-18
TotProt-107 Prot/Cr-0.6*
___ 05:30PM JOINT FLUID ___ RBC-6556* Polys-94*
___ Macro-4
DISCHARGE LABS:
___ 06:28AM BLOOD WBC-8.1 RBC-3.57* Hgb-10.6* Hct-32.5*
MCV-91 MCH-29.7 MCHC-32.6 RDW-14.0 RDWSD-46.7* Plt ___
___ 06:28AM BLOOD Glucose-92 UreaN-20 Creat-1.4* Na-138
K-3.9 Cl-100 HCO3-27 AnGap-15
___ 06:28AM BLOOD CRP-68.7*
___ 06:28AM BLOOD ___ 07:02PM OTHER BODY
FLUID ___ RBC-1500* Polys-97* Lymphs-1* ___ Macro-2*
MICROBIOLOGY:
___ 5:35 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN-------------<=0.25 S
TRIMETHOPRIM/SULFA---- <=0.5 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
IMAGING:
RENAL U/S (___): Normal renal transplant ultrasound. A few
small simple cysts in the
transplant kidney, measure up to 1.4 cm.
___ xray (___): No evidence of fracture, or periprosthetic
loosening.
TTE (___): The left atrium is mildly dilated. The right atrium
is moderately dilated. No atrial septal defect is seen by 2D or
color Doppler. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). No
masses or thrombi are seen in the left ventricle. There is no
ventricular septal defect. Right ventricular chamber size and
free wall motion are normal. The aortic root is mildly dilated
at the sinus level. The ascending aorta is mildly dilated. The
aortic valve leaflets (3) are mildly thickened but aortic
stenosis is not present. No masses or vegetations are seen on
the aortic valve. No aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. No mass or vegetation is
seen on the mitral valve. Mild (1+) mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is mild pulmonary artery systolic hypertension. There is no
pericardial effusion.
TEE (___): No evidence of valvular or pacer lead endocarditis.
Central Line Placement (___): Successful placement of a single
lumen 5 ___ PowerLine tunneled catheter via the right
internal jugular venous approach. The tip of the catheter
terminates in the right atrium. The catheter is ready for use.
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: ___ year old man with Alport's syndrome presents with increased
creatinine from baseline. Evaluate blood flow to the renal transplant.
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: None.
FINDINGS:
The right iliac fossa transplant renal morphology is normal. Specifically,
the cortex is of normal thickness and echogenicity, pyramids are normal, there
is no urothelial thickening, and renal sinus fat is normal. There is no
hydronephrosis and no perinephric fluid collection. There are a few small
simple cysts with the transplant kidney, the largest measuring 1.4 x 1.2 x 1.0
cm in the upper pole.
The resistive index of intrarenal arteries ranges from 0.73 to 0.79, 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 69 cm/second. Vascularity is symmetric throughout transplant. The
transplant renal vein is patent and shows normal waveform.
The bladder is mildly distended and within normal limits.
IMPRESSION:
Normal renal transplant ultrasound. A few small simple cysts in the
transplant kidney, measure up to 1.4 cm.
Radiology Report
EXAMINATION: FEMUR (AP AND LAT) LEFT
INDICATION: History of left knee septic arthritis. Please evaluate for
fracture.
TECHNIQUE: Frontal view of the left hip, two views of the left knee, two
views of the left ankle.
COMPARISON: Outside hospital study from 09:00.
FINDINGS:
The patient is status post total knee replacement. There is no evidence of
fracture, or periprosthetic loosening. No ankle fractures are identified.
The mortise is well preserved. There is a small suprapatellar joint effusion.
IMPRESSION:
No evidence of fracture, or periprosthetic loosening.
Radiology Report
EXAMINATION: KNEE (2 VIEWS) LEFT
INDICATION: ___ year old man with L TKR I D, liner exchange // please include
full implant (distal femur, proximal tibia) please include full implant
(distal femur, proximal tibia)
TECHNIQUE: 5 images of the left knee.
COMPARISON: No prior study for comparison.
FINDINGS:
Patient is status post total left knee arthroplasty. Alignment is anatomic.
Soft tissue edema is noted overlying the knee joint. Air is seen within the
suprapatellar recess. No evidence of fracture.
IMPRESSION:
Status post total right knee arthroplasty with recent I&D and liner exchange.
Expected soft tissue postsurgical changes are seen.
Radiology Report
EXAMINATION: VENOUS MAPPING FOR DIALYSIS ACCESS
INDICATION: ___ year old man with ESRD s/p kidney transplant. Needs PICC and
selection for IV access, possible fistula planning // fistual planning and
PICC line selection
TECHNIQUE: Real-time grayscale and Doppler ultrasound imaging of both
cephalic veins, radial artery, brachial artery, basilic vein and subclavian
veins was performed.
COMPARISON: None.
FINDINGS:
RIGHT:
The cephalic vein measures from 0.08 to 0.14 cm. The basilic vein measures
from 0.08 to 0.34 cm.
The radial artery measures 0.26 cm. The brachial artery measures 0.48 cm. No
arterial calcifications are present.
LEFT:
The cephalic vein measures from 0.08 to 0.14 cm. The basilic vein measures
from 0.10 to 0.55 cm.
The radial artery measures 0.08 cm. The brachial artery measures 0.54 cm. No
arterial calcifications are present.
The subclavian veins have normal and symmetric phasicity.
IMPRESSION:
Cephalic and basilic vein diameters as above. No arterial calcifications
identified.
Radiology Report
INDICATION: ___ with history of multiple L TKR and revisions complicated by
MRSA bacteremia also with ESRD now s/p LRRT presenting with MSSA septic
prosthetic joint and bacteremia now s/p I D, ___. Needs IV access for
outpatient IV antibiotics. Given patient's history of renal transplant with
question of dialysis in the future, a PICC line was deferred and a tunneled
line was placed instead.
COMPARISON: None
TECHNIQUE: OPERATORS: Dr. ___, Interventional Radiology Fellow and Dr.
___, attending radiologist performed the procedure. Dr. ___
___ personally supervised the trainee during the key components of the
procedure and has reviewed and agrees with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
25 mcg of fentanyl and 0.5 mg of midazolam throughout the total intra-service
time of 15 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.
FLUOROSCOPY TIME AND DOSE: 0.8 min, 3 mGy
PROCEDURE:
1. Tunneled non-dialysis line placement
PROCEDURE DETAILS: Following the explanation of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The access site was prepped and draped in the usual sterile fashion.
Under continuous ultrasound guidance, the patent right internal jugular vein
was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and a short ___ wire was
advanced to make appropriate measurements for catheter length. The ___ wire
was then passed distally into the IVC.
Next, attention was turned towards creation of a tunnel over the upper
anterior chest wall. After instilling superficial and deeper local anesthesia
using lidocaine mixed with epinephrine, a small skin incision was made at the
tunnel entry site. A 5 ___ power line 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. 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 each lumen was capped. The catheter was sutured in
place with 0 silk sutures. ___ subcuticular Vicryl sutures were used to close
the venotomy incision site. Steri-Strips were applied. Sterile dressings were
applied. The patient tolerated the procedure well.
FINDINGS:
Patent right internal jugular vein. Final fluoroscopic image showing right
internal jugular approach 5 ___ power line catheter with tip terminating in
the right atrium.
IMPRESSION:
Successful placement of a single lumen 5 ___ PowerLine tunneled catheter
via the right internal jugular venous approach. The tip of the catheter
terminates in the right atrium. The catheter is ready for use.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Knee pain, Transfer
Diagnosed with PYOGEN ARTHRITIS-LOWER LEG, KIDNEY TRANSPLANT STATUS
temperature: 98.6
heartrate: 82.0
resprate: 16.0
o2sat: 98.0
sbp: 118.0
dbp: 69.0
level of pain: 5
level of acuity: 3.0 | ___ with history of multiple L TKR and revisions complicated by
MRSA bacteremia also with ESRD now s/p LRRT presenting with MSSA
septic prosthetic joint and bacteremia now s/p I&D. Course was
complicated by ___.
# SEPTIC PROSTHETIC JOINT/SEPSIS: Joint arthrocentesis WBC >100K
with PMN predominance. Negative crystals. Gram stain was
negative, but grew MSSA in joint and blood. In this patient with
a history of MRSA bacteremia, he was initially treated with
vancomycin/cefazolin for MRSA/MSSA coverage, and was
transitioned to cefazolin when his cultures grew MSSA. Patient
underwent TTE/TEE which were negative for endocarditis. There
was initial concern for seeding of his ortho back hardware and
pacemaker, but TEE and physical exam alleviated these concerns.
His CRP downtrended during hospitalization. He was followed by
Ortho, had joint washout and replacement of liner on ___. He was
followed by ID during hospitalization and planned for 6 weeks of
IV cefazolin (ending ___ All Bcx since those taken in the ED
have been negative. Pt underwent vein mapping ___ to kidney
transplant and poor general access, it showed poor venous access
in the upper extremities b/l, with better access on the Lt UE
that is being preserved in case the patient will require a
fistula for HD. ___ was c/s for PICC placement, they were
concerned about future venous access issues in the Rt UE as
well, so they placed a tunneled central line on ___. ID desired
Rifampin on discharge for better biofilm clearance, but since
patient required Tacrolimus for immunosuppression of his kidney
transplant, due to drug interactions, he will have to wait until
he is switched back to Rapamycin to start Rifampin. ID
recommends 6 months of PO Levaquin and Rifampin after 6 weeks IV
Cefazolin to avoid lifelong suppressive Abx therapy. Pt will f/u
at ___ for ID & Ortho and has OPAT weekly labs. ID will
contact ___ IV team over eventual DC of pt's tunneled central
line when it is no longer needed.
# ESRD s/p RENAL TRANSPLANT: Pt's initial renal transplant U/S
was normal. There was never any tenderness over his graft to
suggest infection. Pt was originally on Rapamycin and
Prednisone for suppression, he was switched to Tacrolimus ___ to
better wound healing after surgery. Tacro levels have been high
during his stay as Renal attempted to optimize his dosing (goal
tacro levels of ___, he is being discharged on 0.5 mg tacro BID
and prednisone 5mg daily. He will f/u with Renal Transplant at
___. Patient will likely need to be transitioned back to
rapamycin in the future.
# ACUTE KIDNEY INJURY: Patient presented with Cr 2.1. Pt's ___
was likely pre-renal given his history of poor PO intake and
labs showing urine sodium < 10, FeNa < 1% and urine osmoles >
500. However, the pt did have mildly active urine sediment with
proteinuria, few RBCs and few WBCs. Renal transplant ultrasound
was normal. Pt's Cr slowly improved to baseline over his
admission (baseline around 1.4-1.7). Cr on discharge 1.4.
Nephrotoxins were avoided and medications were renally dosed
over his admission.
# ATRIAL FIBRILLATION: Pt is on his home metoprolol and
apixaban. Apixaban was held briefly in the setting of his joint
I&D, and was restarted after his surgery
# NORMOCYTIC ANEMIA: His anemia is likely secondary to acute
illness, however there are no priors in ___ system. H&H has
been stable over the admission.
# OSA: Pt wears CPAP o/n w/o issue. No SOB or chest pain
overnight while wearing CPAP. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Tetracycline Analogues /
Iodine / Shellfish / Ace Inhibitors / Ciprofloxacin / Nsaids /
Prednisone / IV Dye, Iodine Containing / Cortisone
Attending: ___.
Chief Complaint:
chest pressure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ male with h/o CAD s/p MI and 5 stents and 7
angioplasties, HTN, HL and mitochondrial disease who presented
from home today after two days of intermittent chest pain and
pressure. Yesterday, pt had sudden onset substernal chest pain
that lasted for about 1.5 hours. It was assoc with nausea and
heaving. Today, pt felt weak and dehydrated. He called his PCP
who recommended that he come to the Emergency Department for
work-up. Of note, patient is to undergo biopsies of tumors in
his legs and has been off Plavix for 5 days. The patient also
has mitochondrial disease that requires him to have regular IV
infusions secondary to dehydration.
.
In ED, inital VS were 98.2 89 150/94 20 98%. When he arrived,
his chest pain returned, and he was diaphoretic and short of
breath. His pain then come down to ___. Labs were remarkable
for Cr 1.5 (baseline 1.2-1.4). Troponin negative X1. EKG showed
sinus rhythm, ST depressions (1mm) laterally. CXR shows no acute
process. Pt was given IVFs, nitroglycerin SL, ASA 325, morphine,
zofran in ED. Vitals on transfer were 88, 160/66, 20, 100 RA,
98.5.
.
On arrival to the floor, pt appears comfortable in bed. Pt
states he is currently chest pain free. Admits to some residual
nausea, but no vomiting. Pt does complain of fatigue, states he
feels like he was "beaten up". Denies fevers. States he was
dizzy when getting up and feels his mouth is dry.
.
Review of systems:
(+) Per HPI
(-) Denies recent weight loss or gain. Denies headache, sinus
tenderness, rhinorrhea or congestion. Denied cough. Denies
diarrhea, constipation or abdominal pain. No recent change in
bowel or bladder habits. No dysuria. Denied arthralgias or
myalgias.
Past Medical History:
- CARDIAC HISTORY: CAD s/p mult PCIs, proximal LAD stenting in
___ on ___, 2.5 x 15-mm pixel stent to the mid
LAD on ___ angioplasty to OM3 on ___
angioplasty to S1 on ___ PCI in ___ in ___ where PDA was 70% stenosed with no intervention; report of
cath ___ in ___ w/o intervention
- Mitochondrial myopathy, resulting in abnormal oxygen
transport
- Hypogammaglobinemia requiring regular IVIG
- HTN
- HL
- Low IgG
- Interstitial Cystitis
- Orthostatic hypotension requiring frequent IVF infusions
- GERD
- s/p TURP x2 (in ___ and ___.
- s/p left wrist reconstruction, ulnar nerve reconstruction
- s/p cholecystectomy ___
- h/o cardiac arrest under general anesthesia
- multiple infections, including 2x MRSA infections ___ years
ago and C.dif colitis
- >50% hearing loss bilaterally secondary to mitochondrial
disease
- squamous cell carcinoma on L leg s/p resection ___ years ago
- congenital spinal stenosis, multilevel degenerative disc dz
Social History:
___
Family History:
Father had MI at ___, died at ___. Mother had MI at ___, lived
until ___; no history of mitochondrial disease. Younger brother,
___, alive and well. Son,___, has asthma.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 97.8 BP 146/89 HR 56 RR 16 O2 sat 96% RA
GA: AOx3, NAD
HEENT: PERRLA. dry mucous membranes. no LAD. no JVD. neck
supple.
Cards: RRR S1/S2 heard. no murmurs/gallops/rubs.
Pulm: CTAB no crackles or wheezes
Abd: soft, distended, NT, +BS. neg HSM. neg ___ sign. no
fluid waves.
Extremities: wwp, no edema. 2cm sized masses in left thigh,
+ttp.
Skin: no bruises, rashes
Neuro/Psych: CNs II-XII intact. ___ strength in U/L extremities.
sensation intact. gait deferred.
.
DISCHARGE PHYSICAL EXAM:
VS: 98.6 137/86 58 16 97%RA
I/O: 1120/550
Tele: sinus ___, no events
GA: AOx3, NAD
HEENT: PERRL. Moist mucous membranes. No LAD. No JVD. Neck
supple. No carotid bruits.
Lungs CTAB
CV: RRR, normal S1/S2, no murmurs/gallops/rubs.
Abd: Soft, protuberant. TTP in RUQ (pt reports this is
chronic), normoactive bowel sounds. No HSM.
Extremities: WWP, trace pedal edema, 2cm sized masses in left
thigh, +ttp.
Skin: no rashes
Neuro/Psych: CNs II-XII intact. ___ strength in U/L extremities.
Sensation equal and intact. Gait deferred.
Pertinent Results:
ADMISSION LABS:
___ 01:00PM BLOOD WBC-6.6 RBC-4.87 Hgb-14.1 Hct-42.4 MCV-87
MCH-28.8 MCHC-33.2 RDW-13.8 Plt ___
___ 01:00PM BLOOD ___ PTT-22.0 ___
___ 01:00PM BLOOD Glucose-145* UreaN-28* Creat-1.5* Na-142
K-3.9 Cl-107 HCO3-26 AnGap-13
___ 01:00PM BLOOD cTropnT-<0.01
.
RELEVANT LABS:
___ 07:31PM BLOOD cTropnT-<0.01
___ 12:55AM BLOOD CK-MB-2 cTropnT-<0.01
___ 08:40AM BLOOD CK-MB-2 cTropnT-<0.01
.
DISCHARGE LABS:
___ 12:55AM BLOOD ALT-18 AST-22 CK(CPK)-57 AlkPhos-70
TotBili-0.3
___ 08:40AM BLOOD WBC-4.5 RBC-4.63 Hgb-13.4* Hct-40.1
MCV-87 MCH-29.0 MCHC-33.4 RDW-13.5 Plt ___
___ 08:40AM BLOOD Glucose-90 UreaN-18 Creat-1.2 Na-143
K-4.0 Cl-113* HCO3-24 AnGap-10
___ 08:40AM BLOOD Calcium-7.6* Phos-2.9 Mg-1.9
.
Exercise Stress/Echo ___:
Left Ventricle - Ejection Fraction: >= 60%
Aortic Valve - Peak Velocity: 1.0 m/sec
Mitral Valve - E Wave: 0.4 m/sec
Mitral Valve - A Wave: 0.6 m/sec
Mitral Valve - E/A ratio: 0.67
Mitral Valve - E Wave deceleration time: *313 ms
___ patient exercised for 13 minutes and 17 seconds according to
a Gervino treadmill protocol ___ METS) reaching a peak heart rate
of 110 bpm and a peak blood pressure of 158/78 mmHg. The test
was stopped because of fatigue. This level of exercise
represents an average exercise tolerance for age. In response to
stress, the ECG showed non-diagnostic ST changes (see exercise
report for details). There were normal blood pressure and heart
rate responses to stress.
.
Resting images were acquired at a heart rate of 54 bpm and a
blood pressure of 120/82 mmHg. These demonstrated normal
regional and global left ventricular systolic function. Doppler
demonstrated no aortic stenosis, aortic regurgitation or
significant mitral regurgitation or resting LVOT gradient.
Echo images were acquired within 69 seconds after peak stress at
heart rates of 96 - 80 bpm. These demonstrated appropriate
augmentation of all left ventricular segments with slight
decrease in cavity size.
.
IMPRESSION: Average functional exercise capacity. No 2D
echocardiographic evidence of inducible ischemia to achieved
workload.
.
Chest x-ray ___:
FINDINGS: Portable AP upright chest radiograph is obtained.
Lungs are clear
bilaterally. No signs of pneumonia or CHF. No pleural effusion
or
pneumothorax. Cardiomediastinal silhouette is stable. Bony
structures are
intact. No free air below the right hemidiaphragm.
IMPRESSION: No acute intrathoracic process.
Medications on Admission:
atorvastatin [Lipitor] 20 mg Tablet daily
clopidogrel [Plavix] 75 mg Tablet daily (held for 5 days,
restarted yesterday when he had CP)
esomeprazole 40 mg Capsule, Delayed Release(E.C.) BID
ezetimibe [Zetia] 10 mg Qdaily
intravenous Fluids 2L NS infusion/2 hours/3 x per week
metoprolol succinate 25 mg Er BID
ranolazine 500 mg ER BID
valsartan 160 mg BID
aspirin 81 mg Tablet, Delayed Release (E.C.) BID
polyethylene glycol daily as needed for constipation
sodium phosphate enema 19 gram-7 gram/118 mL rectally ___
Discharge Medications:
1. atorvastatin 20 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. clopidogrel 75 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. esomeprazole magnesium 40 mg Capsule, Delayed Release(E.C.)
Sig: One (1) Capsule, Delayed Release(E.C.) PO BID (2 times a
day).
4. ezetimibe 10 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. metoprolol succinate 25 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO BID (2 times a day).
6. ranolazine 500 mg Tablet Extended Release 12 hr Sig: One (1)
Tablet Extended Release 12 hr PO BID (2 times a day).
7. valsartan 160 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
8. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO twice a day.
9. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) PO once a day as needed for constipation.
Discharge Disposition:
Home
Discharge Diagnosis:
Mitochondrial Myopathy
Coronary Artery Disease
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 ___
___.
CLINICAL HISTORY: CHF, pneumonia.
FINDINGS: Portable AP upright chest radiograph is obtained. Lungs are clear
bilaterally. No signs of pneumonia or CHF. No pleural effusion or
pneumothorax. Cardiomediastinal silhouette is stable. Bony structures are
intact. No free air below the right hemidiaphragm.
IMPRESSION: No acute intrathoracic process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: C/P
Diagnosed with DEHYDRATION, CHEST PAIN NOS
temperature: 98.2
heartrate: 89.0
resprate: 20.0
o2sat: 98.0
sbp: 150.0
dbp: 94.0
level of pain: 6
level of acuity: 2.0 | Mr. ___ is a ___ year old gentleman with ___ CAD s/p MI with 7
angioplasties and 5 stents, HTN, HLD, mitochondrial disease,
admitted with intermittent episodes of chest pressure, with no
EKG changes and three negative sets of cardiac enzymes.
.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Allergies/ADRs on File
Attending: ___.
Chief Complaint:
s/p assault
Major Surgical or Invasive Procedure:
___ craniotomy for ___ evacuation
History of Present Illness:
HPI: Patient is a ___ year old woman who was transferred to ___
from an OSH for a left Subdural Hematoma. Per report she was
assaulted by a punch in the head and then fell striking her head
on the pavement. She initially lost consciousness but was awake
alert and oriented on scene and during transport to the OSH.
While there a CT head was done which showed a acute left
subdural
hematoma with midline shift. As a result of this it was
determined she would be transferred to ___ for further care by
Medflight. Upon medflight arrival she was intubated for airway
protection in the setting of bradycardia.
Past Medical History:
Unknown
Social History:
___
Family History:
Unknown
Physical Exam:
Gen: WD/WN, intubated.
HEENT: Pupils: equal in size, Left ___, right minimally reacts
and 3mm
Neck: Supple.
Lungs: CTA bilaterally.
Cardiac: RRR. S1/S2.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
Neuro:
Mental status: intubated, no commands, no eye opening
Orientation: intubated
Language: intubated
Cranial Nerves:
I: Not tested
II: Pupils equal size 3mm, left reacts ___ right minimally
reacts
III-XII: unable to assess
Motor: Localizes BUE, withdraws BLE
Sensation: unable to adequately assess
Reflexes:
cough/gag/corneals positive
Toes upgoing bilaterally
Coordination: unable to assess
Discharge exam:
Patient is alert and oriented to person, place and time, pupils
equaly and reactive to light, EOMI, L ptosis, tongue midline,
strength full ___ bilaterally.
Pertinent Results:
CT: CT Head ___ 0116
1. Slight interval increase in size of the left cerebral
subdural
hematoma. There is also likely a small component of
subarachnoid
blood, particularly on the right (2, 14). No new focal
hemorrhage. 2. Slight increase in mass effect with up to 10 mm
of
rightward shift of the midline structures and increased
compression of the left lateral ventricle. There is persistent
effacement of the basal cisterns, worrisome for uncal
herniation.
3. Slight increase in the prominence of the right lateral
ventricle. This may represent early entrapment. Close follow-up
is recommended.
___ ___ F ___ ___
Cardiovascular Report ECG Study Date of ___ 12:51:46 AM
Sinus bradycardia with sinus arrhythmia. Borderline
atrio-ventricular
conduction delay. Q-T interval prolongation with prominent U
waves concerning for hypokalemia. Clinical correlation is
suggested. Non-diagnostic Q waves inferiorly. No previous
tracing available for comparison.
Read by: ___.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
49 198 90 528/___ 60 59 44
Radiology Report CHEST (PORTABLE AP) Study Date of ___ 1:00
AM
IMPRESSION:
1. Enteric tube with the tip in the esophagus.
2. Endotracheal tube in satisfactory position.
3. Opacity at the right base is most likely atelectasis.
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
8:39 AM
IMPRESSION: Postoperative changes with a decrease in shift of
the midline
structures, now 3 mm to the right, and improved patency of the
basal cisterns.
Cardiovascular Report ECG Study Date of ___ 6:39:56 AM
Profound sinus bradycardia with junctional escape beats.
Prolonged computed
Q-T interval. Delayed anterior R wave progression in leads V1-V3
of uncertain
significance, but prior anteroseptal myocardial infarction
cannot be excluded.
Compared to the previous tracing of ___, the rate is even
more bradycardic
with more junctional escape beats with retrograde P waves.
Prominent U waves
are again seen. Hypokalemia cannot be excluded. Clinical
correlation is
suggested.
Read by: ___
Intervals Axes
Rate PR QRS QT/QTc P QRS T
38 ___
Radiology Report CT HEAD W/O CONTRAST Study Date of ___
5:44 ___
IMPRESSION:
Status post left parietal craniotomy with postoperative changes.
No new
hemorrhage or mass effect.
___ ___ ___ ___
Cardiovascular Report ECG Study Date of ___ 9:22:10 AM
Sinus bradycardia. Compared to the previous tracing of ___
the rate has
increased. The Q-T interval has normalized.
TRACING #1
Read by: ___
Intervals Axes
Rate PR QRS QT/QTc P QRS T
66 150 78 ___ 15 39 31
Radiology Report CHEST (PA & LAT) Study Date of ___ 11:40
AM
Final Report
HISTORY: Productive cough.
FINDINGS: In comparison with the study of ___, the
endotracheal and
nasogastric tubes have been removed. Right IJ catheter again
extends to the mid-to-lower portion of the SVC. A relatively
vertical area of opacification in the left base medially most
likely reflects atelectatic changes. No definite acute focal
pneumonia.
___ ___ ___ ___
Cardiovascular Report ECG Study Date of ___ 7:49:30 AM
Sinus rhythm. Borderline prolonged Q-T interval. Compared to the
previous
tracing the Q-T interval has increased slightly.
TRACING #2
Read by: ___
Intervals Axes
Rate PR QRS QT/QTc P QRS T
67 158 78 458/470 41 47 33
___ ECHOCARDIOGRAPHY REPORT
___ ___ MRN: ___ Portable TTE
(Complete) Done ___ at 5:51:53 ___ FINAL
Conclusions
The left atrium and right atrium are normal in cavity size.
There is mild symmetric left ventricular hypertrophy with normal
cavity size and regional/global systolic function (LVEF>55%).
The estimated cardiac index is normal (>=2.5L/min/m2). Right
ventricular chamber size and free wall motion are normal. The
aortic valve leaflets (3) appear structurally normal with good
leaflet excursion and no aortic stenosis. Mild (1+) aortic
regurgitation is seen. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. The estimated pulmonary artery systolic pressure
is high normal. There is no pericardial effusion.
IMPRESSION: Mild aortic regurgitation with normal valve
morphology. Mild symmetric left ventricular hypertrophy with
preserved regional and global biventricular systolic function.
Medications on Admission:
Unknown
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN fever/pain
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN wheezing
3. Bisacodyl 10 mg PO/PR DAILY
4. Docusate Sodium 100 mg PO BID
5. Heparin 5000 UNIT SC TID
6. HydrALAzine ___ mg IV Q6H:PRN SBP>160
7. HYDROmorphone (Dilaudid) ___ mg PO Q8H:PRN headache
8. LeVETiracetam 500 mg PO BID
9. Methadone 40 mg PO DAILY
10. Nicotine Patch 14 mg TD DAILY
11. Senna 1 TAB PO BID
12. Sodium Chloride 0.9% Flush 3 mL IV Q8H and PRN, line flush
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Subdural hematoma
Methadone for withdrawal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance.
Followup Instructions:
___
Radiology Report
INDICATION: Intracranial hemorrhage. Evaluate endotracheal tube.
COMPARISONS: None.
TECHNIQUE: A single supine AP view of the chest was obtained.
FINDINGS: An endotracheal tube is in satisfactory position, approximately 4
cm from the carina. An enteric tube is present with the tip in the distal
esophagus. There is a consolidation at the right medial base. The lungs are
otherwise clear. There is no pulmonary edema, pleural effusion, or
pneumothorax. The cardiomediastinal silhouette is normal.
IMPRESSION:
1. Enteric tube with the tip in the esophagus.
2. Endotracheal tube in satisfactory position.
3. Opacity at the right base is most likely atelectasis.
Results were discussed with Dr. ___ at 5:45 a.m. on ___ via telephone
by Dr. ___ at the time the findings were discovered.
Radiology Report
INDICATION: Known subdural hematoma with a cushingoid reflex. Evaluate for
interval change.
COMPARISONS: CT of the head obtained at an outside hospital from ___.
TECHNIQUE: Contagious axial MDCT images were obtained through the brain
without the administration of IV contrast. Sagittal, coronal and thin section
bone reformatted images were obtained and reviewed.
FINDINGS: There is a hyperdense subdural hematoma layering along the left
cerebral convexity measuring up to 10 mm in width (2, 16). In comparison to
the prior exam obtained approximately three hours earlier, it is slightly
increased in size. It previously measured approximately 7 mm in width at a
similar location. Additionally, there is likely a component of some
subarachnoid hemorrhage, particularly on the right (2, 14). There is no new
focal hemorrhage. There is a slight interval increase in the mass effect with
approximately 10 mm of rightward shift of the normal midline structures and
increased compression of the left lateral ventricle. The right lateral
ventricle may be very slightly increased in size, particularly in the frontal
and temporal horns. The third ventricle, fourth ventricle and basal cisterns
remain effaced, consistent with uncal herniation. This does not appear
significantly changed from the prior exam. There is no evidence of tonsillar
herniation.
No fracture is identified. The visualized paranasal sinuses, mastoid air
cells and middle ear cavities are clear. The soft tissues are unremarkable.
IMPRESSION:
1. Slight interval increase in size of the left cerebral subdural hematoma.
There is likely a small component of subarachnoid hemorrhage, particularly on
the right (2, 41).
2. Increasing mass effect with up to 10 mm of rightward shift of the normal
midline structures and increased compression of the left lateral ventricle.
There is persistent effacement of the basilar cisterns, concerning for uncal
herniation.
3. Slight interval increase in prominence of the right lateral ventricle.
This may represent early entrapment. Close followup is recommended.
Radiology Report
INDICATION: Evaluate new central line placement.
COMPARISONS: Chest radiograph from ___ at 00:57.
TECHNIQUE: A single semi-upright AP view of the chest was obtained.
FINDINGS: The endotracheal tube is in satisfactory position, 4 cm from the
carina. An enteric tube in unchanged position with the tip in the distal
esophagus. A new right internal jugular central venous catheter is present
with the tip in the mid SVC.
The opacity in the right medial base is improved. There is no new opacity,
pulmonary edema, pleural effusion, or pneumothorax. The cardiomediastinal
silhouette is normal.
IMPRESSION:
1. Satisfactory position of the new right internal jugular central venous
catheter. No evidence of pneumothorax.
2. Unchanged position of the enteric tube with the tip in the distal
esophagus.
3. Improving right basilar consolidation, which is likely atelectasis.
Radiology Report
HISTORY: ___ woman with new line status post crani, evaluate line
placement.
TECHNIQUE: Portable semi-supine chest radiograph was obtained.
COMPARISON: Chest radiograph from ___.
FINDINGS:
Right central venous line ends in the lower SVC, and the ET tube is in
appropriate position. Nasogastric tube ends in the body of stomach with the
sideport near the GE junction below the diaphragm. Heart size is normal, and
the lungs are clear of focal consolidation, effusion or pulmonary edema. The
mediastinal and hilar contours are normal.
IMPRESSION:
Gastric tube ends in the body of stomach with side port near the GE junction
below the diaphragm.
Radiology Report
HISTORY: Left subdural hematoma status post craniotomy for evacuation.
TECHNIQUE: Continuous axial sections were acquired through the brain without
the administration IV contrast. Coronal and sagittal reformations were
provided and reviewed.
DLP: 891.93 mGy/cm.
COMPARISON: Head CT ___ at 1:16.
FINDINGS: The patient is status post a left parietal craniotomy for evacuation
of a subdural hematoma. There are expected postoperative changes including
pneumocephalus and subcutaneous air. The degree of midline shift has
decreased, now 3 mm and previously 10 mm. The degree of crowding of the basal
cisterns has improved. There is decreased compression upon the left lateral
ventricle and the temporal horn of the right lateral ventricle is normal in
size.
There is no new hemorrhage or edema. There is no evidence for an acute
territorial vascular infarction. The imaged paranasal sinuses are well
aerated.
IMPRESSION: Postoperative changes with a decrease in shift of the midline
structures, now 3 mm to the right, and improved patency of the basal cisterns.
Radiology Report
HISTORY: History of subdural hemorrhage status post left craniotomy for
evacuation with increasing headaches. Please evaluate for interval changes.
TECHNIQUE: MDCT axial imaging was obtained through the brain without the
administration of intravenous contrast material.
DLP: 891.9 mGy-cm.
D LP: 53.9 mGy-cm.
COMPARISON: CT head without contrast from ___.
FINDINGS:
The patient is status post left parietal craniotomy for evacuation of a
subdural hematoma. There are expected postoperative changes with
pneumocephalus and air in the soft tissues overlying the scalp. There is a
small amount of fluid in the subdural space, new since the prior study. 3 mm
rightward shift of the normally midline structures is stable. There is no new
mass effect, new intracranial hemorrhage or large territorial infarction. The
visualized paranasal sinuses, mastoid air cells and middle ear cavities are
clear.
IMPRESSION:
Status post left parietal craniotomy with postoperative changes. No new
hemorrhage or mass effect.
Radiology Report
HISTORY: Productive cough.
FINDINGS: In comparison with the study of ___, the endotracheal and
nasogastric tubes have been removed. Right IJ catheter again extends to the
mid-to-lower portion of the SVC. A relatively vertical area of opacification
in the left base medially most likely reflects atelectatic changes. No
definite acute focal pneumonia.
Gender: F
Race: UNKNOWN
Arrive by UNKNOWN
Chief complaint: ICH
Diagnosed with SUBDURAL HEMORRHAGE, OTHER SYMPTOMS INVOLVING NERVOUS AND MUSCULOSKELETAL SYSTEM
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Mrs. ___ is a ___ year old female who was punched on the side
of her head and fell striking her head on the ground. A stat
head CT was obtained after arriving at ___ and showed a left
SDH with an 8mm MLS and poor exam. She was emergently brought to
the OR for a craniotomy for evacuation of her SDH. She was
brought to the neuro ICU for recovery, on post op exam she was
moving all extremities and following commands. She was extubated
and placed on nasal cannula. She was very agitated post
extubation and c/o pain, she was restarted on her methadone and
prn morphine.
On ___, she was awake and pleaseant this morning. Overnight she
had several episodes of trainsiently bradycardia down to the
20's with loss of her blood pressure, but spotaneously self
resolved. Since admission her heart rate as been in the 40's to
50's. Cardiology was consulted and reccomended discontinuing her
Methadone since it could cause QTC prolongation. Cardiology
expects heart rate to improve over the next several days. Later
in the afternoon she complained of severe headaches, dilaudid,
fentanyl and tylenol were given with no relief. A stat head CT
was obtained and it showed a small hyperdensity on the left
crani site with improved pneumocephalus and stable MLS. Chronic
pain is also following patient for pain and methadone
management.
On ___, on exam, L periorbital edema was resolved and she was
seen to have a L ptosis, but was otherwise intact. Ophthalmology
was consulted to rule out orbital injury from trauma and they
felt there was no acute itnervention that was required and
recommended outpatient followup. She was restarted on her
methadone at a lower dose after a stable EKG.
On ___ she remaiend stable and continued to have a elft ptosis.
She was trasnferred to the floor with telemetry and her
methadone was again decreased.
On ___ the chronic pain service was consulted. They recommended
decreasing the Methadone to 80mg daily. An EKG was ordered to
assess QTC interval. The EKG was reviewed by the cardiology
service who recommended discontinuing the methadone because of
increased QTC interval to .48. The Valium was discontinued and
the Methadone was changed to 60mg daily. A PICC line was ordered
due to the bradycardia and potential need for medication access.
On ___, The patients QTC was improved at .46. The patient serum
magnesium was low and repleated with 2 gm Magnesium sulfate. The
chronic pain service consulted and continued to have bradycardia
with heart rate at ___ when sleeping. Chronic pain service
recommended decreasing the methadone to 40 mg po qd and changing
the Dilaudid dosing to ___ mg po q 8 hours. and to repeat the
EKG the following morning. The patient had an ECHO which showed
mild aortic regurgitation with normal valve morphology as well
as mild symmetric left ventricular hypertrophy with preserved
regional and global biventricular systolic function.
On ___, The EKG QTC was stable. Chronic pain felt that the QTC
was stable and her pain/withdrawal was well controlled. She was
discharged to rehabilitation. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Depakote
Attending: ___.
Chief Complaint:
increased seizure frequency
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ yo man with a history of seizures after TBI
(gunshot wound in ___, followed by Dr. ___, who
presents for increased seizure frequency.
The patient is not accompanied by caregivers. ___ history ___
provides is that ___ has a lot of seizures every month. ___ says
that his caregivers give him his medications every day, but
sometimes ___ does not take them. When asked if this happened
today, ___ states yes - that ___ was too busy to take his
medications.
The rest of the history is per chart review from OSH, where the
history was provided by caregivers.
___ had two ___ today, with post-ictal confusion but returned to
baseline in-between the seizures. The first occurred at 10:30 am
and lasted 4 minutes; ___ received 1 mg ativan at the group home.
Then at 19:30 ___ reported feeling hot, attempted to get up, was
confused and became violent and tried to hit/bite a group home
worker (his usual aura, per report from ___ and then had a
GTC lasing 90 seconds. ___ was taken to the hospital and was at
his baseline in the ___. Per caregivers, ___ has not
recently missed a medication dose, been ill, been sleep
deprived,
or had alcohol.
___ was recently hospitalized on ___ at ___ with a
similar
presentation. No etiology for the increased seizure frequency
was
found.
Overall, on review of notes by Dr. ___ seizure frequency
in ___ and before was several per month but no more than 1 per
day. Since ___, ___ has seen Dr. ___ times for follow
up, with reports of increased seizure frequency of ___ in a day,
prompting ED visits and admissions. AEDs were uptitrated, but
Keppra had to be downtitrated because of exacerbations in
behavioral problems. Caretakers have wondered if his seizures
are
precipitated by emotional upset. No precipitating factor has
clearly been identified.
ROS was unable to be obtained.
Past Medical History:
- Gunshot wound ___ (right homonymous hemianopia, right
hemiparesis and expressive aphasia as well as a resultant
seizure disorder)
- Seizure disorder from TBI, with secondarily generalized
seizures
Social History:
___
Family History:
His mother is alive and well. His father died of an unknown
illness. ___ has one sister and two brothers, no history of
seizures in the family.
Physical Exam:
ON ADMISSION:
Vitals:
T= 97.5F, BP= 146/82, HR= 112, RR= 18, SaO2= 98% on RA
General: Awake, cooperative, NAD.
HEENT: scars present from prior TBI, MMM, oropharynx clear
Neck: Supple, no nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x to name and hospital. Unable
to relate history. Language is non-fluent with intact
repetition
but difficulty finding the correct words to say. Pt. was able
to
name high frequency objects. Speech was dysarthric. Able to
follow commands. Able to name ___ forwards but not backwards.
There was no evidence of neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: Pupils R 5 to 2.5, L 3.5 to 2.5, briskly reactive, both
directly and consentually; brisk bilaterally. Right visual
field
cut.
III, IV, VI: EOMI without nystagmus.
V: Facial sensation intact to light touch in all distributions
VII: R facial droop
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue midline.
-Motor: Normal bulk, increased tone throughout though R>L with
Right spasticity. No adventitious movements, such as tremor,
noted. No asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R 0 4+ 0 0 0 0 0 4- ___ 0 0 0
-DTRs:
Bi Tri ___ Pat Ach
L 3 3 3 3 2
R 3+ 3+ 3+ 3+ 1
- Plantar response was flexor on R and extensor on L.
- Pectoralis Jerk was present, and Crossed Adductors are
present.
-Sensory: No deficits to light touch, pinprick throughout.
Impaired proprioception in great toes bilaterally.
-Coordination: No intention tremor, dysmetria or ataxia on L
FNF.
-Gait: Not ambulatory.
==================
ON DISCHARGE: unchanged
Pertinent Results:
LABS:
___ 01:57AM BLOOD WBC-9.3 RBC-5.43 Hgb-15.9 Hct-46.1 MCV-85
MCH-29.3 MCHC-34.6 RDW-16.7* Plt ___
___ 01:57AM BLOOD Neuts-68.0 ___ Monos-6.4 Eos-1.5
Baso-0.7
___ 01:57AM BLOOD Glucose-106* UreaN-13 Creat-0.8 Na-142
K-3.9 Cl-104 HCO3-24 AnGap-18
___ 10:25AM BLOOD ALT-25 AST-23 LD(LDH)-228 AlkPhos-80
TotBili-0.3
___ 07:28AM BLOOD Albumin-4.6 Calcium-9.7 Phos-2.8 Mg-2.0
___ 07:28AM BLOOD Phenyto-11.5
___ 01:57AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 07:28AM BLOOD ZONISAMIDE(ZONEGRAN)-PND
___ 07:28AM BLOOD LEVETIRACETAM (KEPPRA)-PND
___ 12:42AM URINE Color-Yellow Appear-Clear Sp ___
___ 12:42AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-NEG
___ 12:42AM URINE RBC-2 WBC-1 Bacteri-FEW Yeast-NONE Epi-7
___ 12:42AM URINE Mucous-FEW
___ 01:57AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
EEG ___:
IMPRESSION: This telemetry captured no pushbutton activations
but there were two electrographic seizures with clinical
correlate. The first appeared to have an onset in the left
temporal region or hemisphere and rapidly extended to the rest
of the left hemisphere. The second appeared in the right frontal
and temporal region with rapid spread to the rest of the
hemisphere. In addition, there were many epileptiform discharges
arising in the left temporal region or more broadly in the left
hemisphere. There were also intermittent periods of background
slowing in the frontal and temporal regions.
EEG ___:
IMPRESSION: This telemetry captured no pushbutton activations.
It showed
occasional left temporal and left hemisphere epileptiform sharp
wave
discharges suggestive of a focal area of cortical irritability.
Higher
voltages and faster frequencies with superimposed slowing was
seen in the left hemisphere with occasional slowing in the right
frontotemporal region suggestive of areas of subcortical
dysfunction. There were no electrographic seizures.
EEG ___: final read pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO BID
2. Pantoprazole 40 mg PO Q24H
3. Aspirin 81 mg PO DAILY
4. LeVETiracetam 1500 mg PO BID
5. Simvastatin 20 mg PO DAILY
6. Tizanidine 8 mg PO BID
7. Zonisamide 500 mg PO DAILY
8. Lorazepam 1 mg PO DAILY:PRN seizure
9. Phenytoin Sodium Extended 200 mg PO BID
10. Senna 8.6 mg PO BID:PRN constipation
11. Calcium Carbonate 500 mg PO Frequency is Unknown
12. Acetaminophen 650 mg PO Q4H:PRN pain, HA, fever
13. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN
upset stomach
14. meloxicam 15 mg oral DAILY
15. Guaifenesin ER 600 mg PO Q12H:PRN cough
16. Docusate Sodium 100 mg PO BID
17. Amoxicillin ___ mg PO PRN dental procedure
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Calcium Carbonate 500 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Ferrous Sulfate 325 mg PO BID
5. meloxicam 15 mg oral DAILY
6. Pantoprazole 40 mg PO Q24H
7. Phenytoin Sodium Extended 200 mg PO BID
8. Senna 8.6 mg PO BID:PRN constipation
9. Simvastatin 20 mg PO DAILY
10. Tizanidine 8 mg PO BID
11. Zonisamide 500 mg PO DAILY
12. Acetaminophen 650 mg PO Q4H:PRN pain, HA, fever
13. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO QID:PRN
upset stomach
14. Lorazepam 1 mg PO DAILY:PRN seizure
15. Guaifenesin ER 600 mg PO Q12H:PRN cough
16. Oxcarbazepine 600 mg PO QAM
RX *oxcarbazepine 300 mg As directed tablet(s) by mouth 2 tabs
(600 mg) every morning and 3 tab (900 mg) every evening Disp
#*150 Tablet Refills:*11
17. Oxcarbazepine 900 mg PO QPM
18. Amoxicillin ___ mg PO PRN dental procedure
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
epilepsy
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 radiograph
INDICATION: ___ male with seizure. Assess for pneumonia.
COMPARISON: None.
FINDINGS:
Frontal and lateral chest radiographdemonstrates hypoinflated lungs with
crowding of vasculature.No pleural effusion or pneumothorax. Heart size,
mediastinal contour, and hila are unremarkable.
Limited assessment of the upper abdomen is within normal limits.
IMPRESSION:
No pneumonia.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Seizure
Diagnosed with EPILEPSY, NOS WITHOUT INTRACTABLE EPILEPSY
temperature: 97.5
heartrate: 112.0
resprate: 18.0
o2sat: 98.0
sbp: 146.0
dbp: 82.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year old man with history of TBI with
subsequent epilepsy who presented with 2 breakthrough seizures
with secondary ___. Admitted for increase seizure frequency and
AED management.
# Epilepsy:
No inciting factors were found for his breakthrough seizures. ___
was monitored on EEG and ___ had multiple partial seizures. ___
continued his dilantin and zonisamide. His keppra was weaned off
and ___ started oxcarbazepine.
# TBI: Continued home Tizanidine. ___ was seen by psychiatry, who
recommended for his behavior, Ativan 2mg IM/IV for acute
agitation episodes only if agitation rises to level of safety
concern. ___ did not require Ativan during admission.
# Pain: Continued home meloxicam
# GERD: continued PPI
# CV: continued aspirin |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Increased Seizure Frequency
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with complex partial and at times secondarily generalised
epilepsy possibly secondary to a TBI age ___ ___
was previously well controlled on lacosamide, phenytoin and
phenobarbital, mild intellectual disability, h/o depression with
psychosis and h/o alcohol abuse presents with increased seizure
frequency after 3 seizures (at least one of these was a complex
partial seizure and report of others was of GTC) today with his
last seizure before this in ___.
The patient had been well controlled on his AEDs and had no
breakthrough seizures since ___ when he had several events in
the setting of medication non-compliance. He has recently been
treated with swab proven chlamydia after noting penile discharge
on ___. He was in his usual state of health until today
when he was at his ___ clinic when he had 1 typical
seizure in the clinic and another in the waiting room.
Unfortunately I have no further information about the semiology
of these although they were described as GTC. The events were
self-limiting of unclear duration and he was not given
lorazepam. He was sent to the ___ ED and here he then had a
third seizure at roughly 17:55 in the ED triage which was
described to me by the nurses. ___ stated that he had initial
left arm flexion and posturing followed by head and gaze
deviation to the right and left arm flexion with shaking of the
left arm. This lasted for 30 seconds. On assessment in the ED he
was post-ictal but able to give a history.
He denies any provocative factors including no recent infections
save the chlamydia treated with ceftriaxone and ceftriaxone and
no fevers or chills. He claims that he has been taking all his
AEDs at the correct doses. Denies poor sleep save restless at
times but not worse recently and denies other recent medication
changes. He notes no sick contacts. He was drowsy but able to
communicate well at my assessment. He did note some pain with
urination in his abdomen last night and some increased urinary
frequency recently.
On neuro ROS, the pt denies headache, loss of vision, blurred
vision, diplopia, dysarthria, dysphagia, lightheadedness,
vertigo, tinnitus or hearing difficulty. Denies difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation.
No recent change in bowel habits. Denies arthralgias or
myalgias. Denies rash.
Past Medical History:
- Seizure disorder. Secondary to TBI after fell off a wall age
___. Since childhood, difficult to control in the past, now with
excellent control with Dilantin, phenobarbital and Vimpat
(Keppra, Tegretol, and Depakote not previously helpful). Last
seizure ___ in the setting of not taking his AEDs after which
he was admitted to the epilepsy service and nne since. He has a
past history of poor medication compliance.
- Mental retardation - Mild, fairly high functioning but never
employed.
- Depression/psychosis. Developed psychosis in ___, previously
well-controlled on olanzapine. Followed by Cognitive Neurology
and psychiatry at ___. Per psychiatry no longer on olanzapine
and will observe for return of delusional symptoms.
- PPD-positive s/p INH for one year, ___.
- History hematuria/hematospermia. In ___, no recurrence.
- h/o proctocolitis. In ___, likely infectious, no BRBPR
or diarrhea since then.
- h/o STDs with gonorrhea ___ and chlamydia and treated with
IM ceftriaxone and po azithromycin for chlamydia swab positive
___ after penile discharge with negative RPR amnd
gonorrhoea. Patient HIv negative ___.
- s/p inguinal hernia repair ___
Epilepsy history:
- Patient had a TBI age ___ and seizures since childhood.
Social History:
___
Family History:
Both parents are alive and general healthy. His mother suffers
from some problems with her vision and chronic constipation. He
has a brother and a sister, both healthy.
Physical Exam:
Vitals: T:98.4 P:69 R:18 BP:118/75 SaO2:99% RA
General: Awake, cooperative, drowsy but attentive.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity.
Full range of motion save slight limitation on rotation to the
right. No meningismus.
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 bilaterally.
Skin: no rashes or lesions noted.
Neurological examination:
- Mental Status:
Somewhat post-ictal and drowsy.
ORIENTATION - Alert, oriented x person, place and time
The pt. knew president is ___.
SPEECH
Able to relate history without difficulty and recalls his
seizures.
Language is fluent with intact repetition and comprehension.
Normal prosody. There were no paraphasic errors.
Speech was not dysarthric.
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 and difficulty with ___.
REGISTRATION and RECALL
Pt. was able to register 3 objects and recall ___ 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 4 to 3mm and brisk. VFF to confrontation.
Funduscopic exam reveals no papilledema, exudates, or
hemorrhages.
III, IV, VI: EOMI without nystagmus. Slightly jerky pursuits and
normal saccades.
V: Facial sensation intact to light touch. Good power in muscles
of mastication.
VII: No facial weakness, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline with normal velocity movements.
- Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
SAb SAdd ElF ElE WrE FFl FE IO HipF HipE KnF KnE AnkD ___
L 5 5 ___ ___ 5 ___ ___
R 5 5 ___ ___ 5 ___ ___
- Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout in UE and ___. No
extinction to DSS.
- DTRs:
BJ SJ TJ KJ AJ
L ___ 1 0
R ___ 1 0
There was no evidence of clonus.
___ negative.
Plantar response was flexor bilaterally.
- Coordination: No intention tremor, normal finger tapping. 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 undue difficulty. Romberg
absent.
DISCHARGE EXAM:
- More awake alert, remainder of examination unchanged.
Pertinent Results:
___ 09:00PM URINE bnzodzpn-NEG barbitrt-POS opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 09:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-TR
___ 09:00PM URINE RBC-1 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 09:00PM URINE MUCOUS-MOD
___ 06:45PM ALT(SGPT)-57* AST(SGOT)-47* ALK PHOS-167* TOT
BILI-0.2
___ 06:45PM ALT(SGPT)-57* AST(SGOT)-47* ALK PHOS-167* TOT
BILI-0.2
___ 06:45PM ALBUMIN-4.9 CALCIUM-9.2 PHOSPHATE-3.2
MAGNESIUM-2.1
___ 06:45PM PHENOBARB-17.8 PHENYTOIN-7.3*
___ 06:45PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-POS tricyclic-NEG
___ 06:45PM WBC-6.1 RBC-5.45 HGB-16.7 HCT-47.3 MCV-87
MCH-30.6 MCHC-35.2* RDW-12.8
___ CXR IMPRESSION: No acute cardiopulmonary process
___ 06:30AM BLOOD Phenoba-15.0 Phenyto-25.0*
___ 12:03AM BLOOD Phenyto-21.7*
Medications on Admission:
Medications - Prescription
FLUTICASONE - fluticasone 50 mcg/actuation Nasal Spray, Susp. 2
puffs(s) puff qd right and left1 Pt uses as needed -
(Prescribed
by Other Provider) (Not Taking as Prescribed)
LACOSAMIDE [VIMPAT] - Vimpat 200 mg tablet. 1 Tablet(s) by mouth
twice a day
PHENOBARBITAL - phenobarbital 100 mg tablet. 1 Tablet(s) by
mouth
at night
PHENOBARBITAL - phenobarbital 30 mg tablet. 1 Tablet(s) by mouth
at bedtime along with the 100 mg tablet
PHENYTOIN SODIUM EXTENDED - phenytoin sodium extended 100 mg
capsule. 4 Capsule(s) by mouth every night at bedtime
TRAZODONE - trazodone 50 mg tablet. ___ Tablet(s) by mouth at
bedtime
Medications - OTC
CALCIUM CARBONATE-VITAMIN D3 [CALCIUM 500 WITH D] - Calcium 500
With D 500 mg (1,250 mg)-400 unit tablet. 1 tablet(s) by mouth
twice a day
DOCUSATE SODIUM - docusate sodium 100 mg capsule. ___ Capsule(s)
by mouth once to twice daily Pt uses as needed - (Prescribed by
Other Provider) (Not Taking as Prescribed)
Discharge Disposition:
Home with Service
Discharge Diagnosis:
Primary:
- Seizure disorder
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: ___ male with seizure.
FINDINGS: PA and lateral views of the chest are compared to previous exam
from ___. The lungs are clear of focal consolidation, effusion or
pulmonary vascular congestion. The cardiomediastinal silhouette is within
normal limits. Osseous structures demonstrate no acute abnormality.
IMPRESSION: No acute cardiopulmonary process.
Gender: M
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: SEIZURE
Diagnosed with OTHER FORMS OF EPILEPSY AND RECURRENT SEIZURES, WITHOUT MENTION OF INTRACTABLE EPILEPSY
temperature: 98.4
heartrate: 69.0
resprate: 18.0
o2sat: 99.0
sbp: 118.0
dbp: 75.0
level of pain: 0
level of acuity: 2.0 | ASSESSMENT: The patient presents with breakthough seizures with
a subtherapeutic phenytoin level. He has a past history of
medication non-compliance but states that he has been taking his
correct AED doses. It is unclear how acutely his phenytoin level
has dropped as it was last checked on our system in ___.
# NEURO:
The patient was loaded with IV fosphenytoin with good effect
increasing his PHT level to 25. No further ictal activity was
noted. He will return for labs on ___.
# ID:
No infectious source was identified. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
CC: ___ pain, cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old male, with prior history of
Alzheimers' Dementia, and ___ Disease, who is minimally
verbal at baseline, who presents with increased leg swelling,
nonproductive cough, and an episode of ? chest pain this
morning. Patient is unable to provide medical history, and
history obtained from his wife and step ___.
Patient was doing well until about 3 days ago, at which point he
started to deelop a non productive cough. Patient is taken care
of by his wife. She denies any fevers, although has never taken
a temperature. Patient at that time had no episodes of
aspiration that she could tell. Patient now presents today since
over the past 3 days hasn't had any relief in his cough. To his
wife and daughter, he sounds that he has secretions that he is
unable to clear. His chest pain episode was brought on by
coughing, and with increased back pains, patient has. This
morning, patient was drinking water and coughed while drinking
as well. His fatigue is worse than usual.
He also has lower extremity edema, however this has been a
waxing and waning presentation over the past several years when
he doesnt move around.
At baseline, patient is cared for by home nursing services and
by his wife ___. Patient requires help with eating, 1:1
sitting, requires help with ADLs. Patient does speak ___,
however minimally. Per family, he has been interactive with
family and that hasn't changed over the past 3 days.
Per EMS report, patient also gave history of clutching his
chest, however unable to vocalize specific chest pains. There is
no history of aspiration episodes or choking episodes, and eats
specifically with assistance.
In the ED, initial vitals were: 0 98 79 137/93 18 100% 2L Nasal
Cannula. Patient's labs were notable for Hgb 12.8, no
leukocytosis of 5.2, a proBNP of 66, and electrolytes signficant
for an elevated K of 6.4 (verified). Patient underwent
urinalysis which was negative, and was given Ceftriaxone and
Azithromycin. EKG at the time signficant for NSR with inf Q
waves reportedly similar to prior. Lactate drawn was 2.5.
Patient was also given 500 cc NS.
On the floor, patient reports no dyspnea. Patient was currently
on oxygen on 2L, and patient denied chest pains. He was
complaining of back pains. Family states that he usually does
not tell his family about symptoms.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denies arthralgias or myalgias.
Past Medical History:
Depression
Probable ___ disease
Hypertension
Hyperlipidemia
Confusion/Delirium
Social History:
___
Family History:
Non-contributory
Physical Exam:
>> ADMISSION PHYSICAL EXAM:
Vital Signs: 95% on 3L -> 98 on 1L, 146/92, 81, 18
General: Alert, tracks with eyes. Patient minimally says yes or
no to answers. Looks towards family. Patient has loud snoring
sounds from mouth. Contracted in extremities, able to follow
commands limited with function.
HEENT: lesion on top of head, no acute bleeding. Sclera
anicteric. PERRL. Neck is thick, JVD difficult to appreciated.
No cervical LAD appreciated, although very thick neck. Unable to
fully open mouth, multiple dental work apparent, some mucous in
the posterior pharynx visualzied, however thick saliva.
Drooling.
CV: RRR, S1, S2. No extra sounds heard.
Lungs: Upper airways seem transmitted through to bases. On
posterior, mild expiratory wheeze on the left lower base,
however good air entry in upper zones. No crackles appreciated,
however very limited to poor inspiratory effort.
Abdomen: Distedned, +BS. No rebound or guarding. Wearing diaper.
GU: Wearing diaper
Neuro: Fingers contracted bilaterally.
Strength in lower extremities: unable to lift off bed by
himself. 1+ able to move side to side mildly.
2+ ___ edema in the feet bilaterally. Warm to touch.
LABS: --see below--
.
>> DISCHARGE PHYSICAL EXAM:
Vital Signs: 95 RA 97.3 165/89 16
General: Tracks with eyes, alerts, Patient is audibly having
upper airway secretions. Minimially verbal. Loud snoring sounds.
Extremities still contracted. Able to follow simple commands.
HEENT: lesion on top of head, no acute bleeding. Sclera
anicteric. PERRL. Neck is thick, JVD difficult to appreciated.
No cervical LAD appreciated, thick neck. Unable to fully open
mouth, multiple dental work apparent, some mucous in the
posterior pharynx visualzied, however thick saliva. Drooling.
CV: RRR, S1, S2. No extra sounds heard.
Lungs: Upper airways seem transmitted through to bases. On
posterior, mild expiratory wheeze on the left lower base,
however good air entry in upper zones. No crackles appreciated,
however very limited to poor inspiratory effort.
Abdomen: Distedned, +BS. No rebound or guarding. Wearing diaper.
GU: Wearing diaper
Neuro: Fingers contracted bilaterally.
Strength in lower extremities: unable to lift off bed by
himself. 1+ able to move side to side mildly.
2+ ___ edema in the feet bilaterally. Warm to touch.
Pertinent Results:
>> Admission Labs:
___ 12:03PM BLOOD WBC-5.2 RBC-4.26* Hgb-12.8* Hct-37.5*
MCV-88 MCH-30.0 MCHC-34.2 RDW-13.0 Plt ___
___ 12:03PM BLOOD Neuts-61.0 ___ Monos-9.5 Eos-6.2*
Baso-0.7
___ 12:19PM BLOOD Lactate-2.5* K-6.4*
___ 07:23PM BLOOD Lactate-1.5
.
>> Discharge Labs:
___ 07:14AM BLOOD WBC-6.0 RBC-4.31* Hgb-12.9* Hct-37.8*
MCV-88 MCH-29.9 MCHC-34.1 RDW-12.9 Plt ___
___ 07:14AM BLOOD Glucose-84 UreaN-17 Creat-1.0 Na-142
K-4.0 Cl-103 HCO3-28 AnGap-15
.
>> Pertinent Reports:
___ (PORTABLE AP): Lung volumes continue to
be low. There is increased vascular plethora and ll-defined
vascularity. Although lung volumes are low on the has a similar
volume previously when the vasculature did not appear so
engorged. Therefore there is likely an element of fluid
overload. It is difficult to assess for focal infiltrate given
the low lung volumes
IMPRESSION: Vascular plethora likely due to fluid overload
.
___ (PA & LAT): Low lung volumes cause
bronchovascular crowding. Elevation the left hemidiaphragm is
stable from multiple prior studies. Enlarged cardiac silhouette
is unchanged from multiple prior studies, likely related to
tortuous aorta and mediastinal fat. There is no focal
consolidation, pleural effusion, pneumothorax, or pulmonary
edema.
IMPRESSION: No acute cardiopulmonary process
.
>> MICROBIOLOGY:
__________________________________________________________
___ 1:20 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
__________________________________________________________
___ 12:05 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 12:03 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO DAILY
2. Carbidopa-Levodopa (___) 2 TAB PO TID
3. Docusate Sodium 100 mg PO BID
4. Lactulose 15 mL PO BID
5. Omeprazole 40 mg PO DAILY
6. Paroxetine 20 mg PO DAILY
7. Simvastatin 40 mg PO QHS
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. Carbidopa-Levodopa (___) 2 TAB PO TID
3. Docusate Sodium 100 mg PO BID
4. Lactulose 15 mL PO BID
5. Omeprazole 40 mg PO DAILY
6. Paroxetine 20 mg PO DAILY
7. Simvastatin 40 mg PO QHS
8. Azithromycin 250 mg PO Q24H Duration: 4 Doses
Please take until ___
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*4
Tablet Refills:*0
9. Space Chamber Plus (inhalational spacing device) 1
miscellaneous Q6H:PRN
Please use with albuterol MDI as needed
RX *inhalational spacing device Please use spacer with inhaler
every 6 hours Disp #*1 Inhaler Refills:*0
10. Albuterol Inhaler ___ PUFF IH Q6H:PRN shortness of breath
Duration: 1 Dose
Please dispense ___ MDI. Please use as needed for shortness of
breath/wheezing
RX *albuterol ___ puff IH every 6 hours Disp #*1 Inhaler
Refills:*0
11. Wheelchair
ICD9 Code: 332.0 ___ Disease
Sig: Please dispense 1 wheelchair for patient.
Duration: Lifetime.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS: 1. Viral Upper Respiratory Illness
SECONDARY DIAGNOSES: 1. ___ Disease 2. Alzheimer's
Disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with chest pain, evaluate for acute cardiopulmonary disease.
TECHNIQUE: PA and lateral view radiographs of the chest.
COMPARISON: Prior chest radiographs dating back to ___.
FINDINGS:
Low lung volumes cause bronchovascular crowding. Elevation the left
hemidiaphragm is stable from multiple prior studies. Enlarged cardiac
silhouette is unchanged from multiple prior studies, likely related to
tortuous aorta and mediastinal fat. There is no focal consolidation, pleural
effusion, pneumothorax, or pulmonary edema.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with h/o Parkinsons, Alzhemiers, with new cough
// interval change, focal, PNA?
TECHNIQUE: Portable chest
___.
FINDINGS:
Lung volumes continue to be low. There is increased vascular plethora and
ill-defined vascularity. Although lung volumes are low on the has a similar
volume previously when the vasculature did not appear so engorged. Therefore
there is likely an element of fluid overload. It is difficult to assess for
focal infiltrate given the low lung volumes
IMPRESSION:
Vascular plethora likely due to fluid overload
Gender: M
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Chest pain, Cough
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 98.0
heartrate: 79.0
resprate: 18.0
o2sat: 100.0
sbp: 137.0
dbp: 93.0
level of pain: 0
level of acuity: 3.0 | This is a ___ year old male with past medical history of
Alzheimers Dementia, Parkinsons Disease, admitted ___ with
> 1 week of cough, low-grade fevers, CXR with poor visualization
of lung fields, treated empirically for pneumonia with
improvement and discharged home.
.
>> ACTIVE ISSUES:
# Community Acquired Pneumonia: Patient initially presented with
3 days of non productive cough, initially hypoxic in ED; CXR had
poor visualization of lung fields due to body habitus. Patient
was initially treated with IV Ceftriaxone and Axithromycin for
CAP coverage with subsequent improvement in symptoms. He was
transitioned to PO azithromycin. He had mild wheezing on exam,
so was provided albuterol inhaler with spacer with symptomatic
improvement. Team discussed with family re: his risk of
aspiration, and whether patient would benefit from
speech/swallow consultation. Family decided knowledge of
aspiration would not change their management, and they would
prefer to take home without swallow eval, and continue current
feeding regimen with 1:1 supervision. Risks of aspiration were
discussed with family, and voiced back understanding.
.
# Hyperkalemia: Patient initially found to be hyperkalemic,
unclear origin, without EKG changes. With IVF, patient had
repeat labs checked with normal potassium levels. No clear
offenders as far as medications, or renal disease. ___ have been
result of mild prerenal azotemia.
.
# ___ Disease: Patient continued to be at neurologic
baseline per family, and was continued on carbidop-levodopa.
.
# Depression: Patient was continued on paroxetine.
.
# GERD: Patient was continued on omeprazole.
.
# History of constipation: Patient was continued on outpatient
regimen.
.
# Hyperlipidemia: Patient was continued on simvastatin.
.
# Hypertension: Patient was continued on home atenolol.
. .
>> TRANSITIONAL ISSUES:
# Goals of Care: DNR/DNI.
# Contact Information: ___ (daughter): ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Vioxx / Celebrex / Lasix
Attending: ___.
Chief Complaint:
nausea, malaise
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
___ with PMH COPD on ___ (4LNC per nursing ___, obesity
hypoventilation syndrome last FEV1 80%, OSA on BiPAP, morbid
obesity, presenting with malaise and intermittent SOB over the
past several days. Per daughter, nursing ___, has been nauseous
without much of an appetite the past couple of days, and she
endorses this as well. She denies any chest pain, vomiting,
lower extremity edema, abdominal pain. She reports last BM 2
days ago. Denies fevers or chills.
On arrival on the ED, HR 66 115/66 15 92% Nasal Cannula. She was
given nebs, azithromycin, methylpred 125mg, zofran. She was
thought to have diminished breath sounds bilaterally. She had
two gases done, one VBG, one ABG without respiratory
intervention other than nebs, and then she was placed on BiPAP
and sent up to the floor.
On transfer, vitals were: 0 96.9 61 128/73 14 95% BIPAP.
On arrival to the MICU, T98 BP 125/71 HR 62 RR 10 88% 4LNC.
She is comfortable appearing, speaking full sentences.
Past Medical History:
- COPD
- Hypertension
- Diastolic CHF
- Hypothyroidism
- Hypercholesterolemia
- Diabetes mellitus, diet controlled
- Morbid obesity
- Obesity hypoventilation syndrome, on ___ O2
- Obstructive sleep apnea, on CPAP
- Gout
- Depression
- GERD
Social History:
___
Family History:
No lung disease or allergic disease. Mother with hypertension.
Physical Exam:
ADMISSION EXAM:
Vitals- T98 BP 125/71 HR 62 RR 10 88% 4LNC.
General- comfortable, speaking full sentences, no accessory
muscle use
HEENT- large tongue, OP clear, R eye with yellow crusting,
opens eyes but prefers to keep the right eye shut, EOMI, PERRL
Neck- soft, supple, FROM, nontender
CV- RRR, S1, S2, no m/r/g
Lungs- poor air movement, severely diminished at the bases,
clear at the apices
Abdomen- large, obese, nontender, nondistended
GU- no foley, red, excoriated groin folds
Ext- no edema, warm, well-perfused, nontender
Neuro- CN ___ intact, gait not assessed, per patient
non-ambulatory
DISCHARGE EXAM:
General- comfortable, speaking full sentences, no accessory
muscle use
HEENT- large tongue, OP clear, R eye with yellow crusting,
opens eyes but prefers to keep the right eye shut, EOMI, PERRL
Neck- soft, supple, FROM, nontender
CV- RRR, S1, S2, no m/r/g
Lungs- poor air movement, severely diminished at the bases,
clear at the apices
Abdomen- large, obese, nontender, nondistended
GU- no foley, red, excoriated groin folds
Ext- no edema, warm, well-perfused, nontender
Neuro- CN ___ intact, gait not assessed, per patient
non-ambulatory
Pertinent Results:
ADMISSION LABS:
___ 11:20AM BLOOD WBC-9.5 RBC-3.92* Hgb-12.0 Hct-38.2
MCV-98 MCH-30.7 MCHC-31.4 RDW-16.1* Plt ___
___ 11:20AM BLOOD Neuts-64.5 ___ Monos-5.1 Eos-3.9
Baso-0.6
___ 11:20AM BLOOD Glucose-115* UreaN-17 Creat-0.8 Na-134
K-7.2* Cl-92* HCO3-35* AnGap-14
___ 11:20AM BLOOD ALT-19 AST-71* AlkPhos-66 TotBili-0.3
___ 11:20AM BLOOD Albumin-3.3*
___ 11:22AM BLOOD ___ pO2-53* pCO2-103* pH-7.28*
calTCO2-51* Base XS-16
___ 12:20PM BLOOD Lactate-0.7 K-4.2
MICROBIOLOGY:
___ Blood cultures (x 2) - pending
IMAGING STUDIES:
___ CHEST (PORTABLE AP) - Portable upright AP views. There
are low lung volumes. Exam appears stable from prior. There is a
subtle opacity in the right inferior cardiac margin, consistent
with known epicardial fat pad. The lungs are otherwise clear.
Cardiomediastinal silhouette is stable. There is no pneumothorax
or pleural effusion. Visualized osseous structures are
unremarkable. No acute cardiopulmonary process.
EKG: SR @63, IVCD, no acute ischemia changes, unchanged from
priors
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Vitamin D 50,000 UNIT PO QMONTH ___
2. Gabapentin 300 mg PO BID
3. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN sob
4. Allopurinol ___ mg PO TID
5. Amlodipine 5 mg PO DAILY
6. Bumetanide 1 mg PO DAILY
7. BuPROPion 75 mg PO BID
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
10. FoLIC Acid 1 mg PO DAILY
11. Lactulose 15 mL PO Q8H:PRN constipation
12. Levothyroxine Sodium 25 mcg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Ramipril 1.25 mg PO DAILY
15. Senna 3 TAB PO HS
16. Acetaminophen 650 mg PO Q6H:PRN pain
17. Metoprolol Succinate XL 50 mg PO DAILY
18. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
19. Docusate Sodium 100 mg PO BID
20. Omeprazole 40 mg PO BID
21. Simethicone 40-80 mg PO QID:PRN gas, indigestion
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q2H:PRN sob
3. Allopurinol ___ mg PO TID
4. Amlodipine 5 mg PO DAILY
5. Bumetanide 1 mg PO DAILY
6. BuPROPion 75 mg PO BID
7. Docusate Sodium 100 mg PO BID
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
10. FoLIC Acid 1 mg PO DAILY
11. Gabapentin 300 mg PO BID
12. Levothyroxine Sodium 25 mcg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Omeprazole 40 mg PO BID
15. Lactulose 15 mL PO Q8H:PRN constipation
16. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
17. Senna 3 TAB PO HS
18. Simethicone 40-80 mg PO QID:PRN gas, indigestion
19. Metoprolol Succinate XL 50 mg PO DAILY
20. Erythromycin 0.5% Ophth Oint 0.5 in RIGHT EYE QID Duration:
7 Days
21. Vitamin D 50,000 UNIT PO QMONTH ___
22. Ramipril 1.25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Obstructive Sleep Apnea
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
HISTORY: Dyspnea.
COMPARISON: Comparison is made with CT chest from ___ and chest
radiographs from ___.
FINDINGS: Portable upright AP views. There are low lung volumes. Exam
appears stable from prior. There is a subtle opacity in the right inferior
cardiac margin, consistent with known epicardial fat pad. The lungs are
otherwise clear. Cardiomediastinal silhouette is stable. There is no
pneumothorax or pleural effusion. Visualized osseous structures are
unremarkable.
IMPRESSION: No acute cardiopulmonary process.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: NAUSEA
Diagnosed with HYPOXEMIA, NAUSEA, DIABETES UNCOMPL ADULT, HYPERCHOLESTEROLEMIA
temperature: 97.6
heartrate: 66.0
resprate: 20.0
o2sat: 94.0
sbp: 134.0
dbp: 55.0
level of pain: 0
level of acuity: 3.0 | ___ with PMH COPD on ___, obesity hypoventilation syndrome
last FEV1 80%, OSA on BiPAP, morbid obesity, presenting with
malaise and intermittent SOB over the past several days
presenting with nausea and malaise.
# Nausea, malaise: Patient with loss of appetitie and nausea
without vomiting, diarrhea in the few days prior to admission.
Attributed to a possible mild viral illness but without further
symptoms at this time. No known sick contacts. No evidence of
obstruction. She improved with anti-emetics, PPI dosing and
simethicone.
# Obesity hypoventilation syndrome: Given patient's body
habitus, favor obesity hypoventilation as primary cause of her
chronic hypercarbia and hypoxemia. She uses BiPAP when sleeping,
and has ___ ___ and is currently not requiring any more than
that. Following ICU admission, she was quickly transitioned to
her ___ oxygen regimen. Of note, she admitted that she had not
been using her BiPAP regularly over the past several weeks due
to a poorly fitting, somewhat uncomfortable facemask. She
endorsed the mask that we provided in the hospital was more
comfortable, and that she would use that mask at ___. As such,
she was provided that mask to take ___ with her to endeavor to
optimize her compliance with NIPPV at ___.
# COPD: No evidence of acute exacerbation. Patient is without
cough, wheezing, or change in sputum. No leukocytosis or
radiographic changes to suggest acute pulmonary process to drive
exacerbation. Not unlikely that patient has COPD component to
her respiratory disease, but FEV1 in ___ was 82%, suggesting
restrictive rather than obstructive process even then. No
steroids indicated this admission, we continued her inhaler
medications.
# Constipation: This has previously been an issue during her
hospitalizations. Therefore, aggressive bowel regimen to prevent
this with senna, colace, bisacodyl, lactulose.
# Hypertension: Continued ___ amlodipine, metoprolol and
ramipril.
# CHF: TTE in ___ with preserved EF, likely diastolic
dysfunction. CXR on ___ with fluid overload, but no suggestion
of volume overload this admission. We continued her ___
diuretic.
# Gout: We continued Allopurinol ___ mg PO TID.
# Depression: We continued Bupropion.
# GERD: Continued omeprazole as above.
# Hypothyroid: Continued Levothyroxine Sodium 25 mcg PO daily.
# Transitional Issues:
- repeat CT six months, unless clinical suspicion of possible
extrathoracic primary carcinoma is high enough to merit PET-CT
scanning |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Demerol / IVP Dye
Attending: ___
Chief Complaint:
Jaundice, GI bleeding
Major Surgical or Invasive Procedure:
___ EGD and flexible sigmoidoscopy
___ ERCP/sphincterotomy
___ EUS/FNA of pancreatic lesion
History of Present Illness:
___ woman with history of hypertension, cirrhosis and
pancreatic cyst transferred from ___ for jaundice
and blood stools. Patient presented with 2 days of jaundice and
bright red blood per rectum with bowel movements.
Patient reports that she had a bloody nose that required packing
last week. She then developed black stools which she attributed
to her significant nose bleed, eventually the dark stools
resolved. Over the last two days has noticed BRBPR with her
bowel movements. Unclear how much blood she noticed. Not
painful. Has not had any further blood in her stool. Denies any
abdominal pain. No history of GI bleed or bleeding disorder.
She reports feeling fatigued for the past several days. Also
endorsing dizziness. No nausea, vomiting, fevers or chills.
Decreased appetite and 4lb weight loss over the past weeks. No
constipation or diarrhea. She was concerned about her skin
looking yellow which is why she went to ___.
At OSH VS 110/65, HR 68, RR 18, T 98.0, labs notable for
Lipase 12,000, Bili 17.0, AST 107, ALT 67, Cr 1.4. h/h ___ Hep
C Ab nonreactive, Hep A nonreactive Hep B core IGM reactive, Hep
B surface non reactive, Tylenol neg.
Patient had CT abd/pelv w/out contrast: increasing pancreatic
cystic mass of uncertain etiology Dilated intrahepatic biliary
ducts and CBD as well as dilated pancreatic duct. Enlarged
cystic pancreatic head lesion of uncertain etiology. Nonspecific
area of mesenteric inflammatory change or edematous change
inferior to liver and adjacent to R kidney of uncertain
etiology. Colon diverticula w/out diverticulitis.
Patient denies urinary symptoms, states it is darker than
usual. No chest pain or SOB.
In the ED, initial vitals: 99.1 90 119/50 18 99% RA, Blood
pressures dropped to 80/40s with minimal improvement with IVF.
Patient mentating well. No tachycardia.
Exam notable for: skin jaundiced, sclera jaundiced, a&o, RRR +
murmur
CTAB, abd s/nt very mild suprapubic discomfort, rectal: melenic
stool, guaiac +, no ___ edema
Labs notable for: Per report Hgb drop from 11-> 9.7
9.7
7.2 >--< 211
27.7
133 100 37
------------< 87 AGap=18
3.7 19 1.5
AST: 91 ALT: 47 AP: 196 Tbili: 15.1 Alb: 3.0 Lip: 2862
___: 15.8 PTT: 32.2 INR: 1.4
UA: Urobil2 Bili Lg Leuk Mod Bld Tr Nitr Neg RBC4 WBC 133
Bact Few Epi 12 CastHy: 82
GI Consulted: If the concern is bleed from mass into GI track
agree with further imaging in addition to supportive care with
IVF, large bore IV access, T+C, IV PPI and NPO.
ERCP Consulted: will plan to do EGD and flex sig in AM, Plan for
CTA however Cr is rising to 1.5 ERCP okay holding off
Patient was given:
1.5L L NS, 2Unit of PRBC
___ 00:04 IV Pantoprazole 40 mg
___ 00:29 IV Ciprofloxacin 400 mg
___ 01:34 IV MetRONIDAZOLE (FLagyl) 500 mg
IV access: 18g and 20g IV
On transfer, vitals were: 01:34 63 86/49 18 97% RA
On arrival to the MICU, patient was doing well. Denies any
abdominal pain, distension, feels fatigued and dizzy. No further
GI bleeding. No ___ edema.
Review of systems:
(+) Per HPI
Otherwise 10 point review of system is negative.
Past Medical History:
Micronodular liver cirrhosis -- Liver biopsy done on ___: established cirrhosis stage IV thought to be toxic
metabolic.
Pancreatic head mucinous cyst found in ___-- 2.6 x 3.9 cystic
lesion
endoscopic ultrasound, thick fluid was aspirated, but had a
negative cytology. CEA level of 385. Planned to undergo whipple
however it was aborted given nodular contour of liver.
HTN
Depression
Asthma
Endometriosis
Vertigo
"Enlarged heart"- no history of heart failure
PSH:
umbilical hernia repair at age ___
ORIF bilateral ankles
Diagnostic laproscopy for infertility related issues
___ Exploratory laparotomy, open cholecystectomy, liver
biopsies
Social History:
___
Family History:
Family history of pancreatic cancer in her mother and aunt. Her
mother also had diabetes. Her father has a history of coronary
artery disease and COPD.
Physical Exam:
>> ADMISSION EXAM:
Vitals: 98.2 65 92/52 18 97%RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera icteric, MMM, oropharynx clear
NECK: supple, JVP difficult to assess given habitus
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, loud SEM heard
throughout
ABD: large, soft, non-tender, non-distended, bowel sounds
present, no rebound tenderness or guarding, no organomegaly,
large cholecystectomy scar present over right side of abdomen
and prior evidence of midline incision. No spiders or caput.
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: jaundiced, no palmar erythema noted
NEURO: AOX3, normal mentation, no asterixis, strength and
sensation intact in upper and lower extremities
Rectal: deferred, stool in commode liquid with no blood or dark
stool, small pieces of acholic appearing stool
>> DISCHARGE EXAM:
Vitals: T 98.8, BP 138/62(129-148/57-83), P 76(68-76), RR 18,
97% RA
General: Slightly less jaundiced, no distress, no confusion
HEENT: Slightly less icteric sclera, resolved sublingual
jaundice
Neck: Supple
Lungs: Subtle crackles at right base.
CV: RRR, normal S1 + S2, mid-systolic crescendo-decrescendo
murmur best heard over RUSB and LUSB
Abdomen: Soft, obese, non-tender, no fluid wave, bowel sounds
present, well-healed surgical scars
Skin: Jaundice, spider telangiectasias on upper chest and face
Ext: warm, well perfused, 2+ pulses, no edema
Neuro: A&Ox3, normal mentation, no asterixis
Pertinent Results:
>> ADMISSION LABS:
___ 11:07PM BLOOD WBC-7.2 RBC-2.81*# Hgb-9.7*# Hct-27.7*#
MCV-99* MCH-34.5* MCHC-35.0 RDW-16.8* RDWSD-60.7* Plt ___
___ 11:07PM BLOOD ___ PTT-32.2 ___
___ 11:07PM BLOOD Glucose-87 UreaN-37* Creat-1.5* Na-133
K-3.7 Cl-100 HCO3-19* AnGap-18
___ 11:07PM BLOOD ALT-47* AST-91* AlkPhos-196*
TotBili-15.1*
___ 05:30AM BLOOD Calcium-7.8* Phos-3.3 Mg-1.6
___ 11:07PM BLOOD Albumin-3.0*
___ 05:44AM BLOOD Lactate-1.6
>> PERTINENT INTERVAL LABS:
___ 05:44AM BLOOD Lactate-1.6
___ 05:30AM BLOOD CA ___
___ 05:30AM BLOOD AFP-4.5
___ 01:39PM PANCREATIC CYST FLUID: AMYLASE-4205, CEA-244
>> DISCHARGE LABS:
___ 05:40AM BLOOD WBC-6.7 RBC-2.70* Hgb-9.1* Hct-26.8*
MCV-99* MCH-33.7* MCHC-34.0 RDW-18.6* RDWSD-66.1* Plt ___
___ 05:40AM BLOOD Plt ___
___ 05:40AM BLOOD ___
___ 05:40AM BLOOD Glucose-129* UreaN-19 Creat-0.8 Na-139
K-3.1* Cl-104 HCO3-23 AnGap-15
___ 05:40AM BLOOD ALT-30 AST-54* AlkPhos-117* TotBili-13.8*
DirBili-8.0* IndBili-5.8
___ 05:40AM BLOOD Calcium-9.3 Phos-2.8 Mg-1.7
>> IMAGING:
___ Echocardiogram
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy. The left ventricular cavity size
is normal. Left ventricular systolic function is hyperdynamic
(Quantitative (biplane) LVEF = 78%. There is a moderate-severe
resting left ventricular outflow tract obstruction (peak 52
mmHg). No mid-cavitary gradient or apical intracavitary gradient
arepresent. Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. Given the presence of a
significant LVOT gradient, the study is inadequate to assess for
aortic valve stenosis. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. There is systolic anterior motion of the mitral
valve leaflets. Mild to moderate (___) mitral regurgitation is
seen. There is mild pulmonary artery systolic hypertension.
There is no pericardial effusion.
IMPRESSION: Moderate symmetric left ventricular hypertrophy with
slight septal predominance and hyperdynamic systolic function.
Systolic anterior motion of the mitral valve with significant
outflow tract gradient. Mild-moderate mitral regurgitation. Mild
pulmonary artery systolic hypertension.
If clinically indicated, a cardiac MRI (___) would be
better able to differentiate hypertensive myopathy from
hypertrophic obstructive cardiomyopathy.
___ Abdominal Ultrasound
Interval increase in size of pancreatic head/ uncinate process
cyst (3.5 to 5.9 cm) with interval intra and extrahepatic ductal
dilation consistent with obstructive behavior (mass effect
versus invasion). Given the elevated bilirubin, elevated CEA
from the cystic lesion aspirates back in ___, and family
history of pancreatic cancer, differential includes serous cyst
adenoma/adenocarcinoma and IPMN/malignant degeneration.
___ ERCP
The scout film was normal. The common bile duct, common hepatic
duct, right and left hepatic ducts, biliary radicles and cystic
duct were filled with contrast and well visualized. A 3 cm
tight, distal CBD stricture with severe post-obstructive
dilation was noted. The common hepatic duct, right and left
hepatic ducts and intrahepatic branches appeared dilated but
otherwise normal. A biliary sphincterotomy was performed with
the sphincterotome. There was no evidence of post-sphincterotomy
bleeding. Brushings were obtained of the distal CBD stricture
with a cytology brush. A ___ Fr x 8 cm straight plastic biliary
stent was placed across the stricture. Excellent drainage of
bile and contrast was noted endoscopically and fluoroscopically.
___ MRCP
IMPRESSION:
1. Large pancreatic cystic lesion in the head and uncinate
process with enhancing pseudoseptations is larger compared to
the prior CT scan in ___. There are additional millimetric
cysts scattered throughout the body and tail. No nodularity or
duct dilation. Given the multiplicity and previous elevated CEA,
this lesion most likely represents a side-branch IPMN.
2. Cirrhosis without any evidence of portal hypertension or
concerning lesions.
3. Acute interstitial edematous pancreatitis is likely secondary
to recent ERCP. No peripancreatic fluid collections.
___ EUS with FNA
EUS FINDINGS:
A focused EUS examination was performed with the linear
echoendoscope. A 6.5 x 6.3 cm cyst was noted in the pancreas
with eccentric thickened walls. A 1 cm soft tissue component was
noted along the wall of the cyst. Multiple thin septations were
seen. The previously placed plastic biliary stent was seen
abutting the cyst. The PD did not appear dilated. The cyst did
not appear to communicate with the main pancreatic duct. FNA was
performed. Color doppler was used to determine an avascular
path for needle aspiration. A 22-gauge needle with a stylet was
used to perform aspiration. One needle pass was made into the
cyst. A total of 40 cc of thin, greenish fluid was aspirated
from the cyst. Aspirate was sent for cytology, CEA and amylase.
IMPRESSION:
A focused EUS examination was performed with the linear
echoendoscope.
A 6.5 x 6.3 cm cyst was noted in the pancreas with eccentric
thickened walls. A 1 cm soft tissue component was noted along
the wall of the cyst. Multiple thin septations were seen.
The previously placed plastic biliary stent was seen abutting
the cyst.
The PD did not appear dilated. A PD stent was seen.
The cyst did not appear to communicate with the main pancreatic
duct.
FNA was performed. Color doppler was used to determine an
avascular path for needle aspiration. A 22-gauge needle with a
stylet was used to perform aspiration. One needle pass was made
into the cyst.
A total of 40 cc of thin, greenish fluid was aspirated from the
cyst. Aspirate was sent for cytology, CEA and amylase.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Verapamil 120 mg PO Q12H
2. Atenolol 25 mg PO DAILY
3. Diovan HCT (valsartan-hydrochlorothiazide) 320-25 mg oral
DAILY
4. Escitalopram Oxalate 10 mg PO DAILY
5. Evista (raloxifene) 60 mg oral DAILY
6. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Escitalopram Oxalate 10 mg PO DAILY
3. Atenolol 25 mg PO DAILY
4. Diovan HCT (valsartan-hydrochlorothiazide) 320-25 mg oral
DAILY
5. Evista (raloxifene) 60 mg oral DAILY
6. Verapamil 120 mg PO Q12H
7. Ciprofloxacin HCl 500 mg PO Q12H Duration: 5 Days
RX *ciprofloxacin HCl [Cipro] 500 mg 1 tablet(s) by mouth twice
a day Disp #*8 Tablet Refills:*0
8. Outpatient Lab Work
please draw labs for cbc, ast, alt, alp, total bilirubin, pt,
ptt, BUN and creatinin, sodium, potassium, chloride and
bicarbonate
Fax to:
Attn: ___, MD
Phone: ___
Fax: ___
Dx: Cirrhosis
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Obstructive jaundice
SECONDARY DIAGNOSIS:
1. Alcoholic/NASH cirrhosis
2. Internal hemorrhoids
3. Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: DUPLEX DOPP ABD/PEL
INDICATION: ___ year old woman with cirrhosis who presented with BRBPR,
painless jaundice c/f malignancy // evaluate for masses, please obtain with
doppler
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: ___, CT abdomen and pelvis ___.
FINDINGS:
LIVER: The contour of the liver is smooth. There is no focal liver mass.
There is noascites.
DOPPLER EVALUATION:
The main portal vein is patent, with flow in the appropriate direction.
Main portal vein velocity is 30 cm/sec.
Right anterior and posterior portal veins are patent, with antegrade flow.
Hepatofugal flow in the left portal vein.
The main hepatic artery is patent, with appropriate waveform.
Right, middle and left hepatic veins are patent, with appropriate waveforms.
Splenic vein and superior mesenteric vein are patent, with antegrade flow.
BILE DUCTS: Interval development of intra and extrahepatic biliary ductal
dilation involving both hepatic lobes, more pronounced on left. The common
bile duct is markedly dilated and measures 2.4 cm.
PANCREAS: Interval increase in size of pancreatic head/uncinate process cyst
with irregular wall measures 5.3 x 5.6 x 5.9 cm (previously 2.6 x 2.7 x 3.5 cm
in ___.
SPLEEN: Normal echogenicity, measuring 11.8 cm.
KIDNEYS: The right kidney measures 9.9 cm. The left kidney measures 11.3 cm.
Normal cortical echogenicity and corticomedullary differentiation is seen
bilaterally. No hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Interval increase in size of pancreatic head/ uncinate process cyst (3.5 to
5.9 cm) with interval intra and extrahepatic ductal dilation consistent with
obstructive behavior (mass effect versus invasion). Given the elevated
bilirubin, elevated CEA from the cystic lesion aspirates back in ___, and
family history of pancreatic cancer, differential includes serous cyst
adenoma/adenocarcinoma and IPMN/malignant degeneration.
RECOMMENDATION(S): GI consult with potential CD stenting vs MRCP or CT
pancreas.
NOTIFICATION: The findings were discussed with ___ and ___
___, M.Ds. by ___, M.D. on the telephone on ___ at
10:45 AM, 30 minutes after discovery of the findings.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old woman with EtOH/NASH cirrhosis presenting with
hyperbilirubinemia ___ obstructive pancreatic cyst s/p ERCP // Assess known
pancreatic cyst
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 9 mL Gadavist.
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: CT ABDOMEN AND PELVIS DATED ___
FINDINGS:
Non-breath hold technique limits assessment.
Lower Thorax: Bilateral, right greater than left, lower lobe atelectasis.
Trace bilateral, right greater than left pleural effusions. The heart is
enlarged. No pericardial effusion.
Liver: The liver is heterogeneous in signal characteristics with diffuse
peripheral reticular markings hyperintense on the T2 weighted images. The
contours are nodular. This constellation of findings is suggestive of
cirrhosis with confluent fibrosis. In segment 2, there is a 10 x 13 mm lesion
which is incompletely assessed due to a non breath hold technique but may
correspond to the hemangioma seen on the ultrasound dated ___.
There are scattered punctate non-enhancing lesions hyperintense on the T2
weighted images in keeping with biliary hamartoma. The largest hamartoma is
in segment 5 and measures up to 8 mm. There is a trace amount of free fluid
inferior to the liver and adjacent to the duodenum.
Biliary: A common bile duct stent is in situ. There is interval resolution in
the degree of intrahepatic duct dilation. The common bile duct measures up to
13 mm (previously 27 mm) and tapers distally. The gallbladder surgically
absent.
Pancreas: In the head of the pancreas extending into the uncinate process is
large cystic lesion with enhancing thin pseudoseptations. The lesion measures
6.5 x 5.0 x 6.3 cm. No capsule or nodularity. No soft tissue components.
The lesion appears to have mass effect on the adjacent common bile duct.
There are at least 5 cystic lesions scattered throughout the neck and body
ranging in size between 3 and 5 mm. No nodularity. No pancreatic duct
dilation. The parenchyma maintains normal bulk, intrinsic hyperintense T1
signal and enhancement pattern. Peripancreatic stranding and fluid in the
pararenal space on the right is suggestive of interstitial edematous
pancreatitis likely secondary to the recent ERCP.
Spleen: In the superior aspect of the spleen, there are 2 adjacent irregular,
peripherally calcified cystic lesions measuring approximately 38 x 35 and 19 x
11 mm. These lesions are likely secondary to previous trauma. The spleen is
normal in size.
Adrenal Glands: Normal in size and signal characteristics. No focal lesions.
Kidneys: The kidneys are normal in size and signal characteristics. The
corticomedullary differentiation is well-maintained with normal excretion of
contrast on the delayed phase images. There are no solid or cystic lesions.
No hydronephrosis or hydroureter.
Gastrointestinal Tract: The GI tract is of normal caliber throughout. No
mural thickening or abnormal enhancement.
Lymph Nodes: No significant mesenteric, retroperitoneal or porta hepatis
lymphadenopathy by size criteria.
Vasculature: The visualized abdominal aorta and proximal mesenteric vessels
appear patent without any significant areas of narrowing or dilatation.
Osseous and Soft Tissue Structures: Multilevel degenerative changes noted
throughout the thoracolumbar spine. Moderate intervertebral disc space
narrowing is noted at L5/S1 and and L2/3.
IMPRESSION:
1. Large pancreatic cystic lesion in the head and uncinate process with
enhancing pseudoseptations is larger compared to the prior CT scan in ___.
There are additional millimetric cysts scattered throughout the body and tail.
No nodularity or duct dilation. This lesion most likely represents a
side-branch IPMN.
2. Cirrhosis without any evidence of portal hypertension or concerning
lesions.
3. Acute interstitial edematous pancreatitis is likely secondary to recent
ERCP. No peripancreatic fluid collections.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Jaundice, Transfer, Hypotension
Diagnosed with Acute pancreatitis, unspecified, Gastrointestinal hemorrhage, unspecified
temperature: 99.1
heartrate: 90.0
resprate: 18.0
o2sat: 99.0
sbp: 119.0
dbp: 50.0
level of pain: 0
level of acuity: 2.0 | ___ woman with a history of alcoholic and NASH cirrhosis
(liver biopsy ___, pancreatic head mucinous cyst (found in
___, CEA 385, ___ aborted given nodular liver),
hypertension, osteoporosis, and depression who initially
presented to ___ with jaundice, darker urine, and
BRBPR x 2 days, then was transferred to the ___ ED on ___
with CT findings of new 2.3cm CBD dilatation, dilated pancreatic
duct, and enlarging pancreatic cystic mass.
>> ACTIVE ISSUES:
# Biliary Obstruction:
She presented with new jaundice found to have direct
hyperbilirubinemia. OSH CT scan report was notable for intra and
extra hepatic biliary ductal dilation. Abdominal ultrasound here
confirmed biliary ductal dilation with CBD dilation up to 2.3
cm. This also showed interval increase in size of pancreatic
head/uncinate process cyst, 5.3 x 5.6 x 5.9 cm from 2.6 x 2.7 x
3.5 cm in ___. AFP was normal. CA ___ was elevated at 115. She
underwent ERCP on ___ which revealed a 3 cm tight, distal CBD
stricture with severe post-obstructive dilation. Sphincterotomy
was performed, brushings were obtained of the distal CBD
stricture which showed rare atypical glandular epithelial cells,
and a ___ Fr x 8 cm straight plastic biliary stent was placed
across the stricture. Given rising bilirubin levels post-ERCP,
MRCP was performed on ___ which showed enlarging pancreatic
mass since ___, a side-branch IPMN, and acute interstitial
edematous pancreatitis secondary to recent ERCP. She underwent
EUS with FNA of the pancreatic cystic lesion on ___. Forty cc
of fluid was drained from the pancreatic cyst and sent for
cytology which was pending on discharge. Fluid CEA was 244 and
Amylase was 4205. Her total bilirubin levels were downtrending
and she had improving jaundice, icteric sclera, and sublingual
jaundice prior to discharge.
>> RESOLVED ISSUES:
# Hypotension: Patient initially had BPs to the ___ in the
ED unresponsive to IVF so was admitted to the ICU. Her blood
pressures improved with 2U pRBCs and she did not require
pressors or any additional transfusions. Her hypotension was
felt to be secondary to hypovolemia from blood loss.
# Anemia, Hemorrhoidal Bleeding:
She reported intermittent bright red blood per rectum at home.
She was found to have a drop in Hgb from 11 to 9. She was
transfused 2U pRBC. She underwent EGD and flexible sigmoidoscopy
in the ICU which were notable for portal hypertensive
gastropathy and oozing internal hemorrhoids, not requiring
intervention. She was initiated on IV Pantoprazole 40mg Q12H,
which was transitioned to PO Pantoprazole 40mg QD on discharge.
She continued to have minimal bleeding from her internal
hemorrhoids during this hospital admission, though with stable
Hgb 9 and no additional blood transfusion requirements. She was
started on a hemorrhoidal suppository with good effect.
# Acute Kidney Injury: Patient initially presented with Cr 1.5,
which resolved to 0.9 with intravenous fluids and transfusion of
2U pRBCs. Post-ERCP, she had a Cr bump to 1.4. She received
100g total of 25% albumin on ___, with normalization of Cr to
her baseline of 1.0.
>> STABLE ISSUES:
# EtOH and NASH Cirrhosis:
___ Class B, MELD 10. Patient has biopsy-proven cirrhosis
with a combination of alcoholic (3 glasses of wine/day for 30+
years) and NASH etiology. For volume, the patient had no signs
of ascites and did not receive diuretics. For infection, she was
started on PO Ciprofloxacin 500mg BID x 5 days for
intra-abdominal infection prophylaxis after her ERCP on ___ and
after EUS on ___ (antibiotic course will be complete on ___.
For bleeding, the patient had decreasing episodes of BRBPR
during her admission (please see Anemia, Hemorrhoidal Bleeding
above). For encephalopathy, the patient was alert and oriented
without asterixis and did not receive Lactulose or Rifaximin.
# Coagulopathy:
Patient had a supratherapeutic INR of 1.5 on admission. She
underwent an IV vitamin K challenge with 5mg QD x 3 days with no
change in INR. Therefore her supratherapeutic INR is thought to
be secondary to synthetic dysfunction from cirrhosis.
# Hypertension: Patient's home Verapamil 120mg twice a day,
Valsartan-HCTZ 320-25mg daily, and Atenolol 25mg daily were
initially held in the setting of initial hypotension. BP meds
resumed at discharge with stable Blood pressures.
# Cardiomegaly: Patient has known cardiomegaly on CXR but no
history of heart failure, denying dyspnea and syncope. ___ TTE
showed LVH and "systolic anterior motion of the mitral valve
with significant outflow tract gradient." No history of heart
failure. Can consider cardiac MRI as outpatient to distinguish
hypertensive myopathy from hypertrophic obstructive
cardiomyopathy.
# Osteoporosis: Patient continued taking her home Raloxifene
60mg daily.
# Depression: Patient continued taking her home Escitalopram
10mg daily.
>> TRANSITIONAL ISSUES:
[ ] Repeat ERCP in ___ weeks (___) for removal of PD and
biliary stents and reevaluation: ERCP will contact patient to
schedule follow up
[ ] Repeat CA ___ in 4 weeks.
[ ] Given cardiomegaly, consider cardiac MRI (___) as
outpatient to distinguish hypertensive myopathy from
hypertrophic obstructive cardiomyopathy.
[ ]Follow up pancreatic mass FNA pathology results
[ ]Ciprofloxacin given prophylactically post EUS X 5 DAYS |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cipro / bupropion / seasonal / cats / cherries / latex
Attending: ___.
Chief Complaint:
Hypoglycemia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a pleasant, morbidly obese ___ w/ PMH ___
gastric bypass, opioid abuse, depression who syncopized
yesterday at work. She first noticed decreased peripheral
vision and lightheadedness moments before the event, began
drinking sugared soda to decrease her symptoms, but syncopized
regardless. She awoke surrounded by coworkers and paramedics,
who noted no incontinence, tongue laceration, or ___
confusion. they gave her juice and crackers and her sx abated.
She denied nausea, shaking, or palpitations preceding the event.
Pt declined transfer to medical care and proceeded home w/
boyfriend. ___ sx continued this morning, so she
decided to present to outpatient medical care, where she was
found w/ a [Glu = 65], and her PCP recommended transfer to the
___ ED. During transfer, she received glucose paste, had some
symptomatic relief, but then experienced quick return of
symptoms before arrival to the ED.
The pt reports her sx -- lightheadness, decreased alertness,
mild nausea, shakes -- began approx 1mo ago, but she noted sx
abatement w/ chocolate and sweet foods and had been
___. She does not notice sx agitation w/ activity or
fasting. Pt describes GDM w/ her second ___ pregnancy,
but she currently takes no hyperglycemic medications such as
insulin. Pt underwent gastric bypass surgery in ___ and
reported a net loss of 75 pounds.
Endocrinology/PCP ___ UTI is unrelated to symptoms.
Frequent small meals is not working for her. Recommends
admission for glucose monitoring, CT scan for insulinoma
In the ED, initial vital signs were 98.7 92 125/77 18 99%.
Labs were notable for FSBG in ED 154 and 83, UCG: Negative, UA
Yellow Hazy 1.021 pH 6.5 Urobil 4 Bili Neg Leuk Lg Bld Neg Nitr
Pos Prot Tr Glu Neg Ket Neg RBC 6 WBC>182 Bact Mod Yeast None
Epi
- H/H 11.0/33.2, WBC 6.9.
Patient was given 0.5mg Lorazepam PO once, Nitrofurantoin 100mg
q12, 1L NS.
On Transfer Vitals were: T98.0, 86, 116/89, 18, 99%/RA
Review of Systems:
(+) constipation (long history), headache (reports migraine
history)
(-) fever, chills, night sweats, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
- ___ Gastric bypass (___) c/b ventral hernia s/p mesh
repair
- ?Lap Cholescystecomy
- R Ant thigh pain
- Obesity
- Seasonal rhinitis
- Insomnia
- Depression
- Percocet abuse
- Migraines
Social History:
___
Family History:
Father with DM2. Mother with HLD, possible fibroid uterus.
Both children in good health.
Physical Exam:
EXAM ON ADMISSION
Vitals: 98.8 afebrile otherwise, 109/69, HR 88, 18, 98%/RA, Glu:
97
General: Morbidly obese female in NAD, interactive w/ examiner,
alert and oriented X3
HEENT: Atraumatic, normocephalic, EOMI/PERRL, anicteric sclera,
pink conjuctiva w/o injection, MMM, clear buccal surfaces, poor
dentition w/ multiple missing teeth
Lymph: no cervical, postauricular, supra/infraclavicular LAD
appreciated
CV: RRR, no m/r/g but exam limited by body habitus
Lungs: CTAB, no crackles, wheezing, or rhonchi
Abdomen: exam severely limited by body habitus; ND, NT in all
quadrants; no masses appreciated; no rebound or guarding;
prominent longitidual scar and satellite laparoscopic scars
GU: deferred
Ext: ___ strength in all extremities, no myalgias or deformities
Neuro: CN ___ intact, intact sensation in all extremities
Skin: linear erythematous rash distal to suprapubic pannus
EXAM ON DISCHARGE
Vitals: 98.8 afebrile otherwise, 109/69, HR 88, 18, 98%/RA, Glu:
107 (130, 103, 91, 99)
General: Morbidly obese female in NAD, interactive w/ examiner,
alert and oriented X3
HEENT: Atraumatic, normocephalic, EOMI/PERRL, anicteric sclera,
pink conjuctiva w/o injection, MMM, clear buccal surfaces, poor
dentition w/ multiple missing teeth
Lymph: no cervical, postauricular, supra/infraclavicular LAD
appreciated
CV: RRR, no m/r/g but exam limited by body habitus
Lungs: CTAB, no crackles, wheezing, or rhonchi
Abdomen: exam severely limited by body habitus; ND, NT in all
quadrants; no masses appreciated; no rebound or guarding;
prominent longitidual scar and satellite laparoscopic scars
GU: deferred
Ext: ___ strength in all extremities, no myalgias or deformities
Neuro: CN ___ intact, intact sensation in all extremities
Skin: linear erythematous rash inferior to suprapubic pannus,
intrigenous fold
Pertinent Results:
ADMISSION LABS
___ 11:25AM BLOOD ___
___ Plt ___
___ 11:25AM BLOOD ___
___
___ 11:25AM BLOOD Plt ___
___ 11:25AM BLOOD ___
___
DISCHARGE LABS
___ 06:50AM BLOOD ___
___ Plt ___
___ 06:50AM BLOOD Plt ___
___ 06:50AM BLOOD ___
___
PERTINENT LABS
___ 06:50AM BLOOD ___
___ 06:50AM BLOOD ___
___ 01:20PM URINE ___ Sp ___
___ 01:20PM URINE ___
___
___ 01:20PM URINE RBC-<1 ___
___
___ 01:20PM URINE ___
___ 01:20PM URINE ___
___ 12:20PM URINE ___
IMAGING/STUDIES
___ ECG
Sinus rhythm. Diffuse T wave flattening which is ___.
No previous tracing available for comparison.
___ CXR
IMPRESSION: No acute cardiopulmonary process.
MICRO
___ URINE URINE CULTURE - MIXED UROGENITAL FLORA
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactaid (lactase) 3,000 unit oral QID:PRN dairy
2. Albuterol Inhaler 2 PUFF IH ___ wheeze, SOB
3. ALPRAZolam 0.5 mg PO QD:PRN anxiety
4. Amitriptyline 75 mg PO QHS
5. ___ mg oral TID:PRN
migraine
6. Citalopram 40 mg PO QAM
7. Gabapentin 600 mg PO BID
8. Gabapentin 1600 mg PO QHS
9. Ibuprofen 600 mg PO Q8H:PRN hip pain, migraine
10. Cyclobenzaprine 5 mg PO TID:PRN muscle spasm
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH ___ wheeze, SOB
2. Amitriptyline 75 mg PO QHS
3. Citalopram 40 mg PO QAM
4. Gabapentin 600 mg PO BID
5. Gabapentin 1600 mg PO QHS
6. Ibuprofen 600 mg PO Q8H:PRN hip pain, migraine
7. Acetaminophen 650 mg PO Q6H:PRN pain
8. Cyanocobalamin 100 mcg PO DAILY
RX *cyanocobalamin (vitamin ___ 100 mcg 1 tab by mouth once a
day Disp #*30 Tablet Refills:*0
9. Multivitamins 1 TAB PO DAILY
10. Vitamin D 800 UNIT PO DAILY
11. ALPRAZolam 0.5 mg PO QD:PRN anxiety
No more than 10 pills per month.
12. ___ mg oral TID:PRN
migraine
No more than 15 pills per month. 6 per day.
13. Lactaid (lactase) 3,000 unit oral QID:PRN dairy
14. Miconazole 2% Cream 1 Appl TP BID
To the irritated areas under your breasts and stomach.
RX *miconazole nitrate 2 % 1 finger tip amount twice a day
Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Borderline hypoglycemia post gastric bypass
- Morbid obesity
- Candidal dermatitis
Secondary:
- Depression
- Anxiety
- Chronic pain
- Migraine headaches
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 syncope, hypoglycemia
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
The cardiac, mediastinal and hilar contours are normal. Pulmonary vasculature
is normal. Minimal atelectasis seen in the lung bases without focal
consolidation. No pleural effusion or pneumothorax is present. No acute
osseous abnormalities are visualized.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Hypoglycemia
Diagnosed with HYPOGLYCEMIA NOS
temperature: 98.7
heartrate: 92.0
resprate: 18.0
o2sat: 99.0
sbp: 125.0
dbp: 77.0
level of pain: 0
level of acuity: 2.0 | ___ w/ ___ ___ gastric bypass, opioid abuse, depression
p/w recent increased fatigue and found to be hypoglycemic.
# HYPOGLYCEMIA: Likely secondary to recently decreased intake;
pt endorsed trying to reduce "junk foods" immediately prior to
onset of symptoms. HbA1c <6, indicating pt has not developed
DM2. Various endocrine pathologies considered included cortisol
deficiency, insulin antibodies, insulinoma, or ___
hyperplasia secondary to gastric bypass surgery
[nesidioblastosis], which appeared much less likely given
glucose stability in the hospital. AM cortisol WNL. Did not
become hypoglycemic on admission so no labs for insulin,
___, or ___ were drawn.
- STARTED ___ and cyanocobalamin 100 mcg PO/NG DAILY
___ ___ bypass
- Rx given for glucometer, lancets, and testing strips to
monitor FSBG when symptomatic
- Follow up with surgeons for further management of diet, workup
of NIPS
# Contaminated urinalysis: intially treated with nitrofurantoin
for ?UTI, though repeat without epis did not show e/o infection.
# NARCOTICS ABUSE: Lives in sober home. Has not used Percocet in
over one year and has agreements on her ___
medications. No narcotics, muscle relaxants, or benzos in the
house. Ibuprofen 600 mg Q8H:PRN pain.
# DEPRESSION/ANXIETY: H/o. Continue home citalopram 40 mg PO QD.
# MIGRAINES: H/o. Home ___
mg oral TID:PRN migraine, can get one/day here. Ibuprofen 600 mg
Q8H:PRN migraine.
# RIGHT HIP, LEG PAIN: H/o. Has had several imaging studies. No
narcotics, muscle relaxants, or benzos in the house. Ibuprofen
600 mg Q8H:PRN pain.
# CANDIDAL DERMATITIS: Physical exam shows erythematous, itching
rash below pt's inferior pannus. Pt describes long history of
rash, occasionally flaring. Candidal dermatitis thought most
likely given high incidence among obese patients and appearance
of rash. Miconazole Powder 2% 1 Appl TP BID
# TRANSITIONAL ISSUES:
- Dental hygiene is poor, needs f/u with dentistry
- Morbid obesity: needs to see gastric bypass surgeon,
nutrition___
- Blood glucose monitoring supplies given at discharge
- Code: FULL
- Emergency Contact: ___ (dad) ___ and ___
___ (mother) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Phenergan
Attending: ___.
Chief Complaint:
Nausea, vomiting
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
This patient is a ___ yo male with history of Horner's syndrome
and lead exposure as a child who presented on ___ for
evaluation of nausea and emesis. He had multiple episodes of
emesis on the 2 days prior to admission; worst was the day prior
to admission when he had approximately ___ episodes of
non-bloody, non-bilious emesis. Unable to tolerate PO. Passing
flatus. No history of abdominal surgeries. He stated that this
was consistent with his prior episodes of vomiting. He had
approximately 5 episodes of similar nausea/vomiting over the
past ___ years, all of which seem to be brought on by work stress.
He endorses abdominal cramping earlier today but no abdominal
pain at present. No recent travel or sick contacts.
He was last seen by his PCP for similar issues on ___. He
reported vomiting ___, did not have diarrhea. He did not
have any abd pain, back pain, urinary frequency, fever at that
time. He denied any recent travel; he thought this might be
related to him working overtime on a startup ___ 80-100
hrs/week. Over the past 12 hours he had felt more dehydrated. He
was given 1 L of IVF and Zofran, and developed a blotchy rash
afterwards thought to be an allergic reaction to the Zofran and
was given a prednisone taper.
In the ED, initial vitals were: 97.2 F, BP 110/80s, HR 110s, RR
20. 100% RA
Exam unremarkable
Labs notable for: Cr 3.0, K 3.0, 10.6, phos 5.9, Mg 2.0, Albumin
6.6, WBC 14.4, Hgb 17.8, plts 478
Imaging notable for: Renal U/S- No hydronephrosis. Mild fullness
of the left renal pelvis with 4 mm layering crystal at the calyx
in the right kidney.
Patient was given:
___ 09:27 PO Aluminum-Magnesium Hydrox.-Simethicone 30 mL
___ 09:27 IV Ondansetron 4 mg
___ 09:27 PO Donnatal 10 mL
___ 09:27 PO Lidocaine Viscous 2% 10 mL
___ 09:27 IVF NS
___ 10:47 IV DiphenhydrAMINE 50 mg
On the floor, he reported that he was feeling better after the
fluids and medications he received in the ED. He stated that his
episodes of vomiting are usually brought on by work stress. He
has self researched the diagnosis of cyclic vomiting syndrome,
and feels he may have this.
Review of systems:
(+) Per HPI. Endorses marijuana use, but this does not seem to
affect his nausea/vomiting. Uses hot showers, but again, these
do not affect nausea/vomiting.
Past Medical History:
Horner syndrome
Lead exposure as a child
*Notably, pt is unaware of either of these diagnoses
Social History:
___
Family History:
Anxiety/depression on father's side.
Physical Exam:
ON ADMISSION
============
VS: 98.3 138/78 83 18 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No rashes/lesions
Neuro: CN: slight L ptosis, slight L miosis. Otherwise CN II-XII
intact. Moving all extremities equally with no ataxia.
ON DISCHARGE
============
VS: 98.7; 63-85; 121/71; 18; 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No rashes/lesions
Neuro: CN: slight L ptosis, slight L miosis. Otherwise CN II-XII
intact. Moving all extremities equally with no ataxia.
Pertinent Results:
ADMISSION LABS
==============
___ 08:35AM BLOOD WBC-14.4* RBC-6.28* Hgb-17.8* Hct-52.6*
MCV-84 MCH-28.3 MCHC-33.8 RDW-12.2 RDWSD-37.2 Plt ___
___ 08:35AM BLOOD Neuts-76.5* Lymphs-15.8* Monos-7.1
Eos-0.0* Baso-0.2 Im ___ AbsNeut-10.99* AbsLymp-2.27
AbsMono-1.02* AbsEos-0.00* AbsBaso-0.03
___ 08:35AM BLOOD Plt ___
___ 08:35AM BLOOD Glucose-143* UreaN-47* Creat-3.0* Na-137
K-3.0* Cl-81* HCO3-28 AnGap-31*
___ 08:35AM BLOOD ALT-35 AST-27 AlkPhos-107 TotBili-1.2
___ 08:35AM BLOOD Lipase-17
___ 08:35AM BLOOD Albumin-6.6* Calcium-10.6* Phos-5.9*
Mg-2.0
___ 01:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 01:27PM URINE Color-Yellow Appear-Clear Sp ___
___ 01:27PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 01:27PM URINE RBC-2 WBC-6* Bacteri-FEW Yeast-NONE
Epi-<1
___ 01:27PM URINE bnzodzp-NEG barbitr-POS* opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG marijua-POS*
IMAGING
=======
RENAL U/S: No hydronephrosis. Mild fullness of the left renal
pelvis with 4 mm layering crystal at the calyx in the right
kidney.
DISCHARGE LABS
========================
___ 07:10AM BLOOD WBC-7.6 RBC-4.99 Hgb-14.5 Hct-42.4 MCV-85
MCH-29.1 MCHC-34.2 RDW-11.9 RDWSD-36.4 Plt ___
___ 07:10AM BLOOD Glucose-104* UreaN-12 Creat-0.8 Na-139
K-4.0 Cl-100 HCO3-28 AnGap-15
___ 07:10AM BLOOD Calcium-9.7 Phos-2.7 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Omeprazole 40 mg PO DAILY
Discharge Medications:
1. LORazepam 0.5 mg PO Q6H:PRN nausea, anxiety Duration: 3 Days
Do not drive or operate heavy machinery while taking this
medication
RX *lorazepam [Ativan] 0.5 mg 0.5 (One half) mg by mouth every
six (6) hours Disp #*10 Tablet Refills:*0
2. Ondansetron 4 mg PO Q8H:PRN nausea Duration: 5 Days
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*30 Tablet Refills:*2
3. Omeprazole 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
=======
Cyclic vomiting syndrome
Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: History: ___ with acute kidney injury// eval for obstruction
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 11.9 cm. The left kidney measures 13.5 cm. There is
mild fullness of the left renal pelvis. 4 mm hyperechogenic focus maybe
echogenic vessel wall, calculus or sinus medullary fat in the left kidney.
There is no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
No hydronephrosis. Mild fullness of the left renal pelvis without
hydronephrosis. 4 mm hyperechogenic focus maybe echogenic vessel wall,
calculus or sinus medullary fat.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Vomiting
Diagnosed with Acute kidney failure, unspecified, Vomiting without nausea
temperature: 97.2
heartrate: 111.0
resprate: 20.0
o2sat: 100.0
sbp: 119.0
dbp: 83.0
level of pain: 5
level of acuity: 3.0 | TRANSITIONAL ISSUES:
-Patient was counseled and given information on stress
management resources.
-Patient was counseled for marihuana cessation
-Will have PCP and GI follow up in the outpatient setting
___ year old male with history of Horner's syndrome who presented
on ___ with intractable nausea and vomiting over previous
several days prior. On admission he presented with ___
(creatinine 3mg/dL) and several laboratory abnormalities
including hyperphosphatemia, hypercalcemia, and hypokalemia.
These all resolved with IV fluids. His nausea was managed with
IV fluid, Ondansetron, and Lorazepam. By the day of discharge he
was able to tolerate oral food and liquids without signs of
dehydration. He met with a social worker and was given stress
management resources. He will follow up with his PCP and GI in
the outpatient setting.
# Cyclic vomiting syndrome
# nausea/vomiting: No reported history of recent ETOH
ingestion. No diarrhea. We could also consider cannabinoid
hyperemesis, given his marijuana use, but his symptoms are
neither relieved nor exacerbated by marijuana. Episodes likely
triggered by increased stressed as every episode he has had has
been during a time of increased stress at work. He was given
bowel rest, antiemetics and IVF with improvement in his
symptoms. He was discharged home with a short course of
lorazepam (10 tabs) and ondansetron. He was counseled to f/u
with his PCP and to contact stress management resources provided
by ___ while inpatient to possibly help prevent further episodes.
# Acute renal failure: also had hyperphosphatemia,
hypercalcemia, and hypokalemia likely in the setting of his ___.
Creatinine on admission was 3 mg/dL. Renal u/s showed a 4-mm
crystal at the calyx, but he denies any dysuria or hematuria.
Repeat labs showed rapid improvement in Cr after IV fluids.
Creatinine 0.7mg/dL on day of discharge.
# Polycythemia (resolved): Due to hemoconcentration given poor
PO intake. Improved to normal after IVF given for hypovolemia in
the setting of nausea/vomiting from likely ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending: ___
Chief Complaint:
Chest pain, SOB
Major Surgical or Invasive Procedure:
Cardiac catheterization (LHC/RHC) ___
History of Present Illness:
___ w/ hx pericarditis c/b pericardial effusion ___ yrs ago (in
the setting of gallbladder surgery) p/w worsening CP and SOB x 6
weeks with worsening over last week and pericardial effusion.
Patient was first diagnosed with pericarditis in the setting of
hospitalization for cholecystectomy ___ years ago. She has since
had intermittent short courses of pericarditis ___ time per
year. In ___, she was hospitalized for pericarditis
with effusion. During that hospitalization she was given a
course of prednisone and started on colchicine. Since then,
patient has had frequent (most days) chest pain and worsening
SOB with exertion. Her exercise tolerance has severely
decreased. She had seen her cardiologist in ___ who
suggested that she follow up at ___ for evaluation with Dr.
___ w/RHC/LHC. She presented to ___ last week when she
got a cardiac MRI (results still pending). Over the last week
she has had increasing amount of pain. On the morning of
presentation she reported her typical left sided pain that was
worse with laying flat and deep inspiration with radiation to
her right side and jaw. This has been worse than before and
promted her to go to OSH for further evaluation. Her SOB and CP
worse with exertion and when lying supine. When walking 400m she
becomes lightheaded and feels like she is going to faint. Last
time she could exercise was 2 months ago (avid runner and
surfer). Denies fevers/ vomiting/ diarrhea/ coughing. Feels
nauseous. States she recently developed PVCs for which she is
taking mag oxide. Denies any joint pain or swelling.
In the ED, initial vitals were 97 80 114/87 14 97% RA
EKG: NSR 74, no e/o ischemia, no e/o electrical alternans or low
voltage
Labs/studies notable for: CBC, Chem-10, proBNP, coags WNL. Trop
x 1 negative.
Patient was given:
___ 16:19 IVF 1000 mL NS 1000 mL
___ 16:40 IV HYDROmorphone (Dilaudid) .5 mg
Past Medical History:
- Pericarditis, first diagnosed ___ years ago in the perioperative
setting. Attributed at first to viral pericarditis. Frequent
recurrences since.
- Depression
- Gastric ulcers documented on two endoscopies, one in ___ and one in ___
- Cholecystectomy in ___ for recurrent right upper quadrant
pain, and a sphincterotomy and stent placement in the common
bile duct for recurrent stones in ___.
- Hysterectomy and oophorectomy in ___ for "precancerous
changes,"
- Appendectomy
Social History:
___
Family History:
Dementia in her mother, coronary disease in her father, and a
brother with a cerebral arteriovenous malformation, possibly
secondary to trauma.
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributor
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
Vitals: 98 100/41, 70, 18, 98% RA
General: Well appearing woman in NAD.
HEENT: NC/AT. MMM. PERRL, EOMI
Neck: No JVD
CV: RRR, no murmurs, gallops. No friction rub
Lungs: CTAB, no pleural rub. Symmetric breath sounds
Abdomen: S/nt/nd
Extr: No edema, no hemosiderin staining
Neuro: CN ___ intact and symmetric. Strength ___ throughout
Skin: no rash
DISCHARGE PHYSICAL EXAM:
VS: T= 97.6 BP= 94/55 HR= 61 RR= 18 O2 sat=98RA
I/O: Not recorded
Wt: Not recorded
General: Well appearing woman in NAD.
HEENT: NC/AT. MMM. PERRL, EOMI
Neck: No JVD
CV: RRR, no murmurs, gallops. No friction rub
Lungs: CTAB, no pleural rub. Symmetric breath sounds
Abdomen: S/nt/nd
Extr: No edema, no hemosiderin staining
Neuro: CN ___ intact and symmetric. Strength ___ throughout
Skin: no rash
Pertinent Results:
Pertinent Labs:
___ 04:20PM BLOOD WBC-7.4 RBC-4.31 Hgb-13.2 Hct-38.5 MCV-89
MCH-30.6 MCHC-34.3 RDW-13.2 RDWSD-42.8 Plt ___
___ 06:18AM BLOOD WBC-5.2 RBC-3.67* Hgb-11.0* Hct-33.1*
MCV-90 MCH-30.0 MCHC-33.2 RDW-13.1 RDWSD-43.0 Plt ___
___ 04:20PM BLOOD CK-MB-1 proBNP-38
___ 04:20PM BLOOD cTropnT-<0.01
___ 04:20PM BLOOD CRP-0.6
___ 06:55AM BLOOD ___
Studies:
___ cardiac MRI
The left atrial AP dimension is normal with normal left atrial
length. The interatrial septum is dynamic. Right atrial size is
normal. There is normal left ventricular wall thickness and
normal mass index. Normal left ventricular end-diastolic
dimension with normal left ventricular end-diastolic volume.
There is normal regional and global left ventricular systolic
function with normal ejection fraction. There is no left
ventricular late gadolinium enhancement (absence of
scar/fibrosis). Normal right ventricular cavity size with normal
free wall motion and normal ejection fraction. Normal origin of
the right and left main coronary arteries. Normal ascending
aorta diameter and normal descending thoracic aorta diameter.
Normal abdominal aorta diameter. Normal pulmonary artery
diameter. The aortic valve has 3 leaflets. There is no aortic
valve stenosis and trace aortic regurgitation. There is trivial
mitral regurgitation. There is no tricuspid regurgitation. There
is a small circumferential pericardial effusion, most prominent
inferiorly (measuring up to 0.9 cm) and apically, with normal
pericardial thickness. There is no evidence of pericardial
tethering and no evidence of early or late gadolinium
enhancement. No evidence of constriction is seen.
IMPRESSION: Normal left ventricular mass, cavity size and
regional/global systolic function. Normal right ventricular
cavity size and free wall motion. Small circumferential
pericardial effusion most prominent inferiorly and apically.
Normal pericardial thickness, with no evidence of tethering,
late gadolinium enhancement or constriction. The CMR findings
are not consistent with acute or chronic constrictive
pericarditis.
___ TTE:
The left atrium is normal in size. The estimated right atrial
pressure is ___ mmHg. Left ventricular wall thickness, cavity
size and regional/global systolic function are normal (LVEF =
60%). Tissue Doppler imaging suggests a normal left ventricular
filling pressure (PCWP<12mmHg). Right ventricular chamber size
and free wall motion are normal. The diameters of aorta at the
sinus, ascending and arch levels are normal. The aortic valve
leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve appears structurally normal with trivial mitral
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion. There is an
anterior space which most likely represents a prominent fat pad.
There is no pericardial thickening. There is no evidence of
pericardial constriction.
IMPRESSION: no pericardial effusion; no pericardial constriction
___ c. cath
Coronary Anatomy
Dominance: Right
The LMCA, LAD, Cx and RCA were all free of angiographically
apparent CAD.
Impressions:
1. Low filling pressures.
2. Preserved Cardiac output.
3. No coronary artery disease.
4. No hemodynamic evidence for constrictive pericarditis
(Concordance with LV/RV measurement) with
IVF administered.
Recommendations
1. Continue medical management.
2. Follow-up Dr. ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Colchicine 0.6 mg PO DAILY
2. Magnesium Oxide Dose is Unknown PO DAILY
3. Fluoxetine 20 mg PO DAILY
Discharge Medications:
1. Fluoxetine 20 mg PO DAILY
2. Magnesium Oxide 400 mg PO DAILY
3. Indomethacin 25 mg PO TID Duration: 2 Weeks
RX *indomethacin 25 mg 3 capsule(s) by mouth Every 8 hours Disp
#*36 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Costochondritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with pericardial effusion // eval for pleural effusions
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: None.
FINDINGS:
The lungs are clear. The cardiomediastinal silhouette is within normal
limits. No acute osseous abnormalities identified. Mild mid thoracic
dextroscoliosis is noted.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Transfer
Diagnosed with Chest pain, unspecified, Dyspnea, unspecified
temperature: 97.0
heartrate: 80.0
resprate: 14.0
o2sat: 97.0
sbp: 114.0
dbp: 87.0
level of pain: 3
level of acuity: 2.0 | Ms. ___ is a ___ year old woman w/ a hx of pericarditis c/b
pericardial effusion ___ yrs ago p/w worsening CP and SOB x 1 week
and pericardial effusion on echo.
# Chest pain, costochondritis: Pt has reported history of
pericarditis sarting ___ years ago with multiple subsequent
episodes. She presented with chest pain, SOB, and decreased
exercise tolerance for 3 months. She had a cardiac MRI that was
pending from week before discharge that showed small effusion
but no evidence of active inflammation or restrictive heart
disease. She underwent cardiac catherization with right and left
cath which showed no significan CAD and normal filling
pressures. Her left sided chest pain was reproducible on exam on
presentation. She was started on indomethacin with improvement
in her pain. Pain is likely musculoskeletal with costochondritis
most likely. She is being discharged on NSAID regimen. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: PODIATRY
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Necrotizing Infection of Left Foot
Major Surgical or Invasive Procedure:
___: DEBRIDEMENT LEFT FOOT DOWN TO AND INCLUDING BONE, TOTAL
AREA DEBRIDED = 84sq.cm. OPEN RAY AMPUTATIONS ___ & ___ TOES,
LEFT FOOT
___: INCISION AND DRAINAGE LEFT FOOT MULTIPLE SPACES BELOW
FASCIA/FASCIOTOMY, EXCISION OF EXTENSOR TENDONS, ___ METATARSAL
OPEN BONE BIOPSY
___: TRANSMETATARSAL AMPUTATION, LEFT FOOT APPLICATION OF 4
BY 5 INTEGRA GRAFT LEFT FOOT ACHILLES TENDON LENGTHENING, LEFT
FOOT
History of Present Illness:
Patient is a ___ male with history of
non-insulin-dependent diabetes complicated by neuropathy and
necrotizing fasciitis of his right foot ___ ___ who
presents for evaluation of fevers and worsening left foot
pain. Patient is known to have a left diabetic foot wound that
is
currently being managed by Dr. ___ with collagen and
calcium alginate. 4 days ago, the patient noted significant pain
and swelling around the site of the wound. He states he has been
having intermittent fever since that time. Today, the
patient had a temperature to 102.1. Patient notes pain up to
his ankle, but denies any extension of his leg. Patient was
evaluated ___ the ED by podiatric surgery was determined to have
soft tissue gas extending to the dorsal midfoot. Due to his
systemic symptoms, elevated white count, and gas on x-ray,
patient was taken urgent to the OR for an incision and drainage
w/ radical debridement to soft tissue and bone. Patient will be
admitted to the podiatric surgery service and further managed.
Patient seen at bedside ___ PACU resting comfortably. Tolerated
anesthesia well. Micro and path sent from OR. Admits to ___
pain
to his L foot at this time. Denies any n/v/f/c/sob.
Past Medical History:
DM2, HTN, HLD
Past Surgical History:
testicular "varicose vein" surgery as child, stitches from
sports, R thumb surgery
Social History:
___
Family History:
Mother and father with DM, Mother with HTN, no cancers
Physical Exam:
======================
ADMISSION PHYSICAL EXAM
======================
General: Mild distress, A&Ox3
Lungs: Clear to auscultation, normal effort
Cardiovascular: Normal first and second heart sounds,
tachycardic
Abdominal: Soft, Nontender
Lower Extremity Exam: Surgical dressing intact to L foot. No
saturation noted. Able to wiggle digits. Diffuse tenderness
surrounding surgical site.
======================
DISCHARGE PHYSICAL EXAM
======================
Vitals:
Temp: 98.2F BP: 159/76 HR: 62 RR:16 SpO2: 97% Ra
General: Mild distress, A&Ox3
Lungs: Clear to auscultation, normal effort
Cardiovascular: Normal first and second heart sounds,
tachycardic
Abdominal: Soft, Nontender
Lower Extremity Exam: Incisions well-coapted with sutures intact
to left
TMA site; no purulence expressed. No erythema, no edema. No
tenderness with calf compression.
Pertinent Results:
=============
ADMISSION LABS
=============
___ 06:50PM BLOOD WBC-13.0* RBC-3.31* Hgb-10.1* Hct-29.7*
MCV-90 MCH-30.5 MCHC-34.0 RDW-12.3 RDWSD-40.3 Plt ___
___ 06:50PM BLOOD Neuts-85.0* Lymphs-4.4* Monos-8.1
Eos-0.2* Baso-0.2 Im ___ AbsNeut-11.07* AbsLymp-0.57*
AbsMono-1.05* AbsEos-0.03* AbsBaso-0.03
___ 06:50PM BLOOD Glucose-232* UreaN-20 Creat-1.6* Na-135
K-4.2 Cl-101 HCO3-20* AnGap-14
___ 07:09PM BLOOD Lactate-2.1*
==============
DISCHARGE LABS
==============
___ 05:52AM BLOOD WBC-8.1 RBC-2.80* Hgb-8.4* Hct-25.6*
MCV-91 MCH-30.0 MCHC-32.8 RDW-13.4 RDWSD-44.8 Plt ___
___ 05:52AM BLOOD Glucose-110* UreaN-10 Creat-1.6* Na-141
K-4.1 Cl-105 HCO3-25 AnGap-11
___ 05:52AM BLOOD Calcium-8.2* Phos-3.4 Mg-1.7
==============
PERTINENT LABS
==============
___ 06:19AM BLOOD %HbA1c-6.1* eAG-128*
___ 06:04AM BLOOD CRP-118.2*
___ 05:52AM BLOOD CRP-79.2*
=============
MICROBIOLOGY
=============
___ 6:57 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture x2, Routine (Final ___: NO GROWTH.
=====
___ 8:50 pm SWAB LEFT FOOT ABSCESS.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND SINGLY.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
WOUND CULTURE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
___ this
culture.
Work-up of organism(s) listed discontinued (except
screened
organisms) due to the presence of mixed bacterial flora
detected
after further incubation.
GRAM NEGATIVE ROD(S). SPARSE GROWTH.
ANAEROBIC CULTURE (Final ___:
Mixed bacteria are present, which may include anaerobes
and/or
facultative anaerobes. The presence of B.fragilis,
C.perfringens, and
C.septicum is being ruled out.
BACTEROIDES FRAGILIS GROUP. MODERATE GROWTH.
BETA LACTAMASE POSITIVE.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
=====
___ 9:18 am TISSUE LEFT THIRD METATARSAL.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI ___
PAIRS.
SMEAR REVIEWED; RESULTS CONFIRMED.
TISSUE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
VIRIDANS STREPTOCOCCI.
Isolated from broth media only, INDICATING VERY LOW
NUMBERS OF
ORGANISMS.
ANAEROBIC CULTURE (Preliminary): RESULTS PENDING.
=====
___ 9:00 am SWAB LEFT FOOT ABSCESS.
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI ___
PAIRS.
WOUND CULTURE (Final ___:
MIXED BACTERIAL FLORA.
This culture contains mixed bacterial types (>=3) so an
abbreviated workup is performed. Any growth of
P.aeruginosa,
S.aureus and beta hemolytic streptococci will be
reported. IF
THESE BACTERIA ARE NOT REPORTED, THEY ARE NOT PRESENT
___ this
culture.
ANAEROBIC CULTURE (Preliminary):
Mixed bacteria are present, which may include anaerobes
and/or
facultative anaerobes. The presence of B.fragilis,
C.perfringens, and
C.septicum is being ruled out.
=======
IMAGING
=======
Left Foot X-Ray (___):
IMPRESSION:
1. Soft tissue gas involving the left forefoot and midfoot
concerning for necrotizing soft tissue infection.
2. Heel spurs.
3. No signs of osteomyelitis.
=====
Left Foot X-Ray (___):
Final Report
INDICATION: ___ year old man with necrotizing infection of left
foot no s/p
TMA with dorsal foot skin graft// Post op eval
COMPARISON: Compared to prior study from ___
IMPRESSION:
There has been transmetatarsal amputation of the left forefoot.
There is
overlying soft tissue swelling and bandaging material which
limits fine bony
detail. No acute fractures are seen. There is a prominent
inferior calcaneal
spur.
=====
Chest X-Ray (___):
IMPRESSION:
Right-sided PICC line terminates ___ the right atrium, although
exact position
is difficult to estimate. If positioning at the cavoatrial
junction is
desired, recommend withdrawal by 3 cm.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. MetFORMIN (Glucophage) 850 mg PO BID
3. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
Discharge Medications:
1. CefTRIAXone 2 gm IV Q24H
RX *ceftriaxone ___ dextrose,iso-os 2 gram/50 mL 2 g IV q24hours
Disp #*19 Intravenous Bag Refills:*0
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth Twice daily Disp
#*20 Tablet Refills:*0
3. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild NOT relieved by
Acetaminophen
RX *ibuprofen 600 mg 1 tablet(s) by mouth Every 6 hours Disp
#*30 Tablet Refills:*0
4. MetroNIDAZOLE 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth Three times a day
Disp #*54 Tablet Refills:*0
RX *metronidazole 500 mg 1 tablet(s) by mouth Three times a day
Disp #*57 Tablet Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth Every 6 hours Disp
#*15 Tablet Refills:*0
6. Senna 8.6 mg PO BID:PRN Constipation - First Line
RX *sennosides [senna] 8.6 mg 1 Tablet by mouth Twice daily Disp
#*20 Tablet Refills:*0
7. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
RX *acetaminophen 500 mg ___ tablet(s) by mouth Every 6 hours
Disp #*30 Tablet Refills:*0
8. Lisinopril 20 mg PO DAILY
9. MetFORMIN (Glucophage) 850 mg PO BID
Discharge Disposition:
Home With Service
Facility:
___
___ Diagnosis:
Left Foot Necrotizing Infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old man with necrotizing infection of left foot no s/p
TMA with dorsal foot skin graft// Post op eval
COMPARISON: Compared to prior study from ___
IMPRESSION:
There has been transmetatarsal amputation of the left forefoot. There is
overlying soft tissue swelling and bandaging material which limits fine bony
detail. No acute fractures are seen. There is a prominent inferior calcaneal
spur.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with new line// new right PICC 52 ___ ___
Contact name: ___: ___
COMPARISON: Chest radiographs ___
FINDINGS:
Single semi upright portable AP view of the chest is provided.
Compared to prior, lung volumes have decreased. There is no focal
consolidation. A right-sided PICC line is seen with tip in the right atrium,
although exact location is difficult to estimate. There is mild pulmonary
vascular engorgement without frank edema. The cardiomediastinal silhouette is
enlarged, increased in size compared to ___. Probable small
bilateral pleural effusions, left greater than right. There is no
pneumothorax.
IMPRESSION:
Right-sided PICC line terminates in the right atrium, although exact position
is difficult to estimate. If positioning at the cavoatrial junction is
desired, recommend withdrawal by 3 cm.
Low lung volumes and mild cardiomegaly, new from ___.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: L Foot pain
Diagnosed with Necrotizing fasciitis
temperature: 100.0
heartrate: 125.0
resprate: 16.0
o2sat: 98.0
sbp: 152.0
dbp: 75.0
level of pain: 8
level of acuity: 2.0 | The patient presented to the emergency department and was
evaluated by the podiatric surgery team. The patient was found
to have a necrotizing infection of the left foot and was taken
to the operating room immediately on ___. Afterwards, he was
admitted to the podiatric surgery service. For full details of
the procedures, please see the separately dictated operative
reports.
The patient was taken from the OR to the PACU ___ stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor for further management with packed-open
wound. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet by POD#1. On
POD2, ___, he was taken back to the OR for an incision and
drainage.
On ___, he was taken back for a definite left
transmetatarsal amputation, percutaneous tendo Achilles
lengthening with Integra graft to the dorsal foot. He was placed
___ a posterior splint and the dressing was left intact until
POD2, ___.
Initially, he was managed on IV Vancomycin, Metronidazole and
Clindamycin. Infectious Disease evaluated him and recommended a
final home course of 2 grams IV Ceftriaxone daily as well as PO
Flagyl through ___ (3 weeks from last surgical date). He
will have weekly surveillance labs (CBC/Diff, Cr, CRP, LFTs)
drawn weekly and sent to the Infectious Disease office. After
the three weeks of antibiotic treatment and final pathology
results are reviewed, the need for continuation of antibiotic
therapy will be reassessed.
Physical therapy was consulted. The patient worked with ___ who
determined that discharge to home was appropriate. The patient's
home medications were continued throughout this hospitalization.
The ___ hospital course was otherwise unremarkable.
The patient was given anticoagulation per routine for each
procedure and while an inpatient. 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 NWB to the LLE lower extremity. 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:
Sulfa (Sulfonamide Antibiotics)
Attending: ___.
Chief Complaint:
Toxic metabolic encephalopathy
Major Surgical or Invasive Procedure:
___ PICC placement
History of Present Illness:
Ms. ___ is a ___ y/o female with a PMHx of diastolic heart
failure and sick sinus syndrome who is presenting from her
assisted living facility with altered mental status. Her
daughter notes that she has had a worsening mental status over
the last 6 weeks, with a more acute decline over the last
several days. She was recently seen at her PCP's office for
worsening ___ edema L > R. She had a fever prior to that visit
which resolved with Tylenol but has not had any fevers since
then. Her home torsemide was increased. A b/l ___ ultrasound did
not show DVT (___). Blood work at that time had a WBC of 22
(baseline ___ and stable kidney function with Cr 1.1
(baseline 0.9-1.1).
In the ED, VS: 97.1 110 107/69 22 93% RA
Notable labs: WBC 32.1 with 89% PMNs and 4% bands, H/H
11.5/40.2. Cr 1.2, lactate 2.7. VBG 7.4/___. UA with large
leuks, 12 RBCs, 17 WBCs, neg nitrites, no bacteria.
Imaging: CXR with bilateral pleural effusions (full read below).
She was given vancomycin and Zosyn.
On arrival to the MICU, she was somnolent but arousable. Denied
any specific complaints.
REVIEW OF SYSTEMS: Limited due to somnolence. Denies any pain
including her leg. Denies trouble breathing. Feels "fine."
Family reports only subacute decline in mental status,
increasing ___ edema and redness.
Past Medical History:
1. Hypertension.
2. Osteoarthritis.
3. Peripheral edema.
4. Prolapsed bladder, pessary with multiple infections largely
handled by a ___ gynecologists
5. Hypercholesterolemia.
6. Cataracts.
7. Obesity
8. Atrial fibrillation on Apixaban
9. Pelvic schwannoma ___. Larger in ___.
10. Herpes Zoster, facial, ___.
11. dCHF
12. Sick sinus syndrome, s/p PPM in ___
13. COPD
Social History:
___
Family History:
Mother: unknown heart disease
Father: died young in car crash
MGM: Liver cancer.
Physical Exam:
ADMISSION PHYSICAL:
=======================
Vitals: T: 97.9, BP: 91/62, P: 106, R: 17, O2: 99% on 2L NC
GENERAL: Somnolent but arouses to voice, no acute distress
HEENT: R eye with senile ectropion, anicteric sclera, dry MM,
oropharynx clear, dentures
NECK: examination limited by size
LUNGS: course breath sounds bilaterally anteriorly, non-labored
CV: Distant heart sounds, limited by habitus, irregular
ABD: Obese, soft, NT/ND, +BS
EXT: Bilateral ___ are grossly erythematous to the thighs, LLE
with large erythematous area of the shin that is warm but not
tender
Neuro: Moves all extremities with purpose, Alert and oriented x
3
DISCHARGE PHYSICAL:
=======================
VS - T 97.7 HR 72-130 BP 136/92 RR 18 I/O ___ (-900)
General: obese, grumpy, nontoxic, in no acute distress
HEENT: bright erythema at lower eyelid; no erythema in eye; no
scleral icterus; mmm; nl op
Neck: supple, JVP 10
CV: tachycardic, irregular rhythm, no m/r/g
Lungs: on ra, no cough; decreased breath sounds at bases
bilaterally
Abdomen: obese, soft, NT/ND, +bs, no masses
GU: foley in place; draining clear yellow fluid
Ext: 3+ edema in bilateral ___ 6cm area of increased erythema
at left medial calf, marked, warm, non-tender; tiny (2mm)
punctated lesion in center with small amount of pus; no dusky
skin, no crepitus
Neuro: A&O to person, place (___), but not time; confused
Skin: no other areas of cellulitis
Pertinent Results:
ADMISSION LABS:
=============================
___ 10:49AM BLOOD WBC-32.1* RBC-4.43 Hgb-11.5 Hct-40.2
MCV-91 MCH-26.0 MCHC-28.6* RDW-18.7* RDWSD-59.5* Plt ___
___ 10:49AM BLOOD Neuts-89* Bands-4 Lymphs-1* Monos-4*
Eos-0 Baso-0 Atyps-1* Metas-1* Myelos-0 NRBC-3* AbsNeut-29.85*
AbsLymp-0.64* AbsMono-1.28* AbsEos-0.00* AbsBaso-0.00*
___ 02:58AM BLOOD ___ PTT-25.8 ___
___ 10:49AM BLOOD Glucose-214* UreaN-38* Creat-1.2* Na-139
K-4.5 Cl-100 HCO3-23 AnGap-21*
___ 12:02PM BLOOD ___ pO2-55* pCO2-45 pH-7.40
calTCO2-29 Base XS-1
___ 10:52AM BLOOD Lactate-2.7*
___ 11:59PM BLOOD Lactate-1.1
PERTINENT LABS:
============================
___ 05:45AM BLOOD WBC-14.8* RBC-4.31 Hgb-10.9* Hct-39.4
MCV-91 MCH-25.3* MCHC-27.7* RDW-18.9* RDWSD-61.4* Plt ___
___ 01:20PM BLOOD WBC-16.1* RBC-4.20 Hgb-10.8* Hct-38.4
MCV-91 MCH-25.7* MCHC-28.1* RDW-19.0* RDWSD-61.1* Plt ___
___ 04:43AM BLOOD WBC-15.0* RBC-4.12 Hgb-10.8* Hct-37.4
MCV-91 MCH-26.2 MCHC-28.9* RDW-18.6* RDWSD-60.2* Plt ___
___ 08:28AM BLOOD WBC-20.6* RBC-4.84 Hgb-12.5 Hct-44.4
MCV-92 MCH-25.8* MCHC-28.2* RDW-19.1* RDWSD-61.0* Plt ___
___ 06:52AM BLOOD WBC-22.2* RBC-4.43 Hgb-11.4 Hct-40.3
MCV-91 MCH-25.7* MCHC-28.3* RDW-18.7* RDWSD-60.5* Plt ___
___ 06:55AM BLOOD WBC-22.1* RBC-4.56 Hgb-11.8 Hct-41.8
MCV-92 MCH-25.9* MCHC-28.2* RDW-18.9* RDWSD-59.9* Plt ___
___ 06:35AM BLOOD WBC-19.6* RBC-4.56 Hgb-11.8 Hct-41.8
MCV-92 MCH-25.9* MCHC-28.2* RDW-19.1* RDWSD-59.4* Plt ___
___ 03:37AM BLOOD WBC-20.2* RBC-4.22 Hgb-11.1* Hct-38.1
MCV-90 MCH-26.3 MCHC-29.1* RDW-18.9* RDWSD-59.9* Plt ___
___ 06:02AM BLOOD WBC-20.6* RBC-4.32 Hgb-11.3 Hct-39.5
MCV-91 MCH-26.2 MCHC-28.6* RDW-19.1* RDWSD-59.9* Plt ___
___ 02:58AM BLOOD WBC-21.7* RBC-3.93 Hgb-10.1* Hct-35.4
MCV-90 MCH-25.7* MCHC-28.5* RDW-18.1* RDWSD-58.4* Plt ___
___ 10:49AM BLOOD WBC-32.1* RBC-4.43 Hgb-11.5 Hct-40.2
MCV-91 MCH-26.0 MCHC-28.6* RDW-18.7* RDWSD-59.5* Plt ___
___ 06:55AM BLOOD ALT-24 AST-19 LD(LDH)-231 AlkPhos-97
TotBili-0.4
___ 10:49AM BLOOD ___
___ 06:52AM BLOOD proBNP-7044*
___ 03:37AM BLOOD calTIBC-321 Ferritn-77 TRF-247
___ 11:59PM BLOOD Lactate-1.1
DISCHARGE LABS:
============================
___ 05:45AM BLOOD WBC-14.8* RBC-4.31 Hgb-10.9* Hct-39.4
MCV-91 MCH-25.3* MCHC-27.7* RDW-18.9* RDWSD-61.4* Plt ___
___ 05:45AM BLOOD Plt ___
___ 05:45AM BLOOD Glucose-168* UreaN-36* Creat-1.3* Na-144
K-4.5 Cl-101 HCO3-33* AnGap-15
___ 05:45AM BLOOD Calcium-9.0 Phos-3.2 Mg-2.0
MICROBIOLOGY:
============================
Urine culture: URINE CULTURE (Final ___:
YEAST. >100,000 ORGANISMS/ML..
___ Blood culture: Blood Culture, Routine (Final ___:
NO GROWTH.
C dif negative
STUDIES:
============================
CXR (___):
IMPRESSION:
Worsening moderate right pleural effusion with adjacent
atelectasis. Probable effusion on the left. Underlying infection
cannot be excluded in the appropriate clinical setting.
CXR ___
Persistent small-moderate bilateral pleural effusions an
adjacent atelectasis, with increasing opacity involving the
right lung. Findings may represent asymmetric pulmonary edema
versus developing pneumonia.
___ CXR:
The patient is markedly rotated on today's study, this limits
assessment. A dual lead pacemaker appears to be unchanged in
position. A right-sided PICC terminates in the mid SVC. The
appearance of increased opacity in the right lung is likely in
part due to projection, in part due to layering pleural
effusion. The left lung appears grossly clear.
IMPRESSION: Allowing for technical differences, there has been
no significant interval change.
TIB FIB XRAY ___
Diffuse edema of the left lower extremity without evidence of
subcutaneous emphysema or focal osseous erosion to suggest
osteomyelitis.
TTE ___
The left atrium is moderately dilated. No atrial septal defect
is seen by 2D or color Doppler. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). There is no
ventricular septal defect. 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. The mitral valve leaflets
are mildly thickened. Mild to moderate (___) mitral
regurgitation is seen. The tricuspid valve leaflets are mildly
thickened. There is moderate pulmonary artery systolic
hypertension. There is no pericardial effusion.
Compared with the prior study (images reviewed) of ___, no
major change.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ female presenting for evaluation of a fever
TECHNIQUE: Portable chest radiograph
COMPARISON: Chest radiograph ___
FINDINGS:
In comparison to the prior radiograph on ___, there is worsening
moderate effusion and adjacent atelectasis on the right. Opacification of the
left lung base is likely due to a combination of pleural effusion and
atelectasis. Underlying consolidation cannot be excluded. No pneumothorax.
Heart borders are difficult to assess due to adjacent effusions. No acute
osseous abnormalities identified. Pacer leads appropriately terminate in the
right atrium and right ventricle.
IMPRESSION:
Worsening moderate right pleural effusion with adjacent atelectasis. Probable
effusion on the left. Underlying infection cannot be excluded in the
appropriate clinical setting.
Radiology Report
INDICATION: ___ year old woman with LLE cellulitis, on Vanc, difficult IV
access // Need IV access for Abx
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: 0.7 min, 1 mGy
PROCEDURE:
1. Double lumen PICC placement through the basilic vein on the right.
PROCEDURE DETAILS: Using sterile technique and local anesthesia, the basilic
vein on the right was punctured under direct ultrasound guidance using a
micropuncture set. Permanent ultrasound images were obtained before and after
intravenous access, which confirmed vein patency. A peel-away sheath was then
placed over a guidewire. The guidewire was then advanced into the superior
vena cava using fluoroscopic guidance. A double lumen PIC line measuring 39 cm
in length was then placed through the peel-away sheath with its tip positioned
in the distal SVC under fluoroscopic guidance. Position of the catheter was
confirmed by a fluoroscopic spot film of the chest. The peel-away sheath and
guidewire were then removed. The catheter was secured to the skin, flushed,
and a sterile dressing applied.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. The accessed vein was patent and compressible.
2. Basilicvein approach double lumen right PICC with tip in the distal SVC.
IMPRESSION:
Successful placement of a right 39 cm basilic approach double lumen PowerPICC
with tip in the distal SVC. The line is ready to use.
Radiology Report
INDICATION: ___ year old woman with CHF, known cellulitis, persistent
leukocytosis // ?pulmonary edema ?infiltrate
COMPARISON: Radiographs from ___
IMPRESSION:
There are low lung volumes with bilateral effusions. There is mild pulmonary
edema. Left-sided dual lead pacemaker is identified.There is a new right-sided
PICC line with the distal lead tip in the distal SVC. Consolidation at the
right base would be difficult to exclude due to the pleural effusion.
Radiology Report
INDICATION: ___ year old woman with LLE cellulitis, persistent leukocytosis
// evidence of osteomyelitis
COMPARISON: Radiographs from ___
IMPRESSION:
No acute fractures or dislocations are seen. There is severe medial
compartmental joint space narrowing which causes varus alignment of the left
knee. There is soft tissue swelling throughout the lower leg. No soft tissue
gas is seen.There is no periostitis to indicate acute osteomyelitis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with heart failure s/p diuresis // pulmonary
edema?
TECHNIQUE: Portable AP chest radiograph.
COMPARISON: Chest radiograph ___
FINDINGS:
The patient is markedly rotated on today's study, this limits assessment. A
dual lead pacemaker appears to be unchanged in position. A right-sided PICC
terminates in the mid SVC. The appearance of increased opacity in the right
lung is likely in part due to projection, in part due to layering pleural
effusion. The left lung appears grossly clear.
IMPRESSION:
Allowing for technical differences, there has been no significant interval
change.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with Altered mental status, unspecified
temperature: 97.1
heartrate: 110.0
resprate: 22.0
o2sat: 93.0
sbp: 107.0
dbp: 69.0
level of pain: 7
level of acuity: 2.0 | ___ w/ dCHF, HTN, prolapsed bladder with pessary, and Afib c/b
SSS s/p PPM who presented with altered mental status, initially
admitted to the MICU for sepsis, thought to be secondary to a
LLE cellulitis. She was treated empirically with Vancomycin ___ - ___ for which a PICC was placed. Following IV
fluid resuscitation, she was subsequently hypoxic, with labs and
exam consistent with acute decompensated heart failure. She was
diuresed with IV Lasix, after which she was resumed on home
torsemide. Given persistent leukocytosis, pessary was removed on
___ due to concern for infection. She will be discharged home
with a foley and will follow up with OBGYN for further
management of her pessary. Pt is ambulatory at baseline and
therefore would benefit from d/c to ___
rehabilitation to maximize functional potential and facilitate
return to PLOF. Family's wishes are for pt to return home with
increased support services.
# ACUTE METABOLIC ENCEPHALOPATHY:
Patient presented with progressive decline over last 6 weeks,
with acute worsening in days leading up to admission. Of note,
she was septic secondary to a LLE cellulitis and was found to be
in decompensated heart failure, which may have caused a
metabolic encephalopathy. CO2 normal on admission. No focal
neurologic deficits. She was initially admitted to the MICU due
to hypotensions requiring pressors. Once blood pressure was
stabalized, patient transferred to the floor on ___. Upon
arrival to floor, patient was alert, but not oriented to place
or time. Per her nursing age, her baseline was much better. She
was treated with Vancomycin IV for 7 days, and white count was
monitored closely. Also monitored for other infections, as
below. Sedating medications were avoided. At time of discharge,
patient is sleepy, but able to wake up. She is oriented to
person, place, and year.
# SEPSIS, LIKELY SECONDARY TO LLE CELLULITIS:
On admission, patient had bilateral lower extremity edema, with
redness, warmth, and erythema in LLE. WBC 30. Was admitted to
MICU, and treated with Vancomycin IV. Persistent leukocytosis is
concerning for another source of infection. Was briefly on
pressors for hypotension. Once blood pressure stabalized off
pressors, patient was transferred to floor on ___. Due to
persistently elevated white count, other infection was
considered. ___ CXR showed possible pneumonia. ___ plain
films tib/fib showed no signs of osteomyelitis. Consulted OB/Gyn
due to concern for pessary infection; appreciate their recs.
OB/GYN removed pessary on ___. Patient also received
Fluconazole for yeast infection. Wound care was consulted for
leg wound, appreciate their recs. Patient completed 10 day
course of Vancomycin (___). C dif was sent, but patient
has not been having diarrhea. At time of discharge, patient has
been afebrile and leukocytosis is downtrending.
# CHF:
Chronic, but with worse B/L ___ edema on exam. BNP ___ on
___, elevated from prior. Was taking Torsemide 20PO BID at
home, had recently changed to Torsemide 40PO qAM. Was net -400
in ICU, so basically euvolemic. Was actively diuresed with Lasix
160mg IV BID until patient received dry weight on ___. Was
placed back on home Torsemide 40mg daily.
# AFIB WITH SSS S/P PPM:
Metoprolol was fractionated to 50mg q6 originally, then switched
to home 200mg daily. On ___, she had episode of RVR with HR
130s, stable BP and subsequently remained rate controlled.
Patient is currently home Metoprolol 200mg daily and Apixaban 5
mg PO/NG BID. Heart rate upon discharge were stable in ___.
# HYPERTENSION:
Home antihypertensives originally held in the setting of sepsis
and subsequent diuresis, however, resumed prior to discharge.
Continued home Pravastatin 20 mg PO. Upon discharge, patient is
normotensive.
TRANSITIONAL ISSUES
- PESSARY REPLACEMENT: Patient has follow up with OB/GYN on
___ for pessary replacement. She will bring pessary to this
appointment.
- FOLEY CATHETER: Foley will remain in place until pessary is
replaced; after which, a voiding trial should be attempted.
- She was actively diuresed and subsequently discharged on home
torsemide; Cr with mild elevation to 1.3 upon discharge; Please
repeat BMP on ___ to ensure stable Cr and fax results to ___
___ at ___.
- Trend weights; further adjustments of diuretic regimen
deferred to PCP |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Morphine / Codeine / Percodan / Celebrex / Cephalosporins /
bacitracin / Neomycin / mdbgn/pe-euxyl k 400 / iodopropynyl /
tramadol
Attending: ___.
Chief Complaint:
Neck pain
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ female with a history of hypertension,
hyperlipidemia, chronic back pain who presents with back pain.
Patient states that since her fall 1 month ago she has had
chronic neck pain but now radiating throughout her entire back
and today started radiating to bilateral upper extremities.
States it acutely worsened today which is what her brought her
into the emergency room. She denies chest pain, shortness of
breath, abdominal pain, nausea vomiting, change in bowel or
bladder habits, weakness in the upper or lower extremities.
She was admitted on ___ for hip pain after mechanical fall and
was found to have transverse process lumbar fractures. She has
been noted to have gait instability with multiple falls in the
past.
In the ED, initial VS were: 98.3, HR 90, BP 149/68, RR 19, O2
sat
98% RA
Exam notable for:
Diffuse tenderness palpation over her entire back
Cranial nerves II through XII are intact
Normal 5 out of 5 strength in bilateral upper and lower
extremities with normal sensation
Normal rectal tone
Labs showed:
- UA with large leuks, 30 protein, >182 WBCs and 7 RBCs
- Chem 7: ___
- CBC: 9.5/9.5/28.3/231
- Ancillary lytes WNL
- LFTs WNL
Imaging showed:
MR ___:
1. Prevertebral edema without any definite evidence of
ligamentous injury.
2. Cord signal and morphology are normal. Bone marrow signal is
unremarkable.
3. Small disc bulges at C3-C4, C4-C5, C5-C6, and C6-C7 without
evidence of significant spinal canal or neural foraminal
narrowing.
CT ___ w/o contrast:
1. Prevertebral edema spanning from the levels of C2-C6, new as
compared to CT cervical spine ___. MRI cervical spine is
recommended for further characterization as these findings can
be
seen with ligamentous injury.
2. No acute fracture or change in alignment. Mild
anterolisthesis
of C3 over C4 is unchanged as compared to CT cervical spine ___.
3. Moderate to severe multilevel degenerative changes of the
cervical spine, most severe at C4-C5 and C5-C6 with associated
mild spinal canal narrowing at those levels.
CT L-spine w/o contrast:
1. No new fracture or malalignment.
2. Subacute to chronic minimally displaced right L1 through L4
transverse
process fractures and right posterior twelfth rib are unchanged
in alignment
as compared to CT torso ___.
3. Moderate multilevel degenerative changes of the lumbar spine,
most severe
at L4-L5 and L5-S1.
4. Small disc bulges at multiple levels of the cervical spine,
most severe at
L4-L5 and L5-S1, where there is mild to moderate spinal canal
narrowing.
CT T spine without acute fx or malalignment
Right Elbow AP and lateral:
1. While no definite acute fracture is identified, the presence
of a joint
effusion raises concern for a radiographically occult radial
head
fracture.
2. No dislocation.
3. Mild to moderate degenerative changes in the elbow.
Consults:
- Ortho spine recommends soft collar and no acute surgical
intervention
Patient received:
- Diazepam 2mg
- APAP 1g
- Cipro 500mg PO
- Atorvastatin 40mg
- Gabapentin 400mg
Transfer VS were: T 98.2 BP 134/77 HR 99 O2 sat 95% on RA
On arrival to the floor, the patient is sleeping comfortably in
a
J collar.
Past Medical History:
Basal cell carcinoma
Temporal arteritis - diagnosed in ___ s/p temporal artery
biopsy.
Hypertension
Lumbar radiculopathy
Mild dementia
De Queervain's disease
Social History:
___
Family History:
Mother had TB, father was an alcoholic.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: T 98.2 BP 134/77 HR 99 O2 sat 95% on RA
GENERAL: NAD, sleeping comfortably
HEENT: AT/NC, anicteric sclera, MMM
NECK: J collar in place, supple, no LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB anteriorly over mid clavicular and mid axillary
lines,
no wheezes, rales, rhonchi, breathing comfortably without use of
accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ radial pulses bilaterally
NEURO: deferred as patient sleeping
DERM: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
GENERAL: NAD
HEENT: AT/NC, anicteric sclera, MMM, soft collar in place, no
LAD
CV: RRR, S1/S2, no murmurs, gallops, or rubs
PULM: CTAB; no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
GI: abdomen soft, nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema. 4+/5 strength in
all extremities equally
Pertinent Results:
ADMISSION:
___ 02:00PM BLOOD WBC-9.5 RBC-3.16* Hgb-9.5* Hct-28.3*
MCV-90 MCH-30.1 MCHC-33.6 RDW-12.1 RDWSD-40.1 Plt ___
___ 02:00PM BLOOD Neuts-67.1 Lymphs-18.8* Monos-13.3*
Eos-0.3* Baso-0.3 Im ___ AbsNeut-6.38* AbsLymp-1.79
AbsMono-1.27* AbsEos-0.03* AbsBaso-0.03
___ 02:00PM BLOOD Plt ___
___ 02:00PM BLOOD Glucose-104* UreaN-15 Creat-0.7 Na-132*
K-3.8 Cl-94* HCO3-24 AnGap-14
___ 02:00PM BLOOD ALT-11 AST-13 AlkPhos-85 TotBili-0.4
___ 02:00PM BLOOD Albumin-3.6 Calcium-9.1 Phos-2.8 Mg-1.8
___ 05:00AM BLOOD calTIBC-259* Ferritn-217* TRF-199*
___ 05:00AM BLOOD Osmolal-274*
DISCHARGE:
___ 05:00AM BLOOD WBC-9.1 RBC-3.31* Hgb-9.7* Hct-29.3*
MCV-89 MCH-29.3 MCHC-33.1 RDW-12.2 RDWSD-39.6 Plt ___
___ 05:00AM BLOOD Glucose-110* UreaN-13 Creat-0.7 Na-136
K-3.9 Cl-96 HCO3-23 AnGap-17
___ 05:00AM BLOOD CK(CPK)-31
___ 05:00AM BLOOD Calcium-9.3 Phos-3.6 Mg-1.9 Iron-18*
REPORTS:
MR ___ SPINE ___:
1. Prevertebral soft tissue swelling from C2 through C6 with
suspected tears of the anterior annulus fibrosus at C3-C4 and
C5-C6.
2. Moderate multilevel degenerative disc disease, most
pronounced at C4-C5 and C5-C6.
3. Mild anterolisthesis of C3 on C4.
CT C, T, L SPINE ___:
1. Prevertebral edema spanning from the levels of C2-C6, new as
compared to CT cervical spine ___. MRI cervical spine
is recommended for further characterization as these findings
can be seen with ligamentous injury.
2. No acute fracture or change in alignment. Mild
anterolisthesis of C3 over C4 is unchanged as compared to CT
cervical spine ___.
3. Moderate to severe multilevel degenerative changes of the
cervical spine, most severe at C4-C5 and C5-C6 with associated
mild spinal canal narrowing at those levels.
1. No new fracture or malalignment.
2. Subacute to chronic minimally displaced right L1 through L4
transverse
process fractures and right posterior twelfth rib are unchanged
in alignment as compared to CT torso ___.
3. Moderate multilevel degenerative changes of the lumbar spine,
most severe at L4-L5 and L5-S1.
4. Small disc bulges at multiple levels of the cervical spine,
most severe at L4-L5 and L5-S1, where there is mild to moderate
spinal canal narrowing.
R ELBOW XR:
1. While no definite acute fracture is identified, the presence
of a joint
effusion raises concern for a radiographically occult radial
head fracture.
2. No dislocation.
3. Mild to moderate degenerative changes in the elbow.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. amLODIPine 2.5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Docusate Sodium 100 mg PO BID
6. Gabapentin 400 mg PO BID
7. Multivitamins 1 TAB PO DAILY
8. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
9. Senna 17.2 mg PO BID
10. Sucralfate 1 gm PO BID
11. Lidocaine 5% Patch 1 PTCH TD QAM
12. Alendronate Sodium 70 mg PO QTHUR
13. Calcium 500 With D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
14. diclofenac sodium 1 % topical DAILY
15. DULoxetine 20 mg PO DAILY
16. Vitamin D 1000 UNIT PO DAILY
17. Gabapentin 200 mg PO NOON
18. Polyethylene Glycol 17 g PO DAILY
Discharge Medications:
1. Ciprofloxacin HCl 250 mg PO Q12H
END: ___
2. Acetaminophen 650 mg PO Q6H
3. Alendronate Sodium 70 mg PO QTHUR
4. amLODIPine 2.5 mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Calcium 500 With D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -400 unit oral DAILY
8. diclofenac sodium 1 % topical DAILY
9. Docusate Sodium 100 mg PO BID
10. DULoxetine 20 mg PO DAILY
11. Gabapentin 400 mg PO BID
12. Gabapentin 200 mg PO NOON
13. Lidocaine 5% Patch 1 PTCH TD QAM
14. Multivitamins 1 TAB PO DAILY
15. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
16. Polyethylene Glycol 17 g PO DAILY
17. Senna 17.2 mg PO BID
18. Sucralfate 1 gm PO BID
19. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
#Acute on chronic back pain
#Lumbar radiculopathy
#UTI
#HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with severe pain right elbow// ? bony path
TECHNIQUE: Right elbow, three views
COMPARISON: Right humeral radiographs ___.
FINDINGS:
No definite acute fracture or dislocation is identified. Mild to moderate
degenerative spurring is seen involving the humeral ulnar joint. An elbow
joint effusion is present. No dislocation is seen. Partially imaged plate
and screw is seen within the distal humerus. Well corticated ossific
densities adjacent to the medial and lateral condyles likely reflect the
sequela of prior injury. No concerning lytic or sclerotic osseous
abnormality.
IMPRESSION:
1. While no definite acute fracture is identified, the presence of a joint
effusion raises concern for a radiographically occult radial head fracture.
2. No dislocation.
3. Mild to moderate degenerative changes in the elbow.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: ___ female with severe diffuse back pain. Evaluate for
new fracture.
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) = 462 mGy-cm.
COMPARISON: MRI cervical spine ___
CT cervical spine ___ and ___
FINDINGS:
There is prevertebral edema from the level of C2 to C6, new as compared to CT
cervical spine ___. Mild anterolisthesis of C3 over C4 is unchanged
as compared to CT cervical spine ___. No acute fractures are
identified.
Moderate to severe multilevel degenerative changes are noted with
intervertebral disc space narrowing, endplate irregularity, and osteophyte
formation, most severe at C4-C5 and C5-C6, resulting in mild spinal canal
narrowing at those levels. There is uncovertebral hypertrophy and facet
arthropathy with multilevel moderate bilateral neural foraminal narrowing,
worse at C3-4 and C4-5. Ossification in the posterior cervical spinal soft
tissues at the C4 through C6 levels is compatible with nuchal ligament
ossification.
There is a 5 mm hypodense nodule in the left lobe of the thyroid (03:49),
which is grossly unchanged as compared to CT cervical spine ___.
Scarring is seen within the lung apices.
IMPRESSION:
1. Prevertebral edema spanning from the levels of C2-C6, new as compared to CT
cervical spine ___. MRI cervical spine is recommended for further
characterization as these findings can be seen with ligamentous injury.
2. No acute fracture or change in alignment. Mild anterolisthesis of C3 over
C4 is unchanged as compared to CT cervical spine ___.
3. Moderate to severe multilevel degenerative changes of the cervical spine,
most severe at C4-C5 and C5-C6 with associated mild spinal canal narrowing at
those levels.
RECOMMENDATION(S): MRI of the cervical spine without intravenous contrast.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
___ on the telephone on ___ at 4:33 pm, minutes after discovery of the
findings.
Radiology Report
EXAMINATION: CT T-SPINE W/O CONTRAST Q321 CT SPINE
INDICATION: History: ___ with severe diffuse back pain// ? new fx ? new
fx
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 8.3 s, 32.8 cm; CTDIvol = 31.2 mGy (Body) DLP =
1,021.4 mGy-cm.
Total DLP (Body) = 1,021 mGy-cm.
COMPARISON: CT torso ___
CT chest ___
FINDINGS:
Alignment is normal. No acute fractures are identified. Remote fractures of
the right tenth, eleventh, and twelfth posterior ribs are re-demonstrated.
There is moderate intervertebral disc space narrowing, endplate irregularity,
and osteophyte formation at multiple levels of the thoracic spine. There is a
small disc bulge at T11-T12 resulting in mild spinal canal narrowing. There
is no evidence of significant neural foraminal narrowing. There is no
prevertebral soft tissue narrowing. Dependent atelectasis is noted in both
lungs. There is moderate to severe background atherosclerotic disease and
coronary artery calcifications..
IMPRESSION:
No acute fracture or malalignment.
Radiology Report
EXAMINATION: CT L-SPINE W/O CONTRAST Q331 CT SPINE
INDICATION: History: ___ with severe diffuse back pain// ? new fx ? new
fx
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 6.7 s, 26.3 cm; CTDIvol = 30.8 mGy (Body) DLP = 810.5
mGy-cm.
Total DLP (Body) = 810 mGy-cm.
COMPARISON: CT torso ___.
FINDINGS:
5 non-rib-bearing lumbar type vertebral bodies are noted. Alignment is
normal. No acute fractures are identified. Subacute to chronic fractures of
the right L1, L2, L3, and L4 transverse processes are re-demonstrated as well
as the right posterior twelfth rib. There is intervertebral disc space
narrowing, osteophyte formation, and endplate irregularity at multiple levels,
most severe at L4-L5. There is uncovertebral hypertrophy at multiple levels
of the lumbar spine without evidence of high-grade neural foraminal narrowing.
There are small disc bulges at multiple levels of the lumbar spine, most
severe at L4-L5 and L5-S1, where there is associated mild to moderate spinal
canal narrowing. There is no prevertebral soft tissue swelling. There is
moderate to severe background atherosclerotic disease.
IMPRESSION:
1. No new fracture or malalignment.
2. Subacute to chronic minimally displaced right L1 through L4 transverse
process fractures and right posterior twelfth rib are unchanged in alignment
as compared to CT torso ___.
3. Moderate multilevel degenerative changes of the lumbar spine, most severe
at L4-L5 and L5-S1.
4. Small disc bulges at multiple levels of the cervical spine, most severe at
L4-L5 and L5-S1, where there is mild to moderate spinal canal narrowing.
Radiology Report
EXAMINATION: MR ___ SCAN WITH CONTRAST ___ MR ___ SPINE
INDICATION: History: ___ F with prevertebral edema on CT IV contrast to be
given at radiologist discretion as clinically needed. Eval for ligamentous
injury.
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 ___ without contrast dated ___. MR cervical spine
dated ___.
FINDINGS:
There is mild anterolisthesis of C3 on C4. The vertebral body heights are
unchanged compared to prior exam. The signal intensity of the vertebral
bodies appears maintained. There is multilevel loss of signal of the discs on
T2 weighted imaging and intervertebral disc space narrowing, due to
degenerative disease. The visualized portion of the spinal cord appears
normal.
There is fluid along the prevertebral aspects of the C2 through C6 vertebral
bodies with tiny foci of hyperintense signal along the anterior aspect of the
annulus fibrosis and perhaps anterior longitudinal ligament at C3-C4 and
C5-C6, suspicious for tearing. The posterior longitudinal ligament appears
intact.
C2-C3: No significant discogenic abnormalities. The spinal canal and neural
foramina appear patent.
C3-C4: Mild disc bulge with moderate right greater than left neural foraminal
narrowing.
C4-C5: Moderate disc bulge with contact of the spinal cord. Minimal
indentation of the spinal cord at C4-C5 without signal abnormality. Anterior
disc bulge at C4-C5. Mild bilateral neural foraminal narrowing.
C5-C6: Moderate disc bulge. Mild bilateral neural foraminal narrowing.
C6-C7: Mild disc bulge. Mild bilateral neural foraminal narrowing.
C7-T1: No significant discogenic abnormalities. Spinal canal and neural
foramina are patent.
There is no evidence of infection or neoplasm. There is no abnormal
enhancement.
IMPRESSION:
1. Prevertebral soft tissue fluid from C2 through C6 with suspected tears of
the anterior annulus fibrosus and perhaps the anterior longitudinal ligament
at C3-C4 and C5-C6.
2. Moderate multilevel degenerative disc disease, most pronounced at C4-C5 and
C5-C6.
3. Mild anterolisthesis of C3 on C4.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Neck pain
Diagnosed with Cervicalgia
temperature: 98.3
heartrate: 90.0
resprate: 19.0
o2sat: 98.0
sbp: 149.0
dbp: 68.0
level of pain: 5
level of acuity: 3.0 | ___ year old woman with PMHx of HTN, lumbar radiculopathy,
constipation, and hearing loss presenting with acute on chronic
back pain with radiation into bilateral upper extremities.
# Acute on chronic back pain
# Lumbar radiculopathy
Patient had an MRI 1 month ago after a fall which showed
moderate canal narrowing but no evidence of cord compression and
she has had continuous back pain since that time. On this
admission she presented with worsening of pain and radiation
into the bilateral arms. CT of the C/T/L spine showed no acute
abnormalities but chronic disease (see attached reports). As the
CT ___ showed some edema, MRI was obtained which did not
show any cord compression or acute ligamentous injury. CK
normal. Ortho was consulted and recommended soft collar. Her
pain resolved on her home medication regimen and she was
discharged in stable condition for follow-up.
#UTI
Found to have preliminary urine culture with E. coli, pending
sensitivities. In the setting of a limited history of symptoms
due to memory, the patient was started on a 5-day course of
Ciprofloxacin (END ___ for UTI. Follow-up final urine
cultures. Of note, her foley was discontinued and she was noted
to void spontaneously before discharge. Monitor for signs of
urinary retention.
#R Elbow XR findings:
Some concern for R elbow effusion on plain film. Given
resolution of pain and low likelihood of fracture, recommend
follow-up R elbow XR in 4 weeks.
#Anemia:
Iron studies as attached, with elevated ferritin and decreased
Fe/TIBC. Consider Fe repletion or further workup in the
outpatient setting.
# HTN: continued amlodipine 2.5 mg daily
# CAD: continued ASA 81mg and atorvastatin 40mg daily
# Osteoporosis: continued MVI, calcium, and vitamin D,
alendronate qweekly
# Esophagitis: continued sucralfate 1 gm PO BID
TRANSITIONAL ISSUES:
- Reassess need for soft collar pending improvement in pain, low
threshold to discontinue if not helping or no longer needed
- Started on a 5-day course of Ciprofloxacin (END ___ for
UTI.
- Follow-up final urine cultures.
- Monitor for signs of urinary retention (voiding well at
discharge).
- Recommend follow-up R elbow XR in 4 weeks.
- Consider Fe repletion or further workup of anemia in the
outpatient setting.
#CODE: DNR/DNI based on MOLST in OMR from ___
#CONTACT: ___
Relationship: Step Son
Phone number: ___
Cell phone: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
metoprolol / citalopram / Zoloft
Attending: ___.
Chief Complaint:
fall, weakness
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/ dementia (nonverbal at baseline) sent in by PCP after
reporting ___ recent unwitnessed fall. History is obtained from
review of prior records, ED notes, and limited discussion with
pt's husband by phone overnight, whose primary language is
___.
Apparently pt was with her husband at clinic on day of
admission,
husband mentioned that 3 days prior to presentation she suffered
a fall off the couch. Per ED notes, he believes she fell onto
her
left side and is unsure if she struck her head. He states since
that time she has been at her baseline mental status. However
she
has had some difficulty with "limping" and weakness. He
reportedly has not noticed any bruising, or favoring one side or
another. He is not aware of any recent fevers, chills, nausea,
vomiting. He is unable to assess her pain at baseline. Per
notes,
he states that at baseline she has pursed lip breathing and that
she has been like this for the last 5 months. He has noticed a
cough developing over the last 3 days, although upon further
questioning states that cough has been present intermittently
with eating, and has not particularly progressed since her fall.
She presented to clinic for regular checkup appointment after
the
fall and cough, and was in turn sent to ___ ED for a trauma
evaluation.
On arrival, vitals were: 98.1, HR 79, BP 122/65, SpO2 97% RA,
and
a RR that is not objectively recorded, but which was noticeably
tachypneic. Trauma evaluation with CT head and CT c-spine was
negative. CXR showed a possible retrocardiac opacity. UA showed
pyuria.
The patient was not septic or unstable, but in discussion with
family, the level of care she needs while sick exceeds their
capabilities at home; therefore she was admitted to medicine for
her presumptive PNA and UTI.
According to her husband, at baseline pt is able to answer
yes/no
questions "on a good day." She is otherwise nonverbal and not
interactive.
ROS: 10 point review of system reviewed and negative except as
otherwise described in HPI
Past Medical History:
PAST MEDICAL HISTORY
Advanced Dementia, baseline non-verbal
Recurrent dizziness/syncope
HTN
HLD
Aortic sclerosis w/moderate LV hypertrophy, preserved EF
Incontinence - bowel and bladder, wears diaper
PAST SURGICAL HISTORY
L cataract surgery
Total hysterectomy for "polyps" - ___
L Hip Replacement - ___
Social History:
___
Family History:
No breast, ovarian, colon ca
Father died of CAD at the age of ___
Physical Exam:
ADMISSION EXAM:
T 97.6 Axillary BP: 138/61 HR: 58 RR: 16 O2 Sats 96% RA
GEN: alert, not interactive, nonverbal, pursed lip breathing,
otherwise NAD
HEENT: PERRL, anicteric, conjunctiva pink, moist mucus
membranes,
unable to examine posterior oropharynx
LYMPH: no anterior/posterior cervical, supraclavicular
adenopathy
CARDIOVASCULAR: Regular rate and rhythm without murmurs, rubs,
or
gallops
LUNGS: tachypneic, clear to auscultation bilaterally without
rhonchi, wheezes, or crackles
GI: soft, nontender, without rebounding or guarding,
nondistended
with normal active bowel sounds, no hepatomegaly appreciated
EXTREMITIES: no clubbing, cyanosis, or edema
GU: no foley
SKIN: no rashes, petechia, lesions, or echymoses; warm to
palpation
NEURO: nonverbal, not interactive, responds to "say 'aaah'" with
slight mouth opening, says "aaah," otherwise does not follow any
commands
DISCHARGE EXAM
DISCHARGE EXAM:
Pertinent Results:
___ 02:05PM BLOOD WBC-9.7 RBC-4.23 Hgb-12.6 Hct-38.4 MCV-91
MCH-29.8 MCHC-32.8 RDW-12.9 RDWSD-42.4 Plt ___
___ 02:05PM BLOOD Glucose-99 UreaN-27* Creat-1.2* Na-134*
K-4.5 Cl-97 HCO3-23 AnGap-14
___ 02:05PM BLOOD ALT-15 AST-17 AlkPhos-87 TotBili-0.2
___ 02:05PM BLOOD TSH-0.88
___ 02:32PM BLOOD ___ pO2-36* pCO2-39 pH-7.38
calTCO2-24 Base XS--1 Intubat-NOT INTUBA
___ 02:27PM BLOOD Lactate-1.8
Urine Cx + Klebsiella
CXR Focal opacity at the right lateral costophrenic angle which
could be due to
atelectasis in the setting of low lung volumes though infection
would be
possible in the proper clinical setting.
CT head:
IMPRESSION:
1. Severely motion limited examination.
2. Within limits of study, no intracranial hemorrhage or acute
fracture
detected.
3. Severe frontotemporal and generalized atrophy, progressed
from ___.
4. Paranasal sinus disease, as described.
CT Cspine and pelvis X-ray: no acute fracture
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ALPRAZolam 0.5 mg PO QHS
2. BusPIRone 7.5 mg PO BID
3. Desmopressin Acetate 0.2 mg PO QHS
4. Donepezil 5 mg PO QHS
5. LORazepam 0.5 mg PO QAM
6. Metoprolol Succinate XL 25 mg PO DAILY
7. QUEtiapine Fumarate 100 mg PO BID
8. Vitamin D ___ UNIT PO DAILY
Discharge Medications:
1. ALPRAZolam 0.5 mg PO QHS
2. Desmopressin Acetate 0.2 mg PO QHS
3. Donepezil 5 mg PO QHS
4. LORazepam 0.5 mg PO QAM
5. Metoprolol Succinate XL 25 mg PO DAILY
6. QUEtiapine Fumarate 100 mg PO BID
7. Vitamin D ___ UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Urinary tract infection
Aspiration PNA
Fall
Advanced dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert but non-verbal
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ with limp (s/p) fall off couch. able to bear weight. non
verbal.// pna? fx?
TECHNIQUE: AP supine and lateral views of the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
Lung volumes are low. Lateral view is limited secondary to respiratory
motion. There is no opacity at the right lateral costophrenic angle on the
frontal view. There is no significant effusion or edema. Cardiomediastinal
silhouette is stable. Atherosclerotic calcifications seen at the aortic arch.
Chronic posttraumatic changes of the proximal left humerus.
IMPRESSION:
Focal opacity at the right lateral costophrenic angle which could be due to
atelectasis in the setting of low lung volumes though infection would be
possible in the proper clinical setting.
Radiology Report
INDICATION: ___ with limp (s/p) fall off couch. able to bear weight. non
verbal.// pna? fx?
TECHNIQUE: AP views of the pelvis.
COMPARISON: None.
FINDINGS:
Bones are demineralized. Motion of the left lower extremity limits detailed
evaluation of the left femur which is otherwise notable for postoperative
changes of ORIF. There is no acute fracture. Degenerative changes noted in
the lower lumbar spine. Soft tissues are unremarkable.
IMPRESSION:
No fracture.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with fall, lethargy// eval for hemorrhage/fracture
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Total DLP (Head) = 1,104 mGy-cm.
COMPARISON: Head CT from ___
FINDINGS:
Severely motion limited examination. There is no evidence of large acute
infarction, gross intracranial hemorrhage, edema, or mass. Severe bilateral
frontal temporal lobe atrophy are re-demonstrated, progressed from ___.
Ventricles of similarly diffusely progressed in size. Periventricular white
matter hypodensities are nonspecific in someone progressed from ___.
No acute fracture seen. There is mild bilateral mucosal thickening involving
the maxillary sinuses. The remaining paranasal sinuses, mastoid air cells,
and middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
1. Severely motion limited examination.
2. Within limits of study, no intracranial hemorrhage or acute fracture
detected.
3. Severe frontotemporal and generalized atrophy, progressed from ___.
4. Paranasal sinus disease, as described.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: History: ___ with fall, lethargy// eval for hemorrhage/fracture
TECHNIQUE: Contiguous axial images obtained through the cervical spine
without intravenous contrast. Coronal and sagittal reformats were reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.7 s, 18.5 cm; CTDIvol = 22.4 mGy (Body) DLP = 414.9
mGy-cm.
Total DLP (Body) = 415 mGy-cm.
COMPARISON: None.
FINDINGS:
Alignment is normal. No fractures are identified. Moderate multilevel
degenerative changes are noted with loss of disc space, and osteophyte
formation. There is no significant canal or foraminal narrowing.There is no
prevertebral edema. A 3 mm sclerotic focus in C7 vertebral body is likely a
bone island.
The thyroid and included lung apices are unremarkable.
IMPRESSION:
No cervical spine fracture. No traumatic malalignment.
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: Altered mental status, s/p Fall
Diagnosed with Pneumonia, unspecified organism, Urinary tract infection, site not specified
temperature: 98.1
heartrate: 79.0
resprate: 18.0
o2sat: 97.0
sbp: 122.0
dbp: 65.0
level of pain: 0
level of acuity: 2.0 | A/P: ___ w/ dementia (nonverbal at baseline) sent in
by PCP after reporting ___ recent unwitnessed fall, found to have
possible RLL infiltrate concerning for aspiration PNA and UTI
# UTI: Urine Cx was positive for Klebsiella and pt was treated
with
levofloxacin and completed a 5 day course prior to discharge.
# Possible Aspiration PNA: Pt had minimal cough and normal O2
sats.
Pt was seen by speech/swallow who recommended a ground dysphagia
diet with
thin liquids. There was no witness aspiration events and pt was
assisted with meals.
Pt was treated with a 5 day course of Levofloxacin.
# Fall: EKG reassuring and unable to obtain additional history
given baseline mental status. No associated trauma on films.
Husband
has noticed generalized weakness over the last few days. TSH
reassuring and this was felt likely related to UTI. Pt was seen
by ___
who recommended temporary SNF for rehab.
# Dementia: Pt has advanced dementia with frontotemporal
wasting. Pt
is followed by Dr. ___ who has been adjusting meds
recently.
She has a stereotyped behavior of tachypnea with pursed lip
breathing
when distressed that seems to resolve when pt is comfortable
and/or needs addressed.
Buspirone was started recently and was not felt to be helping,
this was
discontinued per Dr. ___. Pt was continued on home regimen of
Lorazepam 0.5mg qam, Alprazolam 0.5mg qhs, Donezepil 5mg and
Seroquel 100mg BID.
Pt has outpatient f/u scheduled with Dr. ___ in ___.
# Nocturnal polyuria: prescribed desmopressin for
nocturnal polyuria - will continue but trend Na daily
# FEN: Adv ground diet with thin liquid per speech
# Prophylaxis: Heparin sc
CODE: DNR/DNI - confirmed with HCP husband at bedside, ___
interpreter present
Dispo: likely SNF in ___ days. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
S/p fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with C1 and C2 fractures seen on CT of
c-spine in addition to increased atlanto-dental interval,
basilar invagination, likely chronic findings. No midline
tenderness.
Past Medical History:
COPD
Complete heart block (pacemaker)
Hypertension
Dyslipidemia
paroxysmal atrial fibrillation: s/p ablation ___ ___
s/p dual chamber placement (___): most recent generator change
in ___
h/o untreated rheumatic fever as child
h/o multiple pulmonary emboli: on chronic coumadin
GERD
s/p tonsillectomy, adenoidectomy
Social History:
___
Family History:
- No family history of early MI, arrhythmia, cardiomyopathies,
or sudden cardiac death; otherwise non-contributory.
- Mother: ___ dementia, died at ___
- Father: CHF
Physical ___:
================
ON ADMISSION
================
PHYSICAL EXAM:
Temp: 98.0 HR: 84 BP: 159/58 RR: 20 O2Sat: 98% RA
Gen: WD/WN, supine, on trauma board, in hard cervical collar
HEENT: Pupils: PERRL EOMs: Intact
Neck: In hard cervical collar. No midline tenderness over
cervical spine
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 Grip IP Q H AT ___ G
Negative ___
negative clonus
Sensation: Intact to light touch
================
ON DISCHARGE
================
AS ABOVE (except no c-collar)
Pertinent Results:
================
IMAGING
================
___ CT HEAD W/O CONTRAST
1. No intracranial hemorrhage or mass effect.
2. Moderate bilateral posterior scalp hematomas with a
laceration and small amount of subcutaneous emphysema on the
left. No definite underlying calvarial fracture.
3. Right arch of C1 appears to be fractured, which will be
specifically
evaluated on the dedicated cervical spine CT from the same day.
This is
unstable.
4. Probable sequelae of chronic small vessel ischemic disease.
5. Cortical atrophy.
___ CT C-SPINE W/O CONTRAST
IMPRESSION:
1. Unstable C1 fracture of the right C1 ring. There are
fractures of the
bilateral lateral aspects of the C2 vertebral body with
extension to the
transverse processes with extension to the transverse foramina.
Associated prevertebral soft tissue swelling. CTA is
recommended to evaluate for injury to the vertebral arteries.
2. Anterior subluxation of C1 vertebral body relative to the
dens an widening of the left lateral atlantodentals interval
concerning also for ligamentous disruption. MRI could be
performed to further evaluate.
3. Bilateral minimally displaced C2 fractures extending into
the neural
foramina. CTA is recommended to evaluate for injury to the
vertebral
arteries.
4. Lucent lesion at the tip of the clivus could be a fracture
fragment.
5. Multilevel degenerate changes of the cervical spine with
mild
retrolisthesis of C4 on C5 and C5 on C6 which could be
degenerative; however, trauma cannot completely be excluded.
MRI could further evaluate.
6. Spinal canal and cord is not well assessed on this exam. MR
could be
performed to further evaluate.
7. Secretions in the partially imaged upper esophagus places
the patient at risk for aspiration.
8. Tiny right thyroid hypodensity, too small to require
dedicated follow-up in a patient of this age.
___ CT CHEST/ABD/PELVIS W/CONTRAST
1. No evidence of acute fracture in the torso.
2. Trace left nonhemorrhagic pleural effusion. Pleural
thickening with
calcifications suggesting chronic process. Associated left
lower lobe opacity could be rounded atelectasis and/or scarring,
although underlying lesion cannot definitely be excluded in the
absence of prior exams. Dedicated chest CT non emergently is
recommended within 3 months to evaluate stability and/or
resolution.
3. Moderate to large L4-L5 disc herniation, along with other
degenerative
changes resulting in severe spinal canal stenosis.
4. Small right gluteal soft tissue contusion/ecchymosis.
___ CTA HEAD AND CTA NECK
IMPRESSION:
1. Unstable fracture of the C1 arch and fractures of the C2
vertebral body with extension to the bilateral transverse
foramina as noted on the prior dedicated cervical spine CT
examination. There is probably moderate central canal at C1
level. There is mild narrowing of the left vertebral artery
secondary to the left transverse foramen fracture fragment,
though there is no evidence of underlying vascular injury.
2. Bilateral scalp hematomas, as previously described, without
underlying
calvarial fracture.
3. No intracranial hemorrhage or large acute territorial
infarct.
4. Patent intracranial vasculature without significant stenosis,
occlusion, or aneurysm formation.
5. Otherwise patent cervical vasculature without significant
stenosis,
occlusion, or dissection.
6. Scattered peribronchovascular ___ nodularity,
nonspecific, which may reflect infectious or inflammatory
etiology.
7. Few small thyroid nodules, should be benign. Suggestion of
exophytic 1.0 cm thyroid nodule, versus less likely parathyroid
adenoma, clinically
correlate.
___ TRAUMA #3 (PORT CHEST ONLY)
In comparison with the study of ___, there is
increased
opacification along the left lateral chest wall, which was
considered
consistent with chronic pleural thickening and calcifications on
the recent CT study. The left lower lobe opacity interpreted as
round atelectasis or scarring is not as well identified as on
the CT. As recommended on that study, dedicated nonemergent CT
is recommended within 3 months to evaluate stability or
resolution.
Medications on Admission:
albuterol nebulizer qAM
Spiriva 1 cap daily
Advair 250 qAM, qPM
Coumadin
Simvastatin 40mg daily
Atenolol 50 mg daily
Benadryl qHS
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth every
12 hours Disp #*30 Capsule Refills:*0
3. Gabapentin 100 mg PO TID
RX *gabapentin 100 mg 1 capsule(s) by mouth every 8 hours Disp
#*84 Capsule Refills:*0
4. Senna 8.6 mg PO BID constipation
5. Sodium Chloride 1 gm PO DAILY
RX *sodium chloride 1 gram 1 tablet(s) by mouth daily Disp #*14
Tablet Refills:*0
6. Tizanidine 2 mg PO TID
RX *tizanidine 2 mg 1 capsule(s) by mouth every 8 hours Disp
#*40 Capsule Refills:*0
7. Albuterol 0.083% Neb Soln 1 NEB IH DAILY
8. Atenolol 50 mg PO DAILY
9. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
10. Simvastatin 40 mg PO DAILY
11. Tiotropium Bromide 1 CAP IH DAILY
12. Warfarin 3 mg PO 4X/WEEK (MO,WE,TH,SA)
13. Warfarin 4 mg PO 3X/WEEK (___)
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
C1/C2 fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ year old woman with C1, C2 fracture // Evaluate for carotid
injury
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 4.5 s, 0.5 cm; CTDIvol = 49.0 mGy (Head) DLP =
24.5 mGy-cm.
3) Spiral Acquisition 5.3 s, 41.3 cm; CTDIvol = 32.1 mGy (Head) DLP =
1,327.7 mGy-cm.
Total DLP (Head) = 2,361 mGy-cm.
COMPARISON: Head CT ___, cervical spine CT ___
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of no evidence of infarction, hemorrhage, edema, or mass.
TThere is prominence of the ventricles and sulci suggestive of involutional
changes. Scattered areas of periventricular and subcortical white matter
hypodensity are in a configuration most suggestive of moderate chronic small
vessel ischemic disease. .
Left parietal and right frontoparietal scalp hematomas and a laceration in the
left parietal scalp are again noted. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
CTA HEAD:
There are mild atherosclerotic calcifications of the bilateral intracranial
internal carotid arteries without significant narrowing. The vessels of the
circle of ___ and their principal intracranial branches otherwise appear
patent without significant stenosis, occlusion, or aneurysm formation. The
dural venous sinuses are patent.
CTA NECK:
There are mild atherosclerotic calcifications of the aortic arch. There is
mild narrowing of the origin of the left subclavian artery secondary to
atherosclerotic calcification. There are mild calcifications at the bilateral
carotid bifurcations, without significant narrowing by NASCET criteria. There
is mild narrowing of the proximal right V2 segment secondary to degenerative
changes, and osteophyte encroachment on the foramen transversarium. There is
mild narrowing of the distal V2 segment of the left vertebral artery secondary
to impingement by fracture fragment at the level of the left C2 transverse
foramen, without evidence of dissection. There is no evidence of underlying
vascular injury of the vertebral arteries at the level of the fractures or
elsewhere. Mid cervical segment of right ICA is not well seen secondary to
dental artifact. The carotid and vertebral arteries and their major branches
appear otherwise normal with no evidence of dissection, stenosis or occlusion.
There is no evidence of internal carotid stenosis by NASCET criteria.
OTHER:
There is moderate biapical scarring. There are numerous areas of
peribronchovascular ___ nodularity in the right upper lobe and left
upper lobe. No dominant nodule is identified. There is partial visualization
of a calcified left upper lobe pleural plaque. There are few small thyroid
nodules, largest measures 1.0 cm, including nodule in the right
tracheoesophageal groove, which may represent exophytic thyroid nodule, it
should be benign, in the absence of any parathyroid gland dysfunction. There
is no lymphadenopathy by CT size criteria.
Again identified is a fracture of the C1 vertebral body involving the right
anterior arch with widening of the atlantodental interval. There is anterior
subluxation of C1 with respect to C2 and rotatory subluxation, stable since
prior. There is associated soft tissue swelling. There is probably moderate
central canal narrowing at C1 level. Again seen are fractures extending to
the lateral masses of C2 with involvement of the transverse processes and
transverse foramina, unchanged. A left anterior chest wall pacer device is
partially visualized. There is moderate multilevel cervical spondylosis.
IMPRESSION:
1. Unstable fracture of the C1 arch and fractures of the C2 vertebral body
with extension to the bilateral transverse foramina as noted on the prior
dedicated cervical spine CT examination. There is probably moderate central
canal at C1 level. There is mild narrowing of the left vertebral artery
secondary to the left transverse foramen fracture fragment, though there is no
evidence of underlying vascular injury.
2. Bilateral scalp hematomas, as previously described, without underlying
calvarial fracture.
3. No intracranial hemorrhage or large acute territorial infarct.
4. Patent intracranial vasculature without significant stenosis, occlusion, or
aneurysm formation.
5. Otherwise patent cervical vasculature without significant stenosis,
occlusion, or dissection.
6. Scattered peribronchovascular ___ nodularity, nonspecific, which
may reflect infectious or inflammatory etiology.
7. Few small thyroid nodules, should be benign. Suggestion of exophytic 1.0
cm thyroid nodule, versus less likely parathyroid adenoma, clinically
correlate.
Radiology Report
EXAMINATION: TRAUMA #3 (PORT CHEST ONLY)
INDICATION: TRAUMA
IMPRESSION:
In comparison with the study of ___, there is increased
opacification along the left lateral chest wall, which was considered
consistent with chronic pleural thickening and calcifications on the recent CT
study. The left lower lobe opacity interpreted as round atelectasis or
scarring is not as well identified as on the CT. As recommended on that
study, dedicated nonemergent CT is recommended within 3 months to evaluate
stability or resolution.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ woman presenting after trauma.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 17.1 cm; CTDIvol = 46.8 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: No prior relevant imaging is available on PACS at the time of
this dictation.
FINDINGS:
No evidence of acute large territorial infarction,intracranial hemorrhage,
edema, or mass effect. Bilateral, periventricular and subcortical white
matter hypodensities are nonspecific but likely sequelae of chronic small
vessel ischemic disease. Bilateral, symmetric prominence of the ventricles
and sulci indicates cortical volume loss. Bilateral calcifications of the
cavernous internal carotid arteries and V4 segments is mild. No
pneumocephalus.
Moderate sized, bilateral posterior-lateral subgaleal soft tissue hematoma is
are demonstrated. The hematoma on the left has a laceration with small amount
of subcutaneous emphysema. No evidence of an underlying skull fracture.
There appears to be an acute fracture of the right arch of C1 which will be
further evaluated on the dedicated CT cervical spine.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are
unremarkable.
IMPRESSION:
1. No intracranial hemorrhage or mass effect.
2. Moderate bilateral posterior scalp hematomas with a laceration and small
amount of subcutaneous emphysema on the left. No definite underlying
calvarial fracture.
3. Right arch of C1 appears to be fractured, which will be specifically
evaluated on the dedicated cervical spine CT from the same day. This is
unstable.
4. Probable sequelae of chronic small vessel ischemic disease.
5. Cortical atrophy.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: ___ woman presenting with trauma.
TECHNIQUE: Non-contrast helical multidetector CT was performed. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.0 s, 23.8 cm; CTDIvol = 32.5 mGy (Body) DLP = 773.0
mGy-cm.
Total DLP (Body) = 773 mGy-cm.
COMPARISON: No prior imaging is available on PACS at the time of this
dictation.
FINDINGS:
There is a fracture of the C1 vertebral body that involves the right arch of
C1 (series 2, image 23, 25, 27, 28) with associated widening of the anterior
atlantodental interval to 8 mm on sagittal images (series 602b, image 30) and
asymmetric widening of the left articulations of the dens (series 601 B, image
25). There is also subluxation of the C1 vertebral body anteriorly relative
to the C2 vertebral body. There is increased prevertebral soft tissue
swelling at this level.
There are bilateral acute fractures extending through the C2 lateral vertebral
bodies and transverse foramina and transverse processes (series 2, image 32,
31, 33, 32; series 601b, image 26, 23, 21, 27 ; series 602 B, image 39, 20).
This exam does not contain intravenous contrast in is not dedicated for
imaging of the traversing vertebral arteries which could be injured and CTA is
recommended.
A fragment at the tip of the clivus could also be a fracture (series 602b,
image 30).
No other definite cervical spine fractures are identified. Multi-level
degenerative changes of the cervical spine are extensive. Multiple levels of
neural foraminal narrowing are noted.
Retrolisthesis of C4 on C5 is mild. Retrolisthesis of C5 on C6 is also mild.
The spondylolisthesis could be degenerative. However, in the setting of
trauma, ligamentous injury is possible and MRI is recommended.
The spinal canal is not well imaged on this nondedicated exam.
A right hypodense thyroid nodule measures up to 4 mm (series 2, image 64).
Bilateral carotid artery calcifications are moderate.
Secretions are demonstrated within the imaged portion of the esophagus,
placing the patient at aspiration risk. Biapical pleural thickening and/or
scarring with calcifications is noted in the partially imaged lung apices.
Please refer to the dedicated CT head report from the same day for description
of findings in the head.
IMPRESSION:
1. Unstable C1 fracture of the right C1 ring. There are fractures of the
bilateral lateral aspects of the C2 vertebral body with extension to the
transverse processes with extension to the transverse foramina. Associated
prevertebral soft tissue swelling. CTA is recommended to evaluate for injury
to the vertebral arteries.
2. Anterior subluxation of C1 vertebral body relative to the dens an widening
of the left lateral atlantodentals interval concerning also for ligamentous
disruption. MRI could be performed to further evaluate.
3. Bilateral minimally displaced C2 fractures extending into the neural
foramina. CTA is recommended to evaluate for injury to the vertebral
arteries.
4. Lucent lesion at the tip of the clivus could be a fracture fragment.
5. Multilevel degenerate changes of the cervical spine with mild
retrolisthesis of C4 on C5 and C5 on C6 which could be degenerative; however,
trauma cannot completely be excluded. MRI could further evaluate.
6. Spinal canal and cord is not well assessed on this exam. MR could be
performed to further evaluate.
7. Secretions in the partially imaged upper esophagus places the patient at
risk for aspiration.
8. Tiny right thyroid hypodensity, too small to require dedicated follow-up
in a patient of this age.
RECOMMENDATION(S): 1. CTA to evaluate vertebral arteries.
2. MRI to further evaluate ligaments and spinal canal/cord. This could also
for her assess possibility of injury to the clivus.
NOTIFICATION: The findings and impression as well as images were reviewed
and discussed in person by ___ with Dr. ___ on ___ at
1:10 ___, less than 1 minutes after discovery of the findings.
The findings and recommendation for CTA were also discussed via telephone by
___ with Dr. ___ on ___ at 420 pm, minutes after
discovery of the findings.
Recommendations for CTA again discussed with ___ on the telephone
at ___ pm on ___. Per our discussion, patient cannot get MRI due to
pacemaker. They will get a CTA now.
Radiology Report
EXAMINATION: ED Trauma torso
INDICATION: ___ woman presenting with 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) Spiral Acquisition 8.0 s, 62.8 cm; CTDIvol = 10.1 mGy (Body) DLP = 631.2
mGy-cm.
Total DLP (Body) = 631 mGy-cm.
COMPARISON: No prior relevant imaging is available on PACS at the time of
this dictation.
FINDINGS:
CHEST:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury. Thoracic aorta atherosclerotic calcifications are
diffuse and mild-to-moderate. The heart may be mildly enlarged. No evidence
of a pericardial effusion. Dual lead pacemaker device is incompletely imaged.
Coronary artery calcifications on this nondedicated exam are mild. The main,
left, right pulmonary arteries are normal in caliber without evidence of a
central filling defect indicate an incidental pulmonary embolus.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass or hematoma.
No pneumomediastinum.
LUNGS/AIRWAYS AND PLEURAL SPACES: Bibasilar atelectasis is mild. A right
lower lobe superior segment subpleural opacity measures 3 mm and could be a
small nodule or focal atelectasis (series 2, image 50). Other scattered areas
of parenchymal scarring and/or focal atelectasis and noted near the pleura. A
left pleural effusion is trace and nonhemorrhagic. There are pleural
calcifications in the left anterior lung suggesting a chronic process (series
604b, image 41; series 2, image 53). Overlying parenchymal opacity most
likely reflects rounded atelectasis, however in the absence of prior exams,
follow-up is recommended to exclude underlying lesion (series 604b, image 45;
series 2, image 55). No pneumothorax. The airways are patent to the
segmental bronchi bilaterally.
BASE OF NECK: A 5-mm hypodensity in the right thyroid lobe is too small to
required imaging follow-up given the patient's age (series 2, image 1).
Another tiny nodule in the right thyroid lobe is also noted (series 2, image
6).
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. No
evidence of focal lesion or laceration. No evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits. No
ascites.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. No peripancreatic stranding.
SPLEEN: A hypodensity in the spleen measuring up to 11 mm is likely a
hemangioma, alternatively a cyst (series 2, image 95). The spleen otherwise
shows normal size and attenuation throughout, without evidence of 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.
The right kidney appears under rotated. Bilateral renal cortical
hypodensities are too small to accurately characterize on CT but statistically
most likely cysts. No evidence of concerning focal renal lesions or
hydronephrosis. No perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. There is colonic
diverticulosis that is at least moderate in severity. The colon and rectum
are otherwise within normal limits. The appendix is normal (series 2, image
138). No evidence of mesenteric injury. No free air or intra-abdominal fluid
collections.
There is no free fluid or free air in the abdomen.
PELVIS: The urinary bladder is distended and grossly unremarkable. No
surrounding fat stranding. The distal ureters are unremarkable. No free
fluid in the pelvis.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: No retroperitoneal or mesenteric lymphadenopathy. No pelvic or
inguinal lymphadenopathy.
VASCULAR: No abdominal aortic aneurysm or retroperitoneal hematoma. Moderate,
diffuse atherosclerotic disease is noted.
BONES: No acute fracture. No focal suspicious osseous abnormality. The
thoracic spine is curved slightly to the right. Sclerotic lesion in an upper
lumbar vertebral body appears benign. (series 604b, image 47). Multilevel
degenerative changes in the lumbosacral spine are severe. There appears to be
a focal moderate to large disc protrusion with disc desiccation at the L4-L5
level, which along with bilateral facet hypertrophy and ligamentum flavum
hypertrophy results in severe spinal canal stenosis (series 602b, image 70;
series 3, image 151, 153). Degenerative changes in the sacroiliac joints are
at least moderate.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits other than
soft tissue stranding and contusion in the right gluteal region (series 2,
image 175, 177, 178). No soft tissue gas. Drainable soft tissue fluid
collections.
IMPRESSION:
1. No evidence of acute fracture in the torso.
2. Trace left nonhemorrhagic pleural effusion. Pleural thickening with
calcifications suggesting chronic process. Associated left lower lobe opacity
could be rounded atelectasis and/or scarring, although underlying lesion
cannot definitely be excluded in the absence of prior exams. Dedicated chest
CT non emergently is recommended within 3 months to evaluate stability and/or
resolution.
3. Moderate to large L4-L5 disc herniation, along with other degenerative
changes resulting in severe spinal canal stenosis.
4. Small right gluteal soft tissue contusion/ecchymosis.
NOTIFICATION: The findings, images, impression, and recommendation were
discussed in person by ___ with Dr. ___ on ___ at
1:10 ___, 1 minutes after discovery of the findings.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: FALL DOWN STAIRS
Diagnosed with Laceration without foreign body of scalp, initial encounter, Fall (on) (from) unspecified stairs and steps, init encntr
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Ms. ___ is a pleasant ___ year old female who was
transported to ___ ED on ___ from home by ambulance after a
fall down her cellar stairs, found to have cervical spine
fractures at C1 and C2.
#c1/c2 fracture
She was admitted to ___ service under Dr. ___. She was
initially placed in a c-collar, but this was cleared per Dr.
___ the nature of the fractures and no posterior
midline tenderness. Her neurologic exam remained intact. CTA of
the neck was negative for vascular injury. No operative
intervention was indicated.
#Pain
She developed increased left side skull pain radiating to jaw
and head, and her pain regimen was adjusted with little
improvement. Pain service evaluated her for further
recommendations. New regimen with Tylenol, PO morphine,
tizanidine, and gabapentin was initiated with good pain control.
She was discharged home with Tizanidine, Tylenol, and
gabapentin.
#Anticoagulation
Patient has a pacemaker and h/o Afib, and takes Coumadin at
home. This was initially held, but restarted when determined no
OR will be needed. Coumadin was restarted at home dosing and INR
was 3.0 at discharge. She will continue to follow up with her
PCP for monitoring.
#Hyponatremia
The patient was noted to be hyponatremic during admission and
treated with sodium chloride tabs, which were able to be weaned
to 1g daily at discharge. Her PCP ___ continue to monitor.
She was evaluated by physical therapy, who cleared her for
discharge home on ___. Pain was well controlled on PO regimen,
she was ambulating, and tolerating PO diet prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
orange juice
Attending: ___
Chief Complaint:
Left flank pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of polycystic kidney disease presenting for
left
flank pain. Patient originally presented 2 days prior, and at
that point his symptoms included back pain that was midline
around the lumbar region radiating to both sides and not
associated with any neurological symptoms and no concern for
acute spinal cord syndrome. Patient had a CT abdomen pelvis at
the time to rule out any other abdominal causes of his pain,
which was significant only for known polycystic kidney disease
and constipation. He was given an enema and laxative and had a
bowel movement, which relieved his symptoms. He was discharged
home. He then developed more left-sided flank pain. The pain is
sharp, exacerbated by breathing, exacerbated by moving around,
not associated with any numbness, weakness, numbness, tingling,
changes in urination. Is localized to the left flank. Patient
has
not had any bowel movements, including diarrhea since his
discharge.
In the ED, initial vitals: T 98.5, HR 90, BP 141/58, RR 18, O2
sat 95% on RA
- Exam notable for: Point tenderness L flank
- Labs notable for: D-dimer 742, Trop 0.04, BUN 95, Cr 7.0,
proBNP 1281, WBC 10.6
- Imaging notable for: renal U/S showing large polycystic
kidneys
without hydro
- Pt given: Morphine sulfate 2mg IV, heparin gtt
On the floor, he complains of left sided flank pain that is
non-radiating. Does not have nausea, fevers, CP, or shortness of
breath. Endorses pleuritic pain.
REVIEW OF SYSTEMS:
Complete ROS obtained and is otherwise negative.
Past Medical History:
PAST MEDICAL HISTORY:
-Chronic Kidney Disease Stage V
-Hyperlipidemia
-Hypertension
-Gout
-Paraseptal and Lobular Emphysema, COPD on home oxygen
-Probable Renal Cell Carcinoma
-Right Lung Lobectomy
-s/p Appendectomy
-Tobacco Abuse
-Osteoarthritis
-Chronic Constipation
PAST SURGICAL HISTORY:
-LUE Brachiocephalic AVF
-RUL Lobectomy for pulmonary nodule, ___
-Laser Prostate Surgery for urinary retention
-Appendectomy
Social History:
___
Family History:
Notable for a mother with hypertension and a father who was
killed during World War II.
Physical Exam:
========================
ADMISSION PHYSICAL EXAM
========================
VITALS: Reviewed in OMR
General: Alert, oriented, no acute distress, on nasal cannula
HEENT: Sclerae anicteric, MMM
CV: Regular rate and rhythm, ___ SEM heard best at left sternal
border, no appreciable rubs or gallops
Lungs: Left sided posterior crackles, no wheezes, rales, rhonchi
Abdomen: Soft, distended, diffusely tender L>R, bowel sounds
present, no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, negative homans sign
Skin: Warm, dry, no rashes or notable lesions.
Neuro: moving all extremities spontaneously, sensation grossly
in
tact
========================
DISCHARGE PHYSICAL EXAM
========================
VITALS: 97.7PO, 147 / 67, 84, 20, 96% on 2L
General: Alert, oriented, no acute distress, sitting in bed, on
2L nasal cannula
HEENT: Sclerae anicteric, MMM
CV: RRR, ___ SEM heard best at left sternal border, no rubs or
gallops
Lungs: CTAB - no wheezes, rales, or rhonchi
Abdomen: +BS, soft, distention stable, NT
Ext: Warm, well perfused, no BLE edema
Skin: Warm, dry, no rashes or notable lesions.
Neuro: Moving all extremities spontaneously, no facial asymmetry
Pertinent Results:
================
ADMISSION LABS
================
___ 08:52AM BLOOD WBC-10.3* RBC-3.25* Hgb-9.6* Hct-29.7*
MCV-91 MCH-29.5 MCHC-32.3 RDW-16.9* RDWSD-56.0* Plt ___
___ 08:52AM BLOOD Neuts-70.2 ___ Monos-7.2 Eos-1.6
Baso-0.3 Im ___ AbsNeut-7.23* AbsLymp-2.08 AbsMono-0.74
AbsEos-0.16 AbsBaso-0.03
___ 08:52AM BLOOD Plt ___
___ 04:09PM BLOOD Glucose-83 UreaN-95* Creat-7.0* Na-146
K-4.4 Cl-99 HCO3-25 AnGap-22*
___ 04:09PM BLOOD CK(CPK)-32*
___ 04:09PM BLOOD CK-MB-1 proBNP-1281*
___ 04:09PM BLOOD cTropnT-0.04*
___ 12:43AM BLOOD cTropnT-0.03*
___ 05:22AM BLOOD Calcium-9.4 Phos-6.3* Mg-2.4
___ 04:09PM BLOOD D-Dimer-742*
___ 06:49PM BLOOD Lactate-1.8
================
IMAGING/STUDIES
================
RENAL ULTRASOUND ___ IMPRESSION: Large bilateral polycystic
kidneys, without hydronephrosis.
CT A/P W/O CONTRAST ___ IMPRESSION:
1. No evidence of mechanical bowel obstruction.
2. Grossly stable appearance of polycystic kidneys, within the
limitations of an unenhanced study.
3. Moderate pericardial effusion, similar to previous.
4. Stable interstitial changes at the lung bases.
================
DISCHARGE LABS
================
___ 07:34AM BLOOD WBC-6.6 RBC-2.97* Hgb-8.6* Hct-28.0*
MCV-94 MCH-29.0 MCHC-30.7* RDW-16.6* RDWSD-56.7* Plt ___
___ 07:34AM BLOOD Plt ___
___ 07:34AM BLOOD Glucose-88 UreaN-79* Creat-6.9* Na-144
K-4.0 Cl-100 HCO3-28 AnGap-16
___ 07:34AM BLOOD Calcium-9.2 Phos-5.2* Mg-4.1*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Finasteride 5 mg PO DAILY
2. Lactulose 30 mL PO BID
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
4. Sodium Bicarbonate 1300 mg PO BID
5. Allopurinol ___ mg PO DAILY
6. Lidocaine 5% Patch 1 PTCH TD QPM
7. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
8. Atorvastatin 10 mg PO QPM
9. Tamsulosin 0.4 mg PO QHS
10. Calcitriol 0.25 mcg PO 5X/WEEK (___)
11. Torsemide 140 mg PO DAILY
12. sevelamer CARBONATE 800 mg PO BID WITH MEALS
13. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
14. Polyethylene Glycol 17 g PO BID
15. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
16. Linzess (linaclotide) 145 mcg oral DAILY
17. Omeprazole 40 mg PO DAILY
18. Verapamil SR 180 mg PO Q24H
Discharge Medications:
1. Glycerin Supps 1 SUPP PR PRN constipation
RX *glycerin (adult) Adult 1 suppository(s) rectally Daily PRN
Disp #*30 Suppository Refills:*0
2. Senna 8.6 mg PO BID Constipation - First Line
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
3. Simethicone 120 mg PO QID:PRN gas, distention
RX *simethicone [Gas Relief] 125 mg 1 capsule by mouth QID PRN
Disp #*30 Capsule Refills:*0
4. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
6. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN SOB
7. Atorvastatin 10 mg PO QPM
8. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
9. Calcitriol 0.25 mcg PO DAILY
10. Finasteride 5 mg PO DAILY
11. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
12. Lactulose 30 mL PO BID
13. Lidocaine 5% Patch 1 PTCH TD QPM
14. Linzess (linaclotide) 145 mcg oral DAILY
15. Omeprazole 40 mg PO DAILY
16. Polyethylene Glycol 17 g PO BID
17. sevelamer CARBONATE 800 mg PO TID W/MEALS
18. Sodium Bicarbonate 1300 mg PO BID
19. Tamsulosin 0.4 mg PO QHS
20. Torsemide 140 mg PO DAILY
21. Verapamil SR 180 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY:
Flank Pain
Constipation
Polycystic Kidney Disease
Chronic Kidney Disease Stage V
SECONDARY:
Benign Prostate Hyperterophy
Chronic obstructive sleep disease
Hyperlipidemia
Gout
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL U.S. PORT
INDICATION: History: ___ with L flank pain/point tenderness in setting of
polycystic kidney disease, recent CT on ___// Cyst burden, any question of
ruptured cyst?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT dated ___.
FINDINGS:
Large polycystic kidneys, as seen on prior CT. Cysts imaged appear simple.
There is no hydronephrosis. No free fluid is seen.
The bladder is mildly distended and grossly normal in appearance.
IMPRESSION:
Large bilateral polycystic kidneys, without hydronephrosis.
Radiology Report
EXAMINATION: CT scan of the abdomen and pelvis without intravenous contrast
INDICATION: ___ year old man with nausea, vomiting, constipation, and
intermittent sharp left abdominal pain- concerning for intermittent
obstruction// Obstruction?
TECHNIQUE: Multi detector CT axial images were acquired through the abdomen
and pelvis without intravenous contrast.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 13.7 s, 47.1 cm; CTDIvol = 10.2 mGy (Body) DLP =
465.3 mGy-cm.
Total DLP (Body) = 479 mGy-cm.
COMPARISON: CT scan of the abdomen and pelvis dated ___.
FINDINGS:
LOWER CHEST: Scattered peripheral cysts are noted at the lung bases
bilaterally, unchanged from previous. Moderate pericardial effusion, also
similar to prior.
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: Polycystic morphology of the renal parenchyma appears similar to
previous. The largest cyst measures 11.4 cm arising from the lower pole of
the right kidney. No hydroureteronephrosis.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are normal.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence of mechanical bowel obstruction.
2. Grossly stable appearance of polycystic kidneys, within the limitations of
an unenhanced study.
3. Moderate pericardial effusion, similar to previous.
4. Stable interstitial changes at the lung bases.
Gender: M
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: Back pain
Diagnosed with Polycystic kidney, unspecified
temperature: 98.5
heartrate: 90.0
resprate: 18.0
o2sat: 95.0
sbp: 141.0
dbp: 58.0
level of pain: 10
level of acuity: 3.0 | PATIENT SUMMARY
================
Mr. ___ is a ___ w/ PMHx of polycystic kidney disease and
probable RCC, CKD stage 5 with left AV fistula, BPH s/p TURP,
COPD, s/p upper
lobectomy presenting with constipation and L flank pain, likely
in the setting of gastroparesis (nausea, vomiting, constipation)
and heavy renal cyst burden (abdominal pain).
ACUTE ISSUES
=============
#Flank pain: Mr. ___ presented with multiple day history of
L-sided abdominal pain, worse with inspiration, that was
intermittent and "sharp" in nature. He also had chronic
constipation, and developed nausea/vomiting while hospitalized.
Underwent a CT on ___ which showed a 1cm increase in R kidney
size and 3mm increase in L kidney size, however no acute
findings to explain his symptoms. Admission renal ultrasound was
without hydronephrosis or obstructing stone. He developed
vomiting on ___, and as such had a repeat CT A/P that did not
demonstrate bowel obstruction. Overall, his symptoms seemed most
likely related to dysmotility (given chronic constipation and
h/o polycystic kidney disease), recurrent pain from cyst burden
iso PKD (pain worsened with increase intraabdominal pressure),
and potentially a musculoskeletal etiology given worsened pain
with palpation of the paraspinal muscles. Was thought to be less
likely to represent intermittent SBO (given no e/o obstruction
on repeat CT A/P), ruptured renal cyst (no free fluid on renal
ultrasound), or nephrolithiasis (no hematuria and no e/o on CT
A/P or renal US). Given concern for gastroparesis, we trialed
Metopclopramide 10mg TIDWM, which reduced his abdominal pain. We
aggressively and successfully treated his constipation during
his hospitalization.
# Polycystic kidney disease and
# CKD: As above, appears to have stable disease. Creatinine has
slowly increased over time, consistent with CKD. We continued
his home Sodium Bicarbonate, Sevelamer, Calcitriol, and
Torsemide.
CHRONIC ISSUES
===============
# BPH s/p TURP: Continued home Finasteride and Torsemide
# COPD: Continued home albuterol, advair, and supplemental O2
(goal SO2 88-92%)
# HLD: Continued home atorvastatin
# Gout: Continued home allopurinol
# HTN: Continued verapimil
TRANSITIONAL ISSUES
====================
[ ] Consider restarting home Verapamil after PCP follow up if
needed for HTN management
[ ] We are working on scheduling an appointment with Dr. ___.
Please call your PCP's office if you have not heard back by
___. You should be seen within 1 week.
[ ] An appointment was scheduled with Dr. ___ to discuss GI
dysmotility related to end stage renal disease and chronic
constipation on ___ at 1:30pm
[ ] New medications: Simethicone 120 mg PO/NG QID:PRN gas
[ ] Patient was encouraged to continue bowel regimen: Colace,
senna, miralax, bisacodyl, suppository and linzess. Home
lactulose was continued as well, though it may be contributing
to abdominal discomfort. Would consider substituting if felt
appropriate.
[ ] Changed medications: Allopurinol to 100mg PO daily (given
kidney function) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
syncope
Major Surgical or Invasive Procedure:
None this hospitalization
History of Present Illness:
This is a ___ year-old healthy man presenting after syncopal
event at the ___ earlier this evening. He was sitting,
and reached below his seat to pick something up when he felt a
severe sharp pain in his right shoulder. He became dizzy and
sweaty, felt like he was going to pass out, so he put his head
between his legs. The next thing he remembers he woke up, and
felt slightly disoriented. Per his wife, he was out for ___
secs. He lost bladder function but had no witnessed shaking or
tongue biting, and no loss of his bowels. He denies any
preceeding CP, palpitations, SOB, cough, N/V. He had been
sitting in the shade, had one beer. Has had good PO intake.
Hasn't passed out since he was a child. Regarding the shoulder
pain, it was located over the anterior shoulder is a discreet
spot, he did not have any pain over the chest.
.
In the ED initial vitals were 96.8, 96, 137/77, 18, 100% on 2L.
ECG showed sinus tachycardia with isolated TWI in lead III and
J-point elevation in V2-V4. He was given 325mg and 2L NS. Labs
unremarkable, trop neg. CXR unremarkable. VS prior to transfer
were 98.0, 92, 121/77, 16, 100%RA.
.
Currently, he is comfortable and has no complaints. He has had
no further shoulder pain.
.
ROS: As noted in HPI. In addition, denies fevers, chills,
headaches, vision changes, cough, abdominal pain, nausea,
vomiting, diarrhea, constipation, melena, hematochezia, dysuria,
or hematuria.
Past Medical History:
Denies
Social History:
___
Family History:
Father died from MI at age ___. Mother alive and healthy. No
family history of early MI or sudden death.
Physical Exam:
ADMISSION EXAM:
.
VITALS: 97.8, 122/84, 99, 16, 97% RA
GENERAL: Pleasant, well appearing man in NAD
HEENT: Normocephalic, atraumatic. No conjunctival pallor. No
scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck Supple, No
LAD, No thyromegaly.
CARDIAC: Regular rhythm, normal rate. Normal S1, S2. No murmurs,
rubs or ___. JVP not elevated.
LUNGS: CTAB, good air movement biaterally.
ABDOMEN: NABS. Soft, NT, ND. No HSM.
EXTREMITIES: No edema or calf pain, 2+ dorsalis pedis/ posterior
tibial pulses. Well healed lesion over right anterior shin from
prior skin excision. No shoulder tenderness, has full ROM.
NEURO: A&Ox3. Appropriate. CN ___ intact. Preserved sensation
throughout. ___ strength throughout. ___ reflexes, equal ___.
Normal coordination. Gait assessment deferred.
.
DISCHARGE EXAM:
.
VITALS: 97.7 97.7 123/68 86 18 95% RA
I/Os: 60 / 400 | 1200 + BRP
GENERAL: Appears in no acute distress. Alert and interactive.
HEENT: Normocephalic, atraumatic. EOMI. PERRL. Nares clear.
Mucous membranes moist.
NECK: supple without lymphadenopathy. JVD difficult to assess
given body habitus.
___: Regular rate and rhythm, without murmurs, rubs or gallops.
S1 and S2 normal. No reproducible sternal tenderness.
RESP: Clear to auscultation bilaterally without adventitious
sounds. No wheezing, rhonchi or crackles. Stable inspiratory
effort.
ABD: soft and obese, non-tender, non-distended, with normoactive
bowel sounds. No palpable masses or peritoneal signs.
EXTR: no cyanosis, clubbing or edema, 2+ peripheral pulses
NEURO: CN II-XII intact throughout. Alert and oriented x 3.
Strength ___ bilaterally, sensation grossly intact. Gait
deferred.
RECTAL: deferred.
Pertinent Results:
ADMISSION & DISCHARGE LABS:
.
___ 10:30PM BLOOD WBC-8.8 RBC-4.72 Hgb-13.2* Hct-40.8
MCV-86 MCH-28.0 MCHC-32.4 RDW-12.0 Plt ___
___ 10:30PM BLOOD Neuts-67.0 ___ Monos-3.5 Eos-1.2
Baso-1.0
___ 10:30PM BLOOD Plt ___
___ 10:30PM BLOOD Glucose-320* UreaN-12 Creat-0.9 Na-137
K-3.9 Cl-103 HCO3-25 AnGap-13
___ 08:10AM BLOOD CK-MB-1 cTropnT-<0.01
___ 10:30PM BLOOD cTropnT-<0.01
___ 10:30PM BLOOD Calcium-8.3* Phos-2.8 Mg-2.0
.
MICROBIOLOGY DATA: None
.
IMAGING:
___ CHEST (PA & LAT) - Two views of the chest demonstrate
clear lungs without effusion or pneumothorax. The cardiac
silhouette is normal in size, mediastinal contours are normal.
Medications on Admission:
Denies
Discharge Medications:
None
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
1. Neurocardiogenic (vasovagal) syncope
.
Secondary Diagnoses: None
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ male with syncope and right shoulder pain. Evaluate for
pneumothorax.
COMPARISON: None.
FINDINGS: Two views of the chest demonstrate clear lungs without effusion or
pneumothorax. The cardiac silhouette is normal in size, mediastinal contours
are normal.
IMPRESSION: No acute chest abnormality.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SYNCOPE
Diagnosed with SYNCOPE AND COLLAPSE, ABNORM ELECTROCARDIOGRAM
temperature: 96.8
heartrate: 96.0
resprate: 18.0
o2sat: 100.0
sbp: 137.0
dbp: 77.0
level of pain: 0
level of acuity: 3.0 | IMPRESSION: ___ with no significant past medical history who
presented following a syncopal episode at a baseball game.
PLAN:
# SYNCOPE - The patient leaned down and reached with his right
arm under his chair and turned his neck inciting sharp pain
without radiation of the right arm while at a baseball game.
Following sitting up he experienced lightheadedness and
dizziness with resulting syncope for ___ sec of LOC following
that. No head trauma or injury. Wife confirms his story. Some
mild bladder incontinence, but this can be seen with
neurocardiogenic syncope. Certainly seizure episode is of
concern given the bladder incontinence, but patient has no
strong family history and no prior seizure episodes. Similarly,
laboratory data reveal no metabolic derangements. He also had no
post-ictal concerns, no paralysis and no tongue biting. A TIA or
stroke is of slight concern in a male with a family history of
cardiac disease, obesity and some hyperglycemia on laboratory
data (without HTN, HLD, diabetes history). He has no focal
neurologic deficits or weakness and no carotid bruit on exam. A
posterior circulation TIA could present with a drop attack and
these symptoms, but again less likely. In terms of cardiac
etiologies, his EKG was reassuring with an isolated TWI in lead
III and sinus tachycardia with mild J-point elevation. He does
have family history of MI in his father, but again no documented
HTN, HLD, or diabetes is noted. Cardiac biomarkers reassuring in
the ED (two-sets) and no chest pain or trouble breathing. CXR
was also negative in the ED. He had no arrhythmia documented on
overnight telemetry and has no family history of sudden cardiac
death or early MI. Hypoglycemia unlikely in this patient.
Overall, this leaves a vasovagal episode (neurocardiogenic)
occurring in the setting of sharp and precipitous pain in the
right shoulder that resulted in hypoperfusion, inciting syncope.
He has had no issues similar to this previously. Of interest,
prior to discharge, his peripheral IV was removed and he
developed sinus bradycardia to 30 bpm with mild hypotension and
lightheadedness that rapidly improved, consistent with
neurocardiogenic syncope. An EKG was reassuring. He was
monitored on telemetry through the afternoon and was discharged
in stable condition.
# RIGHT SHOULDER PAIN - Currently pain free, with complete ROM
of shoulder. No history of trauma. Unclear precipitant though
may have been a muscle strain or outpatient brachial plexus
impingement or transient 'stinger'. No RUQ pain to suggest GB
pathology. We encouraged range of motion exercises and possibly
outpatient physical therapy evaluation
# HYPERGLYCEMIA - No prior history of diabetes or strong family
history. No HTN, HLD reported. Patient has evidence of obesity.
He presented with elevated serum glucose and glucosuria. Will
need outpatient fingerstick rechecked and HbA1c, blood pressure
monitoring and fasting lipid panel as an outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
ibuprofen / Codeine / Enalaprilat / trimethoprim / amlodipine
Attending: ___
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ yo right handed woman with a history of
HTN, HLD, and stroke in ___ who presents after being found down
at home. This morning her niece heard a thud and found the
patient on the floor in the bathroom. She was lying on her side
with eyes closed. Both her arms and legs were shaking and she
appeared to be having a seizure. Niece denied noticing gaze
deviation. It is unknown if she was incontinent. Her face was
bleeding. She was breathing. The niece called ___ and an
ambulance was sent. The niece believes the seizure activity
lasted <5 minutes and was over by the time of EMS arrival, but
she is unsure. Per their report, the EMS crew was dispatched at
08:39, arrived 10 minutes later, and "observed brief period of
seizure activity w/trismus airway and pupils deviated to the
left."
In the ED her GCS was 5. She had another witnessed event. Per
the
resident and attending who witnessed it, she was tremulous, with
tonic extremities, jaw clenching, and leftward gaze deviation;
she was not clearly posturing nor was it clearly a GTC. It
lasted
<1 minute and resolved spontaneously. She was subsequently given
1mg Ativan and 500mg IV Keppra (equivalent to 12.8mg/kg). Pupils
were noted to be small and neurology was consulted to consider
brainstem infarct (or other stroke) on the DDx as well as for
seizure management.
She's been sleepy since her seizure. She's never had a seizure
before. She's had no recent infx sx, neurologic symptoms, nor
sleep changes per niece. She has had some weight loss and
intermittent nausea/vomiting, though this is an ongoing issue.
In ___, she was admitted to the stroke service with left sided
weakness and was found to have right corona radiata and
post-central gyrus infarcts on MRI. On stroke work up, her only
stroke risk factor was hypertension and she was persistently
hypertensive during her hospitalization. She was started on full
dose of aspirin. Per her PCP, labile BP has been an ongoing
issue
and she's been in the 200s systolic and asymptomatic previously.
The ED resident spoke with her PCP and per that discussion, she
has been doing well at home. Her main current medical issue is
labile BP and she has been asymptomatic in the 200s systolic
previously. She has a MOLST form and is DNR/DNI confirmed with
nieces at bedside.
Past Medical History:
CAD s/p MI
HTN
HLD
lumbar spinal stenosis L3-L5
Breast CA
Mitral valve prolapse
intraductal papillary mucinous neoplasm in pancreas, undergoing
radiation therapy, deferred surgery
cystocele
DM - diet controlled
Strple (___)
Social History:
___
Family History:
Family with significant cancer history. Brother with history of
stroke.
Physical Exam:
ADMISSION EXAMINATION
Vitals:
97.3 93 214/19 18 97% RA
FSBG: 167
General: appears ill
HEENT: bleeding left face wounds and ?nasal fracture
Neck: Supple without meningismus
Pulmonary: clear to auscultation anteriorly
Cardiac: RRR, no murmurs
Abdomen: soft, nondistended
Extremities: 2+ pitting edema bilaterally
Skin: no rashes or lesions noted.
NEUROLOGIC EXAMINATION
-Mental Status: Eyes closed. Does not open them to noxious.
Follows no commands initially but upon reassessment later did
follow simple commands. +grasp reflex. Makes occasional groaning
sounds, but otherwise no verbal output.
-Cranial Nerves: PERRL 2->1mm bilaterally and brisk. Gaze is
forward; no skew. No blink to threat. Neg Doll's eye reflex.
Blinks to eyelash stimulation bilaterally. Face appears
symmetric
to grimace, though this exam was limited.
-Motor/Sensory: Increased tone throughout. Withdraws left hand
and BLE to nailbed pressure. Moves all extremities spontaneously
and is initially antigravity in the right arm, but not left.
Upon
reassessment (~1hr later) was antigravity in both arms, but did
seem to have some subtle asymmetry with left sided weakness.
-DTRs: brisk throughout with upgoing toes bilat (previously
documented)
DISCHARGE EXAMINATION
NAD, L eye bruised (improved), no WOB, WWP, ND, bilateral ___
edema improved
Alert, speech fluent, answers appropriate.
Face symmetric
Deltoids ___, Biceps ___, Triceps ___, ECR ___, TA ___ B/L
Pertinent Results:
___ 05:05AM BLOOD WBC-6.2 RBC-2.86* Hgb-8.9* Hct-28.3*
MCV-99* MCH-31.1 MCHC-31.4* RDW-13.2 RDWSD-47.7* Plt ___
___ 09:32AM BLOOD WBC-8.1# RBC-3.31* Hgb-10.4* Hct-33.9*
MCV-102* MCH-31.4 MCHC-30.7* RDW-13.3 RDWSD-49.7* Plt ___
___ 09:32AM BLOOD Neuts-41.3 ___ Monos-9.5 Eos-2.8
Baso-1.1* Im ___ AbsNeut-3.35 AbsLymp-3.64 AbsMono-0.77
AbsEos-0.23 AbsBaso-0.09*
___ 05:05AM BLOOD Plt ___
___ 09:32AM BLOOD Plt ___
___ 09:32AM BLOOD ___ PTT-31.1 ___
___ 05:05AM BLOOD Glucose-121* UreaN-30* Creat-1.8* Na-138
K-4.8 Cl-107 HCO3-19* AnGap-17
___ 05:05AM BLOOD Glucose-83 UreaN-30* Creat-1.4* Na-143
K-3.1* Cl-111* HCO3-19* AnGap-16
___ 09:32AM BLOOD Glucose-176* UreaN-36* Creat-1.8* Na-145
K-3.7 Cl-111* HCO3-15* AnGap-23*
___ 09:32AM BLOOD estGFR-Using this
___ 09:32AM BLOOD ALT-19 AST-24 CK(CPK)-84 AlkPhos-101
TotBili-0.4
___ 09:32AM BLOOD Lipase-9
___ 09:32AM BLOOD cTropnT-0.01
___ 09:32AM BLOOD CK-MB-4
___ 05:05AM BLOOD Calcium-7.6* Phos-3.0 Mg-1.8
___ 05:05AM BLOOD Calcium-7.6* Phos-3.5 Mg-1.1*
___ 09:32AM BLOOD Albumin-3.4*
___ 09:32AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:06AM BLOOD Comment-GREEN TOP
___ 11:06AM BLOOD Lactate-1.6
___ 10:17AM URINE Color-Straw Appear-Clear Sp ___
___ 10:17AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 10:17AM URINE RBC-0 WBC-7* Bacteri-NONE Yeast-NONE
Epi-<1
___ 10:17AM URINE
___ 10:17AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
___ Dopplers
No evidence of deep venous thrombosis in the right or left lower
extremity
veins. Mild lower extremity soft tissue edema is noted.
CXR
Atelectasis at the left lung base. No focal consolidation.
MRI and MRA brain
1. No definite evidence of acute ischemic changes. Several
foci of high
signal intensity are demonstrated in the subcortical white
matter as described
bed, suggesting T2 shine through effect from prior ischemic
changes
demonstrated on ___. Gyriform hyperintensity is
demonstrated in the
right occipital lobe suggestive of pseudo laminar necrosis,
related with
chronic infarction as described above.
2. Prominent ventricles and sulci suggesting cortical volume
loss, confluent
areas of high-signal intensity in the subcortical white matter
are nonspecific
and may reflect changes due to small vessel disease.
3. Arthrosclerotic changes are demonstrated left middle
cerebral artery and
posterior cerebral arteries with mild segmental narrowing. No
aneurysms are
identified.
CT C-Spine
1. No acute fractures or traumatic malalignment.
2. Likely degenerative anterolosthesis of C7 over T1.
3. Moderate to severe degenerative changes of the cervical spine
as noted
above.
CT Head
1. No acute intracranial abnormalities.
2. Chronic appearance of infarctions involving the right
occipital lobe of and
left centrum ovale, new since ___.
3. Left frontal face soft tissue swelling without underlying
fracture.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Atenolol 50 mg PO BID
2. Aspirin 162 mg PO DAILY
3. LOPERamide 2 mg PO QID:PRN Loose BM
4. Omeprazole 40 mg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Acetaminophen 325-650 mg PO Q6H:PRN fever, HA
8. Losartan Potassium 100 mg PO DAILY
9. Ferrex ___ (polysaccharide iron complex) 150 mg iron oral
Q24H
10. Zenpep (lipase-protease-amylase) ___ capsules oral TID
W/MEALS
Discharge Medications:
1. Aspirin 162 mg PO DAILY
2. Atenolol 50 mg PO BID
3. Levothyroxine Sodium 50 mcg PO DAILY
4. Losartan Potassium 100 mg PO DAILY
5. Omeprazole 40 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. LeVETiracetam 500 mg PO BID
8. Acetaminophen 325-650 mg PO Q6H:PRN fever, HA
9. Ferrex ___ (polysaccharide iron complex) 150 mg iron oral
Q24H
10. LOPERamide 2 mg PO QID:PRN Loose BM
11. Zenpep (lipase-protease-amylase) ___ capsules oral TID
W/MEALS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Seizures
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (___
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with fall, seizure activity, hypertension. Evaluate for
intracranial hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 902 mGy-cm.
COMPARISON: MR from ___ and CT from ___.
FINDINGS:
Compared to the prior, there is new hypodensity in the right occipital lobe,
with ex vacuo dilatation of right occipital horn, likely chronic infarction
but new since prior. There is also hypodensity the left centrum ovale,
sequela of chronic infarction though new since ___. There expected evolution
of previously right coronal radiata infarction.
There is no evidence of acute hemorrhage, edema, or mass. There is prominence
of the ventricles and sulci suggestive of involutional changes.
Periventricular and subcortical white matter hypodensities are consistent with
chronic small vessel disease.
There is no evidence of fracture. There is soft tissue swelling over the left
lateral orbital wall. 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 is evidence of bilateral lens replacements.
Vascular calcifications in the carotid siphons and vertebral arteries are
noted bilaterally.
IMPRESSION:
1. No acute intracranial abnormalities.
2. Chronic appearance of infarctions involving the right occipital lobe of and
left centrum ovale, new since ___.
3. Left frontal face soft tissue swelling without underlying fracture.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with fall. Evaluate for fractures.
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) = 761 mGy-cm.
COMPARISON: None.
FINDINGS:
There is a 2 mm anterolisthesis of C7 over T1, likely degenerative given facet
joint disease at that level. No acute fractures are identified.There is no
prevertebral soft tissue swelling.
Multilevel mild to severe degenerative changes of the cervical spine seen,
with mild vertebral body the height loss, disc space narrowing, anterior and
posterior osteophytosis, worst at C4-5 through C6-7. At these levels, there
are central disc bulging, posterior osteophyte and bilateral uncovertebral
hypertrophy, which moderately narrow the spinal canal and bilateral neural
foramina.
Torus palatini is seen. The esophagus is patulous. Right carotid artery is
medialized. There bi apical septal thickening and scarring. Calcification of
the carotid bulb and vertebral arteries are noted. Multiple 7 mm right
thyroid lobe nodules are seen.
IMPRESSION:
1. No acute fractures or traumatic malalignment.
2. Likely degenerative anterolosthesis of C7 over T1.
3. Moderate to severe degenerative changes of the cervical spine as noted
above.
Radiology Report
EXAMINATION: MRI and MRA Head, MRA of the neck.
INDICATION: ___ year old woman with HTN, HLD, CVA presenting with
seizure, concern for new stroke.// evidence of stroke, seizure focus>
TECHNIQUE: Multi planar multi sequence MR images of the brain were obtained
without contrast, including coronal T2 weighted images throughout the temporal
lobes.
MRA of the head, non contrast 3D time-of-flight MRA of the brain was
performed, axial source images and multiplanar reformations were reviewed.
COMPARISON: Head CT dated ___, and prior MRI and MRA of the brain
and neck dated ___.
FINDINGS:
MR Head: There are several bilateral foci of T2 shine through effect in the
subcortical white matter and left centrum semiovale, detected on the DWI
sequence and ADC maps, with no frank evidence of acute ischemic changes.
Gyriform hyperintensities are demonstrated in the right occipital lobe
suggestive of pseudo laminar necrosis related with chronic infarction with
associated right occipital lobe encephalomalacia. The ventricles and sulci
are prominent suggesting cortical volume loss. Scattered foci of high signal
intensity are demonstrated in the subcortical and periventricular white matter
on the T2 weighted images, which are nonspecific and may reflect changes due
to small vessel disease. The major vascular flow voids are present and
demonstrate normal distribution. The orbits are unremarkable. The paranasal
sinuses and the mastoid air cells are clear.
MRA of the head: There is evidence of vascular flow in both internal carotid
arteries as well as the vertebrobasilar system, segmental narrowing is
identified in the left middle cerebral artery at the M1/ M2 junction and also
in the posterior cerebral arteries involving the P2 and P3 segments,
suggesting changes due to arteriosclerotic disease. No aneurysms are
identified.
IMPRESSION:
1. No definite evidence of acute ischemic changes. Several foci of high
signal intensity are demonstrated in the subcortical white matter as described
bed, suggesting T2 shine through effect from prior ischemic changes
demonstrated on ___. Gyriform hyperintensity is demonstrated in the
right occipital lobe suggestive of pseudo laminar necrosis, related with
chronic infarction as described above.
2. Prominent ventricles and sulci suggesting cortical volume loss, confluent
areas of high-signal intensity in the subcortical white matter are nonspecific
and may reflect changes due to small vessel disease.
3. Arthrosclerotic changes are demonstrated left middle cerebral artery and
posterior cerebral arteries with mild segmental narrowing. No aneurysms are
identified.
Radiology Report
INDICATION: ___ with CVA, HTN, HLD presenting with fall, seizure. Evaluate
for pneumonia
TECHNIQUE: Single frontal chest radiograph was obtained.
COMPARISON: Chest x-ray from ___
FINDINGS:
There is atelectasis at the left lung base. No focal consolidation is
identified. The cardiomediastinal silhouette and hilar contours are stable
given differences in patient positioning. There is no pleural effusion or
pneumothorax. Degenerative changes are noted in the cervical spine as well as
the bilateral shoulders. Calcifications of the aortic arch and the
tracheobronchial tree are again noted.
IMPRESSION:
Atelectasis at the left lung base. No focal consolidation.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with swollen ___ // 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.
Soft tissue edema seen in the bilateral calves.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins. Mild lower extremity soft tissue edema is noted.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, Seizure
Diagnosed with Epilepsy, unsp, not intractable, with status epilepticus
temperature: 97.3
heartrate: 93.0
resprate: 18.0
o2sat: 97.0
sbp: 214.0
dbp: 19.0
level of pain: uta
level of acuity: 1.0 | Ms. ___ is a ___ F with a PMHx of HTN, HL, and
stroke (___) who presented after a fall at home and 3 events
concerning for seizure. On exam, she had facial bruising and was
initially obtunded with less movement of her left size. Her CT
and MRI brain did not show any evidence of new strokes or
hemorrhage, and her CT c-spine did not show any fractures or
acute injury. The following morning, she was alert, following
all commands, answering questions appropriately, and had fluent
speech. Additionally, her left-sided weakness had resolved.
Overall, our impression is that she seizures, and her old stroke
was the seizure focus. The obtundation was likely secondary to a
post-ictal state as well as the receipt of benzodiazepines. The
left-sided weakness was likely due to recrudescence of old
stroke symptoms or a ___.
She was started on Keppra 500mg BID. Her EEG showed evidence of
intermittent right posterior slowing and bitemporal slowing, but
there were no further seizures. She initially failed a bedside
swallow evaluation, but she passed a formal swallow evaluation.
She was continued on fall, seizure, and aspiration precautions.
Her LFTs, utox, stox, UA, and CXR were normal. ___ Dopplers
obtained for ___ swelling were also normal. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
MD-___ R
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Laparoscopic cholecystectomy - Dr. ___
___ of Present Illness:
Patient is an ___ year old male with multiple medical problems
including CAD s/p CABG in ___, prostate cancer s/p xrt and HLD
presenting to the ED with abdominal pain. Patient has been in
the
ED for greater than 12 hours when our service was consulted. Per
preexisting reports by emergency department patient presented
with epigastric pain versus chest pain and was ruled out for an
MI. He continued to have back pain as well as epigastric pain
thus the CTA of the torso was obtained to rule out aortic
dissection. Patient underwent a non-contrast CT scan prior to
the
CTA. He continued to have some abdominal pain versus discomfort
and received a total of morphine IV 15 mg by the time ACS
surgery
was called to examine the patient.
At the time of our exam patient was very sleepy and minimally
engaged. He was difficult to arouse. He was able to answer
questions appropriately, but was unable to recall some history
information.
Past Medical History:
PMH: HLD, CAD (IMI/CABG ___, Prostate CA (XRT ___
PSH: 4-vessel CABG ___, PTCA/stent LCX ___, repair RFA
pseudoaneurysm
Social History:
___
Family History:
NC
Physical Exam:
Admission:
VS: 98 ___ 20 96% RA
patient examined in the ED, very drowsy and difficult to wake
up,
keeps falling asleep during the interview and exam, has been
receiving morphine IV for multiple hours
RRR
CTA b/l
abdomen is soft, thin, minimally distended, tender in the RLQ
and
RUQ, minimal tympany, no rebound tenderness, no guarding
Pertinent Results:
___ CTA torso - No pulmonary embolism, acute aortic
process, or ischemic colitis. Distended gallbladder with small
pericholecystic fluid and cholelithiasis. This appearance may be
related to a third-spacing state, but given the suggestion of
hyperemia in the gallbladder fossa and a possible cystic duct
stone, symptoms should be correlated clinically. If indicated,
HIDA scan may be obtained for further evaluation. US may assess
for a possible cystic duct stone.
Large fecal load. Increased displacement of left inferior and
superior pubic ramus fractures without significant interval bony
callus formation. Moderate-sized hiatal hernia
Medications on Admission:
- aspirin 162 mg po qdaily
- tamsulosin 0.4 mg mg po qhs
- lisinopril 2.5 mg po qdaily
- simvastatin 60 mg po qdaily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth twice a day Disp #*14 Tablet Refills:*0
3. Aspirin 162 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*100 Capsule Refills:*0
5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
RX *hydromorphone [Dilaudid] 2 mg ___ tablet(s) by mouth Every
___ hours Disp #*60 Tablet Refills:*0
6. Tamsulosin 0.4 mg PO HS
7. Simvastatin 40 mg PO DAILY
8. Lisinopril 2.5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Cholecystitis s/p Laparoscopic Cholecystectomy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with chest pain. Evaluate for evidence of
pneumothorax or pneumonia.
COMPARISON: CT chest from ___ and chest radiographs from ___.
TECHNIQUE: PA and lateral chest radiographs.
FINDINGS: The lungs are well expanded and clear. The cardiomediastinal and
hilar contours are unremarkable. There is moderate aortic tortuosity,
unchanged. A small right-sided pleural effusion is unchanged. There is no
pneumothorax. Sternotomy wires are intact. Multiple fractures in early stages
of healing are noted in the right rib cage.
IMPRESSION: Stable small right sided pleural effusion.
Radiology Report
INDICATION: ___ male with epigastric and back pain. Evaluate for
evidence of aortic dissection or any other acute abnormality.
COMPARISON: CT torso from ___.
TECHNIQUE: Axial helical MDCT images were obtained from the suprasternal
notch to the pubic symphysis without administration of IV contrast as patient
produced a document stating that he was allergic to IV contrast, in spite of
having received contrast in prior study. Coronal and sagittal reformations
were generated.
DLP: 398.42 mGy-cm.
FINDINGS: The thyroid gland is unremarkable. The airways are patent to the
subsegmental level. There is no central or axillary lymphadenopathy. There
are extensive coronary artery calcifications but the heart, pericardium, and
great vessels are unremarkable otherwise. A large hiatal hernia is unchanged.
Lung windows do not show any focal opacities bilaterally. A moderate-sized
nonhemorrhagic pleural effusion in the right side is not significantly changed
compared with ___. There is no left-sided pleural effusion and
mild left basilar atelectasis is present.
CT ABDOMEN: The liver is homogeneous, without focal lesions or intrahepatic
biliary duct dilatation. The gallbladder is unremarkable. A 1-cm calcified
gallstone is noted in the neck of the gallbladder. The common bile duct size
is top normal at the level of the pancreatic head. Otherwise, the pancreas
and adrenal glands are unremarkable. The spleen demonstrates two coarse
calcifications likely granulomas but is not enlarged. The right kidney is
unremarkable while the left kidney shows a band of hyperdense material in its
lower pole that appears to be a collection of contrast from a rupture of the
collecting duct and formation of a tiny intrarenal urinoma.
The small and large bowel are unremarkable, without wall thickening or
dilatation concerning for obstruction. There are some diverticular tics, but
no diverticulitis. There is no retroperitoneal or mesenteric lymphadenopathy.
The abdominal aorta has normal caliber throughout. There is no ascites, free
air, abdominal wall hernia.
PELVIC CT: The urinary bladder, prostate, seminal vesicles are unremarkable.
There is no pelvic or inguinal lymphadenopathy. No pelvic free fluid is
observed. Two small fat-containing inguinal hernias are present.
OSSEOUS STRUCTURES: Again noted is a non-healed fracture through the inferior
and superior left pubic ramus, with formation of bony callus compared with
prior study but without ___. There are also old healing fractures of the
right lateral ribs ___. Otherwise, there are no lytic or blastic lesions
concerning for malignancy. Left convex scoliosis is present. Severe
degenerative changes of the thoracolumbar spine are also present.
IMPRESSION:
1. No evidence of aortic aneurysm or any other acute intrathoracic or
intra-abdominal process. Please note that aortic dissection cannot be excluded
on the basis of this study.
2. Stable moderate nonhemorrhagic right-sided pleural effusion.
3. Nonunion of left pubic ramus fracture.
4. Chronic conditions include cholelithiasis, scoliosis, severe degenerative
changes of the lumbar spine, coronary artery atherosclerosis, and hiatal
hernia.
If clinical concern for aortic dissection is high, a thoracic MRA should be
pursued for further assessment. Communicated to Dr ___ telephone on
___ at 9:20 am by Dr ___
Radiology Report
INDICATION: ___ male with chest pain and shortness of breath, now
with new fever. Evaluate for new infiltrate.
COMPARISONS: ___ chest radiograph at 4:06 a.m.
FINDINGS: Single frontal view of the chest was obtained. The heart is of
normal size with stable cardiomediastinal contours. A small right pleural
effusion is similar to the exam 10 hours prior. No focal consolidation or
pneumothorax. There is small atelectasis at the right base.
Chronic-appearing right rib fractures are similar to prior. Sternotomy wires
and mediastinal clips are intact.
IMPRESSION: No relevant change from study 10 hours prior. Stable small right
pleural effusion.
Radiology Report
INDICATION: ___ male with epigastric and pleuritic pain with elevated
lactate. Evaluate for pulmonary embolism or ischemic colitis.
COMPARISONS: Same-day non-contrast CT torso of ___ at 5:50
a.m. CT torso of ___.
TECHNIQUE: MDCT images were obtained from the thoracic inlet to the pubic
symphysis after administration of 100 cc of IV Omnipaque contrast timed for
opacification of the aorta. Axial images were interpreted in conjunction with
coronal and sagittal reformats.
FINDINGS:
CHEST CTA: The great vessels are normal caliber. The aorta is normal without
aneurysm or dissection. The main, lobar, segmental, and subsegmental
pulmonary arteries are well opacified without filling defect.
CHEST: The visualized portion of the thyroid is unremarkable. No axillary,
supraclavicular, mediastinal, or hilar lymphadenopathy. Borderline 1 cm AP
window node is seen. The heart is top normal size. The patient is status
post CABG. No pericardial effusion. There is a moderate-sized nonhemorrhagic
right pleural effusion and trace left pleural effusion with adjacent bibasilar
atelectasis. No focal consolidation, pneumothorax, or pneumomediastinum.
Airways are patent to subsegmental levels. A moderate sized hiatal hernia is
present.
ABDOMINAL CTA: Scattered atherosclerotic mural calcifications are present
along the abdominal aorta. The abdominal aorta is otherwise unremarkable
without aneurysm or dissection. The common hepatic artery arises from the
SMA. The SMA and ___ are well opacified. Two left renal arteries are
well-opacified. The portal vasculature is unremarkable.
ABDOMEN:
There is trace perihepatic fluid, new since ___. No focal hepatic
lesion is identified. There is suggestion of liver parenchymal hyperemia
adjacent to the gallbladder fossa. The gallbladder is distended and there is
a small amount of pericholecystic fluid. A 1.2 cm dependent calcified stone
is present at the gallbladder neck. An 8-mm hyperdense focus (2:93, 3:186)
may represent a stone within the cystic duct, although this was not clearly
seen on the preceding non-contrast CT.
The common duct is prominent, similar to prior. No intra-hepatic bile duct
dilatation. The pancreatic duct is also prominent, similar to prior. The
pancreas is otherwise unremarkable. Two coarse calcifications within the
spleen are compatible with granulomas. The adrenal glands are normal. The
kidneys enhance symmetrically. A small band of calcification in the left
renal lower pole is similar to prior. A tiny exophyic low density right renal
lesion containing a calcification is too small to further characterize.
The stomach is unremarkable. The small and large bowel have a normal course
and caliber. Diverticulosis is present without evidence for diverticulitis.
The appendix is not identified, but no secondary signs of appendicitis are
present. There is a large amount of fecal material throughout the colon.
No retroperitoneal or mesenteric lymphadenopathy. No pneumoperitoneum or
abdominal wall hernia.
PELVIS: The bladder contains a Foley catheter. The prostate and seminal
vesicles are unremarkable. There is trace pelvic fluid. No pelvic sidewall
or inguinal lymphadenopathy. Clips are present in right groin. Bilateral
fat-containing inguinal hernias are present, with trace fluid in the right
inguinal hernia.
OSSEOUS STRUCTURES: Chronic fractures are present along the lateral aspect of
all visualized right ribs. Fractures of the inferior and superior left pubic
rami are more displaced than on ___ and there is no significant
bony callus formation. No focal lytic or sclerotic lesion concerning for
malignancy. Significant degenerative changes of the thoracolumbar spine are
similar to prior.
IMPRESSION:
1. No pulmonary embolism, acute aortic process, or ischemic colitis.
2. Distended gallbladder with small pericholecystic fluid and cholelithiasis.
This appearance may be related to a third-spacing state, but given the
suggestion of hyperemia of the liver adjacent to the gallbladder fossa and a
possible cystic duct stone, symptoms should be correlated clinically regarding
acute cholecystitis. If indicated, HIDA scan may be obtained for further
evaluation. US may assess for a possible cystic duct stone.
3. Moderate right pleural effusion, trace left pleural effusion, and trace
perihepatic and pelvic fluid.
4. Large fecal load.
5. Increased displacement of left inferior and superior pubic ramus fractures
without significant interval bony callus formation. All visualized right ribs
remain fractured.
6. Moderate-sized hiatal hernia
Findings were discussed by ___ with Dr. ___ via phone call
on ___ at 1730 pm.
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: CT torso from ___ and chest radiograph also from earlier
today.
CLINICAL HISTORY: Right IJ central venous catheter placement, assess
position.
FINDINGS: Portable AP upright chest radiograph obtained. Midline sternotomy
wires and mediastinal clips are again noted. There has been interval
placement of a right IJ central venous catheter with its tip located in the
distal SVC or cavoatrial junction. No pneumothorax. Otherwise, no change.
Radiology Report
REASON FOR EXAMINATION: Hypercarbic respiratory failure.
COMPARISON: ___ chest radiograph and CT torso.
AP radiograph of the chest
Heart size and mediastinum are grossly stable. Interval increase in right
pleural effusion is suspected, although in part it may be related to different
character of that study being semi-erect as opposite to portable study on the
prior examination as well as more symmetric and not rotated image acquisition.
Left retrocardiac opacity might reflect area of atelectasis, slightly worse
since prior examination. It also might be due to large hiatal hernia.
Infectious process, developing in this location would be another possibility.
Radiology Report
REASON FOR EXAMINATION: Central venous line placement.
Portable AP radiograph of the chest was reviewed in comparison to ___, obtained at 05:47 a.m.
The ET tube tip is approximately 5.2 cm above the carina. The right internal
jugular line tip is at the mid low SVC. Heart size and mediastinum are
grossly unchanged in appearance. Right pleural effusion is enlarged,
unchanged since the most recent prior. Small amount of left pleural effusion
is most likely present. Cardiomediastinal silhouette is stable.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Postoperative hypercarbic respiratory failure.
Comparison is made with prior study, ___.
Large right and small-to-moderate left pleural effusions with adjacent
atelectasis are unchanged. Mild cardiomegaly and tortuous aorta are stable.
The patient has been extubated. Right IJ catheter tip is at the cavoatrial
junction. Sternal wires are aligned. The patient is status post CABG.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: EPIGASTRIC PAIN
Diagnosed with ABDOMINAL PAIN EPIGASTRIC, CHEST PAIN NOS
temperature: 98.3
heartrate: 64.0
resprate: 14.0
o2sat: 99.0
sbp: 122.0
dbp: 62.0
level of pain: 6
level of acuity: 2.0 | Mr. ___ is an ___ who presented to the ___ ED complaining of
lower abdominal pain. He was worked up for MI in the ED and
eventually underwent a CTA of his torso which demonstrated
possible cholecystitis. He became increasingly tachycardic and
hypotensive during his ED course and was started on levophed
prior to admission to the MICU. A right IJ was placed in the
ED.
After further evaluation, Mr. ___ was taken to the OR for
laparoscopic cholecystectomy, which he tolerated without
difficulty. He was admitted to the TSICU postoperatively for
hemodynamic monitoring given his initial decompensation in the
ED.
On ___, Mr. ___ was noted to be increasingly hypercarbic and
had a significant respiratory acidosis, and was intubated. He
required levophed with propofol, both of which were weaned off.
His ventillator support was weaned.
On ___ He was transferred to the floor and advanced to a
regular diet. On ___ his foley was discontinued and he voided.
His platelets were shown to be trending down at a nadir of 49 so
a HIT panel was sent, heparin was stopped and fondaparinux was
restarted. His antibiotics were also changed to po augmentin.
His Blood cultures grew back pansenstive Ecoli so we continued
him on that regimen. He was also shown to be fluid overloaded,
without respiratory compromise so we gave him 10 Iv lasix, which
he responded well. His home meds were also restarted. On ___ he
was dischrged home on PO augmentin. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Nitrate Analogues / Vancomycin
Attending: ___
___ Complaint:
dyspnea on exertion
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ man with a history of
recently-diagnosed Burkitt's lymphoma, a PTLD status post renal
transplant in ___ who prsented to clinic on ___ for day #14
of his first cycle of EPOCH and was found to have bandemia and
dyspnea on exertion. History is obtained from the patient as
well as oncology note in ___. He reports an episode of night
sweats the night before admission which soaked his sheets but
denies fever or chills. He felt well until he walked down the
stairs in the morning and then felt short of breath. This was
not associated with any chest pain, chest tightness, associated
naisea, diaphoresis, lightheadedness, or dizziness. He does
endorse bilateral clavicular pain which he says is common with
neupogen. He denies orthopnea, weight gain, ankle swelling, or
PND. He notes a slight cough the morning of admission with some
white sputum. His daughter has a sore throat, but he does not
feel a sore throat, sinus pain, or rinorrhea. He has missed 2
doses of Lovenox because he was waiting to have his platelet
count checked.
In clinic his vitals were as follows: BP: 123/55. Heart Rate:
70. Weight: 233.4. Height: 71.5.BMI: 32.1. Temperature: 98.3.
Resp. Rate: 20. Pain Score: 0. O2 Saturation%: 99. He was taken
to the ER where he received Cefepime 2g IV and was transferred
to the floor for further management. On arrival to the floor,
he states he is feeling well.
REVIEW OF SYSTEMS:
Complete 10 point review of systems was preformed. All were
negative except where noted above.
Past Medical History:
PAST MEDICAL HISTORY:
1. Coronary artery disease status post CABG in ___ and DES
placed a vein graft in ___.
2. Hyperlipidemia.
3. Diabetes type 2, complicated by retinopathy and neuropathy
4. End-stage renal disease status post renal transplant in ___
5. History of nephrolithiasis
6. DVT, ___ presumed to have PE due to symptoms of shortness
of breath but no CTA was done due to his renal function.
7. Peptic ulcer disease.
PAST ONCOLOGIC HISTORY:
___: Admitted to ___ due to dehydration and abdominal
mass felt on physical exam. CT scan showed a large 16 cm
abdominal mass involving the cecum and terminal ilium as well as
extensive omental implants.
- ___: colonoscopy with biopsy, which showed atypical
lymphoid cells
- ___: Admitted for laparoscopic omental biopsy.
Pathology from this biopsy was consistent with a high-grade
B-cell lymphoma consistent with Bu___'s lymphoma.
Immunohistochemistry showed the tumor was CD20 positive, CD10
positive, CD21 positive and BCL6 positive. The MIB-1
proliferation index was 100%, BCL2 was negative. c-MYC fusion
probe for t(8;14) was negative. The patient was transferred to
the ___ service. He was treated with rasburicase for uric acid
level of 15.
___: received EPOCH chemotherapy cycle #1.
Social History:
___
Family History:
father had CAD, stroke and Renal failure on dialysis
Physical Exam:
T 96.8 bp 120/70 HR 65 RR 17 SaO2 99 RA
GENERAL: Alert, oriented, NAD, joking
HEENT: Anicteric, mucous membranes moist;
CV: Regular rate and rhythm, nl S1/S2, no murmurs, rubs or
gallops
PULM: Clear to auscultation bilaterally, normal effort
ABD: Obese, normoactive bowel sounds, soft, non-tender,
non-distended, no masses or hepatosplenomegaly
LIMBS: Trace edema of the lower extremities bilaterally. Right
lower extremity swelling greater than right.
SKIN: No rashes or skin breakdown
NEURO: no focal deficits, attention normal
PSYCH: cooperative, appropriate
Pertinent Results:
___ 11:24PM cTropnT-<0.01
___ 01:55PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 01:55PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-NEG
___ 12:49PM LACTATE-1.8
___ 12:40PM GLUCOSE-525* UREA N-18 CREAT-1.0 SODIUM-136
POTASSIUM-4.0 CHLORIDE-107 TOTAL CO2-21* ANION GAP-12
___ 12:40PM cTropnT-<0.01
___ 12:40PM WBC-7.7# RBC-3.73* HGB-10.0* HCT-33.7* MCV-90
MCH-26.8* MCHC-29.7* RDW-14.8
___ 12:40PM NEUTS-47* BANDS-17* LYMPHS-16* MONOS-12*
EOS-0 BASOS-0 ___ METAS-5* MYELOS-3*
___ 12:40PM HYPOCHROM-2+ ANISOCYT-NORMAL POIKILOCY-NORMAL
MACROCYT-1+ MICROCYT-NORMAL POLYCHROM-NORMAL
___ 12:40PM PLT SMR-LOW PLT COUNT-70*
___ 12:40PM ___ PTT-34.5 ___
___ 11:30AM UREA N-20 CREAT-1.4* SODIUM-139 POTASSIUM-4.6
CHLORIDE-103 TOTAL CO2-25 ANION GAP-16
___ 11:30AM tacroFK-6.8
___ 11:30AM WBC-2.1* RBC-4.45* HGB-12.7* HCT-38.7* MCV-87
MCH-28.6 MCHC-32.9 RDW-13.6
___ 11:30AM NEUTS-26* BANDS-3 LYMPHS-52* MONOS-5 EOS-3
BASOS-0 ___ MYELOS-0 OTHER-11*
___ 11:30AM PLT SMR-VERY LOW PLT COUNT-79*
___ 11:30AM ___ ___
Echo ___
The left atrium is elongated. No atrial septal defect is seen by
2D or color Doppler. There is mild symmetric left ventricular
hypertrophy. The left ventricular cavity size is normal. There
is mild regional left ventricular systolic dysfunction with
basal inferior hypokinesis. No masses or thrombi are seen in the
left ventricle. There is no ventricular septal defect. The
aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. Trace aortic regurgitation is seen. The mitral
valve leaflets are mildly thickened. There is no mitral valve
prolapse. Mild (1+) mitral regurgitation is seen. The tricuspid
valve leaflets are mildly thickened. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
.
Compared with the prior study (images reviewed) of ___, no
change
.
CXR ___: IMPRESSION: 1. No evidence of pneumonia. 2.
Small left pleural effusion.
EKG: normal sinus rhythm, no significant change from previous
tracing
.
.
___ 06:15AM BLOOD WBC-12.9* RBC-4.26* Hgb-12.1* Hct-37.3*
MCV-88 MCH-28.4 MCHC-32.4 RDW-14.5 Plt Ct-97*
___ 06:15AM BLOOD Hypochr-1+ Anisocy-NORMAL Poiklo-NORMAL
Macrocy-OCCASIONAL Microcy-NORMAL Polychr-OCCASIONAL
___ 06:15AM BLOOD Glucose-115* UreaN-16 Creat-1.0 Na-138
K-4.5 Cl-106 HCO3-27 AnGap-10
___ 06:15AM BLOOD ALT-22 AST-26 LD(LDH)-305* AlkPhos-109
TotBili-0.2
___ 06:15AM BLOOD Calcium-9.0 Phos-3.7 Mg-1.8 UricAcd-8.3*
.
___ Radiology LUNG SCAN
IMPRESSION: Normal V-Q scan. Normal lung scan rules out recent
pulmonary
embolism.
.
___ URINE URINE CULTURE-FINAL- no growth.
.
___ BLOOD CULTURE x 2 - no growth to date.
Medications on Admission:
ALLOPURINOL - 100 mg Tablet - 1 Tablet(s) by mouth once a day
ENALAPRIL MALEATE - 5 mg Tablet - 1 Tablet(s) by mouth once a
day
ENOXAPARIN - 80 mg/0.8 mL Syringe - 1 Syringe(s) every twelve
(12) hours
INSULIN ASP PRT-INSULIN ASPART [NOVOLOG MIX 70-30] -
(Prescribed
by Other Provider) - 100 unit/mL (70-30) Solution - 50 units
twice daily
___ [FIRST-MOUTHWASH BLM] - 400
mg-400
mg-40 mg-25 mg-200 mg/30 mL Mouthwash - 1 teaspoon four times
per
day as needed for mouth pain swish and spit
METOCLOPRAMIDE - 10 mg Tablet - 1 Tablet(s) by mouth four times
per day as needed for nausea
METOPROLOL SUCCINATE - 50 mg Tablet Extended Release 24 hr - one
Tablet(s) by mouth daily
PRAVASTATIN - 40 mg Tablet - 1 (One) Tablet(s) by mouth once a
day
SULFAMETHOXAZOLE-TRIMETHOPRIM [BACTRIM DS] - 800 mg-160 mg
Tablet
- 1 Tablet(s) by mouth three times a week
TACROLIMUS - (Dose adjustment - no new Rx) - 1 mg Capsule - 3
Capsule(s) by mouth twice a day
Medications - OTC
SALIVA STIMULANT AGENTS COMB.2 [BIOTENE ORALBALANCE] - Liquid
-
use as directed four times per day
SENNOSIDES [SENNA] - 8.6 mg Tablet - 1 Tablet(s) by mouth twice
a
day as needed for constipation
Discharge Medications:
1. allopurinol ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
2. enalapril maleate 5 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
3. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) 80mg
Subcutaneous Q12H (every 12 hours).
4. insulin asp prt-insulin aspart 100 unit/mL (70-30) Solution
Sig: One (1) 50 units Subcutaneous twice a day.
5. FIRST-Mouthwash BLM 200-25-400-40 mg/30 mL Mouthwash Sig: One
(1) teaspoon Mucous membrane four times a day as needed for
mouth pain: swish and spit.
6. metoclopramide 10 mg Tablet Sig: One (1) Tablet PO Q6H (every
6 hours) as needed for nausea.
7. metoprolol succinate 50 mg Tablet Extended Release 24 hr Sig:
One (1) Tablet Extended Release 24 hr PO once a day.
8. sulfamethoxazole-trimethoprim 800-160 mg Tablet Sig: One (1)
Tablet PO DAYS (___).
9. pravastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
10. tacrolimus 1 mg Capsule Sig: Three (3) Capsule PO Q12H
(every 12 hours).
11. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day) as needed for constipation.
12. Biotene Oralbalance Liquid Sig: One (1) Mucous membrane
four times a day.
Discharge Disposition:
Home
Discharge Diagnosis:
atypical chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Lymphoma, on chemotherapy, likely neutropenic pneumonia.
COMPARISON: Chest radiograph on ___.
FINDINGS: PA AND LATERAL VIEWS OF THE CHEST. There is a small left pleural
effusion. No right pleural effusion. The lungs are clear. No evidence of
pneumonia. The cardiac, mediastinal, and hilar contours are stable. No
pneumothorax. Median sternotomy wires are in place in appropriate position.
IMPRESSION:
1. No evidence of pneumonia.
2. Small left pleural effusion.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: DOE
Diagnosed with NEUTROPENIA, UNSPECIFIED , LYMPHOMA NEC UNSPEC SITE, HYPERTENSION NOS, DIABETES UNCOMPL ADULT
temperature: 97.8
heartrate: 62.0
resprate: 20.0
o2sat: 99.0
sbp: 133.0
dbp: 58.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ man with a history of renal transplant
in ___ and newly diagnosed burkitt's lymphoma who presented on
cycle 1, day 14 of EPOCH chemotherapy with an episode of mild
cough and dyspnea on exertion.
.
#Dyspnea on exertion: Pt has atyical mild chest "pressure" w/
walking down the stairs, which he says was different from his
prior episodes of stable angina. Significantly, he has a history
of clincally diagnosed PE/DVT ___ (no CTA was done given his
baseline renal insufficiency and renal transplant) and has been
on treatment with enoxaparin. There is no significant historical
or physical change to suggest that his cardiac function has
changed from Echo preformed about 2 weeks prior to admission. MI
was ruled out with unchanged ECG relative to baseline and
negative troponins. Pt was started empirically on levofloxacin
for atypical PNA or tracheobronchitis given normal appearance of
chest film w/ only small L pleural effusion. Although he had
leukocytosis this was most likely due to his use of filgrastim
just prior to admission for neutropenia. He remained afrebrile
throughout his stay. He had a V/Q scan done, which showed no
evidence at all of a pulmonary embolism. By the evening of
admission, Pt stated that he felt completely well and had no
symptoms whatsoever. His ambulatory O2 saturation was 97% on
room air. His is unlikely to have any a true pneumonia or
bronchitis, and his antibiotics were discontinued on discharge.
.
# Leukocytosis - most likely due to Pt's use of filgrastim just
prior to admission for neutropenia. This was discontinued given
current WBC counts.
.
# Coronary artery disease status post CABG in ___ and DES; vein
graft in ___. Pt was ruled out for MI (see above). Pt was
continued on his home beta blocker and statin w/out issue.
# Diabetes type 2, complicated by retinopathy and neuropathy.
70/30 insulin BID and sliding scale as per home med.
#End-stage renal disease status post renal transplant in ___.
Continued home tacrolimus, level appropriate at 5.9, avoid
nephrotoxins. Continued home ACE-I and prophylactic bactrim
w/out issue.
# Peptic ulcer disease - continued home PPI |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Anemia, AFib with RVR
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ with afib recently off ___,
dCHF, HTN, CKD, alzheimer's dementia, schizophrenia, OCD,
depression, who presents after routine lab draw showed H&H of
23.7/6.9, decreased since ___ when HCT was ___. Per
record she may have had a RBC transfusion in the last week.
Denies bloody/black stools, hematuria, emesis,
CP/dyspnea/fatigue. She lives at ___
___. where her ___ and aspirin have been held since recent
admission to ___ where she was admitted ___ f
for hypoxia ___ aspiratoin PNA and possible pulmonary edema
treated with vanc/zosyn. Pro BNP was 6k, diuresed with IV lasix
until she no longer required o2. She was also in the ICU with
afib with RVR started on a dilt gtt then converted to PO dilt,
still with a rate in the 110's-120's so she was dig loaded and
started on 0.125 daily. However she was discharged off dig and
dilt with a plan to reintroduce toprol if HR uncontrolled.
Records are incomplete but it appears there was another
admission at ___(date unknown) or possibly during the same
admission, for acute on chronic anemia thought ___ GI bleed. she
was in the ICU with a lactate of 8.5, transfused 3u RBC's. GI
was consulted and thought she may have ___ tear
however she was stable after transfusion. Her guardian decided
to hold of on scoping since it was not urgent. Heme onc was also
consulted and smear showed hyprersegmented neutrophils, retic
count high, LDH high, direct coombs pending.
Today she was sent to the ED from her facility for consideration
of blood transfusion since her HCT was slightly down, IV iron
and GI workup. Per report her HR at her facility had been in
the 90's to 110's today - her metoprolol had been held since her
previous admission.
Vitals on transfer from her facility were 97.9 HR 125, 135/71,
93%RA
In the ED initial vitals were Triage 18:19 0 98.9 87 125/69 20
98%
Exam significant for guiaic + stool. Labs significant for Hgb
8.0, K 5.5, BUN 27, Cr 1.4 (unknown baseline), glu 149. CXR c/w
with likely COPD, also large hiatal hernia but nothing acute. HR
increased to 130's-150's and EKG c/w afib with RVR. She was
given 500cc IVF and pantoprazole.
Past Medical History:
no history available in our system, per limited records:
anemia, thought multifactorial
h/o aspiration pneumonia
dCHF- EF 60% in ___
afib - stopped ___, metoprolol recently
HTN
CKD unknown baseline
DJD
schizophrenia, alzheimer dementia, ocd, depression
hypokalemia
insomnia
osteoporosis
Recent hospitalization St E''s for hypoxia ___ aspiratoin PNA
and possible pulmonary edema treated with vanc/zosyn. Pro BNP
was 6k, diuresed with IV lasix until she no longer required o2.
She was also in the ICU with afib with RVR started on a dilt gtt
then converted to PO dilt, still with a rate in the 110's-120's
so she was dig loaded and started on 0.125 daily. However she
was discharged off dig and dilt with a plan to reintroduce
toprol if HR uncontrolled.
Social History:
___
Family History:
Noncontributory
Physical Exam:
ADMISSION PHYSICAL EXAM
========================
Vitals: t98.3, HR 130's, BP 138/73 95%RA
General: Alert, oriented to hospital (not sure which) middle of
___, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi, Kaiphosis.
CV: irreg irreg 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. dystrophic toenails
DISCHARGE PHYSICAL EXAM
========================
Vitals: 98.4 126/54 103 21 100%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, poor dentition
Neck: Supple, JVP not elevated, no LAD
Lungs: Trace scattered crackles, otherwise CTAB
CV: Irregular rhythm, regular rate, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: No concerning lesions
Neuro: CN, motor, sensation grossly intact
Pertinent Results:
ADMISSION LABS
===============
___ 07:05PM BLOOD WBC-5.8 RBC-2.79* Hgb-8.0* Hct-27.5*
MCV-99* MCH-28.5 MCHC-28.9* RDW-15.7* Plt ___
___ 07:05PM BLOOD Neuts-61.1 ___ Monos-5.2 Eos-4.1*
Baso-0.7
___ 03:31AM BLOOD ___ PTT-28.8 ___
___ 07:05PM BLOOD Glucose-149* UreaN-27* Creat-1.4* Na-140
K-5.5* Cl-105 HCO3-22 AnGap-19
___ 07:05PM BLOOD ALT-26 AST-35 LD(LDH)-555* AlkPhos-70
TotBili-0.2
___ 07:05PM BLOOD Hapto-242*
PERTINENT LABS
===============
___ 03:31AM BLOOD WBC-5.2 RBC-2.48* Hgb-7.0* Hct-24.2*
MCV-98 MCH-28.1 MCHC-28.8* RDW-15.6* Plt ___
___ 09:30PM BLOOD WBC-5.7 RBC-2.73* Hgb-8.0* Hct-25.8*
MCV-95 MCH-29.4 MCHC-31.1 RDW-15.5 Plt ___
___ 06:00AM BLOOD WBC-5.4 RBC-3.22* Hgb-9.0* Hct-31.8*
MCV-99* MCH-28.1 MCHC-28.5* RDW-15.1 Plt ___
DISCHARGE LABS
===============
___ 07:15AM BLOOD WBC-6.2 RBC-2.81* Hgb-8.0* Hct-27.5*
MCV-98 MCH-28.5 MCHC-29.2* RDW-15.3 Plt ___
___ 07:15AM BLOOD Glucose-91 UreaN-20 Creat-1.2* Na-143
K-5.2* Cl-112* HCO3-26 AnGap-10
IMAGING
=======
___ CHEST X-RAY
Hyperinflated lungs with evidence of biapical scarring, which
most likely relate to COPD. Large hiatal hernia. No focal
consolidation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ferrous Sulfate 325 mg PO DAILY
2. Potassium Chloride 10 mEq PO Q48H
3. TraZODone 25 mg PO HS
4. Senna 8.6 mg PO DAILY
5. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
6. Acetaminophen 650 mg PO Q6H:PRN pain
7. Bisacodyl 10 mg PO DAILY:PRN constipation
8. Calcium Carbonate 500 mg PO DAILY
9. Cyanocobalamin 1000 mcg IM/SC MONTHLY
10. Fluvoxamine Maleate 50 mg PO DAILY
11. Milk of Magnesia 30 mL PO Q6H:PRN constipation
12. Multivitamins 1 TAB PO DAILY
13. Mylanta unknown oral qd
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Bisacodyl 10 mg PO DAILY:PRN constipation
3. Calcium Carbonate 500 mg PO DAILY
4. Ferrous Sulfate 325 mg PO DAILY
5. Fluvoxamine Maleate 50 mg PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Senna 8.6 mg PO DAILY
8. TraZODone 25 mg PO HS
9. Cyanocobalamin 1000 mcg IM/SC MONTHLY
10. Milk of Magnesia 30 mL PO Q6H:PRN constipation
11. Mylanta 1 unknown ORAL QD
12. Vitamin D 50,000 UNIT PO 1X/WEEK (___)
13. Outpatient Lab Work
___ CBC to assess for stability of anemia and digoxin
level to assess for toxicity
14. Digoxin 0.125 mg PO DAILY
15. Aspirin 325 mg PO DAILY
16. Metoprolol Tartrate 25 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY
Anemia
Atrial fibrillation with rapid ventricular response
Hypotension
SECONDARY
Schizophrenia
Dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAM: Chest, single AP upright portable view.
CLINICAL INFORMATION: Tachycardia.
COMPARISON: None.
FINDINGS: Single AP upright portable view of the chest was obtained. The
lungs are hyperinflated, suggesting chronic obstructive pulmonary disease.
Retrocardiac opacity with air-fluid levels consistent with a large hiatal
hernia. The cardiac silhouette is mildly enlarged. The aorta is calcified.
No focal consolidation, large pleural effusion, or evidence of pneumothorax is
seen. There may be some biapical scarring. No overt pulmonary edema is seen.
IMPRESSION: Hyperinflated lungs with evidence of biapical scarring, which
most likely relate to COPD. Large hiatal hernia. No focal consolidation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Anemia
Diagnosed with ANEMIA NOS, ATRIAL FIBRILLATION, GASTROINTEST HEMORR NOS
temperature: 98.9
heartrate: 87.0
resprate: 20.0
o2sat: 98.0
sbp: 125.0
dbp: 69.0
level of pain: 0
level of acuity: 2.0 | ___ with a history of rheumatic heart disease s/p AVR/MVR in
___, Afib on Coumadin, and CKD previously on HD (baseline Cr
1.2-1.6) who presents from nursing home with 5 days BRBPR and
dyspnea.
# Anemia: Patient was transferred from rehab to ___ ED for Hct
drop found at rehab. Repeat Hct in ___ ED was 27.5, showing
stable anemia from prior ___ ___ admission
(Hct ___ for GIB thought ___ to ___ tear.
Throughout this admission, patient was monitored and without
signs of active bleeding. Hct remained stable and was 27 at the
time of discharge. Most likely diagnosis is chronic blood loss
from low-grade GI bleed. Differential also included B12
deficiency (on B12 IM), and myelodysplastic
syndrome/myelofibrosis. Patient will need outpatient Hematology
and Gastroenterology follow-up 1 week after discharge for
further work-up and management of anemia.
# Potential GI Bleed: Patient had a recent admission to ___.
___ ___ for a concern of GI bleed thought ___
___ tear. Upon current presentation to ___ ED,
patient was found to have guaiac=positive stool. Throughout the
rest of the admission, the patient was without evidence of
active bleeding. Anemia was managed and monitored per above.
She will need outpatient GI follow-up for consideration of
EGD/colonoscopy.
# Atrial Fibrillation with Rapid Ventricular Response: During
___ ___ admission, patient received
diltiazem intravenously and orally and digoxin with good hear
rate response but was discharged off all rate-controlling
medications and anticoagulation in the setting of potential
bleed. Upon current presentation to ___ ED, digoxin was
started at 0.125mg daily and metoprolol was started and titrated
to 25mg BID based on blood pressure and heart rate. Heart rate
improved from 140s in ED to 80-100s at the time of discharge.
Her heart rate will need to be monitored as an outpatient.
Aspirin 325mg daily was initiated for anticoagulation, CHADS
score 1.
# Hypotension: Patient developed intermittent asymptomatic
hypotension on ___ and ___ to systolic blood pressure ___,
thought to be a combination of hypovolemia from decreased PO
intake and uptitration of beta blocker. Beta-blocker was
down-titrated (see above) and patient was administered 1 liter
of IV fluids, with stable blood pressure ranging systolic
110-120s at the time of discharge.
# Renal Insufficiency: Patient with unknown baseline renal
function. Creatinine was monitored and improved from 1.4 on
admission to 1.2 at the time of discharge, which was consistent
with recent baseline from rehab laboratory values.
# Thrombocytosis: Patient was found to have thrombocytosis to
platelet count of 600-700k during this admission. Differential
included reactive process vs. myelofibrosis. The patient needs
outpatient Hematology follow-up for further management and
work-up of thrombocytosis.
# Chronic Diastolic Heart Failure: Patient remained without
evidence of decompensation during this admission. She was
started on a beta-blocker per above.
# Schizophrenia, depression, OCD: Patient was continued on her
home psychiatric regimen including trazadone and fluvoxamine.
===================================
TRANSITIONAL ISSUES
===================================
MEDICATIONS
- STARTED Metoprolol tartrate 25mg BID
- STARTED Digoxin 0.125mg daily
- STARTED Aspirin 325mg daily
- STOPPED Potassium supplementation
FOLLOW-UP
- Repeat CBC in on week ___ to assess for stability of
anemia.
- Please monitor digoxin level and for signs of toxicity
- Please monitor patient's heart rate and ensure well-controlled
at 80-100
- Please down-titrate metoprolol to 12.5mg BID if blood pressure
is found to be sBP<90.
- Hematology follow-up needed in 1 week. Appointment needs to be
scheduled, ___ Hematology Department phone number provided.
- Gastroenterology follow-up needed in 1 week. Appointment needs
to be scheduled, ___ Gastroenterology Department phone number
provided.
OTHER
- Please continue goals of care discussion with patient's
gaurdian |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Codeine / ibuprofen / latex
Attending: ___.
Chief Complaint:
Seizure
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old female with PMH significant for
ER+/PR-/HER2+ left ductal BrCa on anastrozole, brain lesions s/p
resection of right frontal lesion and prior CK, large left
occipital cystic lesion, recent grand mal seizure associated
with ICH, recent admission for focal seizure and
post-obstructive pneumonia, who presents with concern for
recurrent seizure.
She was recently admitted from ___ when she
presented with cough and dyspnea x ___s 1 episode
of left hand twitching. She was found to have a post-obstructive
PNA on chest imaging treated initially with IV antibiotics, then
transitioned to levofloxacin and metronidazole with plans for 7
day course. Her left hand twitching was felt to be consistent
with a likely focal partial seizure for which her topiramate was
up-titrated from 50 mg BID to ___ mg BID.
She subsequently presented to the ED on ___ at the
recommendation of Dr. ___ she called reporting three
episodes of self-limited left hand shaking. Each lasted
approximately 5 minutes and were spaced by 2 hours. She remained
awake and aware, no LOC, no ___ involvement, no incontinence. Per
her husband's report in the ED, she appeared cyanotic and was
noted to be tachycardic during the episode.
In the ED, she was afebrile, hemodynamically stable. Her
physical exam was unremarkable. Labs were notable for stable
CBC, HCO3 14, lactate 1.3, troponin <0.01, VBG with pH 7.39,
pCO2 27. CXR without interval change in R hilar mass and
associated post-obstructive changes.
Neurology was consulted who felt her presentation to be
consistent with left hand clonic, focal motor seizures, possibly
arising from right frontal lobe resection bed. They recommended
restarting levetiracetam 1000 mg BID and continuing topiramate
at the current dose. They cited possible etiology for seizure
being levofloxacin, which can lower the seizure threshold. The
patient declined to take levetiracetam given her upcoming
chemotherapy trial. She otherwise received doxycycline 100 mg
and topiramate 100 mg.
Upon arrival to the floor, the patient endorses the above
history. She reports that she felt shortness of breath after the
episodes of shaking that she had. She is scared about going back
home and having more seizures. She is not enthusiastic about the
idea of taking Keppra given her upcoming trial, but she is
willing to do so.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative except for as noted in the HPI.
Past Medical History:
Metastatic breast cancer s/p mastectomy, chemo, radiation
Brain metastases s/p craniotomy, radiation
Lung metastases
Hypothyroidism
Hypertension
Hyperlipidemia
Social History:
___
Family History:
Mother with CAD, deceased. Father with prostate cancer,
deceased.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
PHYSICAL EXAM:
VS: 98.6 128/49 78 18 93 2L
GENERAL: NAD, well appearing, lying in bed
HEENT: AT/NC, Sclerae anicteric
NECK: Supple
CV: NR, RR. Normal S1/S2, III/VI systolic ejection murmur
PULM: Scattered rhonchi, no wheezing or crackles, breathing
comfortably without use of accessory muscles
ABD: Abdomen soft, nondistended, nontender in all quadrants
EXT: WWP, no cyanosis, clubbing, or edema
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
NEURO: Alert, moving all 4 extremities with purpose, face
symmetric
ACCESS: PIV
DISCHARGE PHYSICAL EXAM
=======================
Vitals: ___ 0721 Temp: 98.2 PO BP: 116/60 HR: 79 RR: 18 O2
sat: 100% O2 delivery: RA
GENERAL: NAD, well appearing, lying in bed
HEENT: AT/NC, Sclerae anicteric, MMM
NECK: Supple, no LAD
CV: NR, RR. Normal S1/S2, ___ systolic ejection murmur
PULM: CTAB, scattered rhonchi, no wheezing or crackles,
breathing
comfortably without use of accessory muscles
ABD: Bowel sounds appreciated, abdomen soft, nondistended,
nontender in all quadrants.
EXT: WWP, no edema
SKIN: No excoriations or lesions, no visible rashes
NEURO: AOx3, ___ strength in four limbs, CN II-XII intact,
sensation grossly intact to light touch.
ACCESS: PIV
Pertinent Results:
IMAGING
=======
Chest XRay (___) impression:
No significant interval change in the right hilar mass with
postobstructivechanges in the right upper lobe superimposed
pneumonia cannot be excluded. Postsurgical changes in the left
chest.
MICROBIOLOGY
============
___ 8:41 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
ADMISSION LABS
==============
___ 06:13AM BLOOD WBC-9.8 RBC-4.83 Hgb-14.8 Hct-44.0 MCV-91
MCH-30.6 MCHC-33.6 RDW-13.6 RDWSD-45.5 Plt ___
___ 06:13AM BLOOD Neuts-82.0* Lymphs-9.1* Monos-6.9
Eos-0.6* Baso-0.5 Im ___ AbsNeut-8.00* AbsLymp-0.89*
AbsMono-0.67 AbsEos-0.06 AbsBaso-0.05
___ 06:13AM BLOOD ___ PTT-30.3 ___
___ 06:13AM BLOOD Glucose-111* UreaN-11 Creat-0.8 Na-140
K-3.7 Cl-109* HCO3-14* AnGap-17
___ 06:13AM BLOOD ALT-23 AST-31 AlkPhos-152* TotBili-0.8
___ 06:13AM BLOOD cTropnT-<0.01
___ 06:13AM BLOOD Albumin-4.3
___ 06:13AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 08:19AM BLOOD ___ pO2-54* pCO2-27* pH-7.39
calTCO2-17* Base XS--6
___ 08:19AM BLOOD Lactate-1.3
DISCHARGE LABS
==============
___ 05:55AM BLOOD WBC-8.2 RBC-4.61 Hgb-14.0 Hct-45.8*
MCV-99* MCH-30.4 MCHC-30.6* RDW-13.8 RDWSD-50.8* Plt ___
___ 05:55AM BLOOD Plt ___
___ 05:55AM BLOOD Glucose-129* UreaN-8 Creat-0.6 Na-138
K-3.9 Cl-109* HCO3-15* AnGap-14
___ 05:55AM BLOOD Calcium-8.5 Phos-1.8* Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Anastrozole 1 mg PO DAILY
2. Levothyroxine Sodium 100 mcg PO DAILY
3. Topiramate (Topamax) 100 mg PO BID
4. LevoFLOXacin 750 mg PO DAILY
5. MetroNIDAZOLE 500 mg PO/NG TID
6. Lisinopril 5 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. LevETIRAcetam 1000 mg PO Q12H
RX *levetiracetam [Keppra] 1,000 mg 1 tablet(s) by mouth every
twelve (12) hours Disp #*60 Tablet Refills:*0
3. Anastrozole 1 mg PO DAILY
4. Levothyroxine Sodium 100 mcg PO DAILY
5. HELD- Lisinopril 5 mg PO DAILY This medication was held. Do
not restart Lisinopril until you follow up with your PCP and
have your blood pressure monitored.
Discharge Disposition:
Home
Discharge Diagnosis:
Recurrent Focal Seizures
Post-Obstructive 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 cough, seizurs // eval for pna
TECHNIQUE: Chest AP and lateral
COMPARISON: Chest CT dated ___ performed at Steward Good
Samaritan
Chest radiograph dated ___.
FINDINGS:
There is no significant interval change in the right hilar mass and partial
right upper lobe atelectasis. There is no large pleural effusion or
pneumothorax. The cardiomediastinal and hilar contours are stable. Surgical
clips project over the left lower lung. No displaced fractures are seen.
IMPRESSION:
No significant interval change in the right hilar mass with postobstructive
changes in the right upper lobe superimposed pneumonia cannot be excluded.
Postsurgical changes in the left chest.
Radiology Report
EXAMINATION: MRI CERVICAL AND THORACIC PT21 MR SPINE
INDICATION: ___ year old woman with met. breast Ca. // Spinal lesion?
Cerebellar lesion? Spinal lesion? Cerebellar lesion?
Spinal lesion?
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 Gadavist contrast agent,
additional axial and sagittal T1 images were obtained.
COMPARISON: FDG PET CT dated ___ and CT chest dated ___, outside facility CT chest dated ___
FINDINGS:
CERVICAL:
There is 2 mm retrolisthesis of C5 on C6. The alignment is otherwise
maintained.There is multilevel disc desiccation with loss of intervertebral
disc height predominately at C5-C6 and C6-C7. There is no focal enhancing
lesion. The spinal cord appears normal in caliber and configuration.There is
no abnormal enhancement after contrast administration.
C2-C3: Mild left neural foraminal narrowing due to facet spondylosis. No
significant spinal canal stenosis.
C3-C4: Mild diffuse disc bulge and ligamentum flavum thickening without
significant spinal canal or neural foraminal stenosis.
C4-C5: Mild diffuse disc bulge result in mild narrowing of the spinal canal
without significant neural foraminal stenosis.
C5-C6: Mild diffuse disc bulge results in mild narrowing of the spinal canal
and in conjunction with facet and uncovertebral spondylosis results in mild
bilateral neural foraminal narrowing.
C6-C7: Mild diffuse disc and ligamentum flavum thickening results in mild
indentation on the thecal sac and in conjunction with facet and uncovertebral
spondylosis results in mild left neural foraminal narrowing.
C7-T1: No significant spinal canal or neural foraminal stenosis.
The known enhancing cerebellar mass is partially visualized.
THORACIC:
Alignment is anatomic. There is a 10 mm enhancing T1 hypointense lesion in
the T9 vertebral body and a 1.5 cm enhancing T1 hypointense lesion in the T10
vertebral body with associated STIR hyperintensity. There is associated
vertebral body height loss, retropulsion or soft tissue component. Focal STIR
hyperintensity is noted along the anterior inferior endplates of T4 and T5
without definite corresponding T1 hypointensity or enhancement, possibly
related to degenerative marrow change. Multilevel disc desiccation and loss
of disc height is noted.The spinal cord appears normal in caliber and
configuration. There is no evidence of spinal canal or neural foraminal
narrowing.
The prevertebral and paraspinal soft tissues are normal.
OTHER: The partially visualized lungs demonstrate small bilateral pleural
effusions, greater on the right which are new since the prior CT chest on ___. Right perihilar mass is re-identified, better evaluated on
outside hospital CT chest of ___. Partially visualized bilateral
pulmonary nodules are noted..
IMPRESSION:
1. Enhancing lesions in the T9 and T10 vertebral bodies concerning for
metastatic disease without significant vertebral body height loss,
retropulsion or soft tissue component. No evidence of leptomeningeal
enhancement or focal lesions in the cervical spine.
2. STIR signal abnormality along the anterior inferior endplates of T4 and T5
without corresponding abnormal enhancement may be related to degenerative
marrow changes.
3. Mild multilevel cervical and lumbar spondylosis without significant spinal
canal stenosis and mild neural foraminal narrowing bilaterally at C5-C6 as
detailed above.
4. New small bilateral pleural effusions when compared with the prior CT chest
from ___ and partially visualized airspace disease and pulmonary
nodules. Known right perihilar mass is better evaluated on prior outside
hospital CT chest of ___.
5. Partially visualized known enhancing cerebellar mass.
PREVALENCE: Prevalence of lumbar degenerative disk disease in subjects
without low back pain:
Overall evidence of disk degeneration 91% (decreased T2 signal, height loss,
bulge)
T2 signal loss 83%
Disk height loss 58%
Disk protrusion 32%
Annular fissure 38%
___, et all. Spine ___ 26(10):1158-1166
Lumbar spinal stenosis prevalence- present in approximately 20% of
asymptomatic adults over ___ years old
___, et al, Spine Journal ___ 9 (7):545-550
These findings are so common in asymptomatic persons that they must be
interpreted with caution and in context of the clinical situation.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Seizure
Diagnosed with Epilepsy, unsp, not intractable, without status epilepticus
temperature: 98.2
heartrate: 99.0
resprate: 17.0
o2sat: 92.0
sbp: 157.0
dbp: 57.0
level of pain: 5
level of acuity: 2.0 | Ms. ___ is a ___ year old female with PMH significant for
ER+/PR-/HER2+ left ductal BrCa on anastrozole, brain lesions s/p
resection of right frontal lesion and prior CK, large left
occipital cystic lesion, recent grand mal seizure associated
with ICH, recent admission for focal seizure and
post-obstructive pneumonia, who presented after 3 self-limited
episodes of left hand focal motor seizures, now initiated on
Keppra (from Topamax) and completed antibiotic treatment for
pneumonia.
TRANSITIONAL ISSUES
===================
[ ] Please continue to monitor for seizures on new AED regimen,
Keppra 1 g BID.
[ ] Recommend continued follow up with Dr. ___ your
seizures and brain lesions.
[ ] Recommend continued follow up with Dr. ___ your cancer
care.
[ ] Patient was offered home ___ services, but declined. She
would benefit from physical therapy if she is amenable.
[ ] She will complete 7 day course of antibiotics with augmentin
on the evening of ___. The final dose will be given prior to
discharge.
ACTIVE / ACUTE ISSUES
=====================
#Focal motor seizure
#Brain metastases
Presents with 3 self-resolving episodes of LUE twitching without
LOC or post-ictal state. There was family report of concern for
cyanosis. No ___ involvement or incontinence. Neurology consulted
in ED, suspect current seizures may be arising from prior R
frontal resection bed given seminology. She was recently
admitted with similar complaints, for which topiramate was
uptitrated to 100 mg BID. Seizure threshold may have been
lowered by concurrent antibiotic therapy. Imaging from most
recent admission with stable findings. Topiramate stopped and
Keppra 1000mg BID started. Has not had involuntary movements
since admission. Will continue levetiracetam 1000 mg BID on
discharge. There was no indication to pursue EEG.
#Ataxia
#Lower extremity weakness
She was noted to have left leg weakness and associated ataxia,
despite ___ motor strength testing on her neurologic exam while
in bed. MRI C/T spine was pursued. Final read pending at time of
discharge, however it was reviewed by attending
neuro-oncologist, Dr. ___ did not find any acute change
to account for her symptoms. Her symptoms improved and she was
evaluated by physical therapy. They felt she would benefit from
home ___, however she declined at this time. She was provided
with information for local ___ and ___ services and she will
pursue these in the outpatient setting on an as needed basis.
#R hilar mass
#Post-obstructive pneumonia
She presented on most recent admission with DOE, cough and
hypoxia found to have post-obstructive changes consistent with
pneumonia. She was discharged on levofloxacin/flagyl with plans
for 7 day course to complete ___. Given concern for
levofloxacin reducing the seizure threshold, she was
transitioned to doxycycline in the ED. She received 5 days of
atypical coverage before admission. Given QTc 512ms, will
complete course with Augmentin through ___ to complete 7 day
course.
#Non-gap metabolic acidosis
#Respiratory alkalosis
HCO3 14 with Cl 109. VBG with pH 7.39/pCO27 suggesting likely
respiratory compensation for metabolic acidosis. She has a
chronic component to non-gap metabolic acidosis, potentially
worsened by topiramate administration which can be associated
with decreased serum bicarbonate. Topiramate was discontinued
and her chemistry panel was trended daily.
#Metastatic HER2+ Breast Cancer
Followed by Dr. ___ T4N2M at diagnosis with
infiltrating, left ductal HER2+ BrCa. Prior treatment has
included taxol/Herceptin, followed by anastrozole/Herceptin and
most recently anastrozole monotherapy due to transaminitis. She
was lost to follow up in ___ after PET scan showed
worsening mediastinal and lung metastases. Upcoming plan was for
cyberknife with Dr. ___ to L occipital cystic lesion followed
by likely consent for study protocol ___ (HER-2 antibody
conjugate). She underwent MRI and CK planning with plans to
initiate CK on ___. She was continued on anastrozole 1 mg PO
daily. Drs. ___ were updated throughout the
admission.
CHRONIC ISSUES
==============
#Thrombocytopenia
Chronic, baseline 100-120. Currently at baseline. CBC was
trended daily.
#Hypothyroidism
Continued levothyroxine 100mcg daily.
#Hypertension
Lisinopril held on prior admission, Continued to hold as she is
normotensive.
#HCP/CONTACT: ___ (husband), ___
#CODE STATUS: Full, presumed |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
allopurinol
Attending: ___.
Chief Complaint:
Perianal abscess
Major Surgical or Invasive Procedure:
___, abscess drainage, ___ placement
History of Present Illness:
___ hx of Hodgkin's disease s/p chemo w/recurrent perirectal
abscesses since ___, fistula in ano now ___ s/p ___,
drainage of posterior midline abscess, ___ placement x2.
Patient intially was diagnosed with perirectal abscess when he
presented to ED ___ with perirectal pain, chills after MRI
showing perirectal abscess which was I+D'd at the bedside by
our service and was discharged home after 1 day observation. He
represented to ED 2 days later with fevers with what appeared to
be a well drained abscess however with continued fistula. He was
admitted, started on antibiotics with marked improvement. He was
discharged home the next day, and subsequently underwent an
elective ___, drainage of the posterior midline small abscess
pocket and 2 ___ placements. He tolerated the procedure well
and was discharged home the same day after an uneventful
recovery.
Initially felt fairly well after surgery, but the last few days
has noticed increasing discomfort of his left butt cheek, as
well as continued purulent drainage around his setons. Yesterday
he noted difficulty emptying his bladder, so presented to urgent
care. A foley catheter was placed, after which he felt much
better. Directed to come to ED for further evaluation. ED eval
significant for WBC 25, Lactate 2.5, Cr 1.4 (baseline 1.1), and
left buttock erythema and induration with purulent drainage
around setons.
Past Medical History:
HTN, HLD, Hodgkin's disease, former smoker (quit ___, Hx
colonic polyps, CKD II-III (Cr 1.1-1.3), B/L cataracts,
Recurrent Corneal Erosion
Social History:
___
Family History:
Mother: pancreatic CA; Father (deceased age ___: bladder CA
Pertinent Results:
___ 06:45AM BLOOD WBC-12.5* RBC-3.73* Hgb-10.6* Hct-32.8*
MCV-88 MCH-28.4 MCHC-32.3 RDW-13.7 RDWSD-44.8 Plt ___
___ 07:56AM BLOOD WBC-18.6* RBC-4.04* Hgb-11.6* Hct-37.6*
MCV-93 MCH-28.7 MCHC-30.9* RDW-13.9 RDWSD-47.2* Plt ___
___ 06:45AM BLOOD Glucose-116* UreaN-15 Creat-1.2 Na-140
K-3.5 Cl-103 HCO3-26 AnGap-15
___ 08:07PM BLOOD Glucose-123* UreaN-19 Creat-1.4* Na-136
K-4.5 Cl-94* HCO3-23 AnGap-24*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. Diazepam 5 mg PO Q12H:PRN Anxiety
3. Losartan Potassium 100 mg PO DAILY
4. Simvastatin 40 mg PO QPM
5. Albuterol Inhaler 2 PUFF IH Q6H:PRN Wheeze/Cough
6. Hydrochlorothiazide 25 mg PO DAILY
7. Omeprazole 20 mg PO DAILY
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN Wheeze/Cough
2. Diazepam 5 mg PO Q12H:PRN Anxiety
3. Hydrochlorothiazide 25 mg PO DAILY
4. Losartan Potassium 100 mg PO DAILY
5. Omeprazole 20 mg PO DAILY
6. Simvastatin 40 mg PO QPM
7. Acetaminophen 650 mg PO Q6H:PRN Pain
8. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
9. Bisacodyl 10 mg PO/PR DAILY constipation
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN Pain
11. Polyethylene Glycol 17 g PO DAILY
12. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Perirectal abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI of the Pelvis
INDICATION: Multiple perirectal fistulas and concern for a pelvic abscess.
Please evaluate.
TECHNIQUE: T1- and T2-weighted multiplanar images of the pelvis were acquired
in a 1.5 T magnet.
Intravenous contrast: 10 mL Gadavist.
COMPARISON: MRI of the pelvis from ___, obtained at an outside
hospital.
FINDINGS:
There is ___ present, transversing the low anal sphincter at the 6 o'clock
position (15, 44). There appears to be a short horse-shoe shaped
intersphincteric tract extending superiorly from the drainage pathway of this
___ (16, 24), which is blind ending in the intersphincteric space. Neither
this ___ or the intersphincteric tract is in contact with the large
ischioanal fossa abscess, discussed below. The extraluminal portion of the
___ extends inferiorly very close to the external sphincter and is
surrounded by granulation tissue.
There is a second ___ present in the subcutaneous fat of the left gluteal
cleft (15, 51). There is a small amount of walled off fluid around this
___, but again, it does not connect to the large abscess.
Hugging the left external sphincter, there is a complex ischioanal abscess
which extends from the level of the inferior aspect of the left gluteal fold
to the level or of the puborectalis muscle, measuring approximately 8 cm in
the craniocaudal dimension. In the axial dimension, it measures approximately
5.9 x 4.6 cm (15, 47). There is no direct connection to an internal opening
in the anal sphincter or to either ___, as described above. There are
multiple septations. The abscess dissects between the fibers of the external
sphincter on the left. At the level of the puborectalis muscle, it extends to
the midline posteriorly (15, 33), and dissects into the fibers of the left
puborectalis muscle. This muscle is very abnormal and extremely edematous due
to this involvement. There is minimal extension into the inferior aspect of
the left levator ani muscle, though this involvement is not significant. The
abscess itself stays infralevator. The anterior extent of the abscess extends
along the external sphincter towards the 12 o'clock position, though does not
extend to the base of the penis or the scrotum. There are significant
surrounding inflammatory changes.
There is trace edema in the presacral space. There is no free fluid in the
pelvis. This is likely reactive. The rectum itself is within normal limits.
There is no perirectal abscess. The mesorectal fat is normal. There are no
abnormal lymph nodes. The remainder of the intrapelvic loops of bowel are
grossly unremarkable, though this exam is not optimized for their evaluation.
A Foley catheter is in satisfactory position within the bladder. The bladder
is collapsed, limiting evaluation. The prostate gland is small. The seminal
vesicles are unremarkable.
There is no pelvic or inguinal lymphadenopathy. Several small lymph nodes are
noted bilaterally in the external iliac chains, though are of normal
morphology.
There no concerning osseous lesions. Degenerative changes are noted in the
left femoral acetabular joint with several subchondral cysts. The pelvic
musculature symmetric is within normal limits. There is no hernia.
IMPRESSION:
Large ischioanal fossa abscess dissecting into the muscle fibers of the
external sphincter and the left puborectalis muscle, without extension into
the supralevator space. Two setons, one in the low sphincter at 6 o'clock
which is primarily surrounded by granulation tissue, and one in the
subcutaneous fat of the left gluteal cleft, which has a small amount of
surrounding fluid. Neither are in direct connection to the large abscess.
Short blind ending intersphincteric tract arising from the tract with the
___. No other fistula is identified.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with ULCERATIVE ILEOCOLITIS
temperature: 98.4
heartrate: 102.0
resprate: 16.0
o2sat: 99.0
sbp: 107.0
dbp: 69.0
level of pain: 5
level of acuity: 3.0 | Mr. ___ underwent an ___, drainage of perirectal abscess and
placement of 2 setons on ___ after presenting with urinary
retention and being found to have lateral, anterior, posterior
and deep extension of his perirectal abscess. He tolerated the
procedure well with no complications. He was started on
Augmentin postop and this was continued for a 14 days course
total. A foley catheter was left in postop due to his urinary
retention but it was removed on POD#1 and he was voiding. His
diet was appropriately advanced as tolerated. His pain was
controlled on oral meds. He was deemed fit to discharge home on
Augmentin for 14 day course. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
History of Present Illness: Ms. ___ is a ___ woman
who was in her usual state of health until 2 weeks ago when she
started to notice progressive right-sided and central chest pain
which is typically worse with movement. She had run a mini
triathlon prior to this and thought that she may have provoked
an episode of costochondritis which she has had in the past. She
visited her PCP office and had temporary relief with pain
medication but noticed progressive worsening of pain and dyspnea
which prompted her to re-present to another provider at her PCP
office. She had an x-ray of her sternum which did not reveal
anything abnormal and was treated as though she had
costochondritis. Because of worsening symptoms and concern over
her heart she presented to the ___ ED.
In the ED she reported that she has not had significant
exertional dyspnea. She reports no family history of cardiac
disease, or venous thromboembolism. She reported initially that
she was anxious and was mildly tachycardic, but that the pain
was very similar to prior episodes of costochondritis. She was
taking alleve with some relief of symptoms but had progressive
worsening and growing concern which prompted her presentation to
the ED. She reported that she had in fact had some drenching
sweats for the past several nights, but has not had a productive
cough. She spiked a fever (100.5) while in the ED and a CTA
revealed significant bibasilar pleural effusions, consolidation,
and pericardial effusion concerning for pneumonia so decision
was made to admit to medicine for further workup and treatment.
In the ED, initial vital signs were: Pain ___ T 98.4 HR 104 BP
134/81 RR 18 O2Sat 97% RA
- Labs were notable for:
Leukocytosis to 28.3, thrombocytosis to 499, anemia with H/H
9.___.3
UA with Moderate leuk, moderate blood, negative nitrite, few
bacteria, RBC 16, WBC 16
- Studies performed include:
CXR, CTA chest, blood cultures x2
EKG: Her EKG is sinus. The ST segments show very diffuse
flattening of T waves in essentially all leads relative to
prior, but without reciprocal depression.
- Patient was given:
___ 10:56 IV Ketorolac 15 mg
___ 10:56 IV Lorazepam 1 mg
___ 10:56 IVF 1000 mL NS 1000 mL
___ 14:27 IV Lorazepam 1 mg
___ 16:07 IV CeftriaXONE 1 gm
___ 16:07 PO/NG Acetaminophen 650 mg
___ 19:56 IVF 1000 mL NS 1000 mL
- Vitals on transfer: Pain ___ T 98.9 HR 86 BP 110/77 RR 18
O2Sat 96% RA
Upon arrival to the floor, the patient reports the following:
First incident of chest pain in ___ during snow
shoveling. She was evaluated by her PCP office with normal ECG
and recovered in ___ weeks with supportive care, presumed
chostochondritis. ___ she had recurrence of symptoms
while vacationing in ___ with same resolution pattern. She had
yet another recurrence while traveling in ___ in ___ in
the setting of carrying a heavy backpack which yet again
resolved in ___ weeks. 3 weeks prior to admission, she
participated in a mini-triathalon, 2 weeks ago she helped her
husband carry a television inside their home and had recurrence
of the chest pain. At first it was intermittent, well controlled
with 800mg ibuprofen. 8 days prior to admission, she reports one
night of intense palpitations. Since 4 days prior to admission,
she repots worsening fatigue and dyspnea on exertion, worse when
bending over or laying down. For the past 2 nights she has woken
up drenched in sweat. Additionally, the chest pain has worsened
and is no longer controlled by ibuprofen and acetaminophen
alternating. She developed a non-productive cough only on day of
admission. No rashes or myalgias or arthralgias.
Of note, patient is on day 5 of her most recent monthly
menstrual cycle of a typical 5 day cycle during which she has
typically bleeds heavily for 3 days, going through a pad/tampon
every 1.5 hours.
Past Medical History:
"Costochondritis"
___ phenomenon since ___ years ago
Seasonal affective disorder
Social History:
___
Family History:
Father with ___
MGM died at ___ unknown
MGF died unknown from alcoholism
PGM with parkinsonism and breast cancer
PGF died from unknown cancer
Maternal aunt with breast cancer age ___
Maternal uncle with throat cancer age ___
Physical Exam:
ADMISSION PHYSICAL EXAM
=====================
Vitals- 98.3 119/67 93 20 94%RA
GENERAL: AOx3, NAD
HEENT: NCAT, EOMI, PERRLA, mildly jaundiced mucous membranes,
no tonsillar adenopathy
NECK: Thyroid is normal in size and texture, no nodules.
CARDIAC: Regular rhythm, normal rate, rub most prominent at
RUSB. No JVD.
LUNGS: Bibasilar breath sounds decreased with crackles,
otherwise clear
BACK: Skin. no spinous process tenderness. no CVA tenderness.
ABDOMEN: NABS, nondisnteded, TTP in RUQ and with spleen
palpation, possible hepatomegaly
RECTAL: normal tone, light brown stool, guaiac negative
EXTREMITIES: No clubbing, cyanosis, or edema, no sign of
atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally.
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy. Small tattoo on sacral region
NEUROLOGIC: CN3-12 intact. ___ strength througout. Normal
sensation. No ataxia, dysmetria, disdiadochokinesia. Gait
untested.
LYMPH: no cervical, axillary, supraclavicular or inguinal
lymphadenopathy
DISCHARGE PHYSICAL EXAM
======================
Vitals: 97.8 PO 102 / 57 64 16 96 RA
GENERAL: AOx3, NAD
HEENT: NCAT, EOMI, PERRLA, MMM, no tonsillar adenopathy,
elevated JVD
NECK: Thyroid is normal in size and texture, no nodules.
CARDIAC: RRR, S1 + S2 present no mrg
LUNGS: Reduced lung sounds ___ up lung field on R, ___ up lung
field on left
BACK: No spinous process tenderness. no CVA tenderness.
ABDOMEN: NABS, nondistended, TTP in RUQ, no rebound/guarding, no
HSM
EXTREMITIES: WWP, PPP, no ___ edema.
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy. Small tattoo on sacral region. No splinter
hemorrhages.
NEUROLOGIC: CN3-12 intact. ___ strength througout. Normal
sensation. No ataxia, dysmetria, disdiadochokinesia. Gait
untested.
LYMPH: no cervical, axillary, supraclavicular or inguinal
lymphadenopathy
Pertinent Results:
ADMISSION LABS
=============
___ 01:48PM BLOOD WBC-28.3* RBC-3.29* Hgb-9.9* Hct-31.3*
MCV-95 MCH-30.1 MCHC-31.6* RDW-13.8 RDWSD-48.6* Plt ___
___ 01:48PM BLOOD Neuts-89.9* Lymphs-2.8* Monos-6.3
Eos-0.1* Baso-0.1 Im ___ AbsNeut-25.43* AbsLymp-0.78*
AbsMono-1.77* AbsEos-0.03* AbsBaso-0.04
___ 01:48PM BLOOD Plt ___
___ 10:00AM BLOOD Glucose-77 UreaN-8 Creat-0.6 Na-138 K-4.0
Cl-99 HCO3-24 AnGap-19
___ 04:49PM BLOOD ALT-16 AST-11 LD(LDH)-201 AlkPhos-150*
TotBili-0.3 DirBili-<0.2 IndBili-0.3
___ 04:49PM BLOOD GGT-62*
___ 10:00AM BLOOD cTropnT-<0.01
___ 04:49PM BLOOD Albumin-3.1* Calcium-8.6 Phos-3.8 Mg-1.8
UricAcd-2.5 Iron-14*
___ 04:49PM BLOOD calTIBC-222* Hapto-530* Ferritn-502*
TRF-171*
___ 04:49PM BLOOD TSH-1.5
___ 05:06PM BLOOD Lactate-1.4
MICRO
=====
___ Legionella: negative
___ Blood culture: no growth to date
___ Lyme: negative
___ HIV: AB and VL negative
___ Anaplasma: pending
___ Streptococcus: pending
NOTABLE LABS
===========
___ ESR: ___ CRP: greater than assay
___ ___: Positive, 1:40
___ dsDNA negative
IMAGES
======
CXR ___:
Bilateral pneumonia right greater than left
CTA Chest ___:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Bilateral pleural and pericardial effusions with
consolidation and volume loss, very concerning for bibasilar
pneumonia. Follow-up after the resolution of symptoms is
recommended.
TTE ___:
Normal left ventricular cavity size with preserved regional and
global biventricular systolic function. Mild right ventricular
cavity dilation. Borderline pulmonary artery systolic
hypertension.
DISCHARGE LABS
=============
___ 08:00AM BLOOD WBC-9.9 RBC-3.69* Hgb-11.1* Hct-34.3
MCV-93 MCH-30.1 MCHC-32.4 RDW-14.2 RDWSD-48.0* Plt ___
___ 08:00AM BLOOD Plt ___
___ 08:00AM BLOOD ___ PTT-35.8 ___
___ 08:00AM BLOOD Glucose-82 UreaN-8 Creat-0.6 Na-141 K-4.4
Cl-102 HCO3-27 AnGap-16
___ 08:00AM BLOOD Calcium-9.5 Phos-4.3 Mg-2.3
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with chest pain // eval ptx
TECHNIQUE: Chest PA and lateral
COMPARISON: None
FINDINGS:
There is a large right lower lobe and small left lower lobe infiltrate. The
upper lungs are clear.
IMPRESSION:
Bilateral pneumonia right greater than left
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ with chest pain, ?R lung mass vs. infarct vs. consolidation
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Total DLP (Body) = 218 mGy-cm.
COMPARISON: Chest radiograph from same date.
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus. The
thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. The heart is normal in size. Small to moderate
pericardial effusion is present. The aorta and main pulmonary artery are
normal in caliber.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: Moderate bilateral pleural effusions are present. There is
no pneumothorax.
LUNGS/AIRWAYS: Airspace consolidation in the bilateral lower lobes and to a
lesser extent lingula and right middle lobe likely represent a combination of
atelectasis and pneumonia. No definite nodule of concern.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Moderate layering pleural effusions with lower lobe consolidation
concerning for pneumonia.
3. Pericardial effusion, small to moderate.
NOTIFICATION: The updated findings were discussed with Dr. ___. by ___
___, M.D. on the telephone on ___ at 6:58 ___, 5 minutes after
discovery of the findings.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain, Back pain
Diagnosed with Pneumonia, unspecified organism, Pleural effusion, not elsewhere classified
temperature: 98.4
heartrate: 104.0
resprate: 18.0
o2sat: 97.0
sbp: 134.0
dbp: 81.0
level of pain: 9
level of acuity: 3.0 | Ms. ___ is a ___ year old woman w/ a PMH of ___ and
multiple recurrent episodes of chest pain attributed to
costochondritis who presented with worsening dyspnea and chest
pain for over 2 weeks prior to admission with 2 episodes of
night sweats and a non-productive cough, febrile to 100.5 in ED,
with significant leukocytosis with CTA chest revealing bilateral
pleural effusions and consolidations consistent with CAP.
#Pneumonia. Pt presented with leukocytosis to 28.5 with
associated fever to 100.5 in the ED. CTA showed pleural
effusions R>L with a consolidative process c/f pneumonia.
Presentation was c/w community acquired PNA. Pleural effusions
are likely reactive ___ PNA and less likely ___ autoimmune
process given ___ weakly positive (1:40) and negative dsDNA,
also less likely malignancy. No c/f TB given no symptoms of
weight loss/hemoptysis and no exposure hx or travel to endemic
areas. Leukocytosis down-trending with antibiotics. Patient
initially treated with ceftriaxone/doxycycline out of c/f
tick-borne illness however given negative Lyme, transitioned to
augmentin/azithromycin for PO regimen 5 days total. Ambulatory
sat was 94% at time of discharge. Of note, interventional
pulmonology was consulted and the decision was made not to do
thoracentesis given small size of effusion on US and therefore
high risk for pneumothorax and patien'ts clinical improvement.
#Elevated ESR/CRP. Despite low c/f autoimmune process as primary
pulmonary process, significantly elevated CRP/ESR (greater than
expected for PNA) and history of
___ costochondritis was concerning.
Would recommend reechecking ESR/CRP after resolution of
pneumonia, consider sending RF, anti-CCP, C3/C4 as outpatient if
ESR/CRP persistently elevated or new sxs develop consistent with
rheumatologic disease.
#RUQ tenderness: Likely ___ rib pain from pleural effusion R>L.
LFTs notable only for elevated AlkP/GGT which is likely acute
phase reactant.
#Pericardial Effusion: Noted on CTA in ED. TTE ___ showed
trivial/physiologic pericardial effusion, thus low c/f
development of tamponade.
#Proteinuria. Resolved. Kidney function normal throughout stay,
BUN/Cr ___ on admission. U/A in ED showed proteinuria (also
hematuria possibly contaminant from menstruation). Repeat U/A on
___ showed no proteinuria or hematuria.
#Anemia: Guaiac in ED was negative and hemolysis labs were
negative. Fe studies c/f AOCD. H/H improving during admission to
___ on ___, though per ___ ___ atrius records she did not
have anemia.
#Coagulopathy. INR 1.4 on admission, improved to 1.2 on ___
#Thrombocytosis. Likely acute phase reactant
#Seasonal affective disorder. Pt was continued on home
fluoxetine |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / zoledronic acid
Attending: ___.
Chief Complaint:
left shoulder pain
Major Surgical or Invasive Procedure:
regional nerve block
regional nerve catheter pump placement
History of Present Illness:
___ yo M with stage IV NSCLC adenocarcinoma with mets to brain
and bone who presents to the ED with left shoulder pain.
He states that 2 weeks ago he was moving a hose at his house and
heard and felt a crack in his shoulder. The pain felt dull and
muscular at first but gradually increased in intensity and he
decided to come into the E.D. The pain is located on the outer
posterior portion of his shoulder and is exacerbated by
movement. He is on chronic pain medication at home re: his
cancer diagnosis, including methadone and dilaudid, which have
failed to help. He denies any numbness or tingling or
discoloration of his arm.
He denies fevers, chills, skin changes, nausea/vomiting, chest
pain, shortness of breath, or changes to bowel or bladder
habits.
Patient also had some concern over increased swelling of LLE as
compared to right, of recent onset within the past week or so.
Patient received his last cycle of docetaxel 75 mg/m2 on
___ with subsequent CT showing progression of disease.
.
In the ED, vitals were : 97.6 120P 117/69 22 96%RA. Patient
was administered dilaudid 4mg iv x 1 and dilaudid 0.5mg iv x 1.
A plain film of the humerus showed an acute pathologic fracture
of the left humeral neck. Ortho was consulted and recommended
no surgical intervention.
.
ROS as per HPI, 10 pt ROS otherwise negative
Past Medical History:
Oncologic history:
NSCLC stage IV adenocarcinoma in a heavy smoker.
- ___ Developed worsening L hip pain, worsening cough.
- ___ CT TORSO to follow up AAA repair revealed a large
spiculated left apical pulmonary mass with extensive mediastinal
lymphadenopathy and a large left iliac lytic mass, consistent
with metastatic lung cancer. Possible right apical lung cancer.
- ___ CT guided L iliac bone met consistent with poorly
differentiated NSCLC adenocarcinoma TTF-1+ CK7+ CK20-, PSA-,
PSAP-, p63-.
- ___ to ___ Admit for pain, received XRT to R rib
mets
and L hip met.
- ___ to ___ Admit for pain, started chemo.
- ___ C1D1 carboplatin AUC 6 pemetrexed 500 mg/m2.
- ___ Cycle #2 carboplatin/pemetrexad.
- ___ Cycle #3 carboplatin/pemetrexad.
.
Other Past Medical History:
- AAA s/p repair in ___.
- Prostate CA ___.
- HTN.
- Cholecystectomy.
- Appendectomy.
Social History:
___
Family History:
No known fhx of lung ca
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - 98.5 ___ 18 94% RA
GENERAL: sitting up in bed, holding left arm gingerly. Appears
in no distress.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB, no w/r/r
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: Pain to palpation of outer/posterior left humerus.
Very limited ROM of left arm; neurovascularly intact. Slight
swelling of left lower extremity, not present on the right.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, strength ___ in all 4 ext, sensation
grossly intact
DISCHARGE PHYSICAL EXAM:
GENERAL: lying comfortably with L arm in sling
SKIN: warm and well perfused, no excoriations or lesions, no
rashes; L brachial plexus block catheter in place, covered by
c/d/i dressing
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM
CARDIAC: RRR, S1/S2, no mrg
LUNG: CTAB, no w/r/r
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no pain of L arm. distal sensation altered but
present, distal (digital) motor function intact. Slight
swelling of left lower extremity, not present on the right.
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
Pertinent Results:
ADMISSION LABS
___ 09:18PM ___ PTT-27.2 ___
___ 09:18PM PLT COUNT-383
___ 09:18PM NEUTS-85.1* LYMPHS-10.3* MONOS-3.5 EOS-0.8
BASOS-0.3
___ 09:18PM WBC-14.6* RBC-2.95* HGB-9.1* HCT-29.3*
MCV-99* MCH-30.8 MCHC-31.1 RDW-18.9*
___ 09:18PM estGFR-Using this
___ 09:18PM GLUCOSE-107* UREA N-21* CREAT-1.0 SODIUM-142
POTASSIUM-4.1 CHLORIDE-107 TOTAL CO2-23 ANION GAP-16
DISCHARGE LABS
___ 07:55AM BLOOD WBC-18.3* RBC-3.34* Hgb-10.0* Hct-33.8*
MCV-101* MCH-30.0 MCHC-29.6* RDW-18.8* Plt ___
___ 07:55AM BLOOD ___ PTT-39.1* ___
___ 07:55AM BLOOD Glucose-96 UreaN-29* Creat-0.9 Na-140
K-4.3 Cl-105 HCO3-23 AnGap-16
___ 07:55AM BLOOD Calcium-9.0 Phos-3.5 Mg-1.9
PERTINENT IMAGING
Humerus A/P film (___):
Acute pathologic fracture of the left humeral neck
B/L ___ Venous Ultrasound (___): Non-occlussive thrombosis of
the left greater saphenous vein at the junction to the common
femoral vein. Complete thrombosis of the left lesser saphenous
veins and one of the left gastrocnemius veins at the calf.
On the right side, one of the posterior tibialis veins is
occluded.
CXR (___):
1. New elevation of the left hemidiaphragm raises concern for
phrenic nerve palsy. Fluoroscopic or ultrasound evaluation
recommended.
2. No evidence of pneumonia or congestive heart failure.
Medications on Admission:
Dexamethasone 2mg daily
Folic acid 1mg daily
Gabapentin 300mg qhs
Dilaudid ___ q8h prn
Methadone ___
Olanzapine 2.5mg qhs prn insomnia
Zofran prn
Compazine prn
Ranitidine 150mg bid
Ibuprofren 400mg q6h prn pain
Colace 100mg bid
senna prn
tylenol prn
Discharge Medications:
1. enoxaparin 80 mg/0.8 mL Syringe Sig: One (1) syringe
Subcutaneous Q12H (every 12 hours).
Disp:*60 syringe* Refills:*2*
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. olanzapine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime) as needed for insomnia.
4. Zofran 4 mg Tablet Sig: One (1) Tablet PO every eight (8)
hours as needed for nausea.
5. ranitidine HCl 150 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
6. acetaminophen 500 mg Tablet Sig: Two (2) Tablet PO Q8H (every
8 hours) as needed for pain.
7. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
8. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
9. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily) as needed for
constipation.
Disp:*30 Powder in Packet(s)* Refills:*0*
10. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
11. methadone 40 mg Tablet, Soluble Sig: One (1) Tablet, Soluble
PO TID (3 times a day): Do not drive or drink alcohol while
taking this medication. .
Disp:*90 Tablet, Soluble(s)* Refills:*0*
12. gabapentin 300 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*0*
13. tizanidine 2 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day): Do not drive or drink alcohol while taking this
medication. .
Disp:*60 Tablet(s)* Refills:*0*
14. dexamethasone 4 mg Tablet Sig: One (1) Tablet PO QAM (once a
day (in the morning)): please refer to your oncologist for
dosing of this medication.
Disp:*30 Tablet(s)* Refills:*0*
15. hydromorphone 4 mg Tablet Sig: ___ Tablets PO Q3H (every 3
hours) as needed for breakthrough pain: Do not drive or drink
alcohol while taking this medication. .
Disp:*30 Tablet(s)* Refills:*0*
16. bupivacaine (PF) 0.25 % (2.5 mg/mL) Solution Sig: ___ mL
Injection continuous: Infuse via peripheral nerve catheter
continuous infusion x10d. Continuous infusion at ___ ml/hr;
titrate to pain control. Please mix 2.5mg/ml in 500ml cartridge
.
Disp:*4 cartridges* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Left humerus pathological fracture
Secondary: ___
Bilateral DVTs
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with history of cancer, evaluate for fracture.
COMPARISONS: CT ___.
TWO VIEWS OF THE LEFT HUMERUS: There is a transverse fracture through the
humeral neck. Underlying bone lucencies and cortical destruction seen on
previous the CT at this location are suggestive of a pathologic fracture. The
humeral head maintains its normal anatomic alignment with the glenoid. No
other suspicious osseous lesions are seen.
IMPRESSION: Acute pathologic fracture of the left humeral neck.
Radiology Report
INDICATION: ___ man with lower extremity edema.
TECHNIQUE:
Grayscale and color ultrasound images of the lower extremities were obtained.
COMPARISON: There are no prior studies for comparison available.
FINDINGS:
Non-occlussive thrombosis of the left greater saphenous vein at the junction
to the common femoral vein. Complete thrombosis of the left lesser saphenous
veins and one of the left gastrocnemius veins at the calf.
On the right side, one of the posterior tibialis veins is occluded.
There is normal compressibility and flow in bilateral common femoral,
superficial femoral, popliteal and popliteal veins.
IMPRESSION:
Bilateral lower extremity thrombosis as described above.
dw Dr. ___ at 9.30 am by Dr. ___.
Radiology Report
INDICATION: Evaluate for pulmonary edema or pneumonia. The patient is
experiencing new onset dyspnea and hypoxia.
COMPARISON: Most recent radiograph from ___. CT of the torso from
___.
FINDINGS: PA and lateral radiographs of the chest demonstrate new elevation
of the left hemidiaphragm and minimal bibasilar atelectasis. The lungs are
otherwise clear and heart size is normal. There is a left upper lobe
paraaortic mass which is stable in size. The lungs are otherwise clear.
There is no pneumothorax.
IMPRESSION:
1. New elevation of the left hemidiaphragm raises concern for phrenic nerve
palsy. Fluoroscopic or ultrasound evaluation recommended.
2. No evidence of pneumonia or congestive heart failure.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: SHOULDER INJ
Diagnosed with PATHOLOGIC FX HUMERUS, MAL NEO BRONCH/LUNG NOS, HYPERTENSION NOS, HYPERCHOLESTEROLEMIA
temperature: 97.6
heartrate: 120.0
resprate: 22.0
o2sat: 96.0
sbp: 117.0
dbp: 69.0
level of pain: 9
level of acuity: 3.0 | BRIEF CLINICAL SUMMARY:
___ yo M with stage IV NSCLC adenocarcinoma with metastatic
lesions to brain and bone, who was admitted with a new
pathologic left humerus fracture. The patient completed a
5-episode radiation therapy protocol, with course complicated by
L arm pain that was refractory to large amounts of narcotic
medications. The patient had a brachial plexus block and
catheter placement by anesthesia/pain medicine, with good
effect. The patient was discharged home with the peripheral
catheter nerve block, with infusion support services. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
opiods
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ G2P0 at 31w5d by LMP c/w ___ US transferred from ___ ED
with abdominal pain. Patient reports that at 0200, she was
awakened from sleep with acute onset of colicky LLQ/flank pain.
The pain was initially ___ occurring every few minutes. She
took Tylenol and Pepcid without any relief. The pain intensified
around 0330 to ___ and was radiating to lower midline pelvis.
Presented to ___ ED. SVE performed there revealed closed
cervix/50% effaced/-3 station.
Reports intense nausea at time of pain, but denies emesis.
Denies fevers/chills and diarrhea. Notes constipation throughout
pregnancy, but had normal formed BM yesterday. Has had ___
___ contractions a few weeks ago, however this feels very
different in that it is much more severe and her abdomen is not
tightening. Denies hematuria, dysuria. Reports left sided lower
back pain coinciding with LLQ pain. Reports that yesterday
during the day she felt well and consumed normal amount of
water. Denies any sick contacts, unusual foods, or recent
travel. Denies HA, visual changes, SOB, CP, VB, LOF. Reports
active FM.
Past Medical History:
PNC:
- ___ ___ by ___ ___ c/w ___ US
- Labs ___ unknown
- Screening: NIPT low risk, CF/SMA/Tay ___ LR at ___
- Varicella immune
- FFS wnl, post placenta
- GTT 123
- Issues
*) RH neg s/p RhoGam ___
OBHx: G2P0
- G1: first trimester SAB
- G2: current
GynHx:
- h/o abnormal pap s/p colpo with benign Bx; denies cervical
procedures
- denies fibroids, endometriosis, ovarian cysts
- denies STIs, including HSV
PMH: migraines without aura, ?multiple sclerosis- numbness and
tingling
PSH: tonsillectomy
Social History:
___
Family History:
non-contributory
Physical Exam:
On admission:
Vitals: T 97.8, HR 70-80s, BP 119/72, RR 22
Gen: appears uncomfortable, writhing in bed and moaning in pain
Pulm: nl work of breathing
Abd: soft, gravid, tender in LLQ and L flank
Back: +CVA tenderness
Ext: no calf tenderness
TAUS: deferred given pt unable to lie in bed ___ acute pain
On discharge:
Physical Exam on Discharge:
CONSTITUTIONAL: normal
HEENT: normal, MMM
NEURO: alert, appropriate, oriented x 4
RESP: no increased WOB
HEART: extremities warm and well perfused
ABDOMEN: gravid, non-tender
EXTREMITIES: non-tender, no edema
FHR: present at a normal rate
Pertinent Results:
___ WBC-10.1 RBC-3.36 Hgb-10.2 Hct-29.8 MCV-89 Plt-238
___ Neuts-64.1 ___ Monos-10.9 Eos-1.5 Baso-0.3 Im
___ AbsNeut-6.47 AbsLymp-2.27 AbsMono-1.10* AbsEos-0.15
AbsBaso-0.03
___ BLOOD Glucose-89 UreaN-7 Creat-0.5 Na-139 K-3.8 Cl-105
HCO3-21* AnGap-13
___ URINE Blood-NEG Nitrite-NEG Protein-NEG Glucose-NEG
Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ URINE bnzodzp-NEG barbitr-NEG opiates-NEG cocaine-NEG
amphetm-NEG mthdone-NEG
___ URINE CT-PND NG-PND
SMEAR FOR BACTERIAL VAGINOSIS (Final ___:
GRAM STAIN NEGATIVE FOR BACTERIAL VAGINOSIS.
YEAST VAGINITIS CULTURE (Pending):
R/O GROUP B BETA STREP (Pending):
SMEAR FOR BACTERIAL VAGINOSIS (Final ___:
GRAM STAIN NEGATIVE FOR BACTERIAL VAGINOSIS.
YEAST VAGINITIS CULTURE (Pending):
Medications on Admission:
PNV
Discharge Medications:
Prenatal Vitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
pregnancy at 31w6d
flank pain
Discharge Condition:
stable
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman at 31 weeks gestation with colicky ___
LLQ/flank pain radiating to midline pelvis// ? nephrolithiasis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
There is no hydronephrosis, stones, or masses bilaterally. Normal cortical
echogenicity and corticomedullary differentiation are seen bilaterally.
Right kidney: 9.6 cm
Left kidney: 10.7 cm
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
Normal renal ultrasound. Specifically, no evidence of hydronephrosis or
nephrolithiasis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Pregnant
Diagnosed with Oth pregnancy related conditions, third trimester, 31 weeks gestation of pregnancy
temperature: 96.9
heartrate: 76.0
resprate: 19.0
o2sat: 100.0
sbp: 108.0
dbp: 87.0
level of pain: 10
level of acuity: 2.0 | Ms. ___ was admitted to the hospital with acute onset
colicky LLQ pain concerning for nephrolithiasis or preterm
contractions. She had a U/A that was within normal limits and a
renal ultrasound that showed no evidence of hydronephrosis or
nephrolithiasis. A workup including vaginal cultures and urine
culture were all negative.
She was observed and did not have any contractions, vaginal
bleeding, or rupture of membranes. Her pain resolved by HD#2.
After a period of observation, she was deemed stable for
discharge home with precautions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
elevated creatinine
Major Surgical or Invasive Procedure:
Kidney biopsy ___
History of Present Illness:
___ w/ hx of ESRD s/p transplant ___ years ago c/b by BK viremia,
that is being managed with sirolimus/prednisone with her last BK
VL in ___ was >400,000 who is referred in for worsening
creatinine found on routine labs. She denies fever, chills, CP,
SOB, n/v/d/c, rash, dysuria. She endorses some foot swelling b/l
that she reports comes and goes chronically. She reports feeling
well overall.
K 5.9. EKG ordered: Sinus at 82. NA. NI except QRS 139. RBBB
CWP.
In the ED, initial vital signs were: 97.8 85 169/71 18 100% RA.
Exam notable for pitting edema in lower extremities
Labs were notable for K 5.9, BUN/Crt 64/3.4, glucose 65, Cl 110,
Bicarb 18. H/H 9.3/30.4. UA unremarkable.
Patient was given 20mg IV Lasix and 1L NS
On Transfer Vitals were: 98.0 77 160/59 17 100%RA
On the floor, patient has no complaints. Negative ROS. Came in
due to laboratory abnormalities. No dysuria, hematuria, changes
in frequency or amount. She mentions that she banged her R thigh
getting out of a car the other day and has had pain since.
Per transplant nephrology:
Ms. ___ is a ___ year old woman with history of end-stage renal
disease due to diabetic nepropathy s/p living-unrelated renal
transplant on ___, who presents at the request of
her transplant nephrologist due to outpatient labs revealing
increased creatinine in the setting of worsening BK viremia. The
patient has felt quite well. She notes only stable, mild lower
extremity edema. She denies headache, fever, chills, cough,
nausea, vomiting, diarrhea, chest pain, rash, dysuria, and
change in urine volume or quality.
Of note, she has been dealing with BK viremia since ___. Due to
a slowly rising creatinine, a biopsy was done in ___,
revealing changes consistent with BK nephropathy. She had been
maintained on sirolimus plus leflumonide until the fall, but was
switched to sirolimus plus prednisone in the fall due to the
national shortage of leflunomide. On routine labs this week, her
serum creatinine and BK virus load had risen to 2.9 mg/dl and
416,914 copies/ml, respectively, from 1.8 mg/dl in ___ and
23,090 copies/ml in ___.
Past Medical History:
-End-stage renal disease secondary to diabetes, on HD x ___
-S/P living-unrelated renal transplant on ___,
-Hypertension
-Diabetes
-Asthma
-Hyperlipidemia
-left upper pole lung nodule
Social History:
___
Family History:
father who died from stroke, mother who died from TB
pericarditis, 2 sisters with renal disease and a brother with
diabetes and prostate cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.4 148/74 79 18 100%RA
General: obese, no acute distress, sitting up comfortably in bed
HEENT: NCAT, PERRLA, MMM
CV: RRR, no m/r/g
Lungs: CTAB, no wheezes/rhonchi
Abdomen: soft, nontender, nondistended, RLQ mass c/w
transplanted kidney
GU: no foley
Ext: 1+ pitting edema to bilateral shins
Neuro: A&Ox4, no focal deficits
Skin: no rashes, lesions, or excoriations
DISCHARGE PHYSICAL EXAM:
Vitals: 98.2 153/63 (150-160s/60s) 78 (60-70s) Wt 70.7kg<-71.2kg
General: obese, no acute distress, sitting up comfortably in bed
HEENT: NCAT, PERRLA, MMM
CV: RRR, no m/r/g
Lungs: CTAB, no wheezes/rhonchi
Abdomen: soft, nontender, nondistended, RLQ mass c/w
transplanted kidney, no evidence of hematoma
GU: no foley
Ext: 1+ pitting edema to bilateral shins
Neuro: A&Ox4, no focal deficits
Skin: no rashes, lesions, or excoriations
Pertinent Results:
ADMISSION LABS:
___ 05:14PM BLOOD WBC-6.0 RBC-3.24* Hgb-9.3* Hct-30.4*
MCV-94 MCH-28.7 MCHC-30.6* RDW-14.6 RDWSD-49.9* Plt ___
___ 05:14PM BLOOD Neuts-75.5* Lymphs-13.9* Monos-7.3
Eos-1.0 Baso-0.3 Im ___ AbsNeut-4.56 AbsLymp-0.84*
AbsMono-0.44 AbsEos-0.06 AbsBaso-0.02
___ 06:40AM BLOOD ___ PTT-30.5 ___
___ 05:14PM BLOOD Glucose-65* UreaN-64* Creat-3.4* Na-140
K-5.9* Cl-110* HCO3-18* AnGap-18
___ 06:40AM BLOOD Calcium-9.6 Phos-3.9 Mg-1.9
___ 06:40AM BLOOD rapmycn-5.3
___ 05:14PM URINE Color-Straw Appear-Clear Sp ___
___ 05:14PM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-NEG
___ 05:14PM URINE RBC-<1 WBC-1 Bacteri-FEW Yeast-NONE Epi-0
TransE-<1
OTHER PERTINENT/DISCHARGE LABS:
___ 06:36AM BLOOD WBC-4.1 RBC-2.81* Hgb-8.1* Hct-25.2*
MCV-90 MCH-28.8 MCHC-32.1 RDW-14.1 RDWSD-46.1 Plt ___
___ 06:36AM BLOOD Glucose-64* UreaN-52* Creat-2.4* Na-136
K-4.8 Cl-106 HCO3-21* AnGap-14
___ 06:36AM BLOOD Calcium-9.1 Phos-3.9 Mg-2.0 Cholest-PND
___ 06:10AM BLOOD Hapto-82
___ 05:45PM BLOOD TSH-1.6
___ 07:05AM BLOOD rapmycn-6.5
IMAGING:
Renal transplant ultrasound ___
1. Modestly increased resistive indices are now mildly
elevated, with
unchanged waveform morphology.
2. Normal renal morphology without evidence of hydronephrosis
or perirenal collection.
.
Ultrasound guided kidney graft biopsy ___
Ultrasound guidance for percutaneous right lower quadrant
transplant kidney biopsy.
.
PATHOLOGY:
___ - Kidney biopsy
1. POLYOMA VIRUS NEPHROPATHY.
2. IF/TA GRADE I.
Note: There is no evidence of acute rejection. There is minimal
focal mesangial expansion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Sirolimus 2 mg PO DAILY
2. PredniSONE 5 mg PO DAILY
3. Lisinopril 10 mg PO DAILY
4. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
5. Fish Oil (Omega 3) 1000 mg PO BID
6. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. Metoprolol Succinate XL 200 mg PO DAILY
9. Vitamin D ___ UNIT PO DAILY
10. Fenofibrate 160 mg PO QHS
11. Atorvastatin 80 mg PO QPM
12. NPH 10 Units Breakfast
NPH 24 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
2. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
3. Fenofibrate 160 mg PO QHS
4. Fish Oil (Omega 3) 1000 mg PO BID
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Metoprolol Succinate XL 200 mg PO DAILY
7. Vitamin D ___ UNIT PO DAILY
8. Lisinopril 10 mg PO DAILY
9. NPH 10 Units Breakfast
NPH 20 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
10. PredniSONE 4 mg PO DAILY
RX *prednisone 1 mg 4 tablet(s) by mouth daily Disp #*120 Tablet
Refills:*0
11. Sirolimus 1.5 mg PO DAILY
RX *sirolimus 0.5 mg 3 tablets by mouth once daily Disp #*90
Tablet Refills:*0
12. Amlodipine 10 mg PO DAILY
RX *amlodipine 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
13. Outpatient Lab Work
Please draw on ___.
Chem10 and serum Osms
ICD10 B97.89 and ___
Fax results to ___
Attn Dr. ___
___ Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Acute kidney injury - BK nephropathy
Hyponatremia
Secondary Diagnosis:
Diabetes mellitus, insulin dependent
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with renal transplant and ___ in setting of
worsening BK viremia. Request assistance with urgent biopsy on ___ to define
BK vs rejection. Thank you. // Localization of transplant kidney for
percutaneous biopsy.
TECHNIQUE: Real-time grayscale ultrasound imaging for biopsy guidance.
COMPARISON: Comparison is made to ultrasound from ___.
OPERATORS: Dr. ___ Dr. ___ sonographic guidance for
biopsy that was performed by the Nephrology team.. Dr. ___
radiologist, was present and supervising throughout the guidance and reviewed
and agrees with the trainee's findings
FINDINGS:
This procedure was performed by the Nephrology team; please see Nephrology
procedure note for further details.
Real-time ultrasound guidance for percutaneous renal biopsy was provided by
radiologist. The lower pole of the right lower quadrant transplant kidney was
targeted and 2 biopsy passes performed.
SEDATION: No additional sedation was administered.
IMPRESSION:
Ultrasound guidance for percutaneous right lower quadrant transplant kidney
biopsy.
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: ___ with transplant ___ years ago. worsening cr // hydro?
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: Doppler ultrasound dated ___.
FINDINGS:
The right iliac fossa transplant renal morphology is normal. Specifically,
the cortex is of normal thickness and echogenicity, pyramids are normal, there
is no urothelial thickening, and renal sinus fat is normal. There is no
hydronephrosis and no perinephric fluid collection.
The resistive index of intrarenal arteries ranges from 0.77 to 0.84, mildly
elevated and previously ranging from 0.72 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 142. Vascularity is
symmetric throughout transplant. The transplant renal vein is patent and shows
normal waveform.
IMPRESSION:
1. Modestly increased resistive indices are now mildly elevated, with
unchanged waveform morphology.
2. Normal renal morphology without evidence of hydronephrosis or perirenal
collection.
Radiology Report
INDICATION: Hematocrit drop after recent renal biopsy of a transplanted
kidney. Evaluate for hemorrhage.
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
without the administration of intravenous contrast.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.5 s, 49.9 cm; CTDIvol = 16.2 mGy (Body) DLP = 807.5
mGy-cm.
Total DLP (Body) = 808 mGy-cm.
COMPARISON: Renal transplant biopsy from ___. PET-CT from ___.
FINDINGS:
LOWER CHEST: The imaged lung bases are clear. There is no focal
consolidation, discrete nodule, or pleural effusion. The base of the heart is
normal in size. There is no 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 not distended.
Several small gallstones are noted.
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 native kidneys are atrophic. In the upper pole of the right
kidney, there are two lesions which measure 13 mm and 11 mm (2, 22), and have
the attenuation of simple cysts. Additionally in the midpole, there is a 16
mm simple cyst. In the left kidney, there are several subcentimeter
hypodensities, which are too small to characterize, though also likely
represents cysts. There is no hydronephrosis.
There is a transplanted kidney in right lower quadrant. The kidney is normal
in shape and contour. There is no focal lesion on this noncontrast exam. No
perinephric hematoma is identified. There is no hydronephrosis or
hydroureter.
There is no retroperitoneal hematoma.
GASTROINTESTINAL: The stomach is unremarkable. The small bowel loops
demonstrate normal caliber and wall thickness throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is a
small amount of simple free fluid in the pelvis. There is no evidence of a
hematoma.
REPRODUCTIVE ORGANS: The uterus is normal. The ovaries are not discretely
visualized, though there are no adnexal masses.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Mild-to-moderate multilevel degenerative changes are noted in the lumbar
spine, with posterior osteophytosis at L3-4 and L5-1, as well as a small disc
bulge at L4-5. Mild degenerative changes are noted in the sacroiliac joints.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence of a perinephric hematoma around the transplanted kidney. No
retroperitoneal hematoma.
2. Small amount of nonspecific simple free fluid in the pelvis.
3. Atrophic native kidneys with multiple simple cysts.
4. Cholelithiasis.
Gender: F
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Abnormal labs
Diagnosed with Acute kidney failure, unspecified
temperature: 97.8
heartrate: 85.0
resprate: 18.0
o2sat: 100.0
sbp: 169.0
dbp: 71.0
level of pain: 0
level of acuity: 3.0 | Ms. ___ is a ___ year old woman now ___ years s/p LURT who presents
with acute allograft dysfunction in the setting of worsening BK
viremia despite relatively low-dose immunosuppression. She has
no signs of overt bacterial infection, volume depletion, or
evidence of urinary obstruction which would explain her
worsening creatinine. Thus, the most likely causes are worsening
BK nephropathy versus rejection.
#***Please note: after patient was discharged, notified by
infection control that patient's roommate for <24 hours on
___ was found to be FluA positive***
#Acute renal failure- BK virus versus rejection
- Biopsy done ___ showing BK nephropathy
- Hold ASA, NSAIDs for biopsy; no anticoagulation or
antiplatelets for ___ days starting ___
- Hold lisinopril
- Dose medications for GFR < 10 ml/min
#Immunosuppression: Decreased home sirolimus and prednisone in
setting of BK nephropathy.
- Sirolimus 1.5mg and prednisone 4mg to be titrated by
outpatient transplant nephrology.
#Prophylaxis:
- Held TMP/SMX in setting ___ with hyperkalemia. No need for
PJP coverage at this time and was held on discharge.
- continued home vitamin D |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
tetracycline
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ with no significant PMHx who presents with
syncope. She states that she was eating dinner at a restaurant
when she began to feel lightheaded and nauseous. She then had a
witnessed syncopal event which lasted about 30 seconds.
Reportedly HR was in ___ (there was an MD at dinner with her who
checked her pulse). Per report, no seizure like activities. When
she woke up, she did not feel confused but did feel very
nauseous and weak. She then felt like she needed to go to the
bathroom. She fainted again while walking to the bathroom with
her sons and was seated in a chair. She states that while she
was in the chair, still unconscious, she had a bowel movement.
She then woke up and threw up many times. No head strike or
fall. She regained consciousness, but continued to feel weak and
was very sweaty. No tongue biting or confusion to suggest
post-ictal state. She had 2 glasses of wine with dinner.
She denies recent fever, chills, chest pain, shortness of
breath, palpitations, abdominal pain, diarrhea, melena,
hematochezia, urinary symptoms. No confusion, dysarthria. She
states that her dizziness resolved by the time she came to the
ED.
Patient had a similar episode ___ years ago. She fainted at her
son's house after feeling very dizzy. She had a facial
laceration at that time. She was admitted to ___ for
workup and she reports that workup was normal. She states that
she was diagnosed with vagal syncope. She states that she had a
stress test and ?CTA neck at that time.
In the ED, initial vitals:
97.8 64 86/61 16 100% RA
- Labs notable for: normal CBC, K 3.2, normal LFTs, trop neg x1
and lactate 3.4.
EKG: sinus, TWI I, II, aVL, V2-V6, no STE, NANI
- Imaging notable for: CXR normal.
- Patient given: 1L NS, Zofran, 324mg ASA. KCl 40mEq ordered,
not given.
On arrival to the floor, pt reports that her sons feel like the
food "didn't sit well" with them. She states that she feels
"practically" at her baseline. No palpitations, recent illness.
She has never had syncope with activity. She states that she
continues to feel "queasy". Also states that multiple people who
were at the dinner with her also now feel nauseous.
She states that she used to faint "a lot" when she was a
teenager and always had very low BP.
Past Medical History:
h/o vasovagal syncope
Social History:
___
Family History:
mother with dementia. Details unclear about father health, but
patient states that he had obesity and DM. No FHx of sudden
cardiac death
Physical Exam:
ADMISSION EXAM:
===============
Vitals: 97.6, 66, 123/65, 97/RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple,
JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, no cyanosis or edema
Skin: Without rashes or lesions
Neuro: A&Ox3. CN2-12 intact. ___ strength in all extremities
DISCHARGE EXAM:
===============
Vitals: Tmax 98.5 Tcurrent 97.6 | 100-123/60-71 | 60-66 | 18 |
97/RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, neck supple, JVP
not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, no cyanosis or edema
Skin: Without rashes or lesions
Neuro: A&Ox3.
Pertinent Results:
ADMISSION LABS:
===============
___ 09:45PM BLOOD WBC-7.0 RBC-4.56 Hgb-13.5 Hct-40.9 MCV-90
MCH-29.6 MCHC-33.0 RDW-13.4 RDWSD-43.9 Plt ___
___ 09:45PM BLOOD Neuts-45.9 ___ Monos-6.6 Eos-1.4
Baso-0.4 Im ___ AbsNeut-3.21 AbsLymp-3.19 AbsMono-0.46
AbsEos-0.10 AbsBaso-0.03
___ 09:45PM BLOOD ___ PTT-30.3 ___
___ 09:45PM BLOOD Glucose-107* UreaN-16 Creat-0.8 Na-142
K-3.2* Cl-102 HCO3-19* AnGap-24*
___ 09:45PM BLOOD ALT-19 AST-28 AlkPhos-72 TotBili-0.3
___ 09:45PM BLOOD Lipase-48
___ 09:45PM BLOOD cTropnT-<0.01
___ 09:45PM BLOOD Albumin-4.7 Calcium-9.8 Phos-3.8 Mg-2.3
___ 09:59PM BLOOD Lactate-3.4*
___ 04:41AM BLOOD Lactate-0.9
DISCHARGE LABS:
================
___ 07:13AM BLOOD WBC-4.6 RBC-4.31 Hgb-12.8 Hct-40.0 MCV-93
MCH-29.7 MCHC-32.0 RDW-13.6 RDWSD-46.3 Plt ___
___ 07:13AM BLOOD Glucose-107* UreaN-18 Creat-0.8 Na-141
K-4.6 Cl-106 HCO3-24 AnGap-16
UA UNREMARKABLE
MICRO:
======
___ 11:34 am URINE Source: ___.
URINE CULTURE (Pending):
___ 9:45 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
IMAGING:
========
Imaging CHEST (PA & LAT) ___
FINDINGS:
Cardiac silhouette size is normal. Mediastinal and hilar
contours are within normal limits. The pulmonary vasculature is
not engorged. Pleuro-parenchymal scarring is noted within the
lung apices. No focal consolidation, pleural effusion or
pneumothorax is seen. Moderate multilevel degenerative changes
are noted in the thoracic spine.
IMPRESSION:
No acute cardiopulmonary abnormality.
ECHO ___ (___):
All cardiac chambers are normal in size. Left ventricular
systolic function is preserved with an estimated ejection
fraction of 60%. There is mild concentric LVH. Right
ventricular systolic function is normal. The aortic and mitral
leaflets are minimally thickened with no aortic and mild mitral
regurgitation. There is mild tricuspid regurgitation with a
normal pulmonary artery pressure. A minimal pericardial effusion
is seen.
CAROTID DUPLEX ___ (___):
Carotid duplex examination reveals no plaque within the right
and left carotid bulbs. Velocities within the right and left
internal carotid arteries are within normal limits, indicating
no stenosis. Flow within the right and left vertebral arteries
is antegrade.
CONCLUSIONS:
There is no stenosis of the right and left internal carotid
arteries.
EKG EXERCISE STRESS TEST ___ (___)
Normal exercise duration of 8 minutes 7 seconds in this
___ female referred for syncope. The patient had normal
heart rate, blood pressure and oxygen saturation response. The
patient had no arrhythmias. The patient had no symptoms of chest
pain, stopped for fatigue. There were no significant ST segment
changes seen. The test was negative by ST segment criteria.
EKG
====
EKG ___ (___. ___)
Vent. Rate : 068 BPM Atrial Rate : 068 BPM
P-R Int : 176 ms QRS Dur : 100 ms
QT ___ : 412 ms P-R-T Axes : ___ degrees
QTc Int : 438 ms
EKG ___
Sinus, TWI I, II, aVL, V2-V6, no STE, NANI.
EKG ___
Sinus, TWI V1-V6, no STE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Glucosamine (glucosamine sulfate) unknown oral DAILY
2. Vitamin B Complex 1 CAP PO DAILY
3. Potassium Iodide Dose is Unknown PO Frequency is Unknown
4. Vitamin E Dose is Unknown PO DAILY
5. Calcium Carbonate 1000 mg PO DAILY
6. Vitamin D Dose is Unknown PO DAILY
7. biotin unknown oral DAILY
Discharge Medications:
1. biotin unknown oral DAILY
2. Calcium Carbonate 1000 mg PO DAILY
3. Glucosamine (glucosamine sulfate) unknown oral DAILY
4. Potassium Iodide unknown PO ASDIR
5. Vitamin B Complex 1 CAP PO DAILY
6. Vitamin D UNKNOWN PO DAILY
7. Vitamin E UNKNOWN PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: vasovagal 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 syncope // eval for acute process
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Cardiac silhouette size is normal. Mediastinal and hilar contours are within
normal limits. The pulmonary vasculature is not engorged. Pleuro-parenchymal
scarring is noted within the lung apices. No focal consolidation, pleural
effusion or pneumothorax is seen. Moderate multilevel degenerative changes
are noted in the thoracic spine.
IMPRESSION:
No acute cardiopulmonary abnormality.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Syncope
Diagnosed with Syncope and collapse
temperature: 97.8
heartrate: 64.0
resprate: 16.0
o2sat: 100.0
sbp: 86.0
dbp: 61.0
level of pain: 0
level of acuity: 1.0 | ___ with a PMH of vasovagal syncope who presented after an
episode of syncope.
#Vasovagal syncope:
Patient felt lightheaded and nauseous immediately prior to
episode of syncope. Regained consciousness briefly and began
walking to bathroom when she lost consciousness again; she was
seated in a chair and had a BM. When she regained consciousness,
she threw up several times and felt nauseous, weak, and sweaty.
Denied head strike, tongue biting, post-ictal confusion.
Patient's nausea and weakness subsided after she arrived at
___. Etiology of syncope thought to be vasovagal possibly
secondary to gastroenteritis or viral etiology given dehydration
(lactate 3.4 on presentation), vomiting, diarrhea. Other
possible etiologies include arrhythmia (pulse of 40 could
suggest bradycardia) or atypical angina equivalent. ED EKG
showed NSR with T wave inversion in leads I, II, avL, V2-V6, no
ST changes. Reassuringly, previous EKGs from years past had also
been notable for T-wave inversions. The patient also has a
history of negative stress test (___) and negative carotid
ultrasound. The patient was monitored on telemetry and no
arrhythmias were noted. Her symptoms completely resolved. Urine
and blood cultures showed no growth to date.
# Diffuse T wave inversion
Likely chronic given report of nonspecific T wave abnormality
during ___ admission in ___. Possible diagnoses
includes physiologic precordial t wave inversion, memory t
waves, type II demand ischemia, and LVH (given mild concentric
LVH on echo in ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Zofran (as hydrochloride)
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o EtOH pancreatitis, recurrent torsades due to
electrolyte abnormalities s/p AICD placement in ___
admitted for abdominal pain and hypomagnesemia. Pt reports onset
of epigastric pain 3 days ago consistent with prior episodes of
pancreatitis with associated symptoms of reflux and n/v. She
also experienced a brief episode of sharp chest pain which she
thought may have been a shock delivered by her AICD. She had
been drinking between a fifth and a pint of liquor daily for the
last several months and has been trying to cut back. Last drink
was 3 days ago, she denies withdrawal symptoms. Epigastric pain
has gotten progressively worse, prompting her to present to ED.
In the ED, initial VS 98.1 80 160/110 15 100%. Labs showed
severe hypomagnesemia and elevated lipase, serum tox negative.
The EP team interrogated her AICD which showed no recent shocks
delivered. Pt receieved Iv morphine, metoclopramide, 2L NS and
was admitted to medicine.
On arrival to the floor, pt reports continued ___ abdominal
pain, denies chest pain or withdrawal symptoms. She notes that
she has had sx of her "skin crawling" when discontinuing EtOH in
the past, but no other h/o withdrawal symptoms. She notes that
she has run out of several home medications and has not taken
any medications for approximately 2 weeks. She notes recent
itchy patches of skin which she attributes to a flare of discoid
lupus. A 10 pt ROS is negative except as noted in HPI.
Past Medical History:
Torsade/VT in setting of hypomagnesemia s/p AICD placement
Discoid lupus
Alcohol abuse - reports 1 prior w/w seizure, no h/o DT's
HTN
GERD
h/o SIADH
Social History:
___
Family History:
Father alive and well. Mother died in late ___, with history of
obesity, diabetes mellitus, and hypertension. Multiple siblings
with hypertension.
No h/o MI.
Physical Exam:
Vitals- T 97.3 HR 80 143/87 RR 18 100% RA
General- Alert, oriented, no acute distress
HEENT- Sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- soft, +tenderness to palpation epigastric area,
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- motor function grossly normal
Skin- scattered hypopigmented macules on scalp and posterior
neck
Pertinent Results:
ADMISSION LABS:
==================
___ 01:57PM GLUCOSE-102* UREA N-3* CREAT-0.5 SODIUM-132*
POTASSIUM-3.7 CHLORIDE-93* TOTAL CO2-18* ANION GAP-25*
___ 01:57PM CALCIUM-7.8* PHOSPHATE-2.1* MAGNESIUM-0.9*
___ 05:15AM GLUCOSE-85 UREA N-5* CREAT-0.5 SODIUM-131*
POTASSIUM-3.3 CHLORIDE-91* TOTAL CO2-19* ANION GAP-24*
___ 05:15AM ALT(SGPT)-53* AST(SGOT)-80* ALK PHOS-138* TOT
BILI-0.7
___ 05:15AM LIPASE-245*
___ 05:15AM cTropnT-<0.01
___ 05:15AM ALBUMIN-5.0 CALCIUM-9.6 PHOSPHATE-2.9
MAGNESIUM-1.1*
___ 05:15AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 05:15AM URINE UCG-NEG
___ 05:15AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 05:15AM WBC-8.9 RBC-4.55 HGB-12.4 HCT-39.1 MCV-86
MCH-27.3 MCHC-31.7* RDW-18.7* RDWSD-57.8*
___ 05:15AM NEUTS-77.4* LYMPHS-13.3* MONOS-8.4 EOS-0.1*
BASOS-0.1 IM ___ AbsNeut-6.86* AbsLymp-1.18* AbsMono-0.74
AbsEos-0.01* AbsBaso-0.01
___ 05:15AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-150 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 05:15AM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-2
IMAGING:
==========
EKG: NSR @ 72, TWI V1/V2 (consistent with prior), diffuse peaked
T waves
CXR:
1. Unchanged position of the left pectoral single lead
pacemaker.
2. No pleural effusion.
3. No acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. FoLIC Acid 1 mg PO DAILY
3. Magnesium Oxide 400 mg PO BID
4. Metoprolol Succinate XL 25 mg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Spironolactone 12.5 mg PO DAILY
8. Thiamine 100 mg PO DAILY
9. Vitamin D ___ UNIT PO DAILY
10. Simethicone 40-80 mg PO QID:PRN gas
11. Ibuprofen 400 mg PO Q8H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain
2. Magnesium Oxide 400 mg PO BID
3. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
4. Simethicone 40-80 mg PO QID:PRN gas
5. Spironolactone 12.5 mg PO DAILY
6. Thiamine 100 mg PO DAILY
7. FoLIC Acid 1 mg PO DAILY
8. Ibuprofen 400 mg PO Q8H:PRN pain
9. Multivitamins 1 TAB PO DAILY
10. Vitamin D ___ UNIT PO DAILY
11. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
- Alcoholic induced pancreatitis
- Alcohol withdrawal
- Accelerated hypertension
Secondary:
- Long QT syndrome c/b TdP/VT cardiac arrest; s/p single lead
ICD (Biotonik Ilesto VR-T) ___
- Alcohol abuse
- Discoid lupus
- GERD
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 aicd, pancreatitis, evaluate defibrillator, and evaluate
for pleural effusion.
TECHNIQUE: PA and lateral view radiographs of the chest.
COMPARISON: Prior chest radiographs dating back to ___.
FINDINGS:
The left pectoral single lead pacemaker projects in unchanged position with
the lead projecting over the right ventricle. There is no pleural effusion.
There is no focal consolidation or pneumothorax. There is no pulmonary edema.
Subsegmental atelectasis in the right upper lobe is slightly more prominent.
IMPRESSION:
1. Unchanged position of the left pectoral single lead pacemaker.
2. No pleural effusion.
3. No acute cardiopulmonary process.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with pancreatitis // gallstones?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: ___
FINDINGS:
LIVER: The liver is diffusely echogenic. The contour of the liver is smooth.
There is no focal liver mass. The main portal vein is patent with hepatopetal
flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 2 mm.
GALLBLADDER: There is no evidence of stones or gallbladder wall thickening.
PANCREAS: Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with portions of the pancreatic tail
obscured by overlying bowel gas. No peripancreatic fluid collections are
identified.
SPLEEN: Normal echogenicity, measuring 9.1 cm.
KIDNEYS: Visualized portions of the right kidney show no evidence of
hydronephrosis.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. No gallstones.
2. No sonographic evidence of complications of acute pancreatitis.
3. Echogenic liver consistent with steatosis. Other forms of liver disease
and more advanced liver disease including steatohepatitis or significant
hepatic fibrosis/cirrhosis cannot be excluded on this study.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with h/o torsades s/p ICD now with acute chest
pain // PTX? infiltrate?
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, no relevant change is seen. Non
characteristic scarring at the right upper lobe. No evidence of pneumothorax,
pleural effusions or pulmonary edema. Unchanged position of the left pectoral
pacemaker wire. Normal size of the cardiac silhouette.
Radiology Report
INDICATION: ___ year old woman with h/o torsades s/p ICD, acute pancreatitis
now with acute/y worsening chest/epigastric pain // free air?
TECHNIQUE: Supine abdominal radiographs were obtained.
COMPARISON: CT abdomen and pelvis with contrast dated ___.
FINDINGS:
There is gaseous distention probably involving the transverse colon and
splenic flexure, measuring up to 7.1 cm. There are no dilated loops of small
bowel. There is air seen within the distal colon and rectum. Evaluation for
pneumoperitoneum or air-fluid levels is limited due to supine technique. The
bony structures are unremarkable.
IMPRESSION:
1. Increase in gaseous distention of the transverse colon and splenic flexure
in comparison to prior CT.
2. Evaluation for pneumoperitoneum limited due to supine technique. To
assess for free air, please obtain upright or left lateral decubitus views.
Gender: F
Race: BLACK/AFRICAN
Arrive by AMBULANCE
Chief complaint: Abd pain
Diagnosed with ACUTE PANCREATITIS, CHEST PAIN NOS, HYPOKALEMIA
temperature: 98.1
heartrate: 80.0
resprate: 15.0
o2sat: 100.0
sbp: 160.0
dbp: 110.0
level of pain: 10
level of acuity: 3.0 | ___ woman discoid lupus, GERD, ETOH abuse, long QT
syndrome c/b TdP/VF arrest s/p single lead ICD (___), now
with recurrent ETOH pancreatitis and alcoholic ketoacidosis.
She was treated for acute pancreatitis with IVF, bowel rest, and
antiemetics (using benzodiazepines to avoid QT prolonging
medications) with good results. Her ketoacidosis responded to
D5LR, and her alcohol withdrawal was managed by ___ with
diazepam, but she did not have significant withdrawal symptoms.
Throughout her stay she had marked asymptomatic hypertension
(SBP 160-180/DPB 100-130) which improved on an increased doses
of Toprol (25mg>50mg) and the addition of norvasc, but on the
day of discharge her BP was low normal (110/70), and because of
insurance issues requiring out of pocked expenditure and
concerns about noncompliance, she was discharged only on Toprol
(50mg). It may be that her hypertension while hospitalized was
precipitated by ETOH withdrawal, but this is unclear, and she
will need close follow up and monitoring.
HYPOMAGNESEMIA/HYPOKALEMIA: She had marked electrolytes
derangements which required aggressive repletion. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
fatigue, lethargy, hyperglycemia
Major Surgical or Invasive Procedure:
CVL ___ (removed)
G-J tube placement
History of Present Illness:
As per HPI by admitting MD:
Mr. ___ is a ___ w/ type I DM (A1C 4.9 ___
complicated by multiple toe amputations, gastroparesis & prior
DKA, ESRD (likely ___ DM, no biopsy on file) on HD, bilateral ___
DVT s/p IVC filter ___, L non-occlusive jugular thrombus
(___), R thalamic bleed in the setting of HTN emergency w/
residual L hemiparesis (___), & L hip fracture s/p fixation
___, who presents w/ lethargy and nausea from his rehab
facility.
Brief ED Course:
The patient presented ___ w/ 1 day of lethargy and nausea.
Initial imaging in the ED showed concerns for multifocal
pneumonia. The patient was started on IV vancomycin + pip-taz.
Initial lactate on ED presentation ___ was elevated at 7.0
and the patient was given 200cc of LR w/ recheck of lactate
showing improvement to 3.0 by ___. However, repeat AM BMP
@
___ showed glucose of 498 w/ AG of 29. VBG at this time
showed ___. The patient had not received insulin
since ED presentation. The ___ service was consulted and he
was started on an insulin drip ___ @ 0754 and given an
additional
2L LR. The Renal team was consulted and felt no need for urgent
dialysis and he will continue on his MWF schedule. He will now
be admitted to the ___ for further management of his DKA and
pneumonia.
His full ED course is below:
In the ED,
- Initial Vitals:
T98.6 HR83 BP110/45 RR20 O291% RA
- Exam:
Reportedly normal.
- Labs:
WBC 5.5
HGB 12.4
platelets 216
Na 140
K 4.6
Cl 89
HCO3- 19
BUN 94
Cr 5.6
Glucose 258
___ 35.4
PTT 38.0
INR 3.3
ALT 50
AST 53
AP 178
TB 0.5
VBG ___
lactate 7.0
- Imaging:
CXR ___:
3.5 cm ovoid lucency projecting over the lateral right mid to
lower hemithorax may be artifactual, but a loculated
pneumothorax
is not excluded in the appropriate clinical setting. Mild
pulmonary vascular congestion. Patchy opacity seen at the lung
bases and right upper and midlung could be due to multifocal
pneumonia and/or aspiration. If patient able, dedicated PA and
lateral views would be helpful for further assessment.
CT Chest ___:
1. Extensive ground-glass and consolidative opacities, most
severe in the left lower lobe, have progressed compared to ___ and are most compatible with worsened multifocal
pneumonia.
2. Near complete opacification of the left lower lobe segmental
and
subsegmental bronchi.
3. Prominent mediastinal lymph nodes are slightly increased in
size compared to ___, but are not pathologically
enlarged by CT size criteria.
4. Extensive calcifications involving the coronary arteries,
celiac axis, and renal arteries.
- Consults: ___, Renal
___:
"Plan: - please continue with insulin gtt to avoid DKA -
recommend frequent BG checks given history and per renal status
as high risk for severe hypoglycemia. he cannot sense his low BG
levels. - if you have any questions, please call ___. -
will continue to follow in ICU."
Renal:
___ acute RRT needs
HD ___
- Interventions:
___ 18:53 IV Vancomycin 1000 mg
___ 18:53 IVF LR 100 mL
___ 19:26 IV Piperacillin-Tazobactam 4.5 g
___ 20:57 IVF LR 100 mL
___ 02:54 PO/NG Azithromycin 500 mg
___ 02:54 PO/NG MetroNIDAZOLE 500 mg
___ 04:09 IV CefTRIAXone 1 gm
___ 05:19 SC Insulin Lispro 5 UNIT
___ 06:49 IVF LR (1000 mL ordered) Started 125 mL/hr Stop
___ 07:05 IVF NS (1000 mL ordered) Started 125 mL/hr
___ 07:54 IV DRIP Insulin 8 UNIT/HR
On the floor, he is minimally interactive though does know where
he is, his full name, and reason for being admitted, stating
"diabetes."
Past Medical History:
-type I DM (A1C 4.9 ___ w/ prior DKA
-multiple amputations
-gastroparesis
-ESRD (likely ___ DM, no biopsy on file) on HD
-bilateral ___ DVT s/p IVC filter ___
-L non-occlusive jugular thrombus ___
-R thalamic bleed in the setting of HTN emergency w/ residual L
hemiparesis (___)
-L hip fracture s/p fixation ___
Social History:
___
Family History:
___ significant for stroke.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
GENERAL: Patient lying in bed, appears dazed, staring off,
minimally interactive.
HEAD: NC/AT, conjunctiva clear, EOMI, pupils reactive, sclera
anicteric, oral mucosa w/o lesions
NECK: Supple, no LAD, no thyromegaly. JVP is 5 cm.
CARDIAC: Precordium is quiet, PMI non-displaced, RRR, S1S2 w/o
m/r/g.
RESPIRATORY: Speaking in full sentences, CTABL.
ABDOMEN: Unremarkable inspection, soft, NT, +BS. No palpable
organomegaly.
EXTREMITIES: Warm, no edema, peripheral pulses are strong and
full.
SKIN: No obvious lesions over the face, thorax, abdomen,
extremities.
NEUROLOGIC: Grossly intact, face symmetric, speech fluent,
stands
from seated position, gait normal.
PSYCHIATRIC: Pleasant and cooperative.
DISCHARGE PHYSICAL EXAM:
========================
T97.3, BP 124/58, HR 105, RR 18, O2 98% RA
Gen - sitting up in bed, well appearing
HEENT - moist oral mucosa, no OP lesion
___ - irregularly irregular, tachycardic (low 100s), s1/2, no
murmurs
Pulm - CTAb/l from anterior, no w/r/r
GI - soft, NT, ND, +BS, +GJ tube
Ext - LLE edema 2+, RLE no edema. +fistula LUE
Skin - warm, dry, no rashes
Psych - calm and cooperative
Neuro - left sided hemiparesis, able to move right side
Pertinent Results:
ADMISSION:
==========
___ 04:25PM BLOOD WBC-5.5 RBC-3.71* Hgb-12.4* Hct-38.9*
MCV-105* MCH-33.4* MCHC-31.9* RDW-15.1 RDWSD-59.2* Plt ___
___ 04:25PM BLOOD Neuts-86.7* Lymphs-4.9* Monos-8.0
Eos-0.0* Baso-0.2 Im ___ AbsNeut-4.79 AbsLymp-0.27*
AbsMono-0.44 AbsEos-0.00* AbsBaso-0.01
___ 04:25PM BLOOD ___ PTT-38.0* ___
___ 10:52AM BLOOD ___
___ 04:25PM BLOOD Glucose-258* UreaN-94* Creat-5.6*# Na-140
K-4.6 Cl-89* HCO3-19* AnGap-32*
___ 04:25PM BLOOD ALT-50* AST-53* AlkPhos-178* TotBili-0.5
___ 03:05AM BLOOD Albumin-2.9* Calcium-9.3 Phos-8.0* Mg-2.0
___ 07:27AM BLOOD Hapto-142
___ 07:27AM BLOOD TSH-0.60
___ 04:44PM BLOOD pO2-60* pCO2-42 pH-7.30* calTCO2-21 Base
XS--5 Comment-GREEN TOP
___ 04:44PM BLOOD Lactate-7.0* K-4.2
___ 05:30AM BLOOD freeCa-1.35*
MICROBIOLOGY:
=============
Blood Culture, Routine (Final ___:
STAPH AUREUS COAG +.
Consultations with ID are recommended for all blood
cultures
positive for Staphylococcus aureus, yeast or other
fungi.
FINAL SENSITIVITIES.
Oxacillin RESISTANT Staphylococci MUST be reported as
also
RESISTANT to other penicillins, cephalosporins,
carbacephems,
carbapenems, and beta-lactamase inhibitor combinations.
RIFAMPIN should not be used alone for therapy.
STREPTOCOCCUS ANGINOSUS (___) GROUP. FINAL
SENSITIVITIES.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| STREPTOCOCCUS ANGINOSUS
(MILLERI) GROU
| |
CEFTRIAXONE----------- 0.5 S
CLINDAMYCIN-----------<=0.25 S <=0.25 S
ERYTHROMYCIN----------<=0.25 S <=0.12 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- =>8 R
OXACILLIN------------- =>4 R
PENICILLIN G---------- <=0.06 S
RIFAMPIN-------------- <=0.5 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ <=0.5 S 0.5 S
Anaerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
GRAM POSITIVE COCCI IN PAIRS AND CHAINS.
Reported to and read back by ___ ___ 13:15.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN PAIRS AND CLUSTERS.
Reported to and read back by ___ ___
___ 20:25.
IMAGING:
=========
CXR ___ - IMPRESSION:
3.5 cm ovoid lucency projecting over the lateral right mid to
lower hemithorax
may be artifactual, but a loculated pneumothorax is not excluded
in the
appropriate clinical setting. Mild pulmonary vascular
congestion. Patchy
opacity seen at the lung bases and right upper and midlung could
be due to
multifocal pneumonia and/or aspiration. If patient able,
dedicated PA and
lateral views would be helpful for further assessment.
CT CHEST ___:
1. Extensive ground-glass and consolidative opacities, most
severe in the left lower lobe, have progressed compared to ___ and are most
compatible with worsened multifocal pneumonia.
2. Near complete opacification of the left lower lobe segmental
and
subsegmental bronchi.
3. Prominent mediastinal lymph nodes are slightly increased in
size compared to ___, but are not pathologically
enlarged by CT size criteria.
4. Extensive calcifications involving the coronary arteries,
celiac axis, and renal arteries.
CXR ___ - IMPRESSION:
1. Interval placement of a right IJ central venous catheter
with tip
projecting over the upper SVC.
2. Interval increase in bilateral lower lobe patchy opacities
consistent with
worsening multifocal pneumonia.
TTE ___:
CONCLUSION: The left atrial volume index is SEVERELY increased.
The right atrium is mildly enlarged. There is an intermittent
left-to-right color flow Doppler signal across the interatrial
septum most c/w a secundum atrial septal defect. The estimated
right atrial pressure is ___ mmHg. There is normal left
ventricular wall thickness with a normal cavity size. Overall
left ventricular systolic function is mildly depressed. There is
beat-to-beat variability in the left ventricular contractility
due to the irregular rhythm. The visually estimated left
ventricular ejection fraction is 45%. There is no resting left
ventricular outflow tract gradient. Mildly dilated right
ventricular cavity with normal free wall motion. The aortic
sinus diameter is normal for gender with normal ascending aorta
diameter for gender. The aortic arch diameter is normal 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
trace aortic regurgitation. The mitral valve leaflets are mildly
thickened with no mitral valve prolapse. No masses or
vegetations are seen on the mitral valve. There is moderate
mitral annular calcification. There is trivial mitral
regurgitation. Due to acoustic shadowing, the severity of mitral
regurgitation could be UNDERestimated. The pulmonic valve
leaflets are normal. The tricuspid valve leaflets appear
structurally normal. No mass/vegetation are seen on the
tricuspid valve. There is physiologic tricuspid regurgitation.
The estimated pulmonary artery systolic pressure is normal.
There is systolic notching of the right ventricular outflow
tract/pulmonary artery Doppler spectrum (Flying W sign) is
present, suggesting a significant precapillary component of
right ventricular outflow impedance.There is no pericardial
effusion.
CT A/P ___ - IMPRESSION:
Exam is slightly limited due to lack of oral contrast and
paucity of
intra-abdominal fat. However, within these limitations:
1. New left femoral head lucency with possible cortical
destruction may
represent an active infectious process such as osteomyelitis in
the setting of
reported bacteremia. Alternatively, this finding may reflect a
periprostatic
fracture or avascular necrosis. Orthopedic consultation with
possible
subsequent MRI is recommended.
2. Rectal air-fluid level may represent diarrheal disease.
3. Bilateral lower quadrant abdominal wall heterogeneous fatty
lesions may
represent complex lipomas. These were likely present on the CT
dated ___ however appear more conspicuous on the current study given
mild diffuse
anasarca. Malignancy such as a liposarcoma is less likely.
Ultrasound and/or
MRI is recommended for further evaluation if clinically
warranted.
4. Slight interval improvement of likely multifocal pneumonia
which is only
partially imaged.
5. Extensive coronary artery calcifications.
___ B Hip Films - IMPRESSION:
1. ORIF for intertrochanteric fracture of the Left femur, with
fracture
nonunion, overall similar to appearance to previous. Recent
lucencies within
the femoral head, favored to represent subchondral cystic
changes, and overall
not progressed to osteonecrosis, or septic arthritis.
2. However, there is diffusely mottled appearance, with
permeative
reabsorption of the femoral diaphysis, with periosteal stress
reaction,
concerning for osteomyelitis. This process is in close
proximity to the gamma
nail with no definite periprosthetic lucency concerning for
infection, and
there is attenuation of the articular surfaces of the knee with
possible joint
effusion, that may be seen with associated septic arthritis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 4 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Bisacodyl 10 mg PO BID
4. Labetalol 100 mg PO TID
5. melatonin 3 mg oral QHS
6. Metoclopramide 2.5 mg PO TID
7. Mirtazapine 15 mg PO QHS
8. Nephrocaps 1 CAP PO DAILY
9. Sucralfate 1 gm PO QID
10. Pantoprazole 40 mg PO Q12H
11. Sertraline 25 mg PO DAILY
12. sevelamer CARBONATE 800 mg PO TID W/MEALS
13. Glargine 6 Units Breakfast
Glargine 2 Units Bedtime
Discharge Medications:
1. Metoprolol Succinate XL 50 mg PO BID
2. ___ MD to order daily dose IV HD PROTOCOL
3. Glargine 7 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
4. Warfarin 5 mg PO DAILY16
5. Atorvastatin 40 mg PO QPM
6. melatonin 3 mg oral QHS
7. Mirtazapine 15 mg PO QHS
8. Nephrocaps 1 CAP PO DAILY
9. Pantoprazole 40 mg PO Q12H
10. Sertraline 25 mg PO DAILY
11. sevelamer CARBONATE 800 mg PO TID W/MEALS
12. Sucralfate 1 gm PO QID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Multifocal Pneumonia
MRSA Bacteremia
Dysphagia
Atrial Fibrillation
History of multiple DVTs
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with ams, desat// pna, volume status
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
FINDINGS:
3.5 cm ovoid lucency projecting over the lateral right mid to lower hemithorax
may be artifactual, but a loculated pneumothorax is not excluded in the
appropriate clinical setting. There is mild pulmonary vascular congestion.
Patchy opacity seen at the lung bases and right upper and midlung could be due
to multifocal pneumonia and/or aspiration. If patient able, dedicated PA and
lateral views would be helpful for further assessment.
IMPRESSION:
3.5 cm ovoid lucency projecting over the lateral right mid to lower hemithorax
may be artifactual, but a loculated pneumothorax is not excluded in the
appropriate clinical setting. Mild pulmonary vascular congestion. Patchy
opacity seen at the lung bases and right upper and midlung could be due to
multifocal pneumonia and/or aspiration. If patient able, dedicated PA and
lateral views would be helpful for further assessment.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ with 3.5 cm ovoid lucency projecting over the lateral right
mid to lower hemithoraxmay be artifactual, but a loculated pneumothorax is not
excluded. Rule out pneumothorax.
TECHNIQUE: Contiguous axial images were obtained through the chest without
intravenous contrast. Coronal and sagittal reformats were obtained.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.8 s, 38.0 cm; CTDIvol = 7.4 mGy (Body) DLP = 282.8
mGy-cm.
2) Spiral Acquisition 1.0 s, 8.1 cm; CTDIvol = 7.9 mGy (Body) DLP = 64.4
mGy-cm.
Total DLP (Body) = 347 mGy-cm.
COMPARISON: CT chest performed ___.
FINDINGS:
THORACIC INLET:Visualized portions of the base of the neck show no
abnormality. The visualized thyroid is normal. Supraclavicular lymph nodes
are not pathologically enlarged by CT size criteria.
THORACIC LYMPH NODES: Prominent left axillary lymph node measures up to 8 mm
in short axis and is not appreciably changed compared to ___.
Prominent mediastinal lymph nodes measure up to 7 mm in short axis and are not
pathologically enlarged, but appears slightly increased in size compared to ___ (4:74, 105). Hilar lymph nodes are not well evaluated in the
setting of a noncontrast enhanced exam. Within this limitation no definite
hilar lymphadenopathy is present.
HEART, VESSELS and PERICARDIUM: The thoracic aorta is normal in caliber.
Moderate calcific atherosclerotic disease involving the aortic arch,
descending thoracic aorta, and head neck vessels is noted. Coronary artery
calcifications are severe. No pericardial effusion.
PLEURA: No pleural effusion or pneumothorax.
LUNG: Diffuse ground-glass and consolidative opacities most severe in the left
lower lobe have progressed compared to ___ compatible with
worsening multifocal pneumonia. There is opacification of the left lower lobe
segmental and subsegmental bronchi which may reflect mucus plugging and/or
underlying infection in setting of multifocal pneumonia.
CHEST WALL AND BONES: Unchanged appearance of a sclerotic focus in the right
humeral head (4:8). Lucency within the right T6 vertebral body and posterior
elements is unchanged compared to ___ (4:93).
UPPER ABDOMEN: This study is not tailored for evaluation of the abdomen.
Allowing for this, the partially visualized upper abdomen is notable for
extensive arterial calcifications involving the celiac axis and renal
arteries. An IVC filter is partially imaged.
IMPRESSION:
1. Extensive ground-glass and consolidative opacities, most severe in the left
lower lobe, have progressed compared to ___ and are most
compatible with worsened multifocal pneumonia.
2. Near complete opacification of the left lower lobe segmental and
subsegmental bronchi.
3. Prominent mediastinal lymph nodes are slightly increased in size compared
to ___, but are not pathologically enlarged by CT size criteria.
4. Extensive calcifications involving the coronary arteries, celiac axis, and
renal arteries.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old man with DKA and pneumonia// Right IJ central line
placement Contact name: ___: ___
COMPARISON: Multiple prior chest radiographs dating back to ___, most
recently ___.
Chest CT dated ___.
FINDINGS:
AP portable upright view of the chest provided.
There has been interval placement of a right IJ central venous catheter with
tip projecting over the upper SVC.
There has been interval increase in patchy opacities in the bilateral lower
lobes, compatible with multifocal pneumonia as seen on the recent chest CT.
There is no effusion or pneumothorax. The cardiomediastinal silhouette is a
mildly enlarged, unchanged. No acute osseous abnormalities are identified.
IMPRESSION:
1. Interval placement of a right IJ central venous catheter with tip
projecting over the upper SVC.
2. Interval increase in bilateral lower lobe patchy opacities consistent with
worsening multifocal pneumonia.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 2 EXAMS
INDICATION: ___ year old man with pneumonia.// Dobhoff placement.
COMPARISON: Multiple prior chest radiographs dating back to ___, most
recently ___.
FINDINGS:
Serial AP portable upright views of the chest provided.
There has been interval placement of a Dobhoff feeding tube with tip overlying
the left upper quadrant in the expected location of the stomach on the final
image of the series. A right IJ central venous catheter is in unchanged
position.
There is increased soft tissue density projecting medial to the right IJ
central venous catheter. While this may be positional, this could also
represent a hematoma. Patchy bilateral lower lobe opacities are mildly
improved. There is no effusion, or pneumothorax. The cardiomediastinal
silhouette is mildly enlarged, unchanged.
IMPRESSION:
1. Interval placement of a Dobhoff feeding tube with tip overlying the left
upper quadrant in the expected location of stomach.
2. Interval improvement in bilateral lower lobe patchy opacities.
3. Increased soft tissue density medial to the right IJ central venous
catheter may simply be projectional. However, hematoma cannot be excluded and
short interval follow-up is recommended.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 3:39 pm, 2 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old man with MRSA bacteremia and artificial hip looking
for source in abdominal/hip abscess.// abdominal abscess? hip abscess
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 8.8 s, 57.4 cm; CTDIvol = 10.0 mGy (Body) DLP = 567.2
mGy-cm.
Total DLP (Body) = 567 mGy-cm.
COMPARISON: CT chest ___ abdomen pelvis ___.
FINDINGS:
LOWER CHEST: Again demonstrated, are partially imaged bibasilar consolidations
and ground-glass opacities in the right middle lobe and partially imaged left
upper lobe consistent with persist multifocal pneumonia, which appear slightly
improved compared to ___. There are partially imaged extensive
coronary artery calcifications. There is no evidence of pleural or
pericardial effusion.
ABDOMEN: Exam is slightly limited due to lack of oral contrast and paucity of
intra-abdominal fat.
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 demonstrates mild 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 lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are atrophied bilaterally but appear symmetric in size in
demonstrate relatively normal nephrograms. There is a stable 2 cm exophytic
cyst arising from the right kidney. Otherwise, there is no evidence of focal
renal lesions or hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: An enteric tube terminates in the stomach. The stomach is
unremarkable. Small bowel loops demonstrate normal caliber, wall thickness,
and enhancement throughout. There is an air-fluid level in the rectum which
may represent diarrheal disease. Otherwise, the colon is within normal
limits. The appendix is not definitively visualized, however there are no
secondary signs of acute appendicitis.
PELVIS: The urinary bladder is decompressed and therefore suboptimally
assessed. Otherwise, the distal ureters are grossly unremarkable. There is
no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are grossly
unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: An IVC filter is visualized in place. There is no abdominal aortic
aneurysm. Extensive atherosclerotic disease is noted.
BONES: Patient status post left hip arthroplasty with nonunion of an old
periprosthetic femoral neck fracture (06:31). Compared to ___, there
is new lucency involving the medial portion of the left femoral head (8:78)
with cortical irregularity and possible dehiscence of the anterior aspect of
the femoral head (8:80). Stable multilevel degenerative changes of the
visualized thoracolumbar spine are noted.
SOFT TISSUES: There is a 1.2 x 3.9 cm complex lateral right abdominal wall
fatty lesion with areas a perceived enhancement/nodularity (08:47, 7: 10) as
well as a contralateral similarly appearing lesion measuring 1.4 x 4.4 cm
(08:49). Superinfection cannot be excluded. Additionally, malignancy cannot
be excluded, although less likely.
IMPRESSION:
Exam is slightly limited due to lack of oral contrast and paucity of
intra-abdominal fat. However, within these limitations:
1. New left femoral head lucency with possible cortical destruction may
represent an active infectious process such as osteomyelitis in the setting of
reported bacteremia. Alternatively, this finding may reflect a periprostatic
fracture or avascular necrosis. Orthopedic consultation with possible
subsequent MRI is recommended.
2. Rectal air-fluid level may represent diarrheal disease.
3. Bilateral lower quadrant abdominal wall heterogeneous fatty lesions may
represent complex lipomas. These were likely present on the CT dated ___ however appear more conspicuous on the current study given mild diffuse
anasarca. Malignancy such as a liposarcoma is less likely. Ultrasound and/or
MRI is recommended for further evaluation if clinically warranted.
4. Slight interval improvement of likely multifocal pneumonia which is only
partially imaged.
5. Extensive coronary artery calcifications.
RECOMMENDATION(S): Orthopedic surgery consultation with possible MRI is
recommended for further evaluation of left hip.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with pneumonia and MRSA bacteremia// follow up
pna
TECHNIQUE: AP and lateral chest radiograph
COMPARISON: ___ and CT scan of the abdomen and pelvis from earlier
today
FINDINGS:
The tip of the enteric tube extends below the level the diaphragm but beyond
the field of view of this radiograph. Splenic artery calcification is noted.
As seen on the CT abdomen and pelvis from earlier today, bibasilar
consolidations are compatible with multifocal pneumonia. No pleural effusion
or pneumothorax. The size of the cardiac silhouette is within normal limits.
IMPRESSION:
Bibasilar consolidations are compatible with multifocal pneumonia, better
assessed on the CT scan of the abdomen and pelvis performed a few hours prior.
Radiology Report
EXAMINATION: HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) LEFT; FEMUR (AP AND LAT)
LEFT
INDICATION: ___ year old man with h/o L femur fractures s/p repair with MRSA
bacteremia and CT evidence of osteo vs. fracture vs. necrosis.// osteo vs.
fracture vs. necrosis ; ___ year old man with h/o L femur fractures s/p
repair with MRSA bacteremia and CT evidence of osteo vs. fracture vs.
necrosis.// osteo vs. fracture vs. necrosis.
TECHNIQUE: Frontal view radiograph of the pelvis with additional frontal and
frog-leg lateral views of Left hip
COMPARISON: Multiple CTs of the abdomen/pelvis between ___ and ___ reviewed, as well as the plain radiograph of the Left hip and
pelvis ___.
FINDINGS:
Overall, given patient internal rotation, and lack of 2 orthogonal views,
alignment of the hardware is difficult to ascertain, but there remains a short
gamma nail fixation of the Left intertrochanteric fracture, with fracture
nonunion, and valgus deformity of the Left hip. This is overall similar to
appearance to ___ year ago, and there is no definite migration of the lag screw.
There is a diffuse permeative appearance of the femoral diaphysis also
extending to the femoral stem, with periosteal stress reaction, and
attenuation of the femoral and tibial articular surface of the knee, with
suspicion of a small joint effusion, allowing for non dedicated views.
Diffuse vascular calcifications.
IMPRESSION:
1. ORIF for intertrochanteric fracture of the Left femur, with fracture
nonunion, overall similar to appearance to previous. Recent lucencies within
the femoral head, favored to represent subchondral cystic changes, and overall
not progressed to osteonecrosis, or septic arthritis.
2. However, there is diffusely mottled appearance, with permeative
reabsorption of the femoral diaphysis, with periosteal stress reaction,
concerning for osteomyelitis. This process is in close proximity to the gamma
nail with no definite periprosthetic lucency concerning for infection, and
there is attenuation of the articular surfaces of the knee with possible joint
effusion, that ___ be seen with associated septic arthritis.
NOTIFICATION: The findings were placed in the Radiology reporting dashboard
by ___, M.D. on ___ at 8:03 pm, 2 minutes after discovery of the
findings.
Radiology Report
INDICATION: ___ year old man with ESRD, dysphagia with severe aspiration
requiring better nutrition// J tube placement?
COMPARISON: CT dated ___
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and
Dr. ___, Interventional Radiology fellow performed the procedure.
Dr. ___ supervised the trainee during any key components of
the procedure where applicable and reviewed and agrees with the findings as
reported below.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
75mcg of fentanyl and 0 mg of midazolam throughout the total intra-service
time of 39 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: 1 g ceftriaxone
CONTRAST: 25 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 10 minutes and 30 seconds, 41 mGy
PROCEDURE:
1. Placement of R brachial midline.
2. Placement of an 16 ___ gastrojejunostomy tube
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The tube site was prepped and draped in the usual sterile fashion.
Using sterile technique and local anesthesia, the right basilic vein was
punctured under direct ultrasound guidance using a micropuncture set.
Permanent ultrasound images were obtained before and after intravenous access,
which confirmed vein patency. A peel-away sheath was then placed over a
guidewire. The guidewire was then advanced into the superior vena cava using
fluoroscopic guidance. A single lumen midline measuring 20 cm in length was
then placed through the peel-away sheath with its tip positioned in the
central brachial vein under fluoroscopic guidance. Position of the catheter
was confirmed by a fluoroscopic spot film of the chest. The peel-away sheath
and guidewire were then removed. The catheter was secured to the skin,
flushed, and a sterile dressing applied.
A scout image of the abdomen was obtained. The stomach was insufflated through
the indwelling nasogastric tube. Using a marker, the skin was marked using
palpation to feel the costal margins and the liver edge was marked using
ultrasound. Ultrasound images were stored.
Under fluoroscopic guidance, 3 T fastener buttons were sequentially deployed
in a triangular position elevating the stomach to the anterior abdominal wall.
Intra-gastric position was confirmed with aspiration of air and injection of
contrast. A 19 gauge needle was introduced under fluoroscopic guidance and
position confirmed using an injection of dilute contrast. The needle
trajectory was directed towards the pylorus. A ___ wire was introduced and
coiled within the stomach. A small skin incision was made along the needle and
the needle was removed.
A 7 ___ sheath was placed. A Kumpe catheter was then introduced over the
wire and the ___ was exchanged for a Glidewire. The Glidewire and a Kumpe
cathter was used to advance the wire into the ___ part of the duodenum. The
Glidewire was then exchanged for an Amplatz wire. The sheath was then removed
and a peel-away sheath was placed over the wire. A 16 ___ gastrojejunostomy
catheter was advanced over the wire into position. The sheath was then peeled
away.
The wire and sheath were removed. The catheters balloon was inflated with 7 ml
of contrast in the proximal duodenum and locked in the stomach after
confirming the position of the catheter with a contrast injection. The
catheter was then flushed, capped and secured to the skin with 0-silk sutures.
Sterile dressings were applied. The patient tolerated the procedure well and
there were no immediate complications.
FINDINGS:
1. Patent and compressible basilic vein. Basilicvein approach single lumen
right midline with tip in the central brachial vein. Midline okay to use.
2. Successful placement of a 16 ___ gastrojejunostomy tube with its tip in
the proximal jejunum.
IMPRESSION:
Successful placement of a 16 ___ gastrojejunostomy tube with its tip in the
proximal jejunum. The gastric port should not be used for 24 hours. Jejunal
port may be used immediately.
Midline okay to use.
Radiology Report
INDICATION: ___ year old man with dysphagia// aspiration
TECHNIQUE: Oropharyngeal swallowing videofluoroscopy was performed in
conjunction with the Speech-Language Pathologist from the Voice, Speech &
Swallowing Service. Multiple consistencies of barium were administered.
DOSE: Fluoro time: 03:22 min. Acc Air Kerma: 14.2mGy, DAP 334.97mGy/m2
COMPARISON: None
FINDINGS:
An NG tube is in place.
There was aspiration with thin and nectar thick liquids. There was no
aspiration or penetration with honey thick liquids or pudding texture.
IMPRESSION:
Aspiration with thin and nectar thick liquids.
Please note that a detailed description of dynamic swallowing as well as a
summative assessment and recommendations are reported separately in a
standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation
Services).
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, Lethargy
Diagnosed with Pneumonia, unspecified organism
temperature: 98.6
heartrate: 83.0
resprate: 20.0
o2sat: 91.0
sbp: 110.0
dbp: 45.0
level of pain: 0
level of acuity: 3.0 | ___ man, chronically ill, T1DM, multiple toe
amputations, gastroparesis & prior DKA, ESRD (likely ___ DM, no
biopsy on file) on HD, bilateral ___ DVT s/p IVC filter ___, L
non-occlusive jugular thrombus (___), R thalamic bleed in the
setting of HTN emergency w/ residual L hemiparesis (___), &
L hip fracture s/p fixation ___, who presents w/ lethargy,
found to have multifocal pneumonia, Staph bacteremia and DKA.
# PNA:
# MRSA Bacteremia:
Source of MRSA bacteremia felt to be pulmonary. CT A/P without
evidence of abscess. Of note, CT did mention concern for
possible osteomyelitis; however, ortho evaluated the patient and
did not feel that this was consistent. Central line removed
___. The patient was originally treated with vanc/zosyn. Zosyn
was d/c'ed ___, with plan to continue vancomycin for 6 week
course per ID through ___ with hemodialysis.
# T1DM:
# DKA:
Very brittle, in DKA on admission. He is very sensitive to
insulin and has had hypoglycemic episodes in the past. He was
initially treated with insulin gtt in the ICU. ___ followed
closely and made adjustments to his insulin regimen. Please see
discharge medication list for current insulin regimen. Briefly,
he will continue lantus 7 units daily in AM and insulin sliding
scale. His insulin requirement has slightly increased as he has
been cleared for PO intake along with tube feeds and may require
further adjustment.
# Afib:
Appears to be new in the ICU. Was on amiodarone drip and
eventually transitioned to Metoprolol tartrate q6hrs that is now
transitioned to Metoprolol XL (50mg BID). Coumadin was initially
held in the setting of supratherapeutic INR's, has since been
restarted.
-Rate control: HR's have been in the low 100's on long acting
Metoprolol and the dose can be titrated if felt necessary
however he is asymptomatic
-Anticoagulation: he was bridged in the setting of prior DVT and
new AFib to therapeutic INR. His home dose of warfarin is 4mg
but in the hospital he has received 5mg. Heparin IV was stopped
___ after 2 consecutive therapeutic INR's ___ - ___. INR
today (___) is 2.6.
# Hx VTE:
Complicated coagulation history. He had bilateral ___ DVT s/p IVC
filter ___, L non-occlusive jugular thrombus (___), R
thalamic bleed in the setting of HTN emergency w/ residual L
hemiparesis (___). He has been restarted on Coumadin as
above. Given multiple previous clots, decision was made to
bridge with heparin gtt until INR therapeutic. Notably he has
LLE swelling compared to the right leg; he does have an IVC
filter already and is therapeutic on anticoagulation so an
ultrasound is not likely to change management. He has received 5
days of IV heparin and is now therapeutic on Coumadin.
# Dysphagia
# Aspiration
# Severe Protein Calorie Nutrition
Patient underwent a G-J tube placement ___. After ongoing
discussions with SLP and medical team, pt decided to accept
aspiration risk trial pureed solids with nectar-thick liquids.
His current tube feeding regimen is:
Glucerna 1.5 Cal; Full strength
Tube Type: Percutaneous jejunostomy (PEJ); Placement confirmed.
Starting rate: 50 ml/hr; Do not advance rate Goal rate: 50
ml/hr
Residual Check: Not indicated for tube type
Flush w/ 30 mL water Per standard
Free water amount: 100 mL; Free water frequency: Q6H
Supplements:
Banana flakes: Mix each packet with 120 ml water & stir until
dissolved
Administer by syringe through feeding tube
Flush each packet with 30 ml water; #packets: 1; times/day: 3
-He has had some loose stool in the last 1 week that may be due
to tube feeding. Banana flakes were added ___ but not yet
initiated prior to discharge and can be added if loose stool
persists.
-Sugars have slowly trended up with initiation of PO diet along
with tube feeds, please adjust regimen if needed.
# HTN: Labetalol transitioned to Metoprolol as above. HR's have
been low 90-100s and stable, asymptomatic, in AFib. Can titrate
up on regimen further if needed.
# ESRD: HD MWF. On nephrocaps, sevalamer, low phosphorous diet.
Vancomycin dosed with dialysis (last dose ___, due ___,
dose is given based on vancomycin level per dialysis team).
# Anemia
-H&H noted to drift down slightly. No active signs of bleeding.
Iron studies suggest anemia of inflammation/chronic disease. H&H
8.___.2 at the time of discharge. Suspect also a component of
phlebotomy. Please recheck counts in the next ___ hrs to
ensure stable.
# Incidental Imaging Findings:
- CT A/P showed "Bilateral lower quadrant abdominal wall
heterogeneous fatty lesions may represent complex lipomas.
These were likely present on the CT dated ___ however
appear more conspicuous on the current study given mild diffuse
anasarca. Malignancy such as a liposarcoma is less likely.
Ultrasound and/or MRI is recommended for further evaluation if
clinically warranted."
- CXR ___ showed "Increased soft tissue density medial to the
right IJ central venous catheter may simply be projectional.
However, hematoma cannot be excluded and short interval
follow-up is recommended."
- Continue follow up of anemia/blood counts
#Dispo - discharge to rehab today
#Contact - wife ___ ___ has been updated by case
management
Time spent: 50 minutes |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
lisinopril
Attending: ___.
Chief Complaint:
Cough + Fever
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ with hx of CHF, ILD and HLD who is presenting with cough and
fever that started last night. The majority of the history is
collected from the patient's wife, ___, as the patient is very
hard of hearing and not consistently answering questions.
The patient had been in his usual state of health until
yesterday
evening. He ate his supper, went to bed, and this morning was
very fatigued. ___ said that the patient usually gets up at
some point during the night to urinate; he did not get out of
bed
to urinate last night. He felt warm to the touch this morning,
and had some visible shivering. ___ took his temperature,
noted that was 101 Fahrenheit last night; it was 100 point
something this morning. She gave him 1 pill normal, and brought
him and given that he was persistently unwell.
In the ED, initial VS were: T 37.6 C BP 142/68 HR 76 RR 16 O2
96%
on RA
Exam notable for: AAOx3. Hard of hearing. Tachycardic, rate
102,
regular rhythm. Diffuse coarse crackles bilaterally. NTND abd.
No
c/c/e.
EKG:
Compared to prior EKG dated ___.
Sinus rhythm with intermittent periods of ectopy. Borderline
QRS
with nonspecific intraventricular conduction delay. Left
ventricular hypertrophy is stable. Coving ST elevations in
leads
II and III, with T-wave inversions, are stable compared to
prior.
T-wave inversions in V4 through V6 are improved (at present
there
is mostly flattening).
Labs showed:
-White blood cell count 5.6, hemoglobin 9.1 (baseline ___,
platelets 82 (baseline 76-115)
-Creatinine 2.2 (baseline 1.7-1.9)
-Chloride 111, bicarb 21
-Flu swab A and B both negative
-VBG pH 7.4/PCO2 40, lactate 1.3
Imaging showed:
CXR PA AND LATERAL (___):
1. Multifocal interstitial opacities scattered throughout the
lung fields bilaterally have progressed since most recent prior
___ chest radiograph, suggesting sequela of chronic
interstitial lung disease versus parenchymal scarring. However
superimposed multifocal pneumonia cannot be excluded, particular
in the left lower lobe which demonstrates dense retrocardiac
opacity.
2. No pleural effusion.
Consults: None
Patient received:
-1 L normal saline
-Ceftriaxone and azithromycin
-500 mg p.o. Tylenol
Transfer VS were: T 98.5 BP 113/52 HR 73 RR 24 O2 96% on RA
On arrival to the floor, patient reports that he is having no
pain. He denies ongoing fevers, chest pain, belly pain,
dizziness. ___ additionally states that he denied nausea,
vomiting, diarrhea, dysuria prior to arrival.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
- CKD (baseline Cr 1.7)
- Hypertension
- Hyperlipidemia
- Systolic Heart Failure EF 30%
- Pancytopenia (last seen by Heme/Onc in ___ when they
suspected myelodysplasia)
Social History:
___
Family History:
There is no history of hypertension, diabetes, heart disease, or
stroke. His mother died of cervical cancer. He is not clear of
the health of siblings.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS:
T 98.9 BP 138/59 HR 80 RR 18 O2 90% on room air; improved to 96%
on 1 L nasal cannula
GENERAL: Thin elderly appearing black male, pleasant and
cooperative. Very hard of hearing. Somewhat confused, but
otherwise in no acute distress.
HEENT: Sclerae anicteric, mucous members moist.
NECK: JVP measured at 8 cm of water while sitting at 45°.
HEART: Irregularly irregular, normal S1/S2, no murmurs, gallops,
or rubs
LUNGS: Diffuse rhonchi, with expiratory wheezing best
auscultated
in the mid fields bilaterally. Bibasilar crackles.
ABDOMEN: Abdomen is soft, nondistended, nontender in all
quadrants, with no rebound/guarding.
EXTREMITIES: Warm and well perfused. No cyanosis, clubbing or
edema.
PULSES: 2+ DP pulses bilaterally
NEURO: Appears somewhat confused, but oriented to himself.
Moving all four extremities with purpose.
SKIN: No excoriations or lesions, no rashes
DISCHARGE EXAM:
VS: 24 HR Data (last updated ___ @ ___
Temp: 99.1 (Tm 100.1), BP: 147/70 (95-171/62-88), HR: 71
(54-80), RR: 16 (___), O2 sat: 97% (91-97), O2 delivery: Ra,
Wt: 141.98 lb/64.4 kg
GENERAL: Elderly gentleman, sitting up in bed, eyes narrowly
open, no acute distress
HEENT: Hearing aid in Right ear. MMM, sclera anicteric,
oropharynx clear.
NECK: JVP could not be assessed this AM
CV: Irregularly irregular rate, normal S1/S2, no m/r/g
Pulm: Diffuse, sonorous rhonchi best heard on expiration.
Breathing appears comfortable.
Extremities: WWP, no peripheral edema.
Neuro: Alert and oriented to name and place, not to date.
Able to follow commands during exam and moving all extremities.
Pertinent Results:
ADMISSION LABS:
___ 10:24AM BLOOD WBC-5.6 RBC-3.11* Hgb-9.1* Hct-29.4*
MCV-95 MCH-29.3 MCHC-31.0* RDW-14.8 RDWSD-50.8* Plt Ct-82*
___ 10:24AM BLOOD Neuts-65.5 ___ Monos-8.6 Eos-0.2*
Baso-0.2 Im ___ AbsNeut-3.66 AbsLymp-1.40 AbsMono-0.48
AbsEos-0.01* AbsBaso-0.01
___ 10:24AM BLOOD Plt Ct-82*
___ 10:24AM BLOOD Glucose-111* UreaN-37* Creat-2.2* Na-144
K-4.4 Cl-111* HCO3-21* AnGap-12
___ 10:24AM BLOOD cTropnT-0.03*
___ 10:24AM BLOOD Calcium-9.2 Phos-3.4 Mg-2.1
___ 10:26AM BLOOD ___ pO2-25* pCO2-40 pH-7.40
calTCO2-26 Base XS--1
___ 10:26AM BLOOD Lactate-1.3
TROPONINS:
___ 10:24AM BLOOD cTropnT-0.03*
___ 09:30AM BLOOD CK-MB-1 cTropnT-0.02*
MICRO:
Sputum culture ___ was contaminated.
IMAGING:
CXR: Possible mild cardiac decompensation, on a background of
mild chronic
interstitial abnormality. No good evidence for pneumonia.
DISCHARGE LABS:
___ 06:20AM BLOOD WBC-3.3* RBC-2.98* Hgb-8.7* Hct-28.1*
MCV-94 MCH-29.2 MCHC-31.0* RDW-14.7 RDWSD-50.9* Plt Ct-89*
___ 06:20AM BLOOD Glucose-104* UreaN-31* Creat-1.8* Na-147
K-4.4 Cl-114* HCO3-23 AnGap-10
___ 06:20AM BLOOD Calcium-9.2 Phos-3.0 Mg-2.1
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Simvastatin 40 mg PO QPM
2. Carvedilol 6.25 mg PO BID
3. Finasteride 5 mg PO DAILY
4. Losartan Potassium 12.5 mg PO DAILY
5. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 4 Doses
2. Cefpodoxime Proxetil 400 mg PO Q24H Duration: 3 Days
3. Docusate Sodium 100 mg PO BID
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
5. Carvedilol 6.25 mg PO BID
6. Finasteride 5 mg PO DAILY
7. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
8. Losartan Potassium 12.5 mg PO DAILY
9. Simvastatin 40 mg PO QPM
10. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Community Acquired Pneumonia
Discharge Condition:
Mental Status: Alert and oriented to name, not to place or
time. Able to follow directions, but is very hard of hearing.
Ambulatory Status: Limited. Able to sit up in chair.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with cough, fever// Eval for PNA
TECHNIQUE: Chest PA and lateral
COMPARISON: ___ chest radiograph.
FINDINGS:
Lung volumes are appreciably lower today than on any prior study, exaggerating
mild interstitial abnormality. There may be a component mild cardiac
decompensation, although the moderately large heart is only slightly increased
in size and there is no appreciable pleural effusion.
Small region of pneumonia would be difficult to detect, but there is no large
scale consolidation.
IMPRESSION:
Possible mild cardiac decompensation, on a background of mild chronic
interstitial abnormality.
No good evidence for pneumonia.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Cough, Fever
Diagnosed with Pneumonia, unspecified organism, Acute kidney failure, unspecified, Dyspnea, unspecified
temperature: 99.6
heartrate: 72.0
resprate: 20.0
o2sat: 90.0
sbp: 107.0
dbp: 52.0
level of pain: 0
level of acuity: 1.0 | Mr. ___ is a ___ year-old man with congestive heart failure (EF
30%), myelodysplastic syndrome, chronic kidney disease, and
possible interstitial lung disease presenting with subacute
onset cough + fever, found to have multifocal
consolidations on CXR and rhonchi on exam concerning for
pneumonia vs. exacerbation of chronic interstitial lung disease.
ACTIVE ISSUES
======================================
#Cough/Fever
#?Pneumonia
He presented with several days of cough with reported history of
T ___ at home, though with no recorded fevers upon
presentation. His CXR showed multifocal opacities with no lobar
consolidation that may represent progression of chronic
interstitial disease as compared to prior radiograph from ___.
However, given his age, poor lung volumes on film, and history,
we could not rule out community acquired pneumonia and he was
started on IV ceftriaxone and azithromycin. He also received
ipratropium/albuterol duonebs as needed. A sputum culture was
sent after starting antibiotics, but this was contaminated. His
oxygen requirement initially ranged from 90 - 97% on 1L NC;
later, he was 92-94% on room air. He was not symptomatic, and
was more interactive/responsive on day of discharge. He was
transitioned to PO cefpodoxime/azithro to complete a course for
CAP.
#CKD
His creatine was 2.2 on admission from baseline 1.7 - 1.9, but
eventually trended down to 1.8 on HD #2 and HD#3.
#Swallowing:
Nursing expressed concern about his aspiration risk, and speech
and language pathology evaluated patient. They recommend
continuing a thin liquid and regular solid diet, with meds
crushed in applesauce. They believed patient requires assistance
with all meals with standard aspiration precautions (sitting
upright, 1:1 assistance with meals). Patient's wife was
educated on monitoring for swallowing difficulty.
#Elevated troponins:
Troponin 0.3 on admission with EKG stable compared to prior.
Repeat troponins were stable at 0.2. We thought troponins
likely elevated in setting of possible mild demand ischemia in
the setting of infection with poor clearance of troponin in th
setting of CKD. The patient has follow up scheduled with his
cardiologist.
CHRONIC ISSUES
======================
#Hypertension: We continued his home carvedilol, and initially
held his home losartan in the setting of decreased renal
function. Losartan was restarted day of discharge.
#Atrial Fibrillation:
Patient noted to have ectopic episodes of atrial fibrillation.
His wife reports that he was on apixaban for three months prior
to an eye surgery, and taken off thereafter. He has not been
taking it at home per her report. As of the most recent note
___, apixaban was to be discussed with cardiology given the
patient's advanced age. Discussed risks/benefits of long-term
anti-coagulation with his wife. She verbalized understanding of
risk of stroke vs. bleeding with decision to anti-coagulate or
not, and wanted to speak further with outpatient cardiologist
before making decision.
# Pancytopenia:
Patient has had anemia with hemoglobin in the ___ range,
leukopenia in the range of ___, and thrombocytopenia between
___ over the past ___ years. Based on a hematology oncology
note from ___ (reporting a bone marrow biopsy from ___, this
was thought to be due to myelodysplastic syndrome. His CBC on
admission was consistent with his baseline.
#Congestive Heart Failure (EF 30%):
Reported per echocardiogram in ___. He did not complain of any
symptoms, he was euvolemic on exam, and CXR showed no signs of
pulmonary edema. We did not diurese him.
TRANSITIONAL ISSUES
===============================
[ ] Antibiotic Course: Cefpodoxime/Azithromycin for 5-day course
(___)
[ ] Consideration of anticoagulation: after initial discussion,
patient's wife would like further discussion of risks and
benefits with cardiologist given history of atrial fibrillation.
[ ] Aspiration risk: will require 1:1 observation with meals,
and medicines crushed in food per speech and swallow evaluation.
[ ] Blood cx x 2 pending at the time of discharge, will need to
be followed 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:
Ataxia, headache
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ yo RH male with
hypertension, long standing tobacco and alcohol use who presents
with acute onset severe left sided headache and ataxia. The
patient has been in his normal state of health, other than two
weeks ago when he experiences a few episodes of diplopia that
resolved over about 20 seconds. He also experienced some left
hand clumsiness at the time. Then this past ___ night,
just
over 48 hours ago he was watching football and had a few beers
and experienced a severe headache across the left side of his
head and into the back. He felt like his "head exploded". He
also
heard loud ringing in his ears. He took a couple ibuprofen and
went to bed. ___ morning he woke up and could barely walk. He
was staggering all around. He also was dry heaving and vomiting
through the morning. He walked up to the soup kitchen to visit a
friend and then went upstairs and slept for the afternoon. He
woke up and ate a little dinner and then went back to sleep. He
woke up this morning and was feeling a little bit better, but
still was having trouble walking. He ate a meatball sub and went
to the part and slept on a bench for a while. In the afternoon
he
went to the soup kitchen to visit his friend again and he
insisted that he go to the hospital. He went to ___
where he received a head CT that revealed a large left
cerebellar
stroke.
The patient was referred to ___ for further evaluation and
management. The patient now if feeling much better. He does not
endorse any weakness or changes in sensation. He no longer has a
HA and feels uncoordinated on his left side, but otherwise ok.
Review of Systems: On neuro ROS, No specific vertigo,
dizziness.
Ataxia, HA and tinnitus as above. No loss of vision, diplopia,
dysarthria, dysphagia, or hearing difficulty. Denies
difficulties
producing or comprehending speech. Denies focal weakness,
numbness, parasthesiae. No bowel incontinence. Gait problems
with
ataxia as above.
On ___ review of systems, He denies any URI sxs, rhinorrhea.
He denies recent fever or chills. No night sweats or recent
weight loss or gain. Denies shortness of breath, palpitations,
chest pain. 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
Bipolar
PTSD
Hepatitis C
Social History:
___
Family History:
Aunt had a stroke in her ___. Father either had
an MI or a intracranial hemorrhage.
Physical Exam:
PE ON ADMISSION:
Vitals: T: 98.0, HR 74, BP 119/81, RR 16, O2 96% RA
___: Awake, cooperative, in NAD.
HEENT: NC/AT, no sclera icterus noted, MMM, no lesions noted in
oropharynx. Poor dentition.
Neck: Supple. No nuchal rigidity
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no M/R/G noted.
Abdomen: soft, NT/ND
Extremities: No C/C/E bilaterally, 2+ radial, DP pulses
bilaterally.
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented to hospital, person, and date.
Attentive. Language is fluent. Speech is clear without
dysarthria. Following commands b/l appropriately. No evidence of
apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: Mild left anisicoria, 3.5 to 2.5, versus right is 3 to 2 mm,
both are reactive and brisk. VFF to confrontation. Fundoscopic
exam reveals sharp disc margins.
III, IV, VI: EOMI with a few beats of left beating nystagmus on
left gaze. No diplopia.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to voice.
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. Mild
resting tremor, no other adventitious movements. No asterixis
noted. Nml finger tapping.
Delt Bic Tri FFl FE IO IP Quad Ham TA ___
L 5 5 ___ 5 5 5 5 5 5 5
R 5 5 ___ 5 5 5 5 5 5 5
-Sensory: Intact and symmetric sensation to light touch, sharp
and temp in all ext.
- DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response was flexor b/l.
-Coordination: Marked left dysmetria on FNF and over recovery
when tapping arm on drift testing. Dysmetria on left heel to
shin, less then arm.
-Gait: Wide based with mild ataxia. Falls to left quickly on
tandem gait. No Rhomberg.
PE ON DISCHARGE:
Vitals: Afebrile, BP 140s/70s, vital sigs stable.
PERRL. No anisicoria. EOMI. No more nystagmus on left gaze. Left
dysmetria on FNF and Heel to shin slowly improving. Ataxia to
the left with slightly wide based gait but otherwise stable.
Pertinent Results:
___ 09:00AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-POS amphetmn-NEG mthdone-NEG
___ 01:30AM ALT(SGPT)-116* AST(SGOT)-129* ALK PHOS-72 TOT
BILI-0.4
___ 01:30AM CHOLEST-151
___ 01:30AM TRIGLYCER-154* HDL CHOL-39 CHOL/HDL-3.9
LDL(CALC)-81
___ 01:30AM TSH-1.6
___ 01:30AM WBC-5.6 RBC-4.96 HGB-15.6 HCT-44.9 MCV-90
MCH-31.4 MCHC-34.7 RDW-13.9
___ 01:30AM PLT COUNT-146*
___ 01:30AM ___ PTT-32.8 ___
___ 01:30AM BLOOD %HbA1c-5.6 eAG-114
___ 05:20AM BLOOD Valproate-118*
___ Outside CT with significant left sided cerebellar
infarct with
mild mass effect, but normal ventricles. Very mild tonsillar
herniation on the left.
___ MRI brain and neck
IMPRESSION: Left cerebellar acute infarction, but without
significant mass effect on the fourth ventricle.
Occlusion of the left vertebral artery from its origin to the
mid V2 segment with distal reconstitution.
Focal atherosclerotic plaque in the proximal ICA causing
apparent
mild/moderate stenosis, but this can be better quantified on the
CTA
TCD was completed ___, the report is pending at the time of
discharge.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Divalproex (DELayed Release) 1000 mg PO DAILY
2. Divalproex (DELayed Release) 500 mg PO QPM
3. Quetiapine Fumarate ___ mg PO QHS:PRN insomnia
4. Lisinopril 40 mg PO DAILY
5. Chlorthalidone 25 mg PO DAILY
Discharge Medications:
1. Divalproex (DELayed Release) 1000 mg PO DAILY
2. Divalproex (DELayed Release) 500 mg PO QPM
3. Lisinopril 40 mg PO DAILY
4. Aspirin EC 325 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*1
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. melatonin *NF* 5 mg Oral QHS:PRN insomnia
7. Simvastatin 20 mg PO DAILY
RX *simvastatin 20 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
8. Tiotropium Bromide 1 CAP IH DAILY
9. Chlorthalidone 25 mg PO DAILY
10. Quetiapine Fumarate ___ mg PO QHS:PRN insomnia
11. Clopidogrel 75 mg PO DAILY
RX *clopidogrel 75 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*1
12. Albuterol Inhaler 2 PUFF IH Q6H:PRN wheeze
Discharge Disposition:
Home
Discharge Diagnosis:
Left cerebellar stroke.
Left vertebral artery occlusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
TECHNIQUE: MRI of the brain without gad, MRA of the brain using 3D
time-of-flight. MRA of the neck using 3D gad.
HISTORY: Ataxia and left dysmetria with cerebellar stroke.
COMPARISON: CT head from ___.
FINDINGS: There is a large area of acute ischemia in the left superior vermis
and superior cerebellar hemisphere, extending laterally and inferiorly. There
is mild mass effect on the fourth ventricle. No hydrocephalus is noted.
Possible tiny subacute infarct in the left thalamus is seen. Questionable
tiny subacute infarct in the right cerebellum may be present. No large
hemorrhagic transformation has occurred on the gradient echo images. MRA of
the Circle of ___ demonstrates patency of the anterior circulation. The
right distal vertebral artery appears to terminate in the ___. The distal
vertebral arteries are patent bilaterally. The left proximal vertebral artery
is occluded from its origin with recanalization in its midcervical V2 portion
and likely from collaterals. The right vertebral artery is hypoplastic.
Bilateral carotid arteries are patent, but there is a focal atherosclerotic
plaque in the proximal ICA causing apparent mild/moderate stenosis, but this
can be better quantified on the CTA. No intracranial aneurysm is noted within
limits of this examination.
IMPRESSION:
Left cerebellar acute infarction, but without significant mass effect on the
fourth ventricle.
Occlusion of the left vertebral artery from its origin to the mid V2 segment
with distal reconstitution.
Focal atherosclerotic plaque in the proximal ICA causing apparent
mild/moderate stenosis, but this can be better quantified on the CTA
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ATAXIA
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT
temperature: 97.8
heartrate: 80.0
resprate: 16.0
o2sat: 98.0
sbp: 114.0
dbp: 81.0
level of pain: 0
level of acuity: 2.0 | Neurologic: Was admitted to Neuro-ICU/Stroke service, Attg, Dr.
___. MRI/MRA brain showed occluded left vertebral artery.
Lipid panel showed mildly elevated TGs, otherwise WNL. HBA1C
WNL. Started ASA on ___. He was transferred to the floor
stroke service later in the day on ___. His headache
resolved and his symptoms slowly improved with respect to his
ataxia and dysmetria. We did not start coumadin given his
current social situation (living in shelter, difficulty getting
to blood draws) and also it's potential interaction with
depakote, so we opted for 3 months of plavix with continued low
dose aspirin. We also started a statin prior to discharge.
Cardiovascular: We allowed BP to autoregulate with goal SBP <
180. TTE w/bubble study was ordered but patient refused to wait
for this study as we could not give him a specific time it could
be done by, so instead of allowing him to leave AMA we
officially discharged him with plans to obtain an echocardiogram
with bubble study as an outpatient. He voiced understanding of
this plan upon discharge and stated he would try to see his PMD
one day after discharge to discuss this. We left a message with
the office of Dr. ___ at ___ about our
recommendations for an outpatient echo with bubble study ASAP.
Resp: We continued home COPD med regimen without changes. His
respiratory status was stable on room air throughout the
hospitalization.
FEN/GI: Bedside swallow study completed while in the ICU and he
was allowed to eat prior to transfer to the floor. Continued to
PO well throughout stay on floor. Colace X1 for constipation.
Chemistry labs stable.
Psych: We continued Depakote ___ mg for bipolar disorder.
Depakote level was stable. Melatonin was given for insomnia. He
did not appear to be at risk for withdrawing and did not require
CIWA scoring. We wrote for a nicotine patch but he refused
this. We do not recommend he start chantix for smoking cessation
due to his risk for further strokes.
Prophylaxis: He recieved DVT boots and subcutaenous heparin
while not ambulating. ___ and OT were consulted and cleared him
for discharge home.
AHA/ASA Core Measures for Ischemic Stroke and Transient Ischemic
Attack
1. Dysphagia screening before any PO intake? () Yes, confirmed
done - (x) 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 = 81) - () 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? (x) Yes - () No [reason
() non-smoker - () unable to participate]
7. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given (verbally or
written)? (x) Yes - () No
8. Assessment for rehabilitation or rehab services considered?
(x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No [if LDL >100,
reason not given: ]
10. Discharged on antithrombotic therapy? (x) Yes [Type: (x)
Antiplatelet - () Anticoagulation] - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fevers, left proximal leg pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ male with a remote history left leg length
discrepancy status post LeFort I osteotomy, bone transport at
the
age of ___, who is now recently status post left tibial osteotomy
with intramedullary nailing on ___ by Dr. ___
___
valgus deformity correction and more recently status post left
Achilles tendon lengthening, fifth metatarsal phalangeal joint
capsular release, EDL tenotomy, and pinning of the left fifth
hammertoe by Dr. ___ presents with 48 hours of fevers and
chills. He was seen in clinic yesterday where the fifth
metatarsal phalangeal pin was pulled. Radiographs showed no
evidence of hardware failure or loosening. He was discharged
home with return precautions. However he continued to have
fevers to as high as 101.4. Thus he presents for evaluation.
He
denies any erythema or drainage at the incisions, any cough,
urinary symptoms, abdominal pain, back pain. He states that he
has new increased focal pain at 1 of the proximal incision
sites.
He otherwise feels okay.
Past Medical History:
Above procedures
Otherwise healthy
Social History:
___
Family History:
Noncontributory
Physical Exam:
Left lower extremity exam
-Prior surgical incisions well-healed without evidence of
surrounding erythema or drainage
-fires ___
-silt s/s/sp/dp/t nerve distributions
-foot WWP
Pertinent Results:
___ 05:42AM BLOOD WBC-9.6 RBC-4.48* Hgb-13.5* Hct-41.6
MCV-93 MCH-30.1 MCHC-32.5 RDW-12.3 RDWSD-42.2 Plt ___
Medications on Admission:
2. Finasteride 5 mg PO DAILY
3. Simvastatin 20 mg PO QPM
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
Reason for PRN duplicate override: Alternating agents for
similar severity
Discharge Disposition:
Home
Discharge Diagnosis:
fevers that resolved
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 fever// r/o PNA
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Silhouetting of the right cardiac border secondary to a small pectus
deformity.
Lungs are clear.
IMPRESSION:
No pneumonia.
Radiology Report
EXAMINATION: CT LEFT TIBIA/FIBULA, NO IV CONTRAST
INDICATION: ___ year old man with prior tibial osteotomy, ___ metatarsal
pinning. now with fevers/leukocytosis c/f infection// please obtain from knee
to foot. rule out periprosthetic infection. please protocol with metal
reduction sequence given presence of hardward
TECHNIQUE: Contiguous axial images were obtained of the left lower extremity
after the administration of intravenous contrast. Additional images were
created and MSK reformats, as well as in the coronal and sagittal planes with
metal reduction artifact and sent to PACs for review.
DOSE: Acquisition sequence:
1) Spiral Acquisition 8.1 s, 63.4 cm; CTDIvol = 17.0 mGy (Body) DLP =
1,077.2 mGy-cm.
Total DLP (Body) = 1,077 mGy-cm.
COMPARISON: Prior tibiofibular radiograph ___,
right foot ___
FINDINGS:
We note the patient is post tibial osteotomy, for valgus deformity correction.
There remain postsurgical changes within ___ fat and over the osteotomy
site, with a retrograde IM nail and interlocking screws.
Within the proximal third of the tibia the osteotomy largely persists. Within
the distal third of the shaft (image 52, series 400) there is a linear
lucency, arguably present previously, favored represent nutrient or prior
screw tract, and unlikely healing fracture or osteotomy site. There is
chronic diffuse tibial cortical thickening irregularity/osteitis, overall
unchanged.
We suspect there has been prior distal fibular resection/osteotomy, with
synchondrosis across the distal tibiofibular syndesmosis.
There is osseous fusion of the base of the fourth and fifth metatarsals, with
fifth metatarsal osteotomy, fixated by a fusion plate and screws, with a small
percutaneous pin tract through the head of the fifth metatarsal, K-wire
recently removed.
There is some soft tissue stranding surrounding the fifth toe, lateral aspect
of the foot approaching ankle with additional soft tissue stranding in the
heel and within the fat pad of the midfoot (series 3, image 22).
No suspicious periprosthetic lucency suspicious for hardware infection, soft
tissue emphysema or drainable Fluid collections. No definite ulceration.
Mild OA of the knee, degenerative changes include subchondral and subcortical
cystic cysts and sclerosis throughout the midfoot.
IMPRESSION:
1. No perihardware lucencies suspicious for hardware infection. No osseous
findings suspicious for osteomyelitis. No drainable fluid collections.
2. Nonspecific soft tissue edema over the fifth toe and Left foot, may relate
to recent hardware removal, but overlying infection/cellulitis should be
clinically excluded.
Radiology Report
EXAMINATION: ?osteo
INDICATION: ___ year old man with leg pain// ?osteo
TECHNIQUE: Axial and coronal T1 and T2 weighted images of left calf were
obtained before and after intravenous contrast administration.
COMPARISON: CT left calf without contrast ___, left tibia-fibula
radiographs ___
FINDINGS:
Patient is status post fracture fixation of mid tibial diaphysis with
intramedullary rod and 2 proximal and 1 distal screws. There is no evidence
of marrow replacing process suspicious of osteomyelitis. Mild muscle edema is
demonstrated surrounding the proximal tibial metadiaphysis, at the level of
second most proximal screw as well as surrounding the distal tibial
metadiaphysis.
Mild enhancement of lateral femoral diaphyseal cortical intramedullary bone is
demonstrated at the fracture, likely reactive. Periosteal reaction is present
along the entire length of the tibial metadiaphysis.
Ununited bony gap measuring 1.5 cm is again demonstrated in the distal fibular
diaphysis. No suspicious bone or soft tissue lesion is identified. There is
no fluid collection.
IMPRESSION:
Mild muscle edema is demonstrated surrounding the proximal and distal tibial
metadiaphysis. Mild enhancement of the cortical intramedullary bone is
identified at the lateral femoral diaphysis fracture. The finding may reflect
reactive changes, however osteomyelitis is difficult to exclude. If
clinically indicated, white blood cell nuclear medicine study may be helpful
for further evaluation.
RECOMMENDATION(S): If clinically indicated, white blood cell nuclear medicine
study may be helpful for further evaluation.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 10:56 am, 15 minutes after discovery
of the findings.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with Fever, unspecified
temperature: 99.1
heartrate: 70.0
resprate: 18.0
o2sat: 99.0
sbp: 133.0
dbp: 82.0
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 fevers and an elevated WBC to 15 and was admitted to the
orthopedic surgery service. The patient was given 48 hours of
vancomycin. An MRI and x-rays showed hardware intact without
evidence of osteomyelitis. His WBC resolved to 9 on ___ and he
was afebrile during his admission. He felt well on day of
discharge. It was determined that he would be discharged home
and return if his fevers persisted.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
WBAT LLE. The patient will follow up with Drs ___
per 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:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Endoscopic Ultrasound
History of Present Illness:
___ PMH pituitary macroadenoma, HCV, fibromyalgia, osteopenia,
COPD, PE with recent admission for gallstone pancreatitis s/p
sphincterotomy on ___ who presents with epigastric abdominal
pain and nausea since 11am. Stated that she was discharged with
minimal pain and and no nausea. She then states her pain began
suddently and is constant but does change in intensity. Located
primarily on the left side, is the same as previous pain for
which she was admitted. Has nausea but no vomiting. Could not
take POs. Did have hard stools this AM. No fevers/chills.
In the ED, initial vitals were: 97 67 137/73 18 100% RA
- Labs were significant for unremarkable CBC except for mild
thrombocytosis, mildly elevated alk phos. Normal chem7, INR, UA
- Imaging revealed stable extrahepatic biliary ductal dilation
with no evidence of intrahepatic biliary ductal dilatation and
no evidence of cholelithiasis or acute cholecystitis.
- The patient was given multiple dose of zofran, morphine,
normal lactate and 2L IVF
GI consulted and initially said admit for MRCP. Then decided
that would like to do EUS on ___ AM.
Upon arrival to the floor, patient lying on side due to
abdominal pain.
Past Medical History:
- pituitary macroadenoma (followed by Dr. ___
- HCV (genotype 1a) on Harvoni (followed by ___
- fibromyalgia,
- osteopenia,
- COPD,
- hypercalcemia
- Vitamin D deficiency
- pulmonary embolism on coumadin
PAST SURGICAL HISTORY:
- TAH-BSO (___),
- R knee replacement (___)
Social History:
___
Family History:
Father--DM, EtOH (dead).
Mom-recent CVA.
Uncle recently died from Alzheimers
Physical Exam:
ADMISSION:
Vitals: 98.6 131/77 54 18 94%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft,diffuse tendernes with voluntary 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:
Vitals: 98.6 113/56 63 18 95% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: RRR, no m/r/g
Lungs: CTA b/l
Abdomen: Soft, diffuse tenderness with voluntary guarding,
tenderness most appreciated in epigastric area , normal bowel
sounds
GU: No foley
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: alert and conversant,able to move all extremities
Pertinent Results:
ADMISSION:
___ 07:58PM NEUTS-63.6 ___ MONOS-7.9 EOS-0.6*
BASOS-0.8 IM ___ AbsNeut-6.08 AbsLymp-2.56 AbsMono-0.76
AbsEos-0.06 AbsBaso-0.08
___ 07:58PM WBC-9.6 RBC-3.74* HGB-11.4 HCT-34.2 MCV-91
MCH-30.5 MCHC-33.3 RDW-14.7 RDWSD-49.5*
___ 07:58PM ALBUMIN-4.2 CALCIUM-10.5* PHOSPHATE-3.5
MAGNESIUM-1.9
___ 07:58PM LIPASE-15
___ 07:58PM ALT(SGPT)-21 AST(SGOT)-30 ALK PHOS-169* TOT
BILI-0.5
___ 07:58PM GLUCOSE-101* UREA N-19 CREAT-0.7 SODIUM-139
POTASSIUM-4.3 CHLORIDE-101 TOTAL CO2-25 ANION GAP-17
___ 08:17PM ___ PTT-36.2 ___
___ 08:58PM LACTATE-1.1
DISCHARGE:
___ 06:50AM BLOOD WBC-11.0* RBC-3.17* Hgb-9.8* Hct-30.2*
MCV-95 MCH-30.9 MCHC-32.5 RDW-14.7 RDWSD-51.6* Plt ___
___ 06:50AM BLOOD Glucose-85 UreaN-19 Creat-0.6 Na-140
K-4.4 Cl-101 HCO3-34* AnGap-9
___ 06:50AM BLOOD Calcium-9.4 Phos-3.0 Mg-1.9
Imaging/Other results:
___: RUQ US
1. Similar extrahepatic biliary ductal dilation as compared to
the prior
examinations dated ___. Previously noted
intrahepatic biliary
ductal dilatation has resolved.
2. Gallbladder sludge without cholelithiasis or acute
cholecystitis.
___:
Report not finalized.
Logged in only.
PATHOLOGY # ___
AMPULLA OF VATER, BIOPSY
Microbiology:
none
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. cabergoline 1 mg oral 2X/WEEK
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
3. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
4. Ledipasvir/Sofosbuvir 1 TAB PO DAILY
5. OxyCODONE SR (OxyconTIN) 20 mg PO Q8H
6. Pregabalin 150 mg PO TID
7. 1 mg Other 2X/WEEK
8. ALPRAZolam 0.5 mg PO ONCE MR1 prior to MRI
9. Furosemide 20 mg PO DAILY:PRN leg swelling
10. melatonin 3 mg oral QHS
11. oxyCODONE-acetaminophen 7.5-500 mg oral TID
12. Warfarin 2.5 mg PO DAILY16
13. Enoxaparin Sodium 70 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
Discharge Medications:
1. cabergoline 1 mg oral 2X/WEEK
2. Enoxaparin Sodium 60 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 60 mg/0.6 mL 60 mg SC every twelve (12) hours
Disp #*10 Syringe Refills:*0
3. Fluticasone Propionate NASAL 2 SPRY NU DAILY
4. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
5. Ledipasvir/Sofosbuvir 1 TAB PO DAILY
6. OxyCODONE SR (OxyconTIN) 20 mg PO Q8H
7. Pregabalin 150 mg PO TID
8. Warfarin 5 mg PO DAILY16
RX *warfarin [Coumadin] 5 mg 1 tablet(s) by mouth daily Disp
#*14 Tablet Refills:*0
9. Famotidine 20 mg PO Q12H
RX *famotidine [Acid Controller] 20 mg 1 tablet(s) by mouth
every twelve (12) hours Disp #*30 Tablet Refills:*0
10. 1 mg Other 2X/WEEK
11. Furosemide 20 mg PO DAILY:PRN leg swelling
12. melatonin 3 mg oral QHS
13. oxyCODONE-acetaminophen 7.5-500 mg ORAL TID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Abdominal pain
SECONDARY DIAGNOSIS:
Recent Gallstone Pancreatitis
Recent pulmonary embolism
Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with recent admission for gallstone pancreatitis with
sphincterotomy on ___, presents with epigastric abdominal pain and nausea
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen and pelvis and abdominal ultrasound dated ___.
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: Previously seen intrahepatic biliary dilation has resolved. The
CBD remains dilated, measuring up to 15 mm, similar to that on the previous
ultrasound. The distal common bile duct is not well imaged.
GALLBLADDER: The gallbladder is not distended. Small amount of gallbladder
sludge is seen without stones, pericholecystic fluid, or gallbladder wall
thickening.
PANCREAS: Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with portions of the pancreatic tail
obscured by overlying bowel gas.
IMPRESSION:
1. Similar extrahepatic biliary ductal dilation as compared to the prior
examinations dated ___. Previously noted intrahepatic biliary
ductal dilatation has resolved.
2. Gallbladder sludge without cholelithiasis or acute cholecystitis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Nausea
Diagnosed with Right upper quadrant pain
temperature: 97.0
heartrate: 67.0
resprate: 18.0
o2sat: 100.0
sbp: 137.0
dbp: 73.0
level of pain: 9
level of acuity: 3.0 | ___ PMH pituitary macroadenoma, HCV, PE who presented with
recent abdominal pain consistent with gallstone pancreatitis s/p
sphincterotomy now representing with abdominal pain.
# Abdominal pain: Patient presented with worsening abdominal
pain. She had an EUS that showed Slightly dilated (4mm) but
otherwise normal pancreatic duct. Dilated (12mm) but otherwise
normal common bile duct. The dilation extended to the level of
the ampulla. No cause for the dilation could be identified. Her
diet was advanced and she was discharged home.
# HCV (genotype 1a) on Harvoni - continued Harvoni
# Recent Pulmonary Embolism: Patient with PE diagnosed in
___. She is currently on Lovenox as a bridge to
warfarin. INR on discharge was 1.
# Pituitary macroadenoma: continued cabergoline 1 mg oral
2X/WEEK
# Fibromyalgia: continue home meds
# COPD: continued Fluticasone-Salmeterol Diskus (100/50) 1 INH
IH BID
# Depression: Held citalopram due to prior concern for erratic
behavior
========================= |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENTING ILLNESS: ___ hx CAD s/p CABG and POBA,
HTN, HLP who presents from home with chest pain and hypertension
to the 180s. She was recently admitted in early ___ for
sepsis and pyelonephritis c/b NSTEMI; she was supposed to have a
stress test as an outpatient but never followed up. Today she
describes waking up with a headache and took her BP which was
~180; she normally is 120s during the day. She then notes onset
of exertional chest pain radiating up the neck a/w dyspnea and
diaphoresis that relieved with rest throughout the day. She
took a NTG once, and afterwards felt dizzy and lightheaded; her
BP at that time was ~80/40, so she sought ED evaluation.
In the ED, initial vitals were 64 116/58 20 97%. EKG was
unchanged from baseline. Trops were negative. She was admitted
for a stress test.
Cardiac review of systems is notable for absence of chest pain
currently, dyspnea on exertion currently, paroxysmal nocturnal
dyspnea, orthopnea, ankle edema, palpitations, syncope or
presyncope.
Past Medical History:
1. CARDIAC RISK FACTORS: -Diabetes, +Dyslipidemia, +Hypertension
2. CARDIAC HISTORY: +CAD
-CABG:LIMA to LAD, SVG to D1, LPL, and R-PDA
-PERCUTANEOUS CORONARY INTERVENTIONS: POBA ___ at ___
-PACING/ICD: -
3. OTHER PAST MEDICAL HISTORY:
-CAD: s/p CABG and multiple PCI
-PAD
-HTN
-HL
-OA
-depression
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 97.8 154/86 67 20 97%RA
General: NAD
HEENT: PERRL
Neck: flat neck veins
CV: RRR, ___ SEM throughout, -rg
Lungs: CTAB -wrr
Abdomen: +BS soft NTND
Ext: -c/c/e
Neuro: grossly intact
DISCHARGE PHYSICAL EXAMINATION:
VS: 98.4 144/72 71 20 96%RA
General: NAD
HEENT: PERRL
Neck: flat neck veins
CV: RRR, ___ SEM throughout, -rg
Lungs: CTAB -wrr
Abdomen: +BS soft NTND
Ext: -c/c/e
Neuro: grossly intact
Pertinent Results:
___ 12:20PM BLOOD WBC-5.4# RBC-3.69* Hgb-11.3* Hct-32.6*
MCV-88 MCH-30.7 MCHC-34.8 RDW-15.0 Plt ___
___ 05:56AM BLOOD WBC-5.1 RBC-3.56* Hgb-11.3* Hct-31.8*
MCV-89 MCH-31.6 MCHC-35.4* RDW-14.8 Plt ___
___ 12:20PM BLOOD Neuts-52.5 ___ Monos-9.0 Eos-5.0*
Baso-1.4
___ 12:20PM BLOOD ___ PTT-25.8 ___
___ 12:20PM BLOOD Glucose-88 UreaN-19 Creat-1.1 Na-142
K-3.8 Cl-106 HCO3-22 AnGap-18
___ 05:56AM BLOOD UreaN-20 Creat-1.0 Na-142 K-4.2 Cl-105
HCO3-27 AnGap-14
___ 05:56AM BLOOD CK(CPK)-88
___ 12:20PM BLOOD cTropnT-<0.01
___ 05:56AM BLOOD CK-MB-3 cTropnT-<0.01
___ 12:48PM BLOOD Lactate-2.6*
Nuclear Stress:
EXERCISE RESULTS
RESTING DATA
EKG: SINUS ___, IC RBBB
HEART RATE: 54 BLOOD PRESSURE: 150/74
PROTOCOL GERVINO - TREADMILL /
STAGE TIME SPEED ELEVATION HEART BLOOD RPP
(MIN) (MPH) (%) RATE PRESSURE
1 ___ 1.0 5 82 150/60 ___
2 ___ 1.6 6 85 164/50 ___
TOTAL EXERCISE TIME: 5 % MAX HRT RATE ACHIEVED: 59
SYMPTOMS: NONE
ST DEPRESSION: NONE
INTERPRETATION: ___ yo woman with HTN, HL and DM, s/p CABG and
POBA
and h/o mild AS and CHF with recent admission in ___ for
sepsis
and pyelonephritis c/b NSEMI was referred for evaluation of her
chest
pain and shortness of breath. The patient completed 5 minutes of
a
Gervino protocol representing a poor exercise tolerance; ~ 3.2
METS. The
exercise test was stopped due to progressive and marked
shortness of
breath noted at peak exercise. No chest, back, neck or arm
discomforts
were reported. No significant ST segment changes were noted. The
rhythm
was sinus with rare isolated APBs noted. Resting systolic
hypertension
with a blunted systolic blood pressure response to exercise. To
note, an
exaggerated blood pressure response was noted post-exercise; 3
min
post-ex ___ mmHg, 5 min post-ex ___ mmHg. In the presence
of beta
blocker therapy the peak exercise heart rate was limited.
IMPRESSION: Poor exercise tolerance limited by exertional
dyspnea. No
anginal symptoms or ischemic ST segment changes. Blunted
hemodynamic
response to exercise with exaggerated systolic and diastolic
blood
pressure response noted post-exercise (see above). Nuclear
report sent
separately.
RADIOPHARMACEUTICAL DATA:
10.2 mCi Tc-99m Sestamibi Rest ___
32.2 mCi Tc-99m Sestamibi Stress ___
HISTORY: HTN, HL and DM s/p CABG and POBA also with h/o mild AS
and CHF referred
for evaluation of chest pain and dyspnea.
SUMMARY OF DATA FROM THE EXERCISE LAB:
Exercise protocol: Gervino
Exercise duration: 5 min
Reason exercise terminated: Progressive marked dyspnea
Resting heart rate: 54
Resting blood pressure: 150/74
Peak heart rate: 85
Peak blood pressure: 164/50
Percent maximum predicted HR: 59%
Symptoms during exercise: None
ECG findings: None
METHOD:
Resting perfusion images were obtained with Tc-99m sestamibi.
Tracer was
injected approximately 45 minutes prior to obtaining the resting
images.
At peak exercise, approximately three times the resting dose of
Tc-99m sestamibi was administered IV. Stress images were
obtained approximately 45 minutes following tracer injection.
Imaging Protocol: Gated SPECT
This study was interpreted using the 17-segment myocardial
perfusion model.
INTERPRETATION:
Left ventricular cavity size is normal.
Resting and stress perfusion images reveal uniform tracer uptake
throughout the
left ventricular myocardium.
Gated images reveal normal wall motion.
The calculated left ventricular ejection fraction is 67%.
No prior nuclear medicine stress tests are available for
comparison.
IMPRESSION: 1. No myocardial perfusion defect. 2. Normal LV
size and
function.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Clopidogrel 75 mg PO DAILY
3. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
4. Losartan Potassium 100 mg PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Sertraline 50 mg PO DAILY
7. Simvastatin 40 mg PO DAILY
8. Glycopyrrolate 2 mg PO TID:PRN gas bloating
9. cilostazol *NF* 100 mg ORAL BID
10. Labetalol 400 mg PO BID
11. Furosemide 20 mg PO DAILY
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. cilostazol *NF* 100 mg ORAL BID
3. Clopidogrel 75 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Labetalol 400 mg PO BID
6. Losartan Potassium 100 mg PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. Sertraline 50 mg PO DAILY
9. Simvastatin 40 mg PO DAILY
10. Glycopyrrolate 2 mg PO TID:PRN gas bloating
Discharge Disposition:
Home
Discharge Diagnosis:
Atypical chest pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Chest pain.
COMPARISONS: Chest radiograph from ___.
TECHNIQUE: PA and lateral views of the chest were obtained with a total of
three exposures.
FINDINGS: The previously identified left basilar atelectasis has almost
completely resolved. Minimal linear opacification persists. There is no
focal airspace consolidation, pulmonary edema, pleural effusion, or
pneumothorax. The cardiomediastinal silhouette is unchanged. The heart size
remains mildly enlarged. Sternal wires are intact.
IMPRESSION: No acute cardiopulmonary process.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: CHEST PAIN
Diagnosed with CHEST PAIN NOS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | ___ hx CAD s/p CABG and POBA, HTN, HLP and recent admission for
NSTEMI in setting of pyelonephritis with sepsis who presents
from home with exertional angina and labile blood pressures
after not following up for a stress test.
#CAD/angina: sx sound anginal although pt with sx overnight and
trops continue to be flat. No concern for UA/NSTEMI at this
time. However she did suffer NSTEMI 1 mo prior and did not f/u
for outpt stress testing; she has known 3VD s/p CABG. Admitted
for nuclear stress imaging over the weekend. During the
weekend, had occ episodes of her described CP; enzymes flat
throughout. Nuclear stress showed no reversible ischemia and
normal LVEF, however her RPP was ___ and she demonstrated
delayed exaggerated BP response to exercise after cessation (no
BP rise during stress). Due to these findings, it was felt that
her nitrates were exacerbating her preload dependent diastolic
dysfunction and as well not helping her symptoms (which were
probably not anginal), so nitrates were discontinued at
discharge with consideration of CCB if BP not controlled. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Erythema of leg and fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ male presents with left leg/knee pain, swelling, and fevers
s/p left knee ACI and TTO on ___. Patient had above procedure
at ___ in ___ with Dr. ___
___ and ___ home the same day with instructions to be ___
LLE and CPM ___. Since surgery ___ has had difficulty with pain
control and noticed drainage from the incisions starting POD2.
On POD 2 ___ also developed subjective fevers. On POD3 hetook
his temp and it was 102 so ___ went to an OSH before being
transferred to ___. Febrile to 102 at OSH. Denies LLE
paresthesias. Started on vanco at the OSH.
Past Medical History:
Unremarkable
Social History:
SUBSTANCE ABUSE HISTORY (INCLUDE HISTORY OF D.T.'S, WITHDRAWAL
SEIZURES, BLACKOUTS, DETOX TREATMENT, I.V. USAGE):
alcohol: hx of abuse, denies blackouts or seizures
drugs: hx of abusing oxycontin and percocet, and has
"experimented with pot" denies IVDA
tob:denies
caffeine:"occ"
SOCIAL HISTORY (FAMILY OF ORIGIN, CHILDHOOD, PHYSICAL/SEXUAL
ABUSE HISTORY, EDUCATION, EMPLOYMENT, RELATIONSHIPS, SEXUAL
HISTORY/STD RISKS, MILITARY RECORD, LEGAL HISTORY, ETC.):
The patient was ___ and ___ in ___ and ___., and
is the ___ of 4 brothers ages ___ and ___. ___ reported that his
parents were separatd when ___ was ___ and that ___ lived with his
father. His mother said that this not true that she and her
husband are still together despite marital problems. ___ is
currently in his ___ year @ ___ majoring in criminal
justice and is on co-op and now working 2 jobs. One as a ___
on the weekends and a ___ during the week along with 2
football practices a day. ___ currently lives in ___ with a
friend and his friend's mother and pays rent.
Family History:
NC
Physical Exam:
NAD
LLE:
Erythema receded in leg, however still with significant swelling
and erythema around the site of incision
Multiple blisters to medial and lateral knee
Tender around incision
SILT DPN/SPN
Fires ___
2+ DP pulse
Medications on Admission:
Tylenol, Dilaudid, Xarelto
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. CeFAZolin 2 g IV Q8H
3. Docusate Sodium 100 mg PO BID
4. Vancomycin 1000 mg IV Q 8H LLE cellulitis
5. Rivaroxaban 10 mg PO BID Duration: 12 Days
Discharge Disposition:
Extended Care
Discharge Diagnosis:
___ cellulitis
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: KNEE (AP, LAT AND OBLIQUE) LEFT
INDICATION: ___ with left knee surgery s/p repair w/ redness, swelling,
fever, pain// eval for DVT, subcu gas
TECHNIQUE: Three views of the left knee.
COMPARISON: None
FINDINGS:
There are 2 threaded screws traversing a proximal tibial fracture without
adjacent callus formation. Alignment is near anatomic. Prepatellar soft
tissue swelling and gas reflects recent surgery. Gas seen superior and
inferior to the patella also reflects postop status. In the correct clinical
setting, postop infection cannot be excluded. There is no acute fracture. No
unexpected radiopaque foreign body in the soft tissues. Anterior skin staples
are present.
IMPRESSION:
Postop tibial fixation with prepatellar soft tissue swelling and soft tissue
gas may reflect postop status, difficult to exclude superimposed infection.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ with left knee surgery s/p repair w/ redness, swelling,
fever, pain// eval for DVT, subcu gas
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the left common
femoral, femoral, and popliteal veins. Normal color flow is demonstrated in
the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
There is significant subcutaneous edema in the left lower extremity.
IMPRESSION:
1. No evidence of deep venous thrombosis in the left lower extremity veins.
2. Significant subcutaneous edema without discrete fluid collection.
Radiology Report
INDICATION: History: ___ with fever// ? Pneumonia
TECHNIQUE: AP upright and lateral chest radiographs
COMPARISON: None
FINDINGS:
The lungs are clear. Heart size and mediastinal contours are normal. No
pleural effusion or pneumothorax. The osseous structures are intact.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ year old man with chest pain// ?pneumothorax or pneumonia
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
There is no focal consolidation, pleural effusion or pneumothorax identified.
The size of the cardiac silhouette is within normal limits.
IMPRESSION:
No acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, L Leg swelling, Transfer
Diagnosed with Infection following a procedure, initial encounter, Oth surgical procedures cause abn react/compl, w/o misadvnt, Oth places as the place of occurrence of the external cause
temperature: 102.8
heartrate: 101.0
resprate: 18.0
o2sat: 100.0
sbp: 147.0
dbp: 80.0
level of pain: 10
level of acuity: 3.0 | Patient was admitted to the orthopaedic service for treatment of
post surgical cellulitis. ___ was initially treated with
vancomycin monotherapy and then subsequently Ancef was added for
better strep and MSSA coverage. ___ did have recession of his
erythema on his leg, but continued to have significant swelling
and erythema around the site of the incision with exquisite pain
and inability to ambulate. During this time, we were in contact
with Dr. ___ at the ___ and plan
to transfer him back to Dr. ___.
___ did work with physical therapy. His DVT ppx was continued per
prior instructions. ___ did have a lower extremity ultrasound
that was negative for DVT. His hospitalization was otherwise
unremarkable. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fevers
Major Surgical or Invasive Procedure:
___ Drainage and Drain Placement of Right Thigh
Hematoma/Abscess
History of Present Illness:
Mr. ___ is a ___ y/o M with MDS/Leukemia, not
currently on treatment, who presented to ___ w/2 weeks
intermittent fevers to 102. No cough, shortness of breath or
chest pain, no abdominal pain, nausea, vomiting, diarrhea,
urinary symptoms. He noticed right leg swelling and right thigh
pain without any precursor trauma. He was seen at urgent care on
___ where CXR negative, RLE US negative for DVT. ___ the ED,
orthopedics and surgery were consulted after a hematoma was
discovered. They noted that patient should have ___ drainage.
___ the ED, initial vitals were:
100.5 77 131/59 18 98% RA
- Exam notable for: right leg swollen
- Labs notable for:
132 92 22 AGap=19
------------< 126
3.7 25 1.0
8.5 <8.5/28.7> 157
- Imaging was notable for:
CT RLE:
1. 2.8 x 2.9 x 7.7 cm heterogeneous rim enhancing collection
within the right rectus femoris muscle concerning for abscess.
2. Myofascitis involving the anterior and medial compartments
of the right thigh. Diffuse subcutaneous soft tissue edema.
3. Osseous structures are intact.
4. Prominent right pelvic sidewall and inguinal lymph nodes,
possibly reactive.
- Patient was given:
___ 01:19 IV Piperacillin-Tazobactam 4.5 g
___ 03:15 IV Vancomycin 1 mg ___
Upon arrival to the floor, patient reports
right thigh pain and chills, otherwise no SOB, chest pain,
abdominal pain.
Past Medical History:
Cancer of the oral cavity ___ (T1N0 moderately differentiated
focal papillary adenocarcinoma involving the anterior floor of
the mouth). s/p surgical resection with radical neck dissection
and submental myocutaneous flap, followed by XRT completed
___.
Oral motor dysfunction (late symptoms of fibrosis of the chin
and
jaw )
Keratosis, seborrheic
Dermatitis, seborrheic
Nevus, atypical
Past history of obesity
Hepatic cyst
Radiation fibrosis
Psoriasis
Pulmonary nodules
Former pipe smoker
Basal cell carcinoma face
Colon polyp
Essential hypertension
Hypothyroidism
Hypokalemia
Hypercholesterolemia
Myelodysplastic syndrome/leukemia w/trisomy 8 ___ cells
Compression fracture of vertebral column with routine healing
Social History:
___
Family History:
Mother, diagnosed ovarian cancer at age ___
Maternal grandmother, deceased ___ unknown cause
Female cousin, maternal - deceased age ___ cancer unknown type
Brother deceased age ___, prostate cancer
Brother ___ years old living healthy lives ___ ___
No other siblings
Physical Exam:
ADMISSION EXAM
====================
100.0 114/58 74 18 95 RA
GENERAL: Lying ___ bed, NAD.
HEENT: EOMI, oropharynx clear. Tacky mucus membranes.
NECK: Supple, no LAD.
CARDIAC: RRR, no murmurs.
LUNGS: CTAB
ABDOMEN: Normoactive, soft non tender non distended.
EXTREMITIES: RLE (thigh) significantly more warm and edematous
than the left. Tender to palpation anterior proximal thigh.
NEUROLOGIC: AAOx3, pleasant and cooperative.
SKIN: No rashes.
DISCHARGE EXAM
====================
Vitals: 98.0 138 / 78 59 97
GENERAL: sitting comfortably ___ chair, alert and awake, ___ NAD.
CARDIAC: nml s1/s2, RRR, no murmurs.
LUNGS: CTAB
ABDOMEN: Normoactive, soft non tender non distended.
EXTREMITIES: RUE s/p midline removal, dressing from ___ is dry
and intact no bleeding; RLE (thigh) edema with dressing ___ place
over prior drain site, non-tender, no crepitus. RLE calf trace
pitting edema and LLE without edema. No warmth or erythema.
Pertinent Results:
ADMISSION LABS
===================
___ 08:04PM WBC-8.5# RBC-3.33* HGB-8.5* HCT-28.7* MCV-86
MCH-25.5* MCHC-29.6* RDW-14.4 RDWSD-44.5
___ 08:04PM NEUTS-87.1* LYMPHS-6.6* MONOS-4.2* EOS-0.0*
BASOS-0.1 NUC RBCS-0.2* IM ___ AbsNeut-7.40*# AbsLymp-0.56*
AbsMono-0.36 AbsEos-0.00* AbsBaso-0.01
___ 08:04PM PLT COUNT-157
___ 08:04PM GLUCOSE-126* UREA N-22* CREAT-1.0 SODIUM-132*
POTASSIUM-3.7 CHLORIDE-92* TOTAL CO2-25 ANION GAP-19
___ 08:14PM LACTATE-1.6
___ 10:49PM URINE RBC-<1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 10:49PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 10:49PM URINE MUCOUS-RARE
___ 10:49PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 02:53AM ___ PTT-34.4 ___
DISCHARGE LABS
====================
___ 07:10AM BLOOD WBC-1.1* RBC-3.21* Hgb-8.3* Hct-27.6*
MCV-86 MCH-25.9* MCHC-30.1* RDW-14.8 RDWSD-46.3 Plt ___
___ 07:10AM BLOOD ___ PTT-37.4* ___
___ 07:10AM BLOOD Glucose-99 UreaN-16 Creat-0.7 Na-130*
K-4.3 Cl-98 HCO3-24 AnGap-12
___ 07:10AM BLOOD Calcium-7.8* Phos-2.2* Mg-2.0
MICROBIOLOGY
=====================
___ 11:06 am ABSCESS R ANTERIOR THIGH INTRAMUSCULAR
ABSCESS.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
SMEAR REVIEWED; RESULTS CONFIRMED.
FLUID CULTURE (Preliminary):
STAPH AUREUS COAG +. HEAVY GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
|
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
IMAGING/STUDIES
=====================
CT RIGHT THIGH ___ IMPRESSION:
1. 2.8 x 2.9 x 7.7 cm heterogeneous rim enhancing collection
within the right rectus femoris muscle concerning for abscess.
2. Myofascitis involving the anterior and medial compartments
of the right thigh. Diffuse subcutaneous soft tissue edema.
3. Osseous structures are intact.
4. Prominent right pelvic sidewall and inguinal lymph nodes,
possibly reactive.
ULTRASOUND GUIDED RIGHT THIGH ABSCESS DRAINAGE ___ FINDINGS:
Multiloculated intramuscular collection measuring 10.7 cm SI x
3.6 cm AP x 6.7 cm TV within the anterior right thigh.
IMPRESSION: Successful US-guided placement of ___ pigtail
catheter into the collection, attached 2 a drain bag. Samples
was sent for microbiology evaluation.
ECHOCARDIOGRAM ___:
The left atrial volume index is moderately increased. The right
atrium is moderately dilated. 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%). There
is no ventricular septal defect. Right ventricular chamber size
and free wall motion are normal. The aortic valve leaflets (3)
are mildly thickened but aortic stenosis is not present. No
masses or vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. There is no mitral valve prolapse. No mass or
vegetation is seen on the mitral valve. Mild (1+) mitral
regurgitation is seen. No masses or vegetations are seen on the
tricuspid valve, but a tiny vegetation cannot be fully excluded
due to suboptimal image quality. The estimated pulmonary artery
systolic pressure is normal. There is no pericardial effusion.
IMPRESSION: Normal biventricular chamber size and systolic
function. No definitve 2D echo evidence of endocarditis. Mild
pulmonary hypertension. Biatrial enlargement.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Chlorthalidone 25 mg PO DAILY
2. Cyanocobalamin 250 mcg PO DAILY
3. Potassium Chloride 20 mEq PO DAILY
4. Pravastatin 40 mg PO QPM
5. Levothyroxine Sodium 75 mcg PO DAILY
Discharge Medications:
1. Linezolid ___ mg PO Q12H
RX *linezolid ___ mg 1 tablet(s) by mouth twice a day Disp #*42
Tablet Refills:*0
2. Chlorthalidone 25 mg PO DAILY
3. Cyanocobalamin 2500 mcg PO DAILY
4. Levothyroxine Sodium 75 mcg PO DAILY
5. Potassium Chloride 20 mEq PO DAILY
6. Pravastatin 40 mg PO QPM
7.Outpatient Lab Work
Please check CBC with differential, CHM:Na, BUN, Creatinine,
AST, ALT, TB, ALK PHOS, CRP on ___, and ___.
Fax results to:
___ CLINIC - FAX: ___ AND
___ ___ - FAX: ___
ICD-10 code: ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnoses: Right Thigh Hematoma/Abscess, Coagulopathy-
Unspecified
Secondary Diagnoses: Myelodysplastic Syndrome, Hypertension,
Hypothyroidism
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Ultrasound-guided right thigh abscess drain.
INDICATION: ___ year old man with R thigh abscess on CT// ? purulent material
COMPARISON: CT right thigh ___.
PROCEDURE: Ultrasound-guided drainage of right anterior thigh collection.
OPERATORS: Dr. ___, radiology trainee and Dr. ___
___, attending radiologist. Dr. ___
supervised the trainee during the key components of the procedure and reviewed
and agree with the trainee's findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the US scan table. Limited
preprocedure ultrasound was performed to localize the collection. Based on
the ultrasound findings an appropriate skin entry site for the drain placement
was chosen. The site was marked. Local anesthesia was administered with 1%
Lidocaine solution.
Using continuous sonographic guidance, ___ Exodus drainage catheter was
advanced via trocar technique into the collection. A sample of fluid was
aspirated, confirming catheter position within the collection. The pigtail
was deployed. The position of the pigtail was confirmed within the collection
via ultrasound.
Approximately 8 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: None.
FINDINGS:
Multiloculated intramuscular collection measuring 10.7 cm SI x 3.6 cm AP x 6.7
cm TV within the anterior right thigh.
IMPRESSION:
Successful US-guided placement of ___ pigtail catheter into the
collection, attached 2 a drain bag. Samples was sent for microbiology
evaluation.
Radiology Report
EXAMINATION: UNI LEG ___ BIL
INDICATION: ___ year old man with hx MDS, unknown coagulopathy with new
asymmetrical leg swelling R>L and warmth, concerning for new DVT// ?DVT***Also
concern for new hematoma. Please evaluate right thigh for change in prior
hematoma and right calf for new hematoma***
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.
Additional ultrasound images were obtained of the superficial soft tissues
over the right lateral thigh and right calf. There has been no significant
change in the known hematoma within the rectus femoris muscle. No drainable
fluid is identified. Moderate superficial soft tissue edema is identified
within the right lateral calf, there is no evidence of hematoma or drainable
fluid collection.
IMPRESSION:
1. No evidence of deep venous thrombosis in the right lower extremity veins.
2. No significant change, possible decrease in size of the known right-sided
rectus femoris hematoma. No drainable fluid collection or hematoma identified
within the right calf.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with Cellulitis of right lower limb
temperature: 100.5
heartrate: 77.0
resprate: 18.0
o2sat: 98.0
sbp: 131.0
dbp: 59.0
level of pain: 0
level of acuity: 3.0 | Information for Outpatient Providers: ___ with a ___ MDS,
hypothyroidism, hypertension presented to ___ ED with 2 weeks
of intermittent fevers found to have spontaneous right thigh
hematoma and likely abscess. Patient was taken for ___ drainage
and drain placement with removal of 8cc purulent fluid and
report of a multiloculated fluid collection measuring 10x3x6cm.
Patient was treated with empiric vancomycin, ceftriaxone,
clindamycin. Abscess cultures grew staph aureus that was
pan-sensitive. Antibiotics were narrowed to cefazolin for a ___
week course to be determined by ID as an outpatient. A midline
was placed for continued IV abx as an outpatient, which was
complicated by persistent bleeding despite DDAVP x3, topical
thrombin application, and multiple dressing changings. The
midline was removed and hemostasis was achieved. Prior to
discharge, patient was transitioned to linezolid ___ PO BID
for continuation of 4 week course (D1: ___, end date:
___.
# Right Rectus Hematoma/Abscess: Patient presented with 2 weeks
of fevers, right thigh pain found to have spontaneous right
thigh hematoma on CT RLE. He had no hx of trauma/inciting event
for development of hematoma. Given his feers/chills/pain,
hematoma was felt to be infected/developed into an abscess.
Patient was taken for ultrasound-guided ___ of the
abscess with placement of a drain for source control. Given
report of multiloculated collection with purulent fluid, patient
was started on broad spectrum antibiotcs with vancomycin,
ceftriaxone, clindamycin (D1 = ___. Abscess cultures grew
pan-sensitive staph aureus. Right thigh drain drained <10cc
serosanguinous fluid per day. Echo was negative for signs of
endocarditis. ___ drain was d/c'ed on ___. Patient's abx was
narrowed to cefazolin with plan for continued treatment as
outpatient. However, midline placement was complicated by
persistent bleeding despite DDAVP x3, topical thrombin
application, and multiple dressing changes. Midline was removed
and patient was transitioned to PO linezolid to complete 4 week
course of abx (___) with ID follow-up as outpatient.
# Normocytic Anemia: Patient was found to be acutely anemic from
baseline hemoglobin of ___ based on outpatient results. This
was felt most likely ___ spontaneous bleed/hematoma ___ patient's
right thigh. No other clinical evidence of other sources of
bleeding. Patient also has known baseline anemia due to MDS.
DIC/hemolysis was considered, but fibrinogen and other DIC labs
were normal. Patient received 1u pRBCs on ___ for Hb 6.9. Right
thigh drain output was monitored and drained <10cc
serosanguinous fluid per day.
# Unspecified Coagulopathy: Patient presented with spontaneous
hematoma without trauma/injury. He also gave history of
consistent with an unclear bleeding disorder that included
continued oozing from a small incision following cyst removal
and bleeding for days following superficial cuts/abrasions at
home. He also had midline placement complicated by persistent
bleeding. He received DDAVP x3 over three days and multiple
dressing changes with topical thrombin without resolution of
bleeding. Differential diagnosis included a secondary process
to the patient's known MDS vs primary platelet
dysfunction/coagulopathy that had not been diagnosed. Atrius
heme/onc was consulted. Empiric vitamin K repletion was given
for INR of 1.5 with some response. DIC labs (given infectious
presentation) were negative. Platelet mixing studies and factor
levels were normal. ___ studies pending. Patient to
follow up with Hematology as outpatient for further evaluation.
# MDS: Stable. Atrius heme/onc followed. Outpatient oncologist
aware of admission.
# Hypothyroidism: Stable. Continued home levothyroxine.
# Hypertension: Stable. Given infection, held patient's home
chlorthalidone.
# Psoriasis: Stable.
# Hyperlipidemia: Continued statin.
TRANSITIONAL ISSUES
========================
[] Patient on 3 week course of PO linezolid. Please monitor
patient for signs of persistent or recurrent infection and
determine whether patient will need longer course of abx or IV
abx treatment.
[] Patient with MDS and baseline neutropenia. Please monitor
patient's CBC every week while on linezolid.
[] Patient with unspecified coagulopathy. Please follow up
pending coagulation studies and further evaluate. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Benadryl
Attending: ___
Chief Complaint:
Worsening back pain/burning
Major Surgical or Invasive Procedure:
___: C5 corpectomy, C4-6 anterior fusion
History of Present Illness:
___ is a ___ female with known cervical myelopathy,
scheduled for surgery with Dr. ___ for C5
corpectomy and C4-6 fusion, who presents to ___ ED with
worsening mid thoracic to low back pain as well as "burning on
the inside" from the low back to the groin on the left. She has
had intermittent leg weakness and numbness for several weeks.
Yesterday, she was walking to the bathroom and her left leg went
numb and "did not do as it was told" and she fell. She was able
to get up immediately afterwards with no increase in pain and
void without difficulty. This morning upon wakening, she felt a
worsening in her baseline back pain and did not feel Tylenol
would help. She has been able to void without difficulty since
that time. She also states she feels hypersensitive in the left
groin with wiping and feels "shocks" when her left leg is
palpated. She denies numbness in her lower extremities. She
denies bowel or bladder incontinence.
Past Medical History:
Thyroid nodule allergic, allergic rhinitis, sciatica, colonic
adenoma, sleep apnea, depression, uterine fibroids.
Social History:
___
Family History:
___
Physical Exam:
============
ON ADMISSION
============
O: T: 99.0 BP: 129/74 HR: 96 R: 24 O2Sats: 98%RA
Gen: WD/WN, comfortable, NAD.
HEENT: Normocephalic, atraumatic
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 ___ ___
R ___ ___ ___ 5 5
L 4- 4+ 4- 4- 4- ___- 4- 4- 4
Sensation: Intact to light touch bilaterally. Hyperesthesia to
the lateral aspect of the left lower extremity.
Reflexes: B T Br Pa Ac
Right 2+ 2+ 2+ 3+ 3+
Left 2+ 2+ 2+ 3+ 3+
Propioception intact
Rectal exam normal sphincter control
============
ON DISCHARGE
============
O: T: 98.3 BP: 106/67 HR: 68 R: 16 O2Sats: 100%RA
Gen: WD/WN, comfortable, NAD.
HEENT: Normocephalic, atraumatic; incision c/d/I, no
swelling/hematoma
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Motor:
Delt Bi Tri WrExt WrFlex ___ Quad HS TA ___
___ FHL
R 5 5 5 5 5 ___ 5 ___
5 5
L 5 5 5 5 5 ___ 5 ___
5 5
Sensation: Intact to light touch bilaterally. Mild, persistent
hyperesthesia to
the lateral aspect of the left lower extremity. Intact
proprioception in bilateral upper and lower extremities.
___ bilaterally
Neutral toes bilaterally
No clonus
Pertinent Results:
Please see OMR for pertinent imaging and lab results.
Medications on Admission:
Calcium Citrate + D 315 mg-200 unit 2 tabs, Zyrtec 10 mg tablet
daily as needed, azelastine 137 mcg (0.1 %) nasal spray aerosol
___ spray(s) to each nostril once a day as needed for allergy
symptoms, cholecalciferol (vitamin D3) 5,000 unit capsule 1
capsule(s) by mouth weekly, fluticasone 50 mcg/actuation nasal
spray,suspension ___ spray(s) to each nostril once a day as
needed for allergy symptoms
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen [Pain Reliever] 500 mg 2 tablet(s) by mouth
every 8 hours as needed Disp #*100 Tablet Refills:*1
2. Diazepam 5 mg PO BID:PRN pain
Discontinue when no longer needed. Don't take before or while
driving or operating machinery.
RX *diazepam 2 mg 1 by mouth two times daily as needed for
spasms Disp #*14 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 2 capsule(s) by mouth two times daily
Disp #*60 Capsule Refills:*1
4. Gabapentin 100 mg PO Q8H
Discontinue when no longer needed for pain control.
RX *gabapentin 100 mg 1 capsule(s) by mouth every 8 hours Disp
#*60 Capsule Refills:*1
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
Take for moderate to severe pain. Don't take before driving or
operating machinery.
RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours as needed
Disp #*30 Tablet Refills:*0
6. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 by mouth twice daily Disp #*30
Tablet Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Cervical myelopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory with walker assistance.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI THORACIC AND LUMBAR PT6 MR SPINE
INDICATION: History: ___ with new lower leg weaknes, urinary incontinence.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and IDEAL technique
through the thoracic and lumbar spine. Axial T2 imaging was performed through
the thoracic and lumbar spine.
COMPARISON: Lumbar spine MRI from ___ and lumbar spine radiographs
from ___.
Cervical spine MRI from ___ is available for correlation.
FINDINGS:
There are 7 cervical, 12 rib-bearing, and 5 lumbar-type vertebrae. The
numbering is documented on images 2:6, 4:8, and 9:10.
Limited sagittal T1 weighted images through the cervical spine, intended for
numbering purposes (series 2), a again demonstrate multilevel cervical
degenerative disease with spinal cord compression at C4-C5 and C5-C6, better
assessed on the ___ cervical spine MRI.
THORACIC:
Vertebral body heights are within normal limits. No concerning bone marrow
signal abnormalities are seen. Alignment is normal. The thoracic spinal cord
demonstrates normal morphology and signal intensity, with the conus medullaris
terminating at T12-L1. There is no significant spinal canal or neural
foraminal narrowing. Multiple nerve root sleeve diverticula are present,
largest at T1-T2 on the left, T2-T3 bilaterally, T11-T12 on the left, and
T12-L1 on the right.
LUMBAR:
No suspicious bone marrow signal abnormalities are seen. Vertebral body
heights are preserved. Alignment is normal. There is loss of disc height at
L5-S1 with ___ type 2 discogenic bone marrow changes in the endplates.
L1-L2: No spinal canal or neural foraminal narrowing.
L2-L3: Mild disc bulge without spinal canal or neural foraminal narrowing.
L3-L4: Mild disc bulge and facet arthropathy. The ventral thecal sac is
mildly indented without mass effect on the intrathecal nerve roots.
Subarticular zones are mildly narrowed without frank compression of the
traversing L4 nerve roots. Mild bilateral neural foraminal narrowing.
L4-L5: Mild disc bulge and facet arthropathy. Subarticular zones are slightly
narrowed without frank compression of the L5 nerve roots. No significant
thecal sac narrowing. Right foraminal annular tear. Mild right and moderate
left neural foraminal narrowing with abutment of the exiting left L4 nerve
root by a left foraminal disc protrusion.
L5-S1: There is a disc bulge with a central annular tear and a broad-based
central/right paracentral/right foraminal disc protrusion, deforming the
traversing right S1 nerve root in the subarticular zone. No mass effect on
the intrathecal nerve roots. No significant neural foraminal narrowing.
IMPRESSION:
1. Multiple nerve root sleeve diverticula in the thoracic spine. No thoracic
spinal canal or neural foraminal narrowing. Normal appearance of the thoracic
spinal cord.
2. Lower lumbar degenerative disease affecting several traversing and exiting
nerve roots, as detailed above. No significant mass effect on the thecal sac.
Radiology Report
EXAMINATION: CERVICAL SINGLE VIEW IN OR
INDICATION: C5 CORPECTOMY;C5-C6 ANTERIOR FUSION
IMPRESSION:
Fluoroscopic images show steps in a C5-C6 anterior fusion with C5 corpectomy.
Further information can be gathered from the operative study.
Radiology Report
EXAMINATION: C-SPINE SGL 1 VIEW
INDICATION: ___ year old woman POD 0 from C5 corpectomy and C4-C6 fusion s/p
jp drain removal// soft tissue xray of neck to eval for retained drain
TECHNIQUE: Cervical spine single view
COMPARISON: ___ x-ray, MRI ___
FINDINGS:
C5 corpectomy, anterior C4-C6 fusion with plate, screws, new since prior. No
radiographic evidence of retained drain.
IMPRESSION:
Interval postoperative changes.
No evidence of retained drain.
Radiology Report
EXAMINATION: C-SPINE NON-TRAUMA ___ VIEWS
INDICATION: ___ year old woman s/p C5 corpectomy// post op x-ray post op
x-ray
IMPRESSION:
In comparison with the study of ___, there is little change in the C4-C6
anterior fusion with C5 corpectomy. No alignment abnormality. Prevertebral
soft tissue prominence is related to the recent surgery.
Gender: F
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: Back pain
Diagnosed with Low back pain
temperature: 99.0
heartrate: 96.0
resprate: 24.0
o2sat: 98.0
sbp: 129.0
dbp: 74.0
level of pain: 10
level of acuity: 2.0 | On ___, Ms. ___ presented to the ED with worsening
mid-thoracic and low back pain and burning. She was taken to
the OR on ___ with Dr. ___ C5 corpectomy and C4-6
anterior fusion. Her operative course was uncomplicated; please
see separate operative note for full details of procedure.
On POD1, patient reported improved pain. Her incision was
intact and there was no underlying hematoma or swelling. Her
strength was full and symmetric, and she denied any sensory
deficits other than subjective numbness in her hands. She
tolerated a regular diet and had sufficient urine output.
She was evaluated by ___, who felt she needed an additional
session prior to discharge. However, patient was adamant about
going home. She felt strongly that she would be safe at home, as
long she could be provided with a rolling walker for some
assistance with ambulation. She stated that she understands the
risk she is taking by going home without being cleared by
Physical Therapy as she is in fact medical school graduate from
___. Hinging on that, she also expressed clear understanding
of precautions she should take to prevent falling and when to
call for help or seek medical care. After discussing with
attending, it was decided that she could be discharged home.
She was provided with a short course of low-dose Valium for
muscle spasms and Oxycodone for breakthrough pain, in addition
to a bowel regimen (Senna/Colace) while on Oxycodone. She was
also provided with longer (>1 month) course of Gabapentin for
which she was instructed to discontinue when no longer needed.
Each of the medications and their risks--particularly as they
relate to impaired mental/physical function--were explained to
the patient and she expressed understanding. She is to follow-up
in clinic for repeat AP/Lateral XR in 1 month. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
___ Complaint:
Unresponsiveness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with AF (apixaban) c/b recent CVA
after ___ (___) with retrieval of left ICA/MCA clot, living
in facility with severe dysphagia at baseline, multiple prior
MDR
E. Coli UTI who presents to the ER after an episode of
unresponsiveness.
He was recently admitted in ___ w/ MDR E coli UTI and from
___ with UTI and urinary retention. UCx grew enterococcus
and MDR E coli. ID consulted and recommended 14d course of Zosyn
followed by weekly fosfomycin prophylaxis and vitamin C to
acidify the urine. For his urinary retention, urology was
consulted and felt retention was multifactorial (BPH, neurogenic
bladder from CVA, poor mobility, and UTI). He was started on
doxazosin and discharged w/ a foley that was removed 2 weeks
ago.
Per his wife he had been doing well at his facility until the
past couple of days when she noticed he seemed to have recurrent
suprapubic pain. Per facility records he was started on a course
of macrobid on ___ to complete 14 days, though unclear
circumstances surrounding this. Last night at his facility he
had, per ED report, "approximately ___ minutes of confusion,
unresponsiveness and patient was blue." When EMS arrived, they
recorded SaO2 of 97%, but placed him on a non-rebreather. His
mental status returned to baseline and mask was subsequently
removed.
Past Medical History:
- CVA ___ after DCCV for AF: left ICA and MCA thrombus
retrieved. He has residual dysarthria with limited ability to
communicate and dysphagia; subsequent PEG placement and strict
NPO
- MI ___, with PCI
- Atrial fibrillation, persistent; diagnosed at time of MI
- MR, moderate by echo ___
- Appendectomy
Social History:
___
Family History:
Both parents without any heart conditions died of old age. Has 3
children.
Physical Exam:
Vitals: Afebrile, BP 118/89, HR 68, RR 18, 96% on room air
GENERAL: Alert and interactive, elderly gentleman laying in bed,
looks comfortable
EYES: Anicteric
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate.
CV: RRR, no murmurs. 2+ radial and pedal pulses bilaterally.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored on room air.
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present. Has G-tube.
GU: Condom catheter draining orange tinted urine.
MSK: Neck supple, moves all extremities
SKIN: No rashes or ulcerations noted
NEURO: Alert, moves all limbs spontaneously, speaking but
aphasic and dysarthric, not able to assess orientation or assess
strength/sensation due to aphasia and dysarthria
PSYCH: Calm, cooperative
Pertinent Results:
ADMISSION LABS:
___ 12:00AM WBC-12.4* RBC-3.74* HGB-12.1* HCT-36.1*
MCV-97 MCH-32.4* MCHC-33.5 RDW-13.5 RDWSD-48.0*
___ 12:00AM NEUTS-75.7* LYMPHS-9.5* MONOS-10.8 EOS-2.6
BASOS-0.3 IM ___ AbsNeut-9.35* AbsLymp-1.17* AbsMono-1.34*
AbsEos-0.32 AbsBaso-0.04
___ 12:00AM ___ PTT-28.3 ___ 12:00AM PLT COUNT-228
___ 12:00AM GLUCOSE-124* UREA N-27* CREAT-0.9 SODIUM-139
POTASSIUM-4.5 CHLORIDE-99 TOTAL CO2-24 ANION GAP-16
___ 12:00AM ALT(SGPT)-25 AST(SGOT)-28 ALK PHOS-120 TOT
BILI-0.8
___ 12:17AM LACTATE-5.8*
___ 03:19AM LACTATE-1.3
___ 12:00AM LIPASE-16
___ 12:00AM cTropnT-<0.01
___ 12:00AM ALBUMIN-3.8
___ 12:10AM URINE WBCCLUMP-MANY*
___ 12:10AM URINE BLOOD-MOD* NITRITE-POS* PROTEIN-100*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-2* PH-6.5
LEUK-LG*
___ 12:10AM URINE RBC-135* WBC->182* BACTERIA-MANY*
YEAST-NONE EPI-0
___ 12:10AM URINE COLOR-Yellow APPEAR-Cloudy* SP
___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL. PRESUMPTIVE
IDENTIFICATION.
Culture workup discontinued. Further incubation showed
contamination with mixed skin/genital flora. Clinical
significance
of isolate(s) uncertain. Interpret with caution.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- 32 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 256 R
PIPERACILLIN/TAZO----- 16 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- =>16 R
IMAGING:
___ 02:15 CT Abd & Pelvis With Contrast
1. Large stool burden throughout the colon and rectum with mild
perirectal fat stranding which may correlate clinically with
stercoral colitis.
2. Bilateral indeterminate renal cysts of the right lower and
left upper poles which may reflect hemorrhagic versus
proteinaceous cysts for which follow-up nonemergent ultrasound
could be obtained, as clinically indicated.
3. Diverticulosis without findings of diverticulitis.
DISCHARGE LABS:
___ 05:30AM BLOOD WBC-7.7 RBC-3.35* Hgb-10.8* Hct-32.9*
MCV-98 MCH-32.2* MCHC-32.8 RDW-12.9 RDWSD-46.3 Plt ___
___ 05:30AM BLOOD Glucose-89 Creat-0.9 Na-143 K-3.6 Cl-103
HCO3-28 AnGap-12
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO TID
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - First Line
3. Docusate Sodium 100 mg PO BID
4. Doxazosin 1 mg PO HS
5. Fleet Enema (Saline) ___AILY:PRN constipation
6. Fosfomycin Tromethamine 3 g PO 1X/WEEK (MO)
7. Lidocaine 5% Patch 1 PTCH TD QAM
8. Polyethylene Glycol 17 g PO DAILY
9. Apixaban 5 mg PO BID
10. Aspirin 81 mg PO DAILY
11. Sotalol 40 mg PO BID
12. Phenazopyridine 200 mg PO TID
Discharge Medications:
1. Acetaminophen 1000 mg PO TID
2. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation - First Line
5. Docusate Sodium 100 mg PO BID
6. Doxazosin 1 mg PO HS
RX *doxazosin [Cardura] 1 mg 1 tablet(s) by mouth at bedtime
Disp #*30 Tablet Refills:*0
7. Fleet Enema (Saline) ___AILY:PRN constipation
8. Fosfomycin Tromethamine 3 g PO 1X/WEEK (MO)
RX *fosfomycin tromethamine [Monurol] 3 gram 1 packet(s) by
mouth On ___ Disp #*30 Packet Refills:*0
9. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine 5 % 1 patch to affected area of pain Daily in
morning Disp #*30 Patch Refills:*1
10. Phenazopyridine 200 mg PO TID
RX *phenazopyridine 200 mg 1 tablet(s) by mouth TID PRN Disp
#*90 Tablet Refills:*0
11. Polyethylene Glycol 17 g PO DAILY
12. Sotalol 40 mg PO BID
RX *sotalol 80 mg 0.5 (One half) tablet(s) by mouth twice a day
Disp #*30 Tablet Refills:*0
13.___ lift
Rx: ___ lift
Dx: Deconditioning (___.81), stroke (___.9)
Duration: ___ years
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Urinary tract infection
Moderate sleep apnea
Constipation
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with sepsis// ?pneumonia ?pulm edema
COMPARISON: None
FINDINGS:
Portable semi-upright view of the chest provided.
Bibasilar opacities are concerning for bibasal pneumonia in the context of
sepsis. There is vascular congestion but no overt pulmonary edema.
There is mild elevation of the left hemidiaphragm. No focal consolidation,
effusion, or pneumothorax is identified. The cardiac silhouette is normal.
The hilar and mediastinal contours are unremarkable.
IMPRESSION:
Bibasal opacities, concern for bibasal pneumonia.
Radiology Report
EXAMINATION: CT abdomen pelvis with contrast
INDICATION: NO_PO contrast; History: ___ with abd tenderness, hypoxia,
amsNO_PO contrast// ?intrabdominal infection
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 797 mGy-cm.
COMPARISON: CT abdomen pelvis from ___
FINDINGS:
LOWER CHEST: Visualized lung fields are notable for mild bilateral dependent
atelectasis.
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.
Multiple subcentimeter hypodensities are visualized throughout the bilateral
kidneys, which are too small to characterize, though likely represent renal
cysts. Additionally bilateral intermediate density cystic lesions are
visualized measuring 1.2 cm in the upper pole of the left kidney and 1.3 cm in
lower pole the right kidney which are indeterminate though similar in
appearance to prior study. There is no evidence hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: A small hiatal hernia is demonstrated. A percutaneous
gastrostomy tube is visualized. Small bowel loops demonstrate normal caliber,
wall thickness, and enhancement throughout. A large stool burden is
visualized throughout the colon and rectum with mild fatty stranding adjacent
to the rectum (2:78) which may correlate with stercoral colitis.
Diverticulosis of the sigmoid colon is noted, without evidence of wall
thickening and fat stranding. The appendix is surgically absent.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are normal.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted.
BONES: Diffuse osteopenia and multilevel degenerative changes are visualized
throughout the imaged portion of the thoracolumbar spine without evidence of
worrisome osseous lesions or acute fracture.
SOFT TISSUES: A left inguinal hernia containing fat is noted.
IMPRESSION:
1. Large stool burden throughout the colon and rectum with mild perirectal fat
stranding which may correlate clinically with stercoral colitis.
2. Bilateral indeterminate renal cysts of the right lower and left upper poles
which are indeterminate though unchanged when compared with prior study.
3. Diverticulosis without findings of diverticulitis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with Urinary tract infection, site not specified
temperature: 97.5
heartrate: 80.0
resprate: 24.0
o2sat: 97.0
sbp: 126.0
dbp: 60.0
level of pain: ua
level of acuity: 2.0 | Mr. ___ is an ___ year old gentleman with atrial fibrillation (on
chronic apixaban) complicated by CVA ___/ severe dysarthria
and aphasia and two recent admissions for MDR E coli UTI
presenting from his facility after an episode of
unresponsiveness.
# Sepsis ___ E. Coli UTI:
# Encephaloopathy
He presented with unresponsiveness and sepsis. UA positive and
urine culture growing MRI E. Coli. He was started on Zosyn. He
completed a 10-day course of Zosyn on ___. He will resume
fosfomycin suppression as an outpatient. He will follow-up with
Infectious Disease and Urology for urodynamic testing to ensure
no structural cause for his recurrent UTI as an outpatient. His
mental status improved to baseline and he did not seem confused,
though it's difficult to assess his mental status as he is
aphasic. He follows commands and seems to understand what is
said to him, but cannot communicate back to providers. He had
some episodes in the afternoons/evenings when he would call out
and seem agitated and upset, but this seemed mostly when his
family was not present and at least in part due to frustration
with inability to communicate.
# Pneumonia:
He is at high risk for aspiration. Bibasilar opacities were
seen on CXR. He was treated initially with zosyn and
vancomycin. Vancomycin was subsequently stopped as suspicion
for MRSA PNA was low. He completed the course of Zosyn
(primarily for UTI) as above. He had negative urine Strep and
Legionella antigens.
# Sleep Apnea
He had observed apneic episodes up to 90 seconds while sleeping
overnight. During these episodes he was found to desaturate to
as low as 60%. These episodes were noted to decrease in
frequency and severity as his sepsis was treated. He was seen
by Sleep Medicine who believed he had moderate obstructive sleep
apnea + REM dominant OSA. Sleep recommended that the patient
lie on his side, avoid sedatives, and trial auto-CPAP PRN while
in the hospital. They will follow-up with the patient for
formal sleep testing as an outpatient. He missed his scheduled
appointment due to still being hospitalized, so request that his
PCP's office make sure he gets follow-up with sleep medicine.
# History of Urinary Retention. He was continued on home
doxazosin.
# Stercoral colitis: Evidence was seen on CT abdomen/pelvis. It
was unclear if his bowel regimen had been continued as
outpatient. He was restarted on bisacodyl, Colace, miralax. He
had no GI issues clinically during his hospital course.
# Atrial fibrillation:
# Sinus bradycardia:
His CHADS2VAsC is 5. In his history, he suffered a stroke after
DCCV in ___. He is followed by cardiologist (Dr. ___. He
continues sotalol and apixaban.
# CVA:
He has known CVA after ___ (___) with retrieval of left
ICA/MCA clot with residual R-sided weakness, dysarthria, and
dysphagia s/p PEG. During his hospital course he was maintained
on strict NPO diet with tube feeds. ___ came and did teaching
with his son and wife for administering tube feeds. He was
switched from continuous tube feeds to bolus tube feeds, to
simplify administration, and tolerated this well.
# Renal Cysts:
Incidental finding on CT A/P in the ED: "Bilateral indeterminate
renal cysts of the right lower and left upper poles which may
reflect hemorrhagic versus proteinaceous cysts for which
follow-up nonemergent ultrasound could be obtained, as
clinically indicated." Ultrasound was not obtained while
inpatient, but could be done as outpatient.
Disposition: ___ and OT evaluated him and recommended rehab.
However, the patient's wife wanted to have the patient come back
home with her. Though he was medically stable for discharge for
days, he was unable to be discharged home until his wife/son had
undergone teaching with ___ on giving tube feeds and for a
Hoyer lift to be delivered to their home. He will have ___
services (Art of Care) who will be teaching them how to safely
use the ___ lift.
Check if applies: [ X ] Mr. ___ is clinically stable for
discharge
today. The total time spent today on discharge planning,
counseling and coordination of care today was greater than 30
minutes. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Methadone
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo M with ___ CAD s/p MI, COPD, HTN, DM2, presenting with
abdominal pain and increasing dyspnea. Of note, patient was
hospitalized in ___ for COPD exacerbation which resolved with
steroids and antibiotics. On ___, he was walking to the
bathroom when he became overwhelmed with dyspnea and pushed his
Life-Alert necklace. He denies any recent symptoms other than a
cough which is chronic. He has some clear sputum production. He
states it occasionally hurts to take a deep breath. He also
complains of worsening abdominal pain over the last 12 hours
around the site of his ventral hernia. He has had this pain for
some time, and is waiting on a possible repair surgery.
In the ED, initial VS were 98.6, 90, 136/89, 24, 100% on 4L.
Exam was notable for crackles on lung auscultation. Labs showed
no leukocytosis, 1 set negative troponins, K 6.1 --> 4.6 on
repeat without intervention and Creat 1.6 (baseline 1.3-1.5).
Imaging showed CXR with low lung volumes with bibasilar
atelectasis and small right pleural effusion. He received
albuterol and ipratropium nebs X 2, aspirin 325mg, 60mg
prednisone and 500mg PO azithromycin. Transfer VS were 92,
118/86, 20, 96% on RA.
On arrival to the floor, patient was comfortable and reported no
current shortness of breath. His primary complaint was continued
abdominal pain, which is stable and chronic. He also complained
of ongoing cough. He was in no acute distress and related
history comfortably.
ROS: 10 point ROS negative except as noted above in HPI
Past Medical History:
COPD - followed by Dr ___ at ___ s/p MI in ___, normal catheterization in ___
Hypertension
Diabetes mellitus type II, insulin dependent
Depression
Cataracts
Osteoarthritis
H/o C1-C2 joint fusion and C5-C6 ACDF
H/o of polysubstance abuse
H/o gastric ulcer
S/p abdominal surgery during the ___ War details unclear
Social History:
___
Family History:
HTN, CAD
Physical Exam:
Admission exam:
VS: 98.5, 95, 125/90, 20, 97% RA
GENERAL: Adult male in NAD, sitting comfortably in bed
HEENT: NCAT, no JVD, MMM, PERRL
NEURO: AAOx3, CNII-XII intact, moving all extremities and
sensation intact to light touch
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Lung bases with crackles bilaterally and trace wheezes, no
increased WOB
ABDOMEN: NTND, BS+, no HSM or masses, ventral hernia to left of
umbilicus, nontender and without erythemea, reducible
EXTREMITIES: WWP, no edema
Discharge Exam:
VS: 98.5, 95, 130/90, 17, 96% RA
General: Adult male lying in bed in NAD
HEENT: NCAT, no JVD, MMM
NEURO: AAOx3, moving all extremities and sensation intact to
light touch
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: Lung bases with soft crackles bilaterally and trace
wheezes, no increased WOB
ABDOMEN: NTND, BS+, no HSM or masses, ventral hernia to left of
umbilicus, nontender and without erythemea, reducible
EXTREMITIES: WWP, no edema
Pertinent Results:
Admission labs:
====================
___ 05:35AM BLOOD WBC-5.9 RBC-4.92 Hgb-14.4 Hct-46.4 MCV-94
MCH-29.3 MCHC-31.0* RDW-14.7 RDWSD-50.5* Plt ___
___ 05:35AM BLOOD Neuts-54.8 ___ Monos-10.1 Eos-3.9
Baso-0.3 Im ___ AbsNeut-3.22 AbsLymp-1.80 AbsMono-0.59
AbsEos-0.23 AbsBaso-0.02
___ 08:07AM BLOOD ___ PTT-29.9 ___
___ 12:15PM BLOOD Glucose-156* UreaN-26* Creat-1.6* Na-140
K-4.6 Cl-102 HCO3-27 AnGap-16
___ 05:35AM BLOOD cTropnT-<0.01
___ 12:15PM BLOOD Calcium-9.7 Phos-2.6* Mg-2.0
IMAGING:
====================
___ CXR
IMPRESSION:
Low lung volumes with bibasilar atelectasis. Small right
pleural effusion.
Discharge labs:
====================
None
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
2. Amlodipine 5 mg PO DAILY
3. Atorvastatin 5 mg PO QPM
4. Benzonatate 100 mg PO TID
5. budesonide-formoterol 80-4.5 mcg/actuation inhalation BID
6. BuPROPion (Sustained Release) 300 mg PO DAILY
7. ciclopirox 0.77 % topical DAILY
8. Clotrimazole Cream 1 Appl TP BID
9. Codeine Sulfate ___ mg PO Q12H:PRN cough
10. Vitamin D 50,000 UNIT PO ONCE A MONTH
11. Fentanyl Patch 25 mcg/h TD Q72H
12. Fluticasone Propionate 110mcg 2 PUFF IH BID
13. Gabapentin 300 mg PO QAM
14. Gabapentin 600 mg PO QPM
15. Hydrochlorothiazide 25 mg PO DAILY
16. Ibuprofen 600 mg PO Q12H
17. Lisinopril 40 mg PO DAILY
18. Mirtazapine 30 mg PO QHS
19. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
20. Omeprazole 40 mg PO DAILY
21. Tiotropium Bromide 1 CAP IH DAILY
22. Acetaminophen 650 mg PO Q6H:PRN pain
23. Aspirin 81 mg PO DAILY
24. DiphenhydrAMINE 25 mg PO Q12H:PRN itching
25. Docusate Sodium 100 mg PO BID
26. 70/30 26 Units Breakfast
70/30 26 Units Dinner
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Amlodipine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 5 mg PO QPM
5. Benzonatate 100 mg PO TID
6. BuPROPion (Sustained Release) 300 mg PO DAILY
7. Codeine Sulfate ___ mg PO Q12H:PRN cough
8. Docusate Sodium 100 mg PO BID
9. Fentanyl Patch 25 mcg/h TD Q72H
10. Gabapentin 300 mg PO QAM
11. Gabapentin 600 mg PO QPM
12. Hydrochlorothiazide 25 mg PO DAILY
13. 70/30 26 Units Breakfast
70/30 26 Units Dinner
14. Lisinopril 40 mg PO DAILY
15. Mirtazapine 30 mg PO QHS
16. Omeprazole 40 mg PO DAILY
17. Tiotropium Bromide 1 CAP IH DAILY
18. Azithromycin 250 mg PO Q24H Duration: 3 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*3
Tablet Refills:*0
19. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
20. budesonide-formoterol 80-4.5 mcg/actuation INHALATION BID
21. ciclopirox 0.77 % topical DAILY
22. Clotrimazole Cream 1 Appl TP BID
23. DiphenhydrAMINE 25 mg PO Q12H:PRN itching
24. Fluticasone Propionate 110mcg 2 PUFF IH BID
25. Ibuprofen 600 mg PO Q12H
26. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
27. Vitamin D 50,000 UNIT PO ONCE A MONTH
28. PredniSONE 40 mg PO DAILY Duration: 3 Doses
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*6 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis
COPD exacerbation
Secondary diagnosis
Chronic kidney disease
Hypertension
Type 2 diabetes mellitis
Anxiety
Chronic pain
Discharge Condition:
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ male with periumbilical hernia pain, dyspnea,
hypoxia, evaluate for acute abnormalities.
TECHNIQUE: Portable AP view of the chest
COMPARISON: Chest x-ray from ___ and chest CT from ___.
FINDINGS:
Lung volumes remain low with bronchovascular crowding. There is bibasilar
atelectasis. There is likely a small right pleural effusion with fluid within
the major fissure. The cardiac silhouette is not enlarged. There is no
pneumothorax. Surgical clips project over the right upper quadrant.
IMPRESSION:
Low lung volumes with bibasilar atelectasis. Small right pleural effusion.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abd pain, Dyspnea
Diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION, VENTRAL HERNIA NOS
temperature: 98.6
heartrate: 90.0
resprate: 24.0
o2sat: 100.0
sbp: 136.0
dbp: 89.0
level of pain: 10
level of acuity: 2.0 | Summary
================================
___ male history of CAD status post MI, COPD (GOLD stage
III, FEV1 38% predicted in ___, hypertension, diabetes
presenting with abdominal pain and increasing dyspnea. He was
found to be in COPD exacerbation and treated with prednisone and
azithromycin. He quickly recovered and was discharged in good
condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Codeine / Ciprofloxacin / Percocet
Attending: ___.
Chief Complaint:
Abdominal distention
Urinary retention
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with end stage renal disease status post
kidney transplant, prostate cancer, and recent penile prosthesis
insertion on ___ who presents with abdominal distention and
urinary retention. Following recent penile prosthesis insertion,
Foley catheter was inserted and subsequently removed on the
night prior to admission, following which she has experienced
only drips. He also complains of abdominal distension and poor
appetite. He recalls 1 bowel movement on the day of admission
after laxatives. He denies fevers/chills, chest pain, abdominal
pain, cough, or vomiting.
Per urology, during the operation, he received gentamicin and
vancomycin. He was discharged on ___ with a 7 day course of
cephalexin and hydrocodone-acetaminophen for pain.
In the ED, initial vital signs were as follows: 98.7 80 130/48
18 100% RA. He was found to have mild abdominal tenderness in
the lower quadrants, mild distention, and tympany to percussion.
Admission labs were notable for Cr of 3.0, up from baseline of
1.5-2, Na of 122, and hematocrit of 31.1 consistent with
baseline. Urinalysis showed few bacteria, 30 protein, and trace
ketones, with repeat urinalysis similar. According to the renal
transplant service, acute kidney injury was felt to be due to
obstruction versus gentamicin. Foley placement was advised, as
was renal transplant ultrasound and avoidance of IV fluids. The
urology service recommended Foley placement, with urology follow
up within 72 hours. KUB demonstrated likely ileus, and he
received bisacodyl, senna, and Maalox. After he endorsed
heartburn, troponin was added to labs. Although he voided prior
to Foley catheter placement, bedside ultrasound showed moderate
hydronephrosis. Foley catheter was placed, and formal ultrasound
was ordered. Vital signs on transfer were: 99.3 91 139/57 16 93%
RA.
On arrival to floor, he denies complaints.
Past Medical History:
___ s/p cadavaric renal tx ___
HTN
Cerebrovascular dz (sm infarcts on MRI)
Hx Palpitations and VPCs
Anemia
GERD
Hx prostate CA s/p radical prostatectomy ___
R eye blindness; L cataract repair
Migraine headache
Carpal tunnel syndrome
Hx of CMPY (EF 40%, now improved with 55-60% with mild diasolic
dysfunction)
PMH & PSH:
ED
HTN
HLD
PVD
Gout
CVA
Hyperparathyroidism
Reflux
Renal insufficiency s/p kidney transplant ___
Prostate cancer s/p prostatectomy
Anemia
Hx of blood clot in ___
Cataracts
Social History:
___
Family History:
Diabetes mellitus in brother.
Physical Exam:
On admission:
VS: 97.6 134/54 95 18 92% RA
GENERAL: well appearing
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, no LAD, 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: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses, nontender at RLQ graft site
EXTREMITIES: no edema, 2+ pulses radial and dp
NEURO: awake, A&Ox3
At discharge:
VS: 98.8 147/67 82 18 96/RA
GENERAL: Well appearing
HEENT: NC/AT, PERRL, EOMI, sclerae anicteric, MMM
NECK: supple, no LAD, 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: normal bowel sounds, soft, non-tender, non-distended,
no rebound or guarding, no masses, nontender at RLQ graft site
EXTREMITIES: no edema, 2+ pulses radial and dp, R great toe with
edema/erythema
NEURO: awake, A&Ox3
Pertinent Results:
On admission:
___ 05:40PM BLOOD WBC-9.8# RBC-3.28* Hgb-10.2* Hct-31.1*
MCV-95 MCH-31.0 MCHC-32.7 RDW-13.3 Plt ___
___ 05:40PM BLOOD Neuts-76.6* Lymphs-13.0* Monos-8.6
Eos-1.3 Baso-0.5
___ 05:40PM BLOOD Glucose-103* UreaN-40* Creat-3.0*#
Na-122* K-3.6 Cl-85* HCO3-20* AnGap-21*
___ 05:40PM BLOOD CK-MB-3 cTropnT-<0.01
___ 05:40PM BLOOD tacroFK-15.5
___ 08:09PM URINE Color-Yellow Appear-Hazy Sp ___
___ 08:09PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 08:09PM URINE RBC-1 WBC-3 Bacteri-FEW Yeast-NONE Epi-<1
___ 08:09PM URINE CastGr-6* CastHy-1*
___ 08:09PM URINE Eos-NEGATIVE
___ 08:09PM URINE Hours-RANDOM UreaN-622 Creat-190 Na-17
K-45 Cl-14 Calcium-0.2
___ 08:09PM URINE Osmolal-406
At discharge:
___ 06:25AM BLOOD WBC-13.7* RBC-3.35* Hgb-10.3* Hct-31.8*
MCV-95 MCH-30.6 MCHC-32.3 RDW-13.6 Plt ___
___ 06:25AM BLOOD Glucose-88 UreaN-25* Creat-1.9* Na-127*
K-3.7 Cl-93* HCO3-22 AnGap-16
___ 06:25AM BLOOD Calcium-8.2* Phos-1.8* Mg-2.2
___ 06:25AM BLOOD tacroFK-7.9
In the interim:
___ 08:58AM URINE Hours-RANDOM Na-88 K-18 Cl-84
___ 08:58AM URINE Osmolal-449
Microbiology:
Urine culture (___): No growth
Imaging:
EKG (___):
Sinus rhythm. Frequent atrial premature beats. Left axis
deviation.
Inferolateral ST-T wave changes which are modest and
non-specific. Compared to the previous tracing of ___ heart
rate is faster and frequent atrial
premature beats are now present. Otherwise, no other significant
diagnostic
change.
IntervalsAxes
___
___
KUB (___):
Findings suggestive of adynamic ileus though bowel obstruction
cannot be completely excluded. If there is strong concern for
bowel
obstruction, a CT is advised.
Renal ultrasound (___):
1. Elevated resistive indices with absence of diastolic flow in
the
interpolar renal arteries and main renal artery, which is
concerning for
rejection.
2. Mild fullness in the mid pole collecting system; no evidence
of
hydronephrosis.
3. Simple renal cyst, which is new from the prior exam.
4. Moderately distended bladder despite the presence of a Foley
catheter.
Right foot XR (___):
In comparison with the study of ___, there is little overall
change. Again there is extensive vascular calcification
consistent with
diabetes. Degenerative changes are seen at the first MTP joint
with mild soft tissue prominence medially, but no evidence of
erosive changes to
radiographically suggest gout. Small opacification adjacent to
the base of
the fifth metatarsal again suggests sequela of previous trauma.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever
2. Aspirin 325 mg PO DAILY
3. Chlorthalidone 25 mg PO DAILY
4. cilostazol *NF* 50 mg Oral bid Reason for Ordering: Wish to
maintain preadmission medication while hospitalized, as there is
no acceptable substitute drug product available on formulary.
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Metoprolol Tartrate 100 mg PO BID
7. NIFEdipine CR 60 mg PO DAILY
8. Pravastatin 40 mg PO DAILY
9. PredniSONE 3 mg PO DAILY
10. Tacrolimus 5 mg PO QPM
11. Tacrolimus 6 mg PO QAM
12. TraMADOL (Ultram) 50 mg PO Q12H:PRN pain
13. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q4H:PRN
pain
14. Cephalexin 500 mg PO Q6H
15. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
16. Sulfameth/Trimethoprim SS 1 TAB PO 3X/WEEK (___)
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever
2. cilostazol *NF* 50 mg Oral bid Reason for Ordering: Wish to
maintain preadmission medication while hospitalized, as there is
no acceptable substitute drug product available on formulary.
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
4. Metoprolol Tartrate 100 mg PO BID
5. Nystatin Oral Suspension 5 mL PO QID:PRN thrush
6. Pravastatin 40 mg PO DAILY
7. PredniSONE 3 mg PO DAILY
8. Sulfameth/Trimethoprim SS 1 TAB PO 3X/WEEK (___)
9. Tacrolimus 5 mg PO QPM
10. Tacrolimus 6 mg PO QAM
11. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
12. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*60 Capsule Refills:*0
13. Senna 1 TAB PO BID:PRN constipatoin
RX *sennosides [___] 8.6 mg 1 tablet by mouth daily
Disp #*30 Tablet Refills:*0
14. Colchicine 0.6 mg PO DAILY
RX *colchicine [Colcrys] 0.6 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*0
15. TraMADOL (Ultram) 50 mg PO Q12H:PRN pain
16. NIFEdipine CR 60 mg PO DAILY
17. Hydrocodone-Acetaminophen (5mg-500mg) ___ TAB PO Q4H:PRN
pain
18. Outpatient Lab Work
Please check labs ___: CBC, chemistry panel, tacrolimus
level. Fax results to transplant cener ___ ICD-9 V42.0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Urinary retention
Constipation
Acute on chronic kidney injury in the setting of ESRD s/p
transplant
Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
ABDOMINAL RADIOGRAPH PERFORMED ON ___
COMPARISON: Prior CT of the abdomen and pelvis from ___ and multiple
prior abdominal ultrasound exams.
CLINICAL HISTORY: Recent surgery with abdominal distention, assess SBO.
FINDINGS: Supine and upright views of the abdomen and pelvis were provided.
There is gaseous distention of the colon as well as a few loops of small bowel
centrally. Given the history of recent surgery, most likely etiology is an
adynamic ileus though the possibility of obstruction is not fully excluded.
There is no convincing evidence for free air in the abdomen. Bony structures
are intact. Clips in the mid pelvic region as well as vascular calcifications
are noted. There are degenerative changes at bilateral hip joints with mild
loss of joint space and acetabular spurs.
IMPRESSION: Findings suggestive of adynamic ileus though bowel obstruction
cannot be completely excluded. If there is strong concern for bowel
obstruction, a CT is advised.
Radiology Report
INDICATION: Acute renal failure and urinary retention. Evaluate for
hydronephrosis.
COMPARISONS: Renal ultrasound from ___.
TECHNIQUE: Grayscale, Doppler, and spectral ultrasound images were acquired
through the transplanted kidney in the right lower quadrant.
FINDINGS: The transplanted kidney in the right lower quadrant measures 10.2
cm. It previously measured 11.9 cm. In the mid pole, there is a 2.1 x 1.7 x
1.6 cm cyst, which was not visualized on the last exam. No other focal renal
lesions are identified. There are no renal stones. There is minimal fullness
of the collecting system in the mid pole of the transplanted kidney. No
hydronephrosis is identified.
The resistive indices are elevated with no evidence of diastolic flow. The
resistive indices of the upper pole, midpole, and lower pole are 0.99, 1.0,
and 0.81, respectively. On the prior exam, they were 0.81, 0.81, and 0.73
respectively. The main renal artery additionally has an elevated resistive
index with reversal of flow. The main renal vein is patent.
There is no perinephric fluid collection. Limited views of the bladder
demonstrate a moderately distended bladder with a Foley in place. The imaged
portion of the bladder wall appears to be within normal limits.
IMPRESSION:
1. Elevated resistive indices with absence of diastolic flow in the
interpolar renal arteries and main renal artery, which is concerning for
rejection.
2. Mild fullness in the mid pole collecting system; no evidence of
hydronephrosis.
3. Simple renal cyst, which is new from the prior exam.
4. Moderately distended bladder despite the presence of a Foley catheter.
Results were discussed with Dr. ___ at 11:10 ___ on ___ via telephone by
Dr. ___.
Radiology Report
HISTORY: Gout with right great toe pain.
FINDINGS: In comparison with the study of ___, there is little overall
change. Again there is extensive vascular calcification consistent with
diabetes. Degenerative changes are seen at the first MTP joint with mild soft
tissue prominence medially, but no evidence of erosive changes to
radiographically suggest gout. Small opacification adjacent to the base of
the fifth metatarsal again suggests sequela of previous trauma.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: CONSTIPATION
Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, HYPOSMOLALITY/HYPONATREMIA
temperature: 98.7
heartrate: 80.0
resprate: 18.0
o2sat: 100.0
sbp: 130.0
dbp: 48.0
level of pain: 4
level of acuity: 2.0 | Mr. ___ is a ___ with end stage renal disease status post
kidney transplant, prostate cancer, and recent penile prosthesis
insertion on ___ who presented with abdominal distention and
urinary retention. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Alcohol withdrawal
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo female with previous history of alcohol abuse transfered
to ___ with alcohol withdrawal and sodium of 106.
Pt reports that she has been sober for ___ year, drinking heavily
x 3 weeks in the setting of loosing her job? She presented to
___ overnight and was found to be in alcohol
withdrawal with a sodium of 106. She was noted to have many
ecchymoses and endorsed frequent falls recently. She does state
that she has a history of hyponatremia in the past, though
doesn't know to what level.
At ___, pt received 2L NS and banana bag. She had
a chest xray which was negative per report. Alcohol level was
negative.
In the ED, her initial vitals were 98.3 112 106/70 16 96% 4L.
She received a total of 2 mg ativan and tylenol. Serum and urine
tox were negative. Labs here were notable for sodium of 110, Cl
86, bicarb 18, Mg 1.3, ALT 113, AST 115, AP 73, tbili 0.7,
albumin 3.1, lactate 2.1. UA was negative and urine lytes showed
Na 12, osm 167. Given recent falls, she had a head CT in the ED
which showed no acute process. During her ED course, her BP
dropped to 78/56. Because of hypotension, bedside FAST exam was
performed and negative. She had a CT torso that showed bilateral
aspiration or multifocal pneumonia, new hepatic steatosis, small
bilateral pleural effusions and mild pulmonary edema. She got 2L
fluids in the ED and hydrocortisone 100mg IV with BP increasing
to 100/73. Troponins was elevated at 0.86 and cardiology was
consulted. Per cardiology, based on EKG there is no evidence of
acute ischemia.
On arrival to the MICU, patient complaining of moderate
difficulty breathing and cough that has been present for 1 week.
Also feeling 'jittery'. No other complaints. Of note, patient
fell on ___ in her house after her knees gave out. She fell
on her knees, then backwards. Patient felt lightheaded and dizzy
prior to the episode, but denies any LOC. Last drink was
afternoon of ___. Drinks about 1 bottle of wine per day for
several years. Hx of withdrawal seizures.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, recent weight loss or gain. Denies
headache, rhinorrhea or congestion. Denies chest pain, chest
pressure, palpitations. Denies nausea, vomiting, diarrhea,
constipation, abdominal pain, or changes in bowel habits. Denies
dysuria, frequency, or urgency. Denies rashes or skin changes.
Past Medical History:
1. Macrocytic Anemia. Attributed to ETOH
2. Anxiety.
3. Depression.
4. ETOH abuse. complicated by pancreatitis in ___,
associated LFT abnormalities. Possibly chronic pancreatitis also
(evidence on CT scan today).
5. h/o Seizures.
6. Pancreatic mass. Poorly defined soft tissue density within
the pancreatic body noted on MR in ___. Pancreatic mass
felt to be c/w chronic pancreatitis on EGD ___.
7. Benzodiazepine agreement.
8. Insomnia.
9. PCKD. Dx ___
10. Status post tonsillectomy.
11. hx GI bleed
12. hx hyponatremia
13. HTN
Social History:
___
Family History:
The patient's father and brother both have autosomal dominant
polycystic kidney disease. The patient's father was first
diagnosed in his ___ he is currently ___, and he is told he is
___ years away from needing dialysis. There is no other
recognized history of medical conditions that run in the family.
GF - died of lung cancer at early age. No family hx of IBD or
bleeding diathesis.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: T98.6, BP: 112/72 P: 106 R: 24 O2: 94% on shovel mask
General- anxious, NAD
HEENT- PERRL, EOMI, sclera anicteric, dry MM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- diffuse expiratory rhonchi L>R and diffuse wheezes
CV- tachycardia, normal rhythm, no murmurs, rubs, gallops
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU- foley in place
BACK: several large ecchymosis on lower back. No spinal
tenderness. Paraspinal tenderness in low back
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- A&Ox3, slight tremor bilaterally, CNs2-12 grossly intact,
motor function grossly intact
DISCHARGE PHYSICAL EXAM
VS: T 98.4 BP 106/76 P ___ R 18 Sat 100% on RA
General- anxious, NAD
HEENT- PERRL, EOMI, sclera anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- scattered rhonchi bilaterally but improved from
yesterday,
no noted rales or wheezing
CV- tachycardia, regular rhythm, no murmurs, rubs, gallops.
Abdomen- soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
BACK: several large ecchymosis on lower back. No spinal
tenderness. Mild paraspinal tenderness to palpation bilaterally
in lower back.
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- A&Ox3, slight tremor bilaterally, CNs2-12 grossly intact,
motor function grossly intact
Pertinent Results:
ADMISSION LABS
___ 04:45AM BLOOD WBC-9.0 RBC-3.01* Hgb-10.0* Hct-28.9*
MCV-96 MCH-33.2* MCHC-34.6 RDW-12.6 Plt ___
___ 04:45AM BLOOD Neuts-81.5* Lymphs-12.8* Monos-5.4
Eos-0.2 Baso-0.1
___ 04:45AM BLOOD Glucose-154* UreaN-7 Creat-0.4 Na-110*
K-3.9 Cl-86* HCO3-18* AnGap-10
___ 04:45AM BLOOD ALT-113* AST-115* CK(CPK)-703* AlkPhos-73
TotBili-0.7
___ 04:45AM BLOOD Albumin-3.1* Calcium-7.3* Phos-3.1#
Mg-1.3*
___ 01:22PM BLOOD Triglyc-39 HDL-77 CHOL/HD-2.2 LDLcalc-86
___ 04:45AM BLOOD TSH-1.4
___ 04:45AM BLOOD Cortsol-23.5*
___ 11:14PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE
HBcAb-NEGATIVE
___ 11:14PM BLOOD HCV Ab-NEGATIVE
___ 04:45AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:36PM BLOOD ___ pO2-38* pCO2-31* pH-7.49*
calTCO2-24 Base XS-1
___ 09:16AM BLOOD Lactate-2.1*
___ 02:25PM BLOOD Lactate-1.8
___ 11:36PM BLOOD Lactate-1.6
___ 04:45AM BLOOD cTropnT-1.07*
___ 09:05AM BLOOD cTropnT-0.86*
___ 04:43PM BLOOD CK-MB-18* MB Indx-3.0 cTropnT-0.60*
DISCHARGE LABS
___ 07:10AM BLOOD WBC-9.9 RBC-2.92* Hgb-9.5* Hct-30.1*
MCV-103* MCH-32.6* MCHC-31.6 RDW-13.6 Plt ___
___ 07:10AM BLOOD Glucose-97 UreaN-6 Creat-0.5 Na-129*
K-4.1 Cl-98 HCO3-22 AnGap-13
___ 07:10AM BLOOD ALT-61* AST-41* LD(LDH)-273* AlkPhos-65
TotBili-0.3
___ 04:43PM BLOOD CK-MB-18* MB Indx-3.0 cTropnT-0.60*
___ 07:10AM BLOOD Calcium-8.8 Phos-2.9 Mg-1.4*
MICRO
___ Urine culture: no growth
___ Blood cultures x2: pending
___ Urine legionella: negative
IMAGING
___ ECHO
Suboptimal image quality. 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. Left
ventricular wall thicknesses are normal. The left ventricular
cavity size is normal. There is probably moderate global left
ventricular hypokinesis (LVEF = 30 %). No masses or thrombi are
seen in the left ventricle. There is no ventricular septal
defect. with depressed free wall contractility. 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. Tricuspid regurgitation is present but
cannot be quantified. The pulmonary artery systolic pressure
could not be determined. There is no pericardial effusion.
IMPRESSION: Cardiomyopathy.
___ CT head w/o contrast
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect or acute
large vascular territory infarction. Prominent ventricles and
sulci suggest atrophy, out of proportion to the patient's age
but not significantly changed from ___ year prior.
Periventricular white matter hypodensities are consistent with
chronic small vessel ischemic disease. The basal cisterns
appear patent and there is preservation of gray-white
differentiation. Symmetric bilateral basal ganglia
hypodensities are stable, likely representing prominent
perivascular spaces.
No fracture is identified. There is mucosal thickening of the
bilateral
maxillary sinuses. The remaining visualized paranasal sinuses,
mastoid air cells and middle ear cavities are clear.
Atherosclerotic mural calcification of the internal carotid
arteries is noted. The globes are unremarkable.
IMPRESSION:
No acute intracranial process.
___ CT torso
IMPRESSION:
1. Bilateral aspiration or multifocal pneumonia.
2. New hepatic steatosis.
3. Stable innumerable hepatic and renal cysts and prominence of
the
pancreatic duct.
4. Small bilateral pleural effusions and mild pulmonary edema.
___ CXR (portable)
FINDINGS: Widespread consolidation in the left upper lobe
appears similar, but comparing to the scout view from the prior
examination, there is seemingly new retrocardiac opacification.
In each lung, there is also a widespread new background hazy
appearance; to some extent, this is probably be attributed to
layering pleural effusions, which may have increased, versus
worsening of multifocal pneumonia, coinciding fluid overload, or
developing respiratory distress syndrome.
___ CXR (PA/lateral)
Nearly all of what was extensive pulmonary consolidation on
___ has
resolved. The small residual on the perihilar left mid lung
could be a small pneumonia. Small pleural effusions are also
present. Heart is top normal size.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Lisinopril Dose is Unknown PO DAILY
2. Albuterol Inhaler ___ PUFF IH Frequency is Unknown
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth
daily Disp #*15 Tablet Refills:*0
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*15 Tablet
Refills:*0
4. Levofloxacin 750 mg PO Q24H Duration: 2 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*1
Tablet Refills:*0
5. Multivitamins W/minerals 1 TAB PO DAILY
6. PredniSONE 40 mg PO DAILY Duration: 3 Days
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*2 Tablet
Refills:*0
7. Thiamine 100 mg PO DAILY
RX *thiamine HCl 100 mg 1 tablet(s) by mouth daily Disp #*15
Tablet Refills:*0
8. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
RX *tramadol 50 mg 1 tablet(s) by mouth every six (6) hours Disp
#*20 Tablet Refills:*0
9. Metoprolol Succinate XL 25 mg PO DAILY
RX *metoprolol succinate 25 mg 1 tablet extended release 24
hr(s) by mouth daily Disp #*15 Tablet Refills:*0
10. Lisinopril 2.5 mg PO DAILY
RX *lisinopril 2.5 mg 1 tablet(s) by mouth daily Disp #*15
Tablet Refills:*0
11. Outpatient Lab Work
At follow-up PCP appointment, please check Chem10 to evaluate
response to lisinopril and sodium level
12. Albuterol Inhaler ___ PUFF IH Q6H:PRN dyspnea, wheezing
RX *albuterol sulfate 90 mcg ___ puff IH every six (6) hours
Disp #*1 Inhaler Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Hyponatremia, likely from poor nutrition and SIADH
Alcohol withdrawal
Cardiomyopathy, likely alcoholic
Troponin elevation
Community-acquired vs. aspiration pneumonia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Patient with alcohol abuse who presents after a fall and has
multiple bruises on the back and extremities. The patient is an unreliable
historian. Rule out intracranial hemorrhage.
TECHNIQUE: Contiguous axial MDCT images were obtained through the brain
without administration of IV contrast. Multiplanar reformatted images in
coronal and sagittal axes and thin-section bone algorithm reconstructed images
were acquired.
DLP: 1026 mGy-cm
CTDIvol: 63 mGy
COMPARISON: Nonenhanced head CT from ___
FINDINGS:
There is no evidence of hemorrhage, edema, mass effect or acute large vascular
territory infarction. Prominent ventricles and sulci suggest atrophy, out of
proportion to the patient's age but not significantly changed from ___ year
prior. Periventricular white matter hypodensities are consistent with chronic
small vessel ischemic disease. The basal cisterns appear patent and there is
preservation of gray-white differentiation. Symmetric bilateral basal ganglia
hypodensities are stable, likely representing prominent perivascular spaces.
No fracture is identified. There is mucosal thickening of the bilateral
maxillary sinuses. The remaining visualized paranasal sinuses, mastoid air
cells and middle ear cavities are clear. Atherosclerotic mural calcification
of the internal carotid arteries is noted. The globes are unremarkable.
IMPRESSION:
No acute intracranial process.
Radiology Report
HISTORY: Hypotension of unclear etiology status post multiple falls.
Evaluate for traumatic injury.
TECHNIQUE: Axial helical MDCT images were obtained through the chest, abdomen
and pelvis after administration of 130 cc of Omnipaque intravenous contrast.
Multiplanar reformatted images in coronal and sagittal axes were generated.
DLP: 673 mGy-cm
COMPARISON: CT torso from ___
FINDINGS:
CT chest: The visualized thyroid is unremarkable. There is no
supraclavicular lymph node enlargement. The airways are patent to the
subsegmental level. There is no mediastinal, hilar or axillary lymph node
enlargement by CT size criteria. The heart, pericardium and great vessels are
within normal limits. There are small bilateral pleural effusions measuring
simple fluid density. There are bilateral ground-glass opacities greater in
the left upper lobe and upper segment of the left lower lobe as well as in the
right upper lobe and right lower lobe consistent with aspiration or multifocal
pneumonia. Interlobular septal thickening consistent with pulmonary edema.
CT abdomen: The liver is diffusely hypoechoic attenuating consistent with
hepatic steatosis. Numerous hypodensities within the liver are not
significantly changed from prior. The gallbladder is unremarkable and the
portal vein is patent. There is stable prominence of the pancreatic duct.
The spleen and adrenal glands are unremarkable. There are innumerable
hypodensities in the bilateral kidneys which air not significantly changed
from the prior.
The stomach, duodenum and small bowel are unremarkable. There is
diverticulosis without evidence of diverticulitis. The appendix is visualized
and there is no evidence of appendicitis. The intraabdominal vasculature is
unremarkable. There is no mesenteric or retroperitoneal lymph node
enlargement by CT size criteria. No ascites, free air or abdominal wall
hernia is noted.
CT pelvis: The urinary bladder is unremarkable. The uterus and adnexa are
unremarkable There is no pelvic free fluid. There is no inguinal or pelvic
wall lymphadenopathy.
Osseous structures: No lytic or sclerotic lesions suspicious for malignancy
is present.
IMPRESSION:
1. Bilateral aspiration or multifocal pneumonia.
2. New hepatic steatosis.
3. Stable innumerable hepatic and renal cysts and prominence of the
pancreatic duct.
4. Small bilateral pleural effusions and mild pulmonary edema.
Radiology Report
CHEST RADIOGRAPH
HISTORY: Respiratory distress and multifocal pneumonia.
COMPARISONS: CT torso from the prior day.
TECHNIQUE: Chest, portable semi-upright.
FINDINGS: Widespread consolidation in the left upper lobe appears similar,
but comparing to the scout view from the prior examination, there is seemingly
new retrocardiac opacification. In each lung, there is also a widespread new
background hazy appearance; to some extent, this is probably be attributed to
layering pleural effusions, which may have increased, versus worsening of
multifocal pneumonia, coinciding fluid overload, or developing respiratory
distress syndrome.
Radiology Report
PA AND LATERAL CHEST ON ___
HISTORY: ___ woman with hyponatremia undergoing alcohol withdrawal.
Likely aspiration pneumonia.
IMPRESSION: AP chest compared to ___:
Nearly all of what was extensive pulmonary consolidation on ___ has
resolved. The small residual on the perihilar left mid lung could be a small
pneumonia. Small pleural effusions are also present. Heart is top normal
size.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: HYPONATREMIA
Diagnosed with HYPOSMOLALITY/HYPONATREMIA, ALCOH DEP NEC/NOS-UNSPEC, HYPERTENSION NOS, HISTORY OF FALL
temperature: 98.3
heartrate: 112.0
resprate: 16.0
o2sat: 96.0
sbp: 106.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | ___ F with hx of alcohol abuse/withdrawal, HTN, PKD who
presents with hyponatremia, alcohol withdrawal, and respiratory
distress.
ACTIVE ISSUES
-------------
# Respiratory distress: likely multifactoral including
multifocal/aspiration pneumonia and asthma exacerbation. Patient
presented with tachypnea, tachycardia, and hypotension, possibly
pointing to sepsis although picture complicated by alcohol
withdrawal and hypovolemia. She was treated for
community-acquired pneumonia with levofloxacin and ceftriaxone,
eventually narrowed to a five day course of levofloxacin. Her
asthma exacerbtaion was treated with 5 day course of prednisone
40 mg daily and nebulizers. Patient was able to wean off oxygen
by discharge. Flu vaccine and pneumovax were administered prior
to discharge.
# Hyponatremia: presented to an outside hospital with Na 106 and
initially improved to 113 after NS boluses as she appeared
significantly hypovolemic on exam. Urine lytes obtained and was
most consistent with a ___ picture with elevated sodium and
urine osmolality. In addition, patient had a very limited diet
suggesting nutritional causes from a 'tea and toast' diet.
Patient was then placed on fluid restrition and sodium improved
to 128 on discharge. Patient had no change in mental status
throughout her hospitalization, thus pointing more to a chronic
rather than acute process. She has been instructed to observe a
2 liter fluid restriction at home and to opitimize her nutrition
through 3 meals per day and Ensure supplementation. She will
follow up with her PCP and have sodium rechecked at that time.
# Alcohol withdrawal: history of withdrawal seizures. Patient
was placed on daily folate and thiamine. She was placed on the
phenobarbital protocol for withdrawal, weaned until the time of
discharge, when she did not have symptoms of withdrawal. Social
work consult was obtained, and patient expressed the desire to
stop drinking after this hospitalization. She will be going to
live with her parents initially after discharge.
# Elevated troponins: troponin 1.07 without any ECG changes. No
previous cardiac history, but has risk factors including
smoking, polycystic kidney disease, and hypertension.
Differential included NSTEMI vs. demand ischemia secondary to
tachycardia and metabolic derangements. Patient had no cardiac
symptoms. Per cardiology, they stated to start aspirin and beta
blocker, as well as lisinopril upon discharge, and she will
likely need a cardiac catheterization on discharge. She will
follow up with Cardiology a month after discharge. TTE was
obtained and showed cardiomyopathy with EF 30%, suggestive of
possible alcoholic cardiomyopathy. She was told of this
diagnosis and that she should cease drinking alcohol. She will
get a follow-up TTE at her Cardiology appointment.
# s/p fall: large ecchymosis post fall. Appears to be vasovagal
as patient felt lightheaded prior to episode. No loss of
consciousness reported. In the ED, CT head and torso and abdomen
negative for acute lesion or bleeding. Pain was treated with
acetaminophen and tramadol. Social work consult was obtained to
determine if there was any abuse, which the patient denied.
# Elevated liver function tests: per CT abdomen, the liver is
diffusely hypoechoic attenuating consistent with hepatic
steatosis which is consistent with her history of alcohol use.
AST was not greater than ALT as would we expect with alcohol
use. Hepatitis panel was negative in ___, and was repeated on
this admission and also negative. Possibly also secondary to
hypovolemia leading to decreased perfusion vs. hepatitis. LFTs
downtrended over her hospitalization. They should be rechecked
at her discharge appointment with her PCP.
# Smoking: smoking cessation was encouraged. Nicotine patch was
offered but patient refused.
# Hypertension: lisinopril was held during most of her
admission, but was restarted at discharge. She will get lab
testing (Chem10) at her PCP ___.
# Polycystic kidney disease: with renal and liver cysts on CT
abdomen. Creatinine was normal during her presentation. She
will follow up with her PCP after discharge.
TRANSITIONS OF CARE
-------------------
# Follow-up: patient will follow up with her PCP and with
___. She will need a repeat TTE in one month to evaluate
her valvular function, given her new cardiomyopathy. She will
need a recheck of her Chem10 and LFTs after discharge,
especially her sodium level. Blood cultures pending at
discharge will need to be followed up.
# Communication: brother (___) ___,
mother (___) ___
# Code: Full |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cipro / Bactrim / nitrofurantoin
Attending: ___
Chief Complaint:
CP, dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ no significant PMH who presents for evaluation for PE after
presenting to PCP with CC of DP and dyspnea.
On arrival to the ED her VS were stable. A CTA was done which
showed bilateral PEs so she was started on a hep gtt and was
admitted to the floor.
She reports that she had been feeling the CP and SOB for a
couple
days prior to seeking evaluation. She denies any known personal
or family history of hypercoagulable disorder. No known history
of miscarriages or abnormal bleeding. She is not on any hormonal
birth control. She did have a surgery recently to remove a
cystic
ovary about 2 months ago but she says she has not been sedentary
as she has a ___ year old that she has been taking care of.
Upon arrival to the floor, she reports that she is feeling much
better and denies CP or SOB.
REVIEW OF SYSTEMS:
Complete ROS obtained and is otherwise negative.
Past Medical History:
Cystic ovary s/p removal ___
2 pregnancies
Social History:
___
Family History:
Paternal grandmother with colon cancer
Paternal grandfather with pancreatic cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 24 HR Data (last updated ___ @ 558)
Temp: 97.6 (Tm 97.6), BP: 112/74, HR: 73, RR: 16, O2 sat:
99%, O2 delivery: RA
GENERAL: Alert, NAD, appears stated age
HEENT: atraumatic, normocephalic, EOMI, PERRL
CARDIAC: RRR, no m/r/g
LUNGS: faint bibasilar crackles, otherwise clear without
increased respiratory effort
ABDOMEN: soft, mildly tender diffusely, but no distention and no
rebound or guarding
EXTREMITIES: no edema, wwp
NEUROLOGIC: AAOx3, CN grossly intact, moving all 4 extremities
spontaneously and with purpose, speech fluent
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 558)
Temp: 97.6 (Tm 97.6), BP: 112/74, HR: 73, RR: 16, O2 sat:
99%, O2 delivery: RA
GENERAL: Alert, NAD, appears stated age
HEENT: atraumatic, normocephalic, EOMI, PERRL
CARDIAC: RRR, no m/r/g
LUNGS: faint bibasilar crackles, otherwise clear without
increased respiratory effort
ABDOMEN: soft, mildly tender diffusely, but no distention and no
rebound or guarding
EXTREMITIES: no edema, wwp
NEUROLOGIC: AAOx3, CN grossly intact, moving all 4 extremities
spontaneously and with purpose, speech fluent
Pertinent Results:
ADMISSION LABS:
___ 08:30PM BLOOD WBC-6.5 RBC-3.94 Hgb-11.1* Hct-34.9
MCV-89 MCH-28.2 MCHC-31.8* RDW-12.2 RDWSD-40.0 Plt ___
___ 08:30PM BLOOD Neuts-57.1 ___ Monos-5.7 Eos-1.5
Baso-0.6 Im ___ AbsNeut-3.72 AbsLymp-2.27 AbsMono-0.37
AbsEos-0.10 AbsBaso-0.04
___ 08:30PM BLOOD ___ PTT-28.0 ___
___ 08:30PM BLOOD D-Dimer-4621*
___ 08:30PM BLOOD Glucose-101* UreaN-11 Creat-0.9 Na-140
K-4.2 Cl-106 HCO3-23 AnGap-11
___ 08:30PM BLOOD cTropnT-<0.01 proBNP-<5
___ 09:00AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.8
___ 08:30PM BLOOD HCG-<5
DISCHARGE LABS:
___ 09:00AM BLOOD WBC-5.3 RBC-3.75* Hgb-10.6* Hct-33.5*
MCV-89 MCH-28.3 MCHC-31.6* RDW-12.4 RDWSD-40.2 Plt ___
___ 09:00AM BLOOD Glucose-83 UreaN-10 Creat-0.9 Na-138
K-4.9 Cl-107 HCO3-20* AnGap-11
MICRO:
None
IMAGING:
CTA chest ___
Left segmental and right subsegmental pulmonary emboli. No CT
evidence of
right heart strain.
NIVS LEs ___
No evidence of deep venous thrombosis in the right or left lower
extremity
veins.
Medications on Admission:
none
Discharge Medications:
1. Rivaroxaban 15 mg PO BID Duration: 21 Days
RX *rivaroxaban [___] 15 mg 1 tablet(s) by mouth twice a day
Disp #*42 Tablet Refills:*0
2. Rivaroxaban 20 mg PO DAILY
Do not begin taking this medication until you complete the 21
day course of rivaroxaban 15 mg PO BID
RX *rivaroxaban [___] 20 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Class I pulmonary embolism
Secondary diagnosis:
Normocytic 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 PE on CT// lower extremity blood clots
present? If so what is the clot burden?
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility and flow of the bilateral common femoral,
femoral, and popliteal veins. Normal color flow and compressibility are
demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Chest pain, Elevated D-dimer
Diagnosed with Other pulmonary embolism without acute cor pulmonale
temperature: 98.1
heartrate: 73.0
resprate: 14.0
o2sat: 99.0
sbp: 128.0
dbp: 78.0
level of pain: 6
level of acuity: 2.0 | ___ no significant PMH who presented with several days of chest
pain and dyspnea, admitted for treatment of bilateral PEs.
ACTIVE ISSUES
=============
#Pulmonary embolism
The patient presented with chest pain and shortness of breath.
CTA chest showed left segmental and right subsegmental pulmonary
emboli, and no CT evidence of right heart strain. Given her low
PESI score (39), this is a Class I, very low risk PE, and
outpatient management is appropriate. No obvious reason based on
history to be hypercoagulable, though she did undergo surgery 2
months ago. Doppler US of LEs negative. She was started on a
heparin gtt. Given that she is not tachycardic, had negative
trop, no evidence of heart strain on CTA, hemodynamically stable
and no oxygen requirement, the heparin gtt was discontinued and
she was started on a loading dose of apixaban (10 mg PO BID).
This was changed to rivaroxaban for insurance coverage reasons.
At time of discharge, she was continued on rivaroxaban 15 mg PO
BID for 21 days, which will be followed by rivaroxaban 20 mg PO
daily afterward.
#Normocytic anemia
She was noted to be anemic during this admission. Her anemia has
unclear etiology and is stable from prior. She was noted to have
no signs/symptoms of bleeding.
CHRONIC ISSUES
==============
None
TRANSITIONAL ISSUES
===================
[] She was started on rivaroxaban on ___. She was instructed
to take rivaroxaban 15 mg PO BID for 21 days, followed by
rivaroxaban 20 mg PO daily afterward. Her outpatient provider
should determine the appropriate duration for anticoagulation.
[] She should receive a hypercoagulability work up as an
outpatient. Protein C and S were sent while inpatient, and were
pending at time of discharge. She could also receive factor V
Leiden, cardiolipin, and beta-2 glycoprotein testing.
[] She was noted to have normocytic anemia during this
hospitalization. Her outpatient providers should consider a
workup for anemia (iron studies, B12, folate) and possible
treatment, such as iron supplementation if indicated.
#CODE: Full presumed
#CONTACT: ___ ___ (husband) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythrocin
Attending: ___.
Chief Complaint:
___ otherwise healthy ambulatory F w/ R periprosthetic fx and
L LC1 fx
Major Surgical or Invasive Procedure:
___: Open reduction and internal fixation of left
periprosthetic femur fracture
History of Present Illness:
Ms. ___ is a ___ year-old-female with mild cognitive
impairment (vs. mild dementia), supraventricular tachycardia vs.
nonsustained VT (unclear history), diet-controlled DM,
spine/hip/knee OA, retinal TIA, remote history of breast cancer
s/p lumpectomy, radiation, and hormonal therapy (in her ___,
prior syncopal episodes and hx SVT on verapamil, cholecystectomy
(___), and bilateral hip replacements (10 and ___ yrs ago
approximately), who presented after a fall with hip fracture and
is being transferred to medicine for thrombocytopenia,
hyponatremia and transaminitis.
Per patient's family and prior documentation, ___ has been
functionally declining slowly since ___. Her recent
history is most notable for multiple episodes vasovagal syncope
(dating back as long a ___ years), postural hypotension,
micturition syncope. Her biggest complaint over the past few
weeks has been mild fatigue, which is worse today.
Per review of ___ notes, she has had 4 visits for syncope
(two ___, one ___, one ___, though family reports
syncope x at least ___ years. Evaluation at ___ in ___
included TTE, with normal biventricular function and EF 60%, 2+
MR and 2+ AR. Cardiology thought her symptoms were most likely
vasovagal. Neurology who noted no clear neurologic etiology.
On ___, there was note of another episode of syncope. Was
hyponatremic to 127. Etiology ultimately unclear but was
attributed to "postural hypotension or her history of VT". Neg
trop. No telemetry events during that hospitalization. Note
refers to "nonsustained VT months ago, now on verapamil."
She had a cold with runny nose about ___ days ago, sleeping
more, less active in her facility. Then, on the evening of
presentation, she told her aid that she would brush her teeth in
the bathroom alone. She slipped and fell in the bathroom, and
was brought to the ER. At the bedside, the patient reports she
feels better lying flat, has no pain when her leg is not moving.
She states no seizure, head injury or LOC occurred with the
fall. She denies any preceding lightheadedness, dizziness, or
chest pain.
ROS: Full 10 point ROS otherwise negative.
Past Medical History:
- mild cognitive impairment vs. dementia
- syncope
- skin carcinomas all resected
- venous stasis change, right lower extremity
- Type II DM, diet controlled
- Macular degeneration
- OA and Lumbar stenosis
- cardiac murmur
- breast cancer ___ year ago
- diminished hearing, wears hearing aids
- History of urinary incontinence.
Past Surgical History:
- Breast lumpectomy and radiation therapy many years ago
- Bilateral hip replacements
- Bilateral cataract surgery
Social History:
___
Family History:
- no history of leukemia
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
___ 1203 Temp: 97.9 PO BP: 115/67 HR: 82 RR: 18 O2 sat: 98%
O2 delivery: 2LNC
General: Thin, elderly woman in no distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, no thrush, neck
supple, JVP not elevated, no LAD.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops, soft murmur at RUSB
Lungs: CTAB
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, 2+ pulses, right leg externally
rotated, patient unable to move without pain.
Skin: No rashes, scattered ecchymoses over upper extremities
Neuro: alert and oriented, moves all extremities, follows
commands.
MSK - Right lower extremity:
- Skin intact
- No deformity, edema, ecchymosis, erythema, induration
- Soft thigh, tenderness to palpation of the right proximal
femur
- Fires ___
- SILT S/S/SP/DP/T distributions
- 1+ ___ pulses, WWP
DISCHARGE PHYSICAL EXAM:
========================
VS: ___ 0403 Temp: 97.5 PO BP: 129/78 L Lying HR: 87 RR: 18
O2 sat: 96% O2 delivery: Ra
GENERAL: Elderly woman sitting in bed in NAD, mildly confused at
times
HEENT: hearing aids in place but still hard of hearing. No
scleral icterus.
HEART: Systolic flow murmur heard in all auscultative fields.
LUNGS: +Mild bibasilar crackles
ABDOMEN: Soft, non-tender, non-distended.
EXTREMITIES: WWP. Right thigh w/ dressing c/d/I; mild edema;
TTP;
mild bruising outside bandage but not spreading.
NEURO: No facial droop or dysarthria
SKIN: No jaundice, no bruising.
Pertinent Results:
ADMISSION LABS:
================
___ 02:04AM BLOOD WBC-0.8* RBC-1.84* Hgb-6.9* Hct-20.8*
MCV-113* MCH-37.5* MCHC-33.2 RDW-14.6 RDWSD-60.1* Plt ___
___ 02:04AM BLOOD Neuts-57.9 ___ Monos-9.6 Eos-1.2
Baso-0.0 Im ___ AbsNeut-0.48* AbsLymp-0.25* AbsMono-0.08*
AbsEos-0.01* AbsBaso-0.00*
___ 03:23AM BLOOD ___ PTT-21.6* ___
___ 02:04AM BLOOD Glucose-179* UreaN-23* Creat-0.9 Na-131*
K-5.2 Cl-97 HCO3-23 AnGap-11
___ 01:10PM BLOOD ALT-747* AST-758* LD(___)-595*
AlkPhos-286* TotBili-0.5
___ 01:10PM BLOOD Albumin-3.5 Iron-60
___ 01:10PM BLOOD calTIBC-246* ___ Folate->20
___ Ferritn-4068* TRF-189*
___ 03:31AM BLOOD Neuts-54 ___ Monos-10 Eos-0* Baso-0
AbsNeut-0.49* AbsLymp-0.32* AbsMono-0.09* AbsEos-0.00*
AbsBaso-0.00*
PERTINENT INTERVAL LABS:
========================
___ 08:12AM BLOOD Neuts-79* Lymphs-17* Monos-3* Eos-1
Baso-0 AbsNeut-1.98 AbsLymp-0.43* AbsMono-0.08* AbsEos-0.03*
AbsBaso-0.00*
___ 11:04AM BLOOD ALT-231* AST-126* LD(___)-258*
AlkPhos-184* TotBili-0.6
___ 11:04AM BLOOD Acetmnp-12
___ 11:04AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG
___ 11:04AM BLOOD HCV Ab-NEG
___ 08:12AM BLOOD TotProt-4.8*
___ 11:04AM BLOOD Albumin-3.1*
___ 08:12AM BLOOD PEP-PND FreeKap-1770* ___ Fr
K/L-178.79* IgG-372* IgA-33* IgM-25*
___ 07:55AM BLOOD WBC-3.4* RBC-2.33* Hgb-7.8* Hct-23.2*
MCV-100* MCH-33.5* MCHC-33.6 RDW-19.0* RDWSD-68.0* Plt ___
___ 07:55AM BLOOD Neuts-88* Bands-4 Lymphs-8* Monos-0*
Eos-0* Baso-0 NRBC-0.6* AbsNeut-3.13 AbsLymp-0.27* AbsMono-0.00*
AbsEos-0.00* AbsBaso-0.00*
___ 07:55AM BLOOD Anisocy-1+* Ovalocy-1+* Schisto-1+* RBC
Mor-SLIDE REVI
___ 07:55AM BLOOD ___ PTT-24.4* ___
___ 07:55AM BLOOD Glucose-137* UreaN-24* Creat-0.9 Na-130*
K-4.5 Cl-98 HCO3-23 AnGap-9*
___ 07:55AM BLOOD ALT-51* AST-42* LD(LDH)-192 AlkPhos-150*
TotBili-0.6
___ 07:55AM BLOOD Calcium-8.3* Phos-2.9 Mg-1.8
IMAGING:
========
___ CT PELVIS AND RLE IMPRESSION:
1. Comminuted and mild-to-moderate displaced right femoral
intertrochanteric/subtrochanteric periprosthetic fracture.
2. Comminuted, mildly displaced left superior ramus, inferior
pubic ramus and pubic body fractures.
3. Concern for nondisplaced right sacral ala fracture.
4. Given patient's osteopenia additional nondisplaced fracture
may be occult. This can be further evaluated on MRI if
warranted.
___ FEMUR XRAY IMPRESSION:
No evidence of acute fracture or dislocation. Periprosthetic
fracture right upper femur shown by radiographs of the pelvis
performed elsewhere on ___.
___ ABDOMINAL ULTRASOUND IMPRESSION:
1. Status post cholecystectomy with normal spleen size. No
specific findings to explain the patient's abnormal
laboratories.
2. Trace right pleural effusion.
___ CXR IMPRESSION:
In comparison with study of ___, there are lower lung
volumes.
Cardiomediastinal silhouette is essentially unchanged. Mild
blunting of the left costophrenic angle consistent with pleural
fluid with underlying
atelectatic changes.. Indistinctness of pulmonary vessels is
consistent with some elevation in pulmonary venous pressure.
No evidence of acute focal consolidation, though this would be
difficult to unequivocally exclude in the appropriate clinical
setting.
DISCHARGE LABS:
===============
___ 08:31AM BLOOD WBC-5.0 RBC-2.79* Hgb-9.2* Hct-27.1*
MCV-97 MCH-33.0* MCHC-33.9 RDW-18.2* RDWSD-62.8* Plt ___
___ 08:31AM BLOOD Glucose-114* UreaN-18 Creat-0.6 Na-134*
K-4.5 Cl-99 HCO3-24 AnGap-11
___ 08:31AM BLOOD ALT-20 AST-31 LD(LDH)-255* AlkPhos-159*
TotBili-0.9
___ 08:31AM BLOOD Albumin-3.0* Calcium-8.8 Phos-2.2* Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Verapamil SR 180 mg PO Q24H
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 30 mg SC QHS
Continue 30 days after surgery ___ - ___
5. GuaiFENesin ___ mL PO Q6H:PRN cough
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
8. Senna 8.6 mg PO BID Constipation second line
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Periprosthetic hip fracture
Secondary:
Pancytopenia
Acute anemia likely secondary to multiple myeloma
Transaminitis
Syncope
History of SVT
Hyponatremia
Diabetes
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: Q433
INDICATION: History: ___ with L pelvic fracture R periprosthetic fx// extent
of fractures
TECHNIQUE: Mole axial CT of the pelvis was performed without intravenous
contrast. Sagittal and coronal reformats were provided.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.3 s, 33.1 cm; CTDIvol = 22.9 mGy (Body) DLP = 759.9
mGy-cm.
Total DLP (Body) = 760 mGy-cm.
COMPARISON: Radiographs from same day.
FINDINGS:
There is prominent generalized osteopenia.
There is prominent generalized osteopenia. There are postsurgical changes of
right hip arthroplasty. There is a scratch comminuted mild to moderately
displaced right femoral periprosthetic fracture involving both the
intertrochanteric and subtrochanteric regions with dominant obliquely oriented
fracture line extending to the greater trochanter.
There is an associated 10 cm butterfly fragment displaced anteromedially. The
lesser trochanter appears spared. Mild degenerative changes are seen of the
right knee. There are mild degenerative changes of the pubic symphysis.
There is a mildly comminuted, mildly displaced fracture of the left superior
and inferior pubic rami extending to the pubic body.
Additionally there is minimal cortical irregularity of the anterior aspect of
the right sacral ala concerning for a nondisplaced zone 1 fracture.
There are multiple calcified fibroids within the uterus. The pelvis is
partially obscured by metallic artifact from patient's bilateral hip
arthroplasties.
There is mild presacral edema. There are extensive atherosclerotic
calcifications of the aorta and iliacs.
There is a subcutaneous injection granuloma in the left gluteal region.
Additionally seen is stranding in hematoma in the right thigh musculature,
centered in the quadriceps muscle. There is a small right knee joint
effusion. There are mild tricompartment degenerative changes of the right
knee.
IMPRESSION:
1. Comminuted and mild-to-moderate displaced right femoral
intertrochanteric/subtrochanteric periprosthetic fracture.
2. Comminuted, mildly displaced left superior ramus, inferior pubic ramus and
pubic body fractures.
3. Concern for nondisplaced right sacral ala fracture.
4. Given patient's osteopenia additional nondisplaced fracture may be occult.
This can be further evaluated on MRI if warranted.
NOTIFICATION: The findings were discussed with Dr. ___. by ___
___, M.D. on the telephone on ___ at 9:47 am, 10 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: Q61R
INDICATION: History: ___ with L pelvic fracture R periprosthetic fx// extent
of fx
TECHNIQUE: Multiaxial CT of the right femur without intravenous contrast.
Sagittal and coronal free femorals were provided.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.5 s, 55.2 cm; CTDIvol = 19.8 mGy (Body) DLP =
1,092.0 mGy-cm.
Total DLP (Body) = 1,092 mGy-cm.
COMPARISON: There is prominent generalized osteopenia. There are
postsurgical changes of right hip arthroplasty. There is a scratch comminuted
mild to moderately displaced right femoral periprosthetic fracture involving
both the intertrochanteric and subtrochanteric regions with dominant obliquely
oriented fracture line extending to the greater trochanter.
There is an associated 10 cm butterfly fragment displaced anteromedially. The
lesser trochanter appears spared. Mild degenerative changes are seen of the
right knee. There are mild degenerative changes of the pubic symphysis.
There is a mildly comminuted, mildly displaced fracture of the left superior
and inferior pubic rami scratch extending to the pubic body.
Additionally there is minimal cortical irregularity of the anterior aspect of
the right sacral ala concerning for a nondisplaced zone 1 fracture.
FINDINGS:
1. Comminuted and mild-to-moderate displaced right femoral
intertrochanteric/subtrochanteric periprosthetic fracture.
2. Comminuted, mildly displaced left superior and inferior pubic ramus
fractures, extending to the pubic body.
3. Concern for nondisplaced right sacral ala fracture.
4. Given patient's osteopenia additional nondisplaced fracture may be occult.
This can be further evaluated on MRI if warranted.
Radiology Report
EXAMINATION: Fracture
INDICATION: History: ___ with left mid femur tenderness to palpation//
Fracture
TECHNIQUE: Three views of the left femur from hip to knee.
COMPARISON: Reference radiograph from prior day ___.
FINDINGS:
Status post left total hip arthroplasty without evidence of periprosthetic
fracture. There is heterotopic ossification lateral to the left acetabulum.
There is diffuse osteopenia which limits evaluation for subtle fractures. No
suspicious lytic or sclerotic osseous lesion. There are moderate severe
degenerative changes of the left knee joint. There is a small knee joint
effusion.
IMPRESSION:
No evidence of acute fracture or dislocation.
Periprosthetic fracture right upper femur shown by radiographs of the pelvis
performed elsewhere on ___ one.
Radiology Report
EXAMINATION: Intraoperative fluoroscopy of right femur.
INDICATION: Open reduction internal fixation of right periprosthetic fracture
in the operating room.
TECHNIQUE: 24 fluoroscopic spot images of the right femur were obtained in
the operating room without presence of radiologist.
DOSE: Fluoroscopy time 56.8 seconds, cumulative dose 469.83 mrad.
COMPARISON: Prior studies from ___.
FINDINGS:
These views show open reduction internal fixation of the right femur involving
placement of lateral fixation plate along the femur secured by multiple
interlocking screws and cerclage wires.
IMPRESSION:
Fluoroscopic images depicting on going open reduction internal fixation of the
right femur.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old woman with hx breast ca s/p lumpectomy, xrt,
tamoxifen ___ years ago, presented with pancytopenia and hip fracture, noted on
labs to have hepatocellular pattern transaminitis; s/p cholecystectomy in
past// R/o splenomegaly, r/o liver process given hepatocellular pattern
transaminitis
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of
the liver is smooth. There is no focal liver mass. The main portal vein is
patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 4 mm
GALLBLADDER: The patient is status post cholecystectomy.
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.
Spleen length: 5.2 cm
KIDNEYS: Limited views of the kidneys demonstrates no hydronephrosis..
Right kidney: 8.1 cm
Left kidney: 8.8 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
Trace right pleural effusion.
IMPRESSION:
1. Status post cholecystectomy with normal spleen size. No specific findings
to explain the patient's abnormal laboratories.
2. Trace right pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ post-op from hip surgery, worsening productive cough// Eval
pneumonia, pulm edema
IMPRESSION:
In comparison with study of ___, there are lower lung volumes.
Cardiomediastinal silhouette is essentially unchanged. Mild blunting of the
left costophrenic angle consistent with pleural fluid with underlying
atelectatic changes.. Indistinctness of pulmonary vessels is consistent with
some elevation in pulmonary venous pressure.
No evidence of acute focal consolidation, though this would be difficult to
unequivocally exclude in the appropriate clinical setting.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Femur fracture, s/p Fall
Diagnosed with Periprosth fracture around internal prosth r hip jt, init, Fall same lev from slip/trip w/o strike against object, init
temperature: 96.0
heartrate: 88.0
resprate: 18.0
o2sat: 98.0
sbp: 126.0
dbp: 62.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ year-old-female with mild cognitive
impairment (vs. mild dementia), supraventricular tachycardia vs.
nonsustained VT (unclear history), diet-controlled DM,
spine/hip/knee OA, retinal TIA, remote history of breast cancer
s/p lumpectomy, radiation, and hormonal therapy (in her ___,
prior syncopal episodes and hx SVT on verapamil, cholecystectomy
(___), and bilateral hip replacements (10 and ___ yrs ago
approximately), who presented after a fall with periprosthetic
hip fracture s/p uncomplicated ORIF on ___, and was transferred
to Medicine for thrombocytopenia, hyponatremia, and
transaminitis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Hypertension
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ presenting to the emergency department with headache,
hypertension, and diaphoresis. Patient has noted not feeling
very well for the last couple of days, noting mild headache
every morning. He was evaluated by his primary doctor 2 days ago
and was noted to have BP of 202/120 at that time so was started
on hctz and ACEI. This AM, headache was worse than prior,
located over entire head and did not resolve on its own. He also
had blurry vision. Was accompanied by diaphoresis, nausea, and
vomiting x2. Called PCP about these ___ and was referred to ER
for further evaluation. He denies any specific chest pain,
shortness of breath, left arm pain, numbness, back pain,
abdominal pain, peripheral edema, hematuria, dyspnea, orthopnea.
Has blurry vision due to not wearing glasses, though reports
previous episode of altered vision x ___ last week.
In the ED, initial vitals were 96.8 62 183/111 18 100%. ECG
showed TWI in lateral leads, J point elevations in anterior
leads. Labs were notable for Cr 1.4, Troponins neg x1. Patient
received Aspirin 325mg, Nitroglycerin gtt, Ondansetron, and
labetalol 10mg IV and was transferred to ___ for HTN management
and rule out ACS. Nitro gtt was d/c'ed and BP on transfer was
150/100.
On the floor, patient's vital signs are 98.4 153/86 70 20 99%RA.
Nitro gtt was discontinued. His headache has improved and he has
no complaints. Pt dose note that he thinks that his uncontrolled
HTN is due to recent marital issues causing him a lot of stress.
Past Medical History:
COLONIC POLYP 211.3N
HEPATITIS - C, completed IFN therapy
Obesity
Lactose intolerance
Hypertension - newly diagnosed
Social History:
___
Family History:
pos HTN parents and siblings.
No CAD/CVA in family.
Physical Exam:
Admission physical exam:
VS- 98.4 153/86 70 20 99RA
GENERAL- WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK- Supple without JVD.
CARDIAC- PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN- Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES- No c/c/e. No femoral bruits.
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES-
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Discharge physical exam:
VS- 98.4 156/115R 173/110L 70 18 100% 98.8kg
GENERAL- WDWN male in NAD. Oriented x3. Mood, affect
appropriate.
HEENT- NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthalesma.
NECK- Supple without JVD.
CARDIAC- PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. No m/r/g. No thrills, lifts. No S3 or
S4.
LUNGS- No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. CTAB, no crackles,
wheezes or rhonchi.
ABDOMEN- Soft, NTND. No HSM or tenderness. Abd aorta not
enlarged by palpation. No abdominial bruits.
EXTREMITIES- No c/c/e. No femoral bruits.
SKIN- No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES-
Right: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Left: Carotid 2+ Femoral 2+ Popliteal 2+ DP 2+ ___ 2+
Pertinent Results:
Admission labs:
___ 12:38PM BLOOD WBC-6.0 RBC-5.98 Hgb-16.8 Hct-50.2 MCV-84
MCH-28.1 MCHC-33.5 RDW-13.1 Plt ___
___ 12:38PM BLOOD ___ PTT-33.5 ___
___ 12:38PM BLOOD Glucose-98 UreaN-17 Creat-1.4* Na-139
K-5.9* Cl-104 HCO3-29 AnGap-12
___ 12:38PM BLOOD cTropnT-<0.01
___ 07:18PM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:56AM BLOOD CK-MB-2 cTropnT-<0.01
___ 06:56AM BLOOD Calcium-9.3 Phos-3.1 Mg-2.1
___ 01:37PM BLOOD K-4.5
Discharge labs:
___ 08:10AM BLOOD WBC-4.1 RBC-5.65 Hgb-16.1 Hct-47.5 MCV-84
MCH-28.6 MCHC-34.0 RDW-12.9 Plt ___
___ 08:10AM BLOOD Glucose-99 UreaN-19 Creat-1.4* Na-139
K-3.8 Cl-101 HCO3-31 AnGap-11
___ 08:10AM BLOOD Calcium-9.8 Phos-2.7 Mg-1.9
Pertinent micro/path: none
Pertinent imaging:
___ CXR:
There is no focal consolidation, pleural effusion, or
pneumothorax. Minimal atelectasis is present at the left base.
Cardiomediastinal silhouette is unremarkable. Osseous
structures are intact.
IMPRESSION: No acute cardiopulmonary process.
___ TTE:
The left atrium is mildly dilated. There is moderate symmetric
left ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Tissue Doppler
imaging suggests a normal left ventricular filling pressure
(PCWP<12mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. 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. Trace
aortic regurgitation is seen. The mitral valve appears
structurally normal with trivial mitral regurgitation. There is
no mitral valve prolapse. There is mild pulmonary artery
systolic hypertension. There is no pericardial effusion.
IMPRESSION: Moderate symmetric left ventricular hypertrophy with
preserved regional and global systolic function. Dilated
thoracic aorta. Pulmonary artery hypertension.
These findings are c/w hypertensive heart.
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.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Hydrochlorothiazide 25 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Hydrochlorothiazide 25 mg PO DAILY
RX *hydrochlorothiazide 25 mg 1 tablet(s) by mouth ONCE DAILY
Disp #*30 Tablet Refills:*1
2. Lisinopril 10 mg PO DAILY
3. Aspirin 81 mg PO DAILY
RX *aspirin [Adult Low Dose Aspirin] 81 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
4. NIFEdipine CR 30 mg PO DAILY
hold for SBP<90
RX *nifedipine [Afeditab CR] 30 mg 1 tablet(s) by mouth ONCY
DAILY Disp #*30 Tablet Refills:*1
5. Blood pressure cuff
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
1. Hypertensive urgency
Secondary:
1. Hypertension
2. Hepatitis C
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Hypertension and EKG changes, evaluate for cardiopulmonary
process.
COMPARISON: None.
TECHNIQUE: Single portable AP radiograph provided.
FINDINGS: There is no focal consolidation, pleural effusion, or pneumothorax.
Minimal atelectasis is present at the left base. Cardiomediastinal silhouette
is unremarkable. Osseous structures are intact.
IMPRESSION: No acute cardiopulmonary process.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: HYPERTENSION
Diagnosed with HYPERTENSION NOS, UNSPECIFIED VIRAL HEPATITIS C WITHOUT HEPATIC COMA
temperature: 96.8
heartrate: 62.0
resprate: 18.0
o2sat: 100.0
sbp: 183.0
dbp: 111.0
level of pain: 0
level of acuity: 2.0 | ___ with PMH of HTN and hepatitis C presents with SBP >200, HA,
nausea, and diaphoresis.
# Hypertensive urgency:
Pt with SBP >200 at PCP ___ ___, prescribed lisinopril
and HCTZ. Now with refractory HTN to SBP >200 having taken these
new medications. Presented to ED with symtoms and EKG concerning
for ACS. Troponins were negative. He was started on nitro gtt,
and his pressures improved to SBP 150s prior to transfer. His
symtoms resolved as well. He was started on his home meds
overnight in addition to amlodipine 5mg. On the floor, his BP
elevated overnight but resolved with medications again. His
amlodipine was uptitrated to 10mg daily, but he continued to
have refractory HTN overnight. He was then changed to nifedipine
30mg long acting daily. Lisinopril and HCTZ could not be
uptitrated due to elevated Cr. An echo was performed to evaluate
for structural damage secondary to HTN, which showed mild LVH,
normal EF, and mild pulmonary hypertension.
# ___:
Pt with Cr of 1.4, baseline unknown. No known hx of renal
insufficiency per atrius notes, but pt had not been followed by
a PCP ___. Possibly elevated at baseline due to chronic
uncontrolled HTN. UA shows protein in the urine, supporting
chronic renal insufficiency. In addition, could be acutely
elevated in the setting of recently starting HCTZ and
lisinopril. It is also possible that the acute injury is in the
setting of hypertensive emergency, thus reflecting end organ
damage. FeUrea 52%, which is borderline ATN/prerenal territory.
Most likely a mixed picture which will improve with management
of his HTN.
# ACS rule out:
EKG with J point elevations and TWI concerning for ACS first
seen at ___'s office. Pt denies CP or SOB. Not started on
heparin gtt. Trops negative x3. Most likely hypertensive
structural heart changes causing EKG patterns.
# Hep C: stable. s/p interferon-ribavirin therapy with
resolution.
# CAD risk: No family history. Pt risk factors include HTN and
obesity. Last lipid panel ordered in atrius ___, pending. Pt
was started on ___ daily. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
green soap
Attending: ___.
Chief Complaint:
"decreased kidney function"
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old F with hx of HTN, DM, HLD, CKD (Stage III), and
papillary thyroid carcinoma s/p total thyroidectomy on ___
presents for elevated creatinine. She has routine blood work
last week and noted to have elevated Cr (baseline 1.1 in
___ per PCP's records). Repeat Cr on ___ and today
showed continued gradual worsening creatinine (3.5). As a
result, PCP (___) sent to ___ where
Cr was 3.9 and BUN 58.
Patient transferred to ___ because due to have a total body
scan today as part of her thyroid treatment. Creatinine in our
system is 0.9 on ___. Denies dysuria and polyuria.
Continues to make same amount of urine and denies foamy urine or
hematuria. Has horseshoe kidney, but never had problems with
obstruction/stones. Several UTIs (less than 1/year) and last one
was many years ago. States that her PO intake has been less
since ___ when she started her low iodine diet and stopped
taking levothyroxine.
Also reports feeling generalized weakness, "crappy" and "I
couldn't get out of bed for a week." Cold intolerance and weight
gain since starting low iodine diet and discontinuing
levothyroxine ___. No constipation, confusion, changes in skin,
fevers, chills, CP, abdominal pain, sob, URI like symptoms.
In the ED, initial vs were: 98.8 58 108/66 16 100% RA. Renal
ultrasound was obtained which showed no hydronephrosis,
+horseshoe kidney.
Vitals on Transfer: 97.8 56 113/62 16 98% RA.
All antihypertensives (amlodipine, HCTZ, lisinopril,
spirinolactone) were discontinued with the exception of her home
metoprolol. Her omeprazole was also held given the concern for
acute interstitial nephritis. She received 2L IVF upon
admission.
Past Medical History:
Hypertension
Diabetes Mellitus
Hyperlipidemia
Obstructive Sleep Apnea
Gastroesophageal Reflux Disease
Multinodular goiter --> papillary thyroid carcinoma
Surgical hypothyroidism
PSH:
total thyroidectomy (___) for papillary thyroid carcinoma
cholecystectomy
D&C
Social History:
___
Family History:
NC
Physical Exam:
Vitals:
T 98 BP ___ P ___ RR 18 Sa02 100% on room air
General: Obese middle aged woman lying in bed with multiple
blankets in NAD.
HEENT: Sclerae/conjunctivae without lesions. Oral mucosa moist.
Could not see OP. Thyroidectomy scar.
NECK: could not see JVP given habitus. No LAD. Thyroidectomy
scar
CV: RRR, no murmurs gallops or rubs.
Pulm: good air movement, no rales/wheezes/rhonchi
NEURO: Alert & oriented x4. Cranial nerves intact. Speech fluent
with marked speech delay. DTRs were ___ but delayed relaxation.
Strength ___ throughout.
EXT: 2+ DP pulses, no edema, no rashes, skin cool
Pertinent Results:
___ 07:10AM BLOOD WBC-8.2 RBC-4.30 Hgb-12.5 Hct-36.1 MCV-84
MCH-29.0 MCHC-34.5 RDW-14.1 Plt ___
___ 07:10AM BLOOD Neuts-55.9 ___ Monos-3.3 Eos-5.8*
Baso-0.6
___ 07:10AM BLOOD Glucose-102* UreaN-51* Creat-3.2*# Na-137
K-4.5 Cl-100 HCO3-22 AnGap-20
___ 06:55AM BLOOD Glucose-111* UreaN-31* Creat-2.1*# Na-140
K-4.5 Cl-107 HCO3-18* AnGap-20
___ 06:30AM BLOOD Glucose-124* UreaN-23* Creat-2.1* Na-142
K-4.4 Cl-107 HCO3-23 AnGap-16
___ 07:10AM BLOOD ALT-26 AST-35 LD(LDH)-341* AlkPhos-78
TotBili-0.2
___ 07:10AM BLOOD Albumin-4.8 Calcium-10.1 Phos-3.2 Mg-2.5
Renal US ___
INDICATION: Worsening renal failure.
TECHNIQUE: Renal ultrasound.
COMPARISONS: None available.
FINDINGS: The kidneys measure approximately 11.1 and 11.8 cm on
the right and left, respectively. However, the kidneys are
inferiorly and medially located, consistent with a horseshoe
kidney. There is no hydronephrosis, stone, or mass.
IMPRESSION: No hydronephrosis. Horseshoe kidney. The study and
the report were reviewed by the staff radiologist.
I-123 scan
RADIOPHARMACEUTICAL DATA:
1.0 mCi I-123 Sodium Iodide ___
HISTORY: Thyroid cancer, s/p thyroidectomy.
INTERPRETATION: Approximately 24 hours following the oral
ingestion of tracer,uptake of tracer in the thyroid bed is
measured to be 0.6%.
Scan of thyroid bed shows no obvious remnant.
Images of the whole body show no evidence of distant metastasis.
IMPRESSION: No evidence of residual functioning thyroid tissue.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. GlipiZIDE 10 mg PO DAILY
3. Hydrochlorothiazide 25 mg PO DAILY
4. Lisinopril 20 mg PO DAILY
5. Metoprolol Tartrate 25 mg PO BID
6. Omeprazole 20 mg PO DAILY
7. Spironolactone 25 mg PO DAILY
Discharge Medications:
1. Metoprolol Tartrate 25 mg PO BID
2. GlipiZIDE 10 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
#Acute on chronic renal failure
SECONDARY DIAGNOSES
#Chronic kidney disease, stage III
#Hypothyroidism
#Papillary thyroid carcinoma
#Gastroesophageal reflux disease
#Obstructive sleep apnea
#Type 2 diabetes mellitus
Discharge Condition:
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Mental Status: Clear and coherent.
Followup Instructions:
___
Radiology Report
INDICATION: Worsening renal failure.
TECHNIQUE: Renal ultrasound.
COMPARISONS: None available.
FINDINGS: The kidneys measure approximately 11.1 and 11.8 cm on the right and
left, respectively. However, the kidneys are inferiorly and medially located,
consistent with a horseshoe kidney. There is no hydronephrosis, stone, or
mass.
IMPRESSION: No hydronephrosis. Horseshoe kidney.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ACUTE RENAL FAILURE
Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, DIABETES UNCOMPL ADULT, HYPERTENSION NOS
temperature: 98.8
heartrate: 58.0
resprate: 16.0
o2sat: 100.0
sbp: 108.0
dbp: 66.0
level of pain: 0
level of acuity: 2.0 | Ms ___ is a ___ yo woman with DMII, HTN, papillary thyroid
carcinoma s/p resection in ___, and CKDIII who presents as a
transfer from ___ for acute on chronic
kidney injury likely secondary to pre-renal azotemia.
#Acute on chronic kidney failure:
This patient has a baseline Cr of 1.1-1.2 per her PCP's records
(reviewed over phone) back in ___. She was noted to
have a Cr of 3.5 on ___ then 3.9 at ___
___ yesterday (3.9). She has not had any extra fluid losses
(diarrhea, polyuria, profuse sweating) nor has she had poor PO
intake. However, she has not taken any thyroid medication since
___ and her gland is surgically absent. Clinically she is very
hypothyroid. Despite being without thyroid hormone replacement
she was on multiple antihypertensive medications (HCTZ,
amlodipine, lisinopril, metoprolol, and spironolactone). The ACE
would directly impair renal blood flow and the diurectics could
indirectly cause the same effect through hypovolemia. All of
these together likely caused pre-renal azotemia which explains
her responsiveness to IV fluid (Cr 3.9 > 2.1) with 2L saline.
On urine microscopy today there were no casts or dysmorphic
RBCs, and there were moderate WBC w/o white cell casts. This
non-specific urinary sediment did not suggest acute tubular
necrosis or acute interstitial nephritis.
#Hypothyroidism: This is secondary to surgical removal of the
thyroid in ___ for papillary thyroid carcinoma. The patient
has been off levothyroxine since ___ in order to increase her
TSH prior to a iodine-123 uptake scan which she had during this
admission. She was maintained on a low iodine diet in accordance
with the nuclear medicine protocol. She will resume her
levothyroxine in accordance with their protocol after discharge.
#Hypertension: See above. All of her home medications except
metoprolol were discontinued in the setting of her acute kidney
injury. Her blood pressures were on the low side (93-115/50-72)
in the last 24 hours on a single agent after 3L of IV fluids.
She was discharged on only metoprolol and her other home
antihypertensives can be restarted after she resumes her
levothyroxine by her PCP.
#Obstructive sleep apnea: The patient is on CPAP at home. She
tolerated sleeping without CPAP x2 days.
#GERD: On outpatient omeprazole for GERD. Discontinued in the
setting of possible acute interstitial nephritis, but because of
the sudden overnight improvement in creatinine after IV fluids
AIN was considered less likely as a cause of her acute renal
failure. She was discharged on her home omeprazole. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
trimethoprim / Sulfa (Sulfonamide Antibiotics) / amoxicillin
Attending: ___.
Chief Complaint:
jaundice
Major Surgical or Invasive Procedure:
Paracentesis ___
History of Present Illness:
Mr. ___ is a ___ year-old man
with a history of alcohol use disorder, who presents as a
transfer from ___ with jaundice.
Patient reports that jaundice has been progressive over the last
several months. Symptoms acutely worsened over last 2 weeks.
Referred to ___, where he was found to have tbili 46,
direct bili 38, lipase 800-900, Na 128,INR 2.2, creat 1.8.
Transferred to ___ for further evaluation. Patient reports no
pain. He has been drinking heavily, 3 L per week. Reports last
drink yesterday. Reports history of alcohol withdrawal in the
past, usually after 3 days, signaled by worsening tremors.
Patient does not feel that he is currently withdrawing. Denies
hallucinosis, seizure. No medication. Lives at home with his
father. ___ fevers, chills, nausea, vomiting, chest pain,
shortness of breath, abdominal pain, change in bowel or bladder
function, calf swelling or edema, new lesion or lymphadenopathy
In the ED initial vitals: T 98.1, HR 106, BP 119/83, RR 18, O2
sat 99% RA
- Exam notable for: Patient tachycardic. Grossly icteric and
jaundiced. Mildly tremulous. No asterixis. Reduced breath sounds
bilaterally. Abdomen mildly distended, stretch marks visible. No
calf swelling or edema.
- Labs notable for:
-INR 2.2
-CBC: WBC 13.8, Hgb 12.3 Plt 158
-LFTs: ALT 31, AST 89, AP 187 Tbili 47.2, Dbili 35, Alb 3.3
-Chemistry: Na 133, BUN 15, Sr Cr 1.6
-Lactate: 1.3
-UA: Notable for 11RBC, 18WBC bacteria, small leuks
-Utox: Negative
- Imaging notable for: CT abdomen ___ at ___
consistent with cirrhosis and portal hypertension. Atelectasis
with and without superimposed developing infiltrate in the right
lower lobe. 0.9 cm hypodense lesion in the dome of the liver,
not
characterized on this examination indeterminate. While this may
represent a cyst, this can be further evaluated with nonemergent
MRI of the abdomen with and without contrast, given the higher
risk of malignancy in this patient given the suggested
cirrhosis.
Acute right-sided colitis versus under distention. Some
limitation of the absence of oral contrast.
CXR ___: minimal elevation of the right hemidiaphragm and
minimal associated right basilar atelectasis. No discrete lobar
consolidation, congestive heart failure or pleural effusion.
RUQ US ___: 1. Patent portal venous vasculature, however
with
slow flow demonstrated in the main portal vein and reversal of
flow within the anterior and posterior branches of the right
portal vein.
2. Coarsened liver without evidence of concerning focal lesions.
3. Moderate splenomegaly, measuring up to 18.9 cm.
4. Mildly distended common bile duct measuring up to 9 mm and
tapering
distally. Recommend further evaluation with MRCP on a
nonemergent
basis.
- Consults: Hepatology-
- chest x ray, US abd and diagnostic para, urine blood culture.
- IV albumin
- admit to Farr10
- Patient was given: T 99.2 HR 107, BP 119/81, RR 16, O2 sat 95%
RA
- ED Course:
IV Albumin 25% (12.5g / 50mL) 25 g
PO/NG LORazepam 2 mg
On the floor, the patient confirmed the above history. He states
that his jaundice has progressed over the past several months.
Of
note, the patient has a history of DTs in the past. No history
of
withdrawal seizures or intubations. Does not report fevers,
chills, chest pain, shortness of breath, nausea, vomiting,
abdominal pain, and changes in bowel or bladder habits.
Past Medical History:
Alcohol use disorder
Depression
Social History:
___
Family History:
Mother with bipolar disorder. Both mother and
father with alcohol use disorder.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
==============================
VS: 99.6 PO 133 / 88 118 18 95 RA
GENERAL: NAD, pleasant, comfortable
HEENT: AT/NC, EOMI, PERRL, icteric sclerae, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: tachycardic, regular rhythm, nl S1/S2, no murmurs,
gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: mildly distended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: diffusely jaundiced
DISCHARGE PHYSICAL EXAMINATION:
==============================
24 HR Data
Temp: 99.1 (Tm 99.2), BP: 126/79 (110-153/71-82), HR: 103
(94-109), RR: 18 (___), O2 sat: 100% (97-100), O2 delivery:
RA,
Wt: 180.4 lb/81.83 kg
GENERAL: sitting in bed, NAD, alert and responding to questions.
Jaundiced
HEENT: EOMI, PERRL, icteric sclerae, MMM
NECK: supple, no LAD, no JVD
HEART: RRR, nl S1/S2, systolic flow murmur+. No gallops, or rubs
LUNGS: CTAB, breathing comfortably
ABDOMEN: distended, mildly tender in RUQ and RLQ, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose. Mild
tremors
in hands
SKIN: diffusely jaundiced. Para site with recent dressing that
was clean and dry
Pertinent Results:
ADMISSION LABS:
=======================
___ 08:15PM BLOOD Neuts-86.4* Lymphs-2.6* Monos-8.1 Eos-1.5
Baso-0.5 Im ___ AbsNeut-11.88* AbsLymp-0.36* AbsMono-1.11*
AbsEos-0.21 AbsBaso-0.07
___ 08:15PM BLOOD ___ PTT-42.0* ___
___ 08:15PM BLOOD Glucose-105* UreaN-15 Creat-1.6* Na-133*
K-3.6 Cl-93* HCO3-21* AnGap-19*
___ 08:15PM BLOOD ALT-31 AST-89* AlkPhos-187* TotBili-47.2*
DirBili-35.0* IndBili-12.2
___ 08:15PM BLOOD Albumin-3.3* Calcium-8.6 Phos-2.0* Mg-1.8
___ 07:15AM BLOOD Triglyc-286* HDL-LESS THAN
___ 08:15PM BLOOD Osmolal-277
___ 01:05PM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG HAV Ab-NEG
___ 08:15PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
EtGlycl-LESS THAN Tricycl-NEG
___ 01:05PM BLOOD HCV Ab-NEG
___ 08:26PM BLOOD Lactate-1.3
___ 10:00PM URINE Color-Yellow Appear-Clear Sp ___
___ 10:00PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-LG* Urobiln-2* pH-7.5 Leuks-SM*
___ 10:00PM URINE RBC-11* WBC-18* Bacteri-FEW* Yeast-RARE*
Epi-0
___ 10:00PM URINE Hours-RANDOM UreaN-285 Creat-90 Na-32
___ 10:00PM URINE Osmolal-330
___ 10:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG oxycodn-NEG mthdone-NEG
MICRO:
====================
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
STUDIES:
=======================
LIVER OR GALLBLADDER US (SINGLE ORGAN) Study Date of ___
10:07 ___
1. Coarsened liver echotexture concerning for cirrhosis without
evidence of
worrisome focal lesions.
2. Patent portal venous vasculature, however with slow flow
demonstrated in
the main portal vein.
3. Findings indicative of portal hypertension including
splenomegaly and
hepatofugal flow in the main portal and anterior and posterior
branches of the
right portal vein.
4. Mildly dilated common bile duct measuring up to 9 mm without
intrahepatic
biliary dilatation. Recommend further evaluation with MRCP if
there is
concern for biliary obstruction.
MRCP (MR ABD ___ Study Date of ___ 5:21 ___
Findings most consistent with acute on chronic hepatic injury
including portal
hypertension. No evidence for biliary obstruction or filling
defects.
Increased retroperitoneal fluid; query coinciding acute
pancreatitis.
___ EGD (___)
Grade II v arices at distal esophagus
Congestion, petechiae and mosaic pattern in the stomach fundus
and stomach body compatible with portal hypertensive gastrophaty
Normal muscoase in duodenum
NJ tube was placed passed the third portion of the duodenum
___ US ABD LIMIT, SINGLE OR
Minimal ascites, most notable in the right lower quadrant.
___ ABD & PELVIS W/O CON
1. No evidence of acute intra-abdominal process within the
confines of a noncontrast study. Specifically, no bowel
obstruction, ileus, or gross perforation.
2. Cirrhotic liver with small to moderate ascites, moderate to
severe splenomegaly, paraumbilical vein recanalization, and
intra-abdominal varices.
DISCHARGE LABS:
========================
___ 04:30AM BLOOD WBC-36.8* RBC-3.07* Hgb-9.9* Hct-28.0*
MCV-91 MCH-32.2* MCHC-35.4 RDW-28.5* RDWSD-94.1* Plt ___
___ 04:30AM BLOOD ___ PTT-38.2* ___
___ 04:30AM BLOOD Glucose-113* UreaN-57* Creat-1.6* Na-136
K-3.6 Cl-101 HCO3-15* AnGap-20*
___ 04:30AM BLOOD ALT-67* AST-79* LD(LDH)-292* AlkPhos-204*
TotBili-43.6*
___ 04:30AM BLOOD Albumin-3.8 Calcium-8.8 Phos-3.6 Mg-2.3
Medications on Admission:
None
Discharge Medications:
1. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. HydrOXYzine ___ mg PO Q4H:PRN Itching
RX *hydroxyzine HCl 25 mg ___ tablets by mouth every four (4)
hours Disp #*120 Tablet Refills:*0
3. LORazepam 0.25 mg PO BID insomnia
RX *lorazepam 0.5 mg 1 by mouth twice a day Disp #*6 Tablet
Refills:*0
4. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth three times a day Disp
#*10 Tablet Refills:*0
6. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
7. Sodium Bicarbonate 1300 mg PO BID
RX *sodium bicarbonate 650 mg 2 tablet(s) by mouth twice daily
Disp #*120 Tablet Refills:*0
8. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
9. TraZODone 50 mg PO QHS
RX *trazodone 50 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
10. Ursodiol 600 mg PO BID
RX *ursodiol 300 mg 2 capsule(s) by mouth twice a day Disp #*120
Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
==================
Alcohol Hepatitis
Alcohol Cirrhosis complicated by:
-Ascites
-Coagulopathy
SECONDARY DIAGNOSIS:
=====================
#Spontaneous Bacterial Peritonitis
#Acute Kidney Injury
#Depression
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRCP.
INDICATION: Query stone or obstructing mass at the ampulla. Common bile duct
dilatation. History of cirrhosis high total bilirubin.
TECHNIQUE: Multiplanar T1- and T2-weighted images of the abdomen were
obtained on a 1.5 tesla magnet, including sequences obtained prior to and
following intravenous gadolinium contrast administration, including dedicated
MRCP imaging sequences.
COMPARISON: CT and ultrasound studies dated ___.
FINDINGS:
Liver is moderately enlarged. Liver appears heterogeneous particularly on
arterial phase imaging suggesting acute parenchymal injury. Fatty
infiltration is heterogeneous. A round lesion in the right hepatic dome
measures 12 mm in diameter and is consistent with a simple cyst. Trace
ascites is found about the liver.
No stones are identified in the gallbladder. Mild wall thickening and
intramural edema is very probably secondary to the acute liver failure.
The spleen is moderately enlarged, measuring up to 17 point 6 cm in length.
There is small quantity of ill-defined peripancreatic fluid as well as fluid
in the right anterior pararenal space, which may have increased since the
recent prior CT raising concern for pancreatitis. Adrenals appear
unremarkable. Kidneys appear normal.
The biliary ducts show no substantial dilatation. No filling defects are
found among biliary ducts. Maximum caliber of extrahepatic biliary ducts
measures up to only 6 mm on this study.
Esophageal and paraesophageal varices are demonstrated. Umbilical vein is
patent. Retroperitoneal collaterals are also present. Portal vein and other
major mesenteroportal venous structures are patent.
Visualized bowel is unremarkable. No substantial lymph nodes are found.
IMPRESSION:
Findings most consistent with acute on chronic hepatic injury including portal
hypertension. No evidence for biliary obstruction or filling defects.
Increased retroperitoneal fluid; query coinciding acute pancreatitis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with EtOH hepatitis// Increased leukocytosis and
clinically feeling worse. Please assess if respiratory infection findings
IMPRESSION:
In comparison with the study of ___ there are lower lung volumes with
elevation of the right hemidiaphragmatic contour and atelectatic changes just
above it.. Cardiac silhouette is at the upper limits of normal in size and
there is engorgement of pulmonary vessels consistent with elevated pulmonary
venous pressure.
In the appropriate clinical setting, it would be difficult to unequivocally
exclude superimposed pneumonia, especially in the absence of a lateral view.
Radiology Report
EXAMINATION: US ABD LIMIT, SINGLE ORGAN
INDICATION: ___ year old man with EtOH hepatitis// Is there any ascites?
Looking to r/o SBP with tap if present
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: MRCP from ___.
FINDINGS:
There is minimal ascites, most notable in the right lower quadrant.
IMPRESSION:
Minimal ascites, most notable in the right lower quadrant.
Radiology Report
INDICATION: ___ year old man with alc hep, cirrhosis, new fever// diagnostic
para for ?SBP
TECHNIQUE: Ultrasound guided diagnostic paracentesis
COMPARISON: MRI from ___
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a small
amount of ascites. In the right lower quadrant.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
A 5 ___ catheter was advanced into the small fluid pocket in the right
lower quadrant under direct ultrasound guidance and 400 cc of serous fluid
were removed. A sample was sent for requested analysis.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ performed the procedure.
IMPRESSION:
1. Diagnostic paracentesis, 400 cc of fluid removed. Samples were sent for
analysis
Radiology Report
EXAMINATION: Ultrasound-guided interventional procedure
INDICATION: ___ year old man with ETOH Cirrhosis, alcoholic hepatitis//
diagnostic/therapeutic tap
TECHNIQUE: Ultrasound guided diagnostic and therapeutic paracentesis
COMPARISON: Paracentesis from ___.
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a large
amount of ascites. A suitable target in the deepest pocket in the right lower
quadrant was selected for paracentesis.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
A 5 ___ catheter was advanced into the largest fluid pocket in the right
lower quadrant and 1.1 L of clear, straw-colored fluid were removed.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ supervised the trainee during the key components of the
procedure and reviewed and agrees with the trainee's findings.
IMPRESSION:
1. Technically successful ultrasound guided diagnostic and therapeutic
paracentesis.
2. 1.1 L of fluid were removed.
Radiology Report
EXAMINATION: CR - CHEST PORTABLE AP
INDICATION: ___ year old man with EtOH cirrhosis p/w new SOB// eval for cause
of SOB
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___.
FINDINGS:
There are low lung volumes. The right hemidiaphragm is elevated. There is no
focal consolidation, pleural effusion or pneumothorax. The cardiomediastinal
silhouette is within normal limits. No acute osseous abnormalities are
identified. An enteric tube crosses the diaphragm and terminates outside of
the field of view. The stomach is distended with air.
IMPRESSION:
1. No pneumonia or acute cardiopulmonary process.
2. The stomach is distended with air.
Radiology Report
EXAMINATION: CT ABDOMEN AND PELVIS WITHOUT CONTRAST
INDICATION: ___ year old man with EtOH hepatitis/decompensated cirrhosis with
acute onset of abdominal pain, evaluate for ileus vs. SBO vs perforation
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 4.9 s, 65.2 cm; CTDIvol = 13.8 mGy (Body) DLP = 896.8
mGy-cm.
Total DLP (Body) = 897 mGy-cm.
COMPARISON: MRCP dated ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: Liver is enlarged and heterogeneous with a mildly nodular
contour consistent with known cirrhosis. There is small to moderate simple
perihepatic, perisplenic, and free intraperitoneal ascites. The paraumbilical
vein is recanalized. Hypodensity in segment VII corresponds to the simple
cyst or biliary hamartoma seen on recent MRCP (02:18). There is no evidence
of intrahepatic or extrahepatic biliary dilatation. The gallbladder is
decompressed, limiting assessment.
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: There is moderate to severe splenomegaly with the spleen measuring up
to 18 cm in greatest coronal dimension (601:41).
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no evidence
of focal renal lesions within the limitations of an unenhanced scan. There is
no hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Enteric tube courses through
the stomach and terminates in the third portion of the duodenum. Small bowel
loops demonstrate normal caliber and wall thickness throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy,
although mesenteric lymph nodes are increased in number, likely reactive.
There is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: An umbilical hernia containing fat is noted.
IMPRESSION:
1. No evidence of acute intra-abdominal process within the confines of a
noncontrast study. Specifically, no bowel obstruction, ileus, or gross
perforation.
2. Cirrhotic liver with small to moderate ascites, moderate to severe
splenomegaly, paraumbilical vein recanalization, and intra-abdominal varices.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal labs, Jaundice
Diagnosed with Acute and subacute hepatic failure without coma, Unspecified abdominal pain
temperature: 98.1
heartrate: 106.0
resprate: 18.0
o2sat: 99.0
sbp: 119.0
dbp: 83.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ year-old man with a history of alcohol use
disorder, who presents as a transfer from ___ with
jaundice. Overall picture most concerning for severe alcoholic
hepatitis, complicated by SBP and found to be steroid non
responder. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodine-Iodine Containing / Amoxicillin / Doxazosin / Terazosin
Attending: ___.
Chief Complaint:
sent from PCP due to lightheadedness and chest discomfort
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH of CAD s/p multiple stents, hx of multiple MIs,
CVA, DMII, Afib (on metoprolol and coumadin) who presents with
progressive chest discomfort and lightheadedness.
Patient has had chest discomfort for the past 6 month. He
describes it as a "funny feeling in his chest" but no chest
pain. It is nonpleuritic. The pain occurs at rest and at
exertion. There are no associated symptoms of nausea, vomiting,
diaphoresis, numbness or tingling. These symptoms have been
increasing in frequency and duration, occurring now daily. He
uses sub lingual nitro (up to 3 times), which sometimes
alleviates the pain. The pain usually resolves after one hour
of rest.
Patient had recent admission ___ for chest chest pain with
troponin leak of .05 and EKG showing lateral, non-specific T
wave changes. After discussion with patient and outpatient
cardiologist, medically managed with imdur increased to 90mg
daily and atorvastatin was decided. He was recently seen in
cardiology clinic ___ and given progressive symptoms
increased to imdur 120 mg daily. At that time he had plan for
catheterization if symptoms continue to increase.
Patient awoke on morning of admission feeling lightheaded. He
progressed through the day and while he was sitting down noticed
his usual chest discomfort beginning. He went to his PCP for ___
scheduled appointment and was found to look "unwell" with
tachycardia and hypotension and was sent to the ___ ED by
ambulance.
In the ED patient was found to be in Afib/flutter with RVR with
rates in 150s. Initial vitals in the ED were ___ 18 96%
RA. He was given adenosine 6mg, diltiazem 50 mg, and metoprolol
tartrate 25 mg. By 1:30pm, patient's heart resolved to ___.
Unable to gain access so placed RIJ central line. EKG had
concern for worsening ST elevations. Troponins were 0.05.
Labs: CBC 6.5>13.6/39.2<142. Chem, INR 1.7.
On arrival to the floor patient did not report chest pain or
lightheadedness. He was in NSR with HRs in the ___. Admitted for
cardiac catheterization. Overnight no acute events.
No recent dyspnea on exertion, weight gain, swelling.
Past Medical History:
CAD: status post MI in ___ and stent ___ years ago. He had a
non-Q-wave MI in ___ with PTCA of the LAD at that time. He also
had an anterior infarction in ___, which was treated with TPA.
Cardiac cath ___: The LAD had a 100% proximal occlusion.
TheLCx had a 30% in the proximal portion. There was a 100%
occlusion of the OM1 which was not stented as technally
challenging. The RCA had patent stents with a 40% stenosis in
the mid portion.
sHF: (EF 30%)
Aortic stenosis
OTHER PAST MEDICAL HISTORY:
Kidney stones
Diabetes type 2: dx in ___.
Hypertension: long standing
CVA: ___ with no residual deficits
Depression.
Hypothyroidism.
Right frontal meningioma followed by Dr. ___, MD
___
Abdominal hernia repair
Colon cancer
Social History:
___
Family History:
No family history of early MI or sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 37.1 BP 145/98 HR62 RR18 SaO2 95 on RA
General: Patient is lying in bed in no apparent distress
HEENT: EOMI
Neck: RIJ in place, JVP not assessed
CV: heart sounds faint, regular rate and rhythm, S1 and S2, no
murmurs, rubs, or gallops appreciated
Lungs: clear to auscultation bilaterally
Abdomen: soft, nondistended, nontender
Ext: warm and well perfused, no evidence of edema
Neuro: CNXII grossly in tact
Skin: no evidence of rashes
DISCHARGE PHYSICAL EXAM
VS: 97.6, BP 148/56, HR54, RR20, 94RA
General: Patient is lying in bed in no apparent distress
HEENT: EOMI
Neck: RIJ in place, JVP not assessed
CV: heart sounds faint, regular rate and rhythm, S1 and S2, no
murmurs, rubs, or gallops appreciated
Lungs: clear to auscultation bilaterally
Abdomen: soft, nondistended, nontender
Ext: warm and well perfused, no evidence of edema
Neuro: CNXII grossly in tact
Skin: no evidence of rashes
Pertinent Results:
ADMISSION LABS
___ 02:30PM BLOOD WBC-6.5 RBC-4.20* Hgb-13.6* Hct-39.2*
MCV-93 MCH-32.3* MCHC-34.6 RDW-14.3 Plt ___
___ 03:59AM BLOOD ___ PTT-49.3* ___
___ 02:30PM BLOOD Glucose-157* UreaN-19 Creat-1.1 Na-137
K-3.1* Cl-103 HCO3-24 AnGap-13
___ 02:30PM BLOOD CK(CPK)-110
___ 02:30PM BLOOD CK-MB-4
___ 02:30PM BLOOD Calcium-8.7 Phos-3.2 Mg-1.6
.
DISCHARGE LABS
___ 03:59AM BLOOD WBC-6.6 RBC-3.95* Hgb-12.9* Hct-35.7*
MCV-90 MCH-32.7* MCHC-36.2* RDW-13.7 Plt ___
___ 03:59AM BLOOD Plt ___
___ 03:59AM BLOOD Glucose-58* UreaN-17 Creat-1.0 Na-144
K-3.6 Cl-111* HCO3-28 AnGap-9
.
CXR ___
1. Right internal jugular central venous catheter tip in the mid
SVC. No
large pneumothorax identified.
2. Elevated venous pressures.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Losartan Potassium 25 mg PO DAILY
7. Senna 1 TAB PO BID:PRN constipation
8. Tamsulosin 0.4 mg PO HS
9. Atorvastatin 80 mg PO DAILY
10. Albuterol Inhaler 1 PUFF IH PRN SOB, wheezing
11. cilostazol 100 mg ORAL BID
12. Diphenoxylate-Atropine 1 TAB PO DAILY:PRN diarrhea
13. GlyBURIDE 5 mg PO BID
14. LOPERamide 2 mg PO BID:PRN diarrhea
15. Metoprolol Succinate XL 25 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-6-150
mg-unit-mg-mg Oral Daily
18. Polyethylene Glycol 17 g PO DAILY:PRN constipation
19. travoprost 0.004 % OS QHS
20. Warfarin 5 mg PO DAILY16
21. Warfarin 4 mg PO 3X/WEEK (___)
22. Omeprazole 20 mg PO BID:PRN heartburn
23. Vitamin D ___ UNIT PO DAILY
24. Fish Oil (Omega 3) 1000 mg PO DAILY
25. Bisacodyl 5 mg PO DAILY:PRN constipation
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. cilostazol 100 mg ORAL BID
5. Docusate Sodium 100 mg PO BID
6. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
7. Levothyroxine Sodium 75 mcg PO DAILY
8. Losartan Potassium 25 mg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Senna 1 TAB PO BID:PRN constipation
12. Tamsulosin 0.4 mg PO HS
13. Warfarin 5 mg PO 4X/WEEK (___)
14. Warfarin 4 mg PO 3X/WEEK (___)
15. Enoxaparin Sodium 150 mg SC DAILY Start: ___, First
Dose: First Routine Administration Time
until INR above 2.0
RX *enoxaparin 150 mg/mL 150 mg sc once daily Disp #*3 Syringe
Refills:*1
16. Albuterol Inhaler 1 PUFF IH PRN SOB, wheezing
17. Bisacodyl 5 mg PO DAILY:PRN constipation
18. Diphenoxylate-Atropine 1 TAB PO DAILY:PRN diarrhea
19. Fish Oil (Omega 3) 1000 mg PO DAILY
20. GlyBURIDE 5 mg PO BID
21. LOPERamide 2 mg PO BID:PRN diarrhea
22. Multivitamins 1 TAB PO DAILY
23. Ocuvite (vit C-vit E-lutein-min-om-3) 150-30-6-150
mg-unit-mg-mg Oral Daily
24. Omeprazole 20 mg PO BID:PRN heartburn
25. travoprost 0.004 % OS QHS
26. Vitamin D ___ UNIT PO DAILY
27. Outpatient Lab Work
INR
Fax results to:
___
___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis: Afib with RVR, Lightheadedness
Secondary diagnosis:
CAD
HTN
HLD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Atrial fibrillation.
TECHNIQUE: Supine AP view of the chest.
COMPARISON: ___.
FINDINGS:
The right internal jugular central venous catheter tip terminates in the mid
SVC. The lung volumes are low. The heart size remains moderately enlarged.
The aorta is tortuous and calcified. Widening of the mediastinum is likely
related to supine positioning and elevated venous pressures which is mild.
There is no focal consolidation, large pleural effusion or large pneumothorax
on this supine study. No acute osseous abnormalities detected.
IMPRESSION:
1. Right internal jugular central venous catheter tip in the mid SVC. No
large pneumothorax identified.
2. Elevated venous pressures.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with ATRIAL FIBRILLATION
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | Mr. ___ is an ___ year old male with PMH of CAD s/p multiple
stents, with hx of multiple MIs, CVA, DMII, Afib (on metoprolol
and coumadin) who presented with progressive chest discomfort
and lightheadedness and found to be in Afib/flutter with RVR was
rate controlled with diltiazem, metoprolol with self resolution
to sinus rhythm. Previously scheduled catheterization was
deferred given that symptoms were thought to be more likely
related to progressive Afib vs. coronary disease with plan for
further work up and management of Afib.
.
ACTIVE ISSUES
.
# Chest discomfort: progressive over past few months despite
increase in isosorbide mononitrate. Occurs daily at both rest
and exertion. Patient presented with chest discomfort and
lightheadedness in Afib with RVR. Trops neg x2 and mild ST
depression on EKG v5 and v5. Chest discomfort resolved once
patient was back in normal sinus rhythm. Touched base with
patient's outpatient cardiologist and scheduled catheterization
was deferred given symptoms seemed more consistent with Afib
than ACS. Asymptomatic on discharge.
.
# Parox Afib: CHADS2 6. Rate controlled and anticoagulated.
Presented to ED in Afib with RVR to 150s. Beta blocked with
metoprolol and diltiazem. Was been in sinus since arrival to
floor. Warfarin held prior to cath. Patient was started on
lovenox bridge to coumdadin with follow up in ___
clinic. Strategy for rhythm was discussed with outpatient
cardiologist, Dr. ___ @ ___. Unable to use amiodarone
given iodine allergy, decision was made to send home w/ ___
___ to ensure that the lightheadedness and chest discomfort
episodes were related to his atrial fibrillation. Will f/u w/
Cardiology.
.
# CAD: Extensive. Prior cath ___ showed LAD 100% proximal
occlusion, LCx 30% occlusion, 100% occlusion of OM1. Trops neg
x2. Continued with home aspirin, isosorbide mononitrate,
metoprolol, and atorvastatin.
.
# HTN: pressures were elevated to 140s-150s during
hospitalization. Continued home Losartan 25mg, Metoprolol
Succinate 25mg, and Imdur 120 mg.
.
CHRONIC ISSUES
.
# sHF: Etiology ischemic. EF 30% ___. No shortness of breath,
wt gain, orthopnea. Euvolemic on exam. Continued home
metoprolol, losartan. Consider spironolactone given EF < 35%.
.
# Hyperlipidemia: ___ with HDL 48 and LDL of 89.
.
# Moderate AS: ___ of 1.4 and mean gradient of 13 on echo from
___. Patient is not symptomatic. Home Losartan 25mg as
above.
.
# DM2: HbA1c 6.4% ___ on oral agents. No end organ damage.
Held home orals. Insulin sliding scale.
.
# BPH: continued home tamsulosin.
.
# Hypothyroidism: continued home levothyroxine.
.
### TRANSITIONAL ISSUES
- Patient was discharged on ___ of hearts with plan to see if
the lightheadedness and chest discomfort episodes were related
to his atrial fibrillation, will follow up in cardiology clinic.
- Patient was started on Enoxaparin Sodium 150 mg SC daily on
___ as bridge to warfarin with plan to follow up in
___ clinic
- Consider outpatient anti-arrhythmics pending ___ of hearts.
AVOID amiodarone given history of anaphylaxis to iodine. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Benadryl / Codeine / Colace / Darvocet-N 100 / Demerol /
Erythromycin Base / Keflex / Morphine / Penicillins / Zantac /
Stadol
Attending: ___.
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo woman with h/o sz disorder, asthma, migraine, chronic back
pain, depression, gastric bypass and multiple SBOs, p/w vague
sxs including malaise, lethargy, and urinary incontinence.
Patient is poor historian. Was visiting her daughter who is a
patient on ___ and daughter noted she was having trouble
sitting up in her chair. Per triage note there was an episode of
urinary incontinence but patient does not recall this. She is
not aware of the episode that caused her to be referred to ED.
Does say she has been feeling unwell for past several days
though is unable to articulate why. Felt cold at home but unsure
if febrile. No cough, SOB, CP, palpitations, n/v/d, dysuria,
hematuria. She has chronic tremor. She is not sure if she had a
seizure but last was ___ y ago. Lives independently.
Per daughter: baseline is fully independent, has ___ 2x/week to
help with meds only. Seizures typically presents with tremors,
head falls back, stares
On ___ seemed "lazy" and then was seen by MD who changed
tremor meds. Seemed to get worse and over weekend seemed "off"
again, slow, delayed answers. Last night noticed as she was
getting ready to leave that tremors were extremely bad, asked to
get wheelchair. As standing up, could not hold self up and fell
back onto bed, almost as though passing out. Having trouble
supporting herself to get up, having trouble following
directions. Wasn't really making eye contact. Stayed overnight
and had urinary incontinence. On ___ had diarrhea with
incontinence as well. Does not think she had any seizures
In the ED, initial vitals were: 98.0 96 109/69 16 94% RA
- Exam notable for: AOx3 but appears tired, CNII-XII intact,
+resting and intention tremor (reports at baseline),
finger-to-nose intact, good strength in b/l UEs/LEs, ___ beats
clonus
- Labs notable for: WBC 12.2 (70.9% PMN), AST/ALT 44/18, Tbili
0.5, Alb 2.8, Ca 8.2, Na 140, Cr 0.5, Trop < 0.01, Serum/urine
tox NEG, valproate level 44 (low), ammonia < 10, U/A ___, Nit+,
24 WBC, 3 Epi, Few bact, mod Bld, 79 RBC,
- Imaging: CXR: no acute intrathoracic process. NCHCT: no mass,
left frontal artifact vs. much less likely SAH. MRI: extremely
limited by motion with no obvious hemorrhage
- IV CTX 1gm was given.
-Neurology was consulted who recommended checking lytes, coags,
ammonia, B12, folate, thiamine and dispo per ED.
Upon arrival to the floor, patient reports she is feeling much
better. She feels her confusion and lethargy has improved. She
reports feeling frightened and confused about being in the
hospital. She continues to experience dysuria, which has been
present for the past three days. She denies fevers, chills,
abdominal pain, increased urinary frequency or urinary urgency.
Past Medical History:
seizure disorder on depakote, asthma, migraine, chronic back
pain, depression vs PTSD, gastric bypass and multiple SBOs,
celiac disease, back pain, obesity, "amnesia" (per OMR, details
unknown), left broken ankle
PSH:
Status post cholecystectomy in ___.
Status post appendectomy in ___.
Status post gastric bypass and revision in ___.
Status post hernia repair in ___.
Abdominal hernia repair with mesh in ___ following an episode
of SBO - performed at ___
R knee surgery
Social History:
___
Family History:
Father has "throat cancer" - in remission
Mother has diabetes
2 sisters are deceased due to lymphoma
No FHx seizures, migraines
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITAL SIGNS - 99.9 PO 119 / 72 89 18 95
GENERAL - Awake and alert, lying comfortably
HEENT - White plaque on tongue
CARDIAC - Regular rate and rhythm, normal S1 and S2, no
murmurs.
LUNGS - Lungs clear to auscultation bilaterally
ABDOMEN - Soft, bowel sounds present, nontender to palpation.
NEUROLOGIC - Patient alert and oriented to ___
Campus, and date. Able to name months of the year backwards.
Able to register 3 objects and recall at five minutes. Patient
with normal speech, speaking in complete sentences. CN II-XII
intact. Strength ___ throughout upper and lower extremities.
Sensation to light touch intact. Increase sensation over the
medial aspect of her right foot (chronic per patient). Patellar
refelexes 2+ bilaterally. Bilateral intention tremor. Finger to
nose intact.
DISCHARGE PHYSICAL EXAM:
VS - 98.6 104 / 69 75 18 92 Ra
GENERAL - Awake and alert, lying comfortably
HEENT - White plaque on tongue
CARDIAC - Regular rate and rhythm, normal S1 and S2, no
murmurs.
LUNGS - Lungs clear to auscultation bilaterally
ABDOMEN - Soft, bowel sounds present, nontender to palpation.
NEUROLOGIC - Patient alert and oriented to ___
Campus, and date. Able to name days of week backwards. Patient
with normal speech, speaking in complete sentences. CN II-XII
intact. Strength ___ throughout upper and lower extremities.
Sensation to light touch intact. Increase sensation over the
medial aspect of her right foot (chronic per patient).
Pertinent Results:
ADMISSION LABS:
==============
___ 04:13PM BLOOD WBC-12.2*# RBC-4.00 Hgb-12.5 Hct-38.6
MCV-97# MCH-31.3 MCHC-32.4 RDW-15.7* RDWSD-55.9* Plt ___
___ 04:13PM BLOOD Neuts-70.9 Lymphs-11.8* Monos-15.3*
Eos-0.1* Baso-0.4 Im ___ AbsNeut-8.62* AbsLymp-1.44
AbsMono-1.86* AbsEos-0.01* AbsBaso-0.05
___ 09:23AM BLOOD ___ PTT-33.2 ___
___ 04:13PM BLOOD Glucose-81 UreaN-8 Creat-0.5 Na-140 K-4.1
Cl-100 HCO3-25 AnGap-19
___ 04:13PM BLOOD Albumin-2.8* Calcium-8.2* Phos-3.5 Mg-1.8
___ 04:13PM BLOOD VitB12-1180* Folate->20
___ 01:32AM BLOOD Ammonia-<10
___ 09:23AM BLOOD TSH-3.5
___ 04:13PM BLOOD Valproa-44*
___ 04:13PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
DISCHARGE LABS:
==============
___ 06:36AM BLOOD WBC-9.5 RBC-3.54* Hgb-11.2 Hct-34.0
MCV-96 MCH-31.6 MCHC-32.9 RDW-15.6* RDWSD-55.5* Plt ___
___ 06:36AM BLOOD Glucose-94 UreaN-7 Creat-0.5 Na-145 K-3.3
Cl-106 HCO3-26 AnGap-16
___ 06:36AM BLOOD Calcium-8.2* Phos-4.5 Mg-2.5
MICRO:
======
___ 7:55 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- 4 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 64 I
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING:
=======
CXR ___:
No acute intrathoracic process
CT head ___:
1. Subtle linear in configuration left frontal hyperdensity is
likely artifactual. (series 2, image 17; series 601b, image 26;
series 602b, image 54). Consider short interval follow-up or
consideration of MRI to further evaluate given seizure disorder
and progressive altered mental status.
2. No mass effect.
3. Cortical atrophy
4. Mild paranasal sinus disease.
MRI Head ___ Prelim report:
Moderately motion limited examination. No evidence for
subarachnoid hemorrhage or other acute abnormalities.
RECOMMENDATION(S): A repeated head CT would be helpful to
confirm that the area of concern in a left frontal sulcus does
not contain subarachnoid hemorrhage.
CT HEAD ___:
1. The previously described hyperdense appearance of a left
frontal sulcus
does not appear significantly changed since the prior exam in
___, and
likely is artifactual. No evidence of acute major vascular
territory
infarction or concerning focus of hemorrhage.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ARIPiprazole 20 mg PO DAILY
2. Sertraline 200 mg PO DAILY
3. Divalproex (EXTended Release) 1500 mg PO DAILY
4. Divalproex (EXTended Release) 1000 mg PO QHS
5. RisperiDONE 2 mg PO QHS
6. Omeprazole 20 mg PO DAILY
7. Midodrine 5 mg PO DAILY
8. Gabapentin 300 mg PO QHS
9. Ondansetron 8 mg PO Q8H:PRN nausea
10. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
11. Pantoprazole 40 mg PO Q24H
12. Aspirin 81 mg PO DAILY
13. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral DAILY
14. Multivitamins 1 TAB PO DAILY
15. Terbinafine 1% Cream 1 Appl TP DAILY
16. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
DAILY:PRN
17. Lidocaine 5% Patch 1 PTCH TD QAM
Discharge Medications:
1. Sulfameth/Trimethoprim DS 1 TAB PO BID
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth Twice daily Disp #*7 Tablet Refills:*0
2. ARIPiprazole 20 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral DAILY
5. Divalproex (EXTended Release) 1500 mg PO DAILY
6. Divalproex (EXTended Release) 1000 mg PO QHS
7. Gabapentin 300 mg PO QHS
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. Midodrine 5 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO DAILY
12. Ondansetron 8 mg PO Q8H:PRN nausea
13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
DAILY:PRN
14. RisperiDONE 2 mg PO QHS
15. Sertraline 200 mg PO DAILY
16. Terbinafine 1% Cream 1 Appl TP DAILY
17.Rolling walker
Rolling walker
Dx: R56.9
Px: Good
___: 13 mos
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Urinary tract infection
Secondary Diagnosis: Delirium
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 Q111 CT HEAD
INDICATION: ___ year old woman with sz disorder presenting with confusion and
UTI. Some concern for SAH on initial CT head and MRI. // Please confirm that
the area of concern in a left frontal sulcus does not contain subarachnoid
hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 5.4 s, 18.2 cm; CTDIvol = 52.4 mGy (Head) DLP =
954.0 mGy-cm.
Total DLP (Head) = 954 mGy-cm.
COMPARISON: CT head without contrast from ___
FINDINGS:
The previously described hyperdense appearance of a left frontal sulcus does
not appear significantly changed since the prior exam in ___, and
likely is artifactual. There is no evidence of acute major vascular territory
infarction infarction,new concerning focus of hemorrhage, edema, or mass.
There is prominence of the ventricles and sulci suggestive of involutional
changes. Ill-defined periventricular subcortical white matter hypodensities
are nonspecific but likely due to chronic sequela of small-vessel ischemic
disease. The basilar cisterns are patent.
There is no evidence of fracture. Mild mucosal thickening is seen in the
ethmoid air cells and right frontal sinus. Otherwise, the remaining
visualized paranasal sinuses, mastoid air cells, and middle ear cavities are
clear. The visualized portion of the orbits are unremarkable.
IMPRESSION:
1. The previously described hyperdense appearance of a left frontal sulcus
does not appear significantly changed since the prior exam in ___, and
likely is artifactual. No evidence of acute major vascular territory
infarction or concerning focus of hemorrhage.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Lethargy
Diagnosed with Disorientation, unspecified
temperature: 98.0
heartrate: 96.0
resprate: 16.0
o2sat: 94.0
sbp: 109.0
dbp: 69.0
level of pain: 0
level of acuity: 3.0 | PCP: ___. ___
Neurologist: Dr. ___ ___, Fax
___
___ yo woman with h/o sz disorder, asthma, migraine, chronic back
pain, depression, gastric bypass and multiple SBOs, p/w vague
sxs including malaise, lethargy, and urinary incontinence found
to have urinary tract infection.
#Delirium
Patient was visiting her daughter in the hospital when she
developed confusion and lethargy. Received head imaging with no
evidence of hemorrhage or infarct including CT head and MRI. Has
a history of seizure disorder, but current episode not
consistent with seizure. She was seen by neurology for stroke
rule out as Code stroke was called; given reassuring neuro exam
and no significant abnormalities on CT head and MRI, she was
ruled out for acute stroke. She was found to have a urinary
tract infection. Her confusion improved with antibiotic therapy.
#Klebsiella Urinary Tract Infection
Patient with urine culture positive for pan-sensitive
Klebsiella. Plan to treat with 5 day course of Bactrim DS BID
(end ___.
#Seizure disorder
Her Depakote level was 44 in setting of two days of missed
medication. Continued on her home dose of Depakote 1500 daily
and 1000 qHS with plan to follow up with Neurologist on ___ to
ensure Depakote is at an adequate level.
#Peripheral neuropathy:
Patient with neuropathy of R lower extremity, which is chronic
in nature. Also with decreased vibratory sensation bilaterally.
Patient will follow-up with neurologist Dr. ___ should get
serum polyneuropathy work-up if not already done as outpatient
given poor vibratory sensation in ___. Continued on home
Gabapentin 300mg QHS.
#Depression vs PTSD: Per ___ patient with recent psychiatric
admission at ___ discharged on ___. Current
symptoms may be related to daughter's illness and diagnosis of
leukemia. History of suicidal ideation and self mutilation.
Continued home Aripiprozole 20mg, Risperidone 2mg qHS and
Sertraline 200 mg.
#Back pain: Holding home Tramadol in setting of confusion,
continue Lidocaine patch.
# CODE: Full presumed
# CONTACT: ___, Relationship: father, Phone number:
___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Motrin / NSAIDS (Non-Steroidal Anti-Inflammatory
Drug) / prednisone
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
___ line placed ___, removed ___
Colonoscopy: ___
History of Present Illness:
Ms. ___ is a ___ year old woman with chronic alcohol use
(sober for ___ year), Stage ___ liver fibrosis, stage I lung
cancer s/p RUL wedge resection, multiple colonoic polyps and
diverticulosis c/b bleed s/p partial colonic resection, who
presents with melena.
The patient shares that this morning she was in her usual state
of health, and noticed she had the urge to stool, which is
unusual for her because she is chronically constipated. She went
to the bathroom and had a large "black tarry loose stool" with
some red blood. At first she ignored it, but it happened again,
and this caused her to come to the ED.
In the ED, initial vitals were: 97.8 86 149/86 18 100. Exam
notable for diffuse abdominal tenderness. Labs notable for H/H
9.6/30, Na 127->132, K 6.3-> 4 with no intervention, Cr 0.8
(baseline). Lactate 3.1 -> 1.7 with 1L NS. She had a CTA AP that
was unrevealing for source of bleed. She was given 1L NS and
Tylenol for pain. While in the ED she had at least 2 additional
melanotic stools.
On the floor, patient gives the above history. She does not
have any lightheadness, chest pain, or dyspnea. She has not
taken any NSAIDs recently and is not on a blood thinner or
aspirin. She shares that she has had multiple episodes of
diverticular bleeds in the past, but they have all been bright
red blood, and she has never had black stools before.
Past Medical History:
- HTN
- HLD
- Alcohol abuse
- Fibromyalgia
- Chronic low back pain
- Sciatica
- Anxiety
- Hx diverticulitis
- Hx intestinal polyps s/p resection in ___
- Hx lower GI bleed (attributed to NSAID use) in ___
- Hx skin grafts s/p burns in ___
Social History:
___
Family History:
-Mother with HTN, type II DM, obesity; died of ovarian cancer at
___.
-Dad had TB; died of throat or lung cancer at ___.
-Has 2 brothers on dialysis for CKD (unknown cause).
-Sister with a fib.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
===========================
Vital Signs: T98.4 BP128/63 HR78 RR18 O2 100 RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1/S2
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, diffusely tender with no rebound or guarding,
nondistended
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.
PHYSICAL EXAM ON DISCHARGE:
===========================
Vitals: T: 98.0 Tm: 98.6 BP: 109/46 (109-143/54-71) HR: 84
(72-86) RR: 20 (___) SpO2: 98-100 RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, +conjunctival pallor
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-distended, tender to palpation in RUQ, bowel
sounds present, no rebound tenderness or guarding
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Scars diffusely over arms secondary to burns
Pertinent Results:
LABS ON ADMISSION:
=================
___ 08:58PM WBC-7.2 RBC-3.42* HGB-9.6*# HCT-30.0*# MCV-88
MCH-28.1 MCHC-32.0 RDW-14.9 RDWSD-46.3
___ 08:58PM NEUTS-46.6 ___ MONOS-7.7 EOS-0.8*
BASOS-0.4 IM ___ AbsNeut-3.34 AbsLymp-3.11 AbsMono-0.55
AbsEos-0.06 AbsBaso-0.03
___ 08:58PM ___ PTT-29.0 ___
___ 08:58PM GLUCOSE-134* UREA N-14 CREAT-0.8 SODIUM-127*
POTASSIUM-6.3* CHLORIDE-99 TOTAL CO2-22 ANION GAP-12
___ 09:09PM LACTATE-3.1* K+-6.3*
___ 11:35PM ALT(SGPT)-15 AST(SGOT)-30 ALK PHOS-67 TOT
BILI-0.5
___ 11:35PM ALBUMIN-3.9
MICRO:
======
NONE
IMAGING/STUDIES:
===============
___: COLONOSCOPY:
Impression: Previous end to end ___ anastomosis of the
sigmoid
Diverticulosis of the sigmoid colon and descending colon
The terminal ileum was normal.
Otherwise normal colonoscopy to cecum and terminal ileum
Recommendations: No evidence of GI bleeding was seen
The prep was inadequate to detect small polyps
Follow-up with inpatient GI team
Additional notes: The procedure was performed by the fellow and
the attending. The attending was present for the entire
procedure. The patient's reconciled home medication list is
appended to this report. The efficiency of colonoscopy in
detecting lesions was discussed with the patient and it was
pointed out that a small percentage of polyps and other lesions
including colon cancer can be missed with the test. Degree of
difficulty 2 (5 most difficult) FINAL DIAGNOSES are listed in
the impression section above. Estimated blood loss = zero. No
specimens were taken for pathology
___ CTA AP:
IMPRESSION:
1. No active extravasation identified. Significant diverticular
disease without diverticulitis.
2. Status post partial colectomy, no obstruction.
3. Mildly prominent pancreatic duct throughout its entirety
remains stable since ___, stability suggestive of benignity
such as sphincter of Oddi dysfunction.
4. Prominent left pelvic veins can be seen with pelvic
congestion syndrome.
LABS ON DISCHARGE:
==================
___ 05:30AM BLOOD WBC-3.7* RBC-2.54* Hgb-7.5* Hct-24.0*
MCV-95 MCH-29.5 MCHC-31.3* RDW-16.1* RDWSD-52.6* Plt ___
___ 05:30AM BLOOD ___ PTT-34.3 ___
___ 05:30AM BLOOD Glucose-93 UreaN-<3* Creat-0.6 Na-144
K-3.6 Cl-111* HCO3-26 AnGap-11
___ 05:30AM BLOOD ALT-13 AST-18 AlkPhos-55 TotBili-0.3
___ 05:30AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.7
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tylenol-Codeine #3 (acetaminophen-codeine) 300-30 mg oral
Q8H:PRN
2. amLODIPine 10 mg PO DAILY
3. Mirtazapine 7.5 mg PO QHS
4. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Moderate
5. Ascorbic Acid ___ mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. DiphenhydrAMINE 50 mg PO Q6H:PRN allergy
Discharge Medications:
1. Ferrous Sulfate 325 mg PO DAILY
___ cause dark stools
RX *ferrous sulfate [iron] 325 mg (65 mg iron) 1 capsule(s) by
mouth Daily Disp #*60 Capsule Refills:*0
2. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
3. Ascorbic Acid ___ mg PO DAILY
4. DiphenhydrAMINE 50 mg PO Q6H:PRN allergy
5. Mirtazapine 7.5 mg PO QHS
6. Tylenol-Codeine #3 (acetaminophen-codeine) 300-30 mg oral
Q8H:PRN
7. Vitamin D 1000 UNIT PO DAILY
8. HELD- amLODIPine 10 mg PO DAILY This medication was held. Do
not restart amLODIPine until your PCP tells you to do so.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
====================
lower gastrointestinal bleed
Secondary diagnoses:
====================
hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ with brisk BRBPR. ?AVM or arterial bleed.
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast
images were acquired through the abdomen and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Total DLP (Body) = 1,343 mGy-cm.
COMPARISON: CTA chest performed ___
FINDINGS:
Chest: The bases of the lungs are clear bilaterally. Trace pericardial fluid
is noted anteriorly.
Abdomen: The liver appears homogeneous in attenuation without a focal lesion.
There is no intrahepatic duct dilation. The portal veins are patent. There
is no radiopaque cholelithiasis. The pancreas is homogeneous in attenuation.
The main pancreatic duct is prominent measuring up to 3 mm within the
pancreatic head and 2 mm within the tail, similar to prior examination dated
___. No focal lesion is seen. The spleen is atrophic. Bilateral
adrenal glands are unremarkable.
There is no nephrolithiasis. Kidneys are without hydronephrosis or
perinephric fluid collections. Cortical hypodensities, the largest within the
right upper pole medially measuring up to 4 mm, are too small blood
characterize.
There is a small hiatal hernia. The stomach, duodenum, and loops of small
bowel are grossly normal. No evidence of obstruction. The appendix is not
definitely visualized though there are no inflammatory changes in the right
lower quadrant to suggest acute appendicitis. Suture material present within
the rectosigmoid region. There is no evidence of obstruction. Extensive
diverticular disease involves the sigmoid colon. No active extravasation is
identified within the bowel.
There is no abdominal free fluid or air.
Pelvis: The bladder is moderately well distended, unremarkable. There is no
pelvic free fluid. Prominent left pelvic veins are noted. There is no
adnexal mass. There is no inguinal or pelvic sidewall adenopathy.
Moderate atherosclerotic calcifications involve the abdominal aorta. The
abdominal aorta becomes totally aneurysmal just above the level of the
bifurcation measuring approximately 1.9 cm. The celiac axis demonstrates
conventional anatomy. The superior mesenteric artery is patent. The inferior
mesenteric artery is not definitely visualized. An accessory left renal
artery is present. A single right renal artery is noted. The inferior
mesenteric vein and superior mesenteric veins are patent as is the portal and
splenic veins.
No lesion worrisome for malignancy or infection is identified. Bones are
minimally diffusely demineralized. Vertebral body heights appear preserved.
IMPRESSION:
1. No active GI bleeding. Significant diverticular disease without
diverticulitis.
2. Status post partial colectomy, no obstruction.
3. Mildly prominent pancreatic duct, stable since ___, stability
suggestive of benignity such as sphincter of Oddi dysfunction.
4. Prominent left pelvic veins can be seen with pelvic congestion syndrome.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with new R PICC // R SL 37cm PPICC, thanks,
___ ___ Contact name: ___: ___
IMPRESSION:
Since the prior radiograph of ___, a right PICC has been placed,
terminating at the expected level of the confluence of the brachiocephalic
veins. Cardiomediastinal contours are within normal limits. Lungs are
grossly clear except for focal pleural and parenchymal scarring at the right
base peripherally. Rounded contour adjacent the left hemidiaphragm is likely
due to focal eventration, more fully evaluated on the prior CT of ___.
Radiology Report
EXAMINATION: Portable chest radiograph
INDICATION: ___ woman with PICC placement, new ectopy on tele,
concern for PICC needing to be pulled back // re-eval for PICC placement
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph dated ___, earlier on the same day at
17:48.
FINDINGS:
The right PICC tip is in the proximal SVC, similar in position to the prior
exam. Otherwise, no significant interval change. Right lateral costophrenic
angle blunting may reflect pleural thickening or small effusion. . A 9-mm
ovoid opacity projecting over the left fifth posterior rib is not clearly
imaged on prior exams and could be superimposed normal structures given the
short interval time course of development. Left basilar atelectasis is mild.
The heart is normal in size. Mediastinal contours are unchanged. The
ascending and descending thoracic aorta is tortuous.
IMPRESSION:
1. Right PICC tip in proximal SVC, similar to the prior exam.
2. Trace right pleural effusion versus pleural thickening.
3. Apparent new nodular opacity in left upper lung is potentially due to a
structure external to the patient. Repeat radiograph following removal or
repositioning of external devices may be helpful in this regard.
NOTIFICATION: The findings were discussed with ___, M.D. requesting a
wet read by ___, M.D. on the telephone on ___ at 1:10 AM, 1
minutes after discovery of the findings.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dizziness, Melena
Diagnosed with Gastrointestinal hemorrhage, unspecified
temperature: 97.8
heartrate: 86.0
resprate: 18.0
o2sat: 100.0
sbp: 149.0
dbp: 86.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ year old woman with chronic alcohol use
disorder (sober for ___ year), Stage ___ liver fibrosis, stage I
lung cancer s/p RUL wedge resection, multiple colonic polyps and
diverticulosis c/b bleed s/p partial colonic resection, who
presents with a GIB.
GI bleed:
Presentation with very dark stool mixed in with frank blood, as
well as right-sided abdominal pain that started around the time
the bowel movements began. A slower-transit lower
gastrointestinal bleed was deemed most likely. After admission,
the patient continued to have bloody bowel movements, requiring
transfusion of a total of 3u PRBC. Due to difficulty obtaining
and maintaining peripheral IV access, a PICC line was placed on
___. Patient underwent a colonoscopy on ___ that was
negative. Given her presentation, BUN was <3 and stable
hemoglobin from ___ to ___, it was deemed that an upper GI
bleed was unlikely and Upper GI endoscopy was deferred. It was
deemed most likely that the patient had a colonic diverticular
bleed that spontaneously resolved. She was discharged home with
close follow-up on ___ for monitoring of CBC. She was instructed
to monitor for further melena or hematochezia and return if
further bleeding. She was also discharged on pantoprazole 40mg
BID.
Abd pain:
For pain during this admission, patient was given a small dose
of oxycodone as needed, with good effect. This was discontinued
on discharge.
HTN:
Amlodipine was held during this admission in the setting of GI
bleed and normotension. |