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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Morphine / Coricidin HBP
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o M with PMhx of CAD s/p CABG in ___, NSTEMI, systolic
CHF (EF 35-40%), PVD s/p bypass, CKD stage III,
history of LLE DVT s/p IVC filter, chronic SDH, dementia and
frequent falls transferred from ___ after a fall. This
morning, he had witness fall in the bathroom at his nursing
facility and hit his head. Of note, his grandchildren reports
that he ___ been doing ___ and ___ been able to walk around. He
was then transported to ___ where a head CT revealed an
acute on chronic subdural hematoma. A cath was re inserted also.
According to his grandchildren, he also had a foley taken out a
few days ago because he had had urinary retention which was
present on his last admission to ___.
In the ___, initial vitals: 97.7 111/52 81 17 99Ra
- Exam notable for: nonfocal, alert, confused, right
periorbital ecchymsosis
- Labs notable for: Hazy urine, +Leuk, + Bld, Tr protein, WBC
50-100, + Bact
Hgb 10.9 Hct 34.0, PTT 26.3, Trop neg
- Imaging notable for: CTA acute on chronic subdural hematoma
- EKG: NSR, prolonged PR interval and RBBB
- Patient was given: CefTRIAXone 1 gm IV Q24H @ 11am
(___) and haloperidol 5mg x2 for agitation
In the ___ ___, initial vitals: 97.6 144/68 92 18 98Ra
- Exam notable for: nonfocal, alert, confused, right
periorbital ecchymsosis
- Labs notable for: Hazy urine, +Leuk, + Bld, Tr Protein, >182,
+ Bact, Hgb 11 Hct 35.0, PTT 26.3
- Imaging notable for:
US ___
1. No evidence of deep venous thrombosis in the left lower
extremity veins.
2. Mild to moderate subcutaneous edema in the left lower
extremity.
CXR PA and LAT ___
Opacity in the left chest, particularly in the left mid
to lower chest
- Neurosurgery was consulted who recommended:
CT head stable with left subacute on chronic SDH, no new
hemorrhage, no midline shift. Exam is nonfocal, alert, following
commands briskly. Recommend follow up in clinic with repeat head
CT in 8 weeks as he is on ASA 81mg.
On the floor, he is with his grandkids who confirms the fall.
They report that this is his baseline mental state. He is able
to eat by himself but continues to attempt to take out his
catheter. Per grandchildren, he ___ not had any fevers, chills,
dysuria, shortness of breath, chest pain. He ___ chronic
asymmetric b/l lower extremity edema related to a prior LLE
bypass surgery. Patient is living at ___ with 24hr supervision.
He is uncooperative and does not respond to questions clearly.
Though he was able to report that he does have a cough and does
not have any CP/SOB/n/v.
Of note, patient was recently admitted for sepsis for UTI and
LLL parapneumonic effusion. See previous discharge summary dated
___ for more information.
Past Medical History:
- Systolic CHF (EF 35-40%, ___
- Dementia
- UGIB ___ s/p endoscopic control of duodenal ulcer
hemorrhage
- PVD s/p right limb ischemia s/p Right Femoral-Peroneal Bypass
with Left Reversed Saphenous Vein Graft ___
- NSTEMI (Type II; ___
- CABG x 2 in ___, LIMA-LAD, s/p angioplasty x 5
- Hypertension
- Hyperlipidemia
- Diabetes mellitus, type II
- Left-sided Sensory Seizures - well controlled on Dilantin
described by the patient as a tingling in his left cheek and
left arm from shoulder to elbow, sometimes spreading down his
torso and left leg. He ___ never had a generalized seizure
(other than possibly one in the setting of taking morphine where
he had bilateral arm haking)
- CKD, stage III
- Arthritis
- Chronic subdural hematoma
- History of LLE DVT, ___
Social History:
___
Family History:
(per OMR)
- negative for stroke, seizure, movement disorders, known
neurological conditions other than migarine
- positive for CAD/MIs (mother, father), migraine (mother)
Physical Exam:
Admission:
VITALS: 98 143/84 113 18 86 Ra
General: Alert & oriented to only his name, no acute distress
HEENT: Large ecchymosis periorbitally on R. Sclerae anicteric,
MMM, oropharynx clear, EOMI, PERRL, neck supple, JVP @ 10cm
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Crackles on the lower left lobe. no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, no rebound or
guarding
GU: ___
___: Warm, well perfused, 2+ pulses, no clubbing, cyanosis. +2
edema on the right +1 edema on the left.
Skin: Warm, dry, no rashes or notable lesions.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation
Labs:
Discharge Exam:
VITALS: 97.7 PO 110 / 64 L Sitting 84 20 97 ra
GENERAL: sitting up in chair comfortably, oriented x2 (does not
know hospital name or year but knows month, date and city)
HEENT: large ecchymosis and swelling of the right eye, PERRLA,
EOMI, MMM
CV: RRR, no r/m/g
RESP: Mild crackles at bilateral bases
GI: +BS, soft, NTND
GU: no foley
MSK: 2+ swelling of the LLE with overlying erythema (chronic)
and
1+ RLE, warm and well perfused, no TTP
NEURO: CN II-XII intact, ___ strength in upper and lower
extremities.
Pertinent Results:
Admission:
___ 02:06PM URINE HOURS-RANDOM
___ 02:06PM URINE UHOLD-HOLD
___ 02:06PM URINE COLOR-Straw APPEAR-Hazy* SP ___
___ 02:06PM URINE BLOOD-SM* NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-LG*
___ 02:06PM URINE RBC-17* WBC->182* BACTERIA-FEW*
YEAST-NONE EPI-0
___ 01:27PM GLUCOSE-122* UREA N-19 CREAT-0.9 SODIUM-141
POTASSIUM-5.0 CHLORIDE-103 TOTAL CO2-23 ANION GAP-15
___ 01:27PM estGFR-Using this
___ 01:27PM WBC-8.6 RBC-3.69* HGB-11.0* HCT-35.0* MCV-95
MCH-29.8 MCHC-31.4* RDW-15.4 RDWSD-53.4*
___ 01:27PM NEUTS-81.2* LYMPHS-10.8* MONOS-6.3 EOS-0.8*
BASOS-0.3 IM ___ AbsNeut-6.96*# AbsLymp-0.93* AbsMono-0.54
AbsEos-0.07 AbsBaso-0.03
___ 01:27PM PLT COUNT-208
Discharge:
___ 06:57AM BLOOD WBC-5.9 RBC-3.56* Hgb-10.5* Hct-33.6*
MCV-94 MCH-29.5 MCHC-31.3* RDW-15.4 RDWSD-53.9* Plt ___
___ 01:27PM BLOOD Neuts-81.2* Lymphs-10.8* Monos-6.3
Eos-0.8* Baso-0.3 Im ___ AbsNeut-6.96*# AbsLymp-0.93*
AbsMono-0.54 AbsEos-0.07 AbsBaso-0.03
___ 06:57AM BLOOD Glucose-121* UreaN-17 Creat-0.9 Na-138
K-4.7 Cl-103 HCO3-22 AnGap-13
___ 06:57AM BLOOD Calcium-8.5 Phos-3.2 Mg-2.3
Micro:
___ ___
URINE CULTURE Preliminary
___
Organism 1 PROTEUS MIRABILIS
COLONY COUNT >100,000 org/ml
Organism 2 GRAM NEGATIVE BACILLI
COLONY COUNT >100,000 org/ml
1. PROTEUS MIRABILIS
Target Route Dose RX AB
Cost M.I.C. IQ
------ ----- ------------------ ------ --
------ --------- ------
AMPICILLIN R
>=32
CEFAZOLIN R
>=64
CEFTAZIDIME S
<=1
CEFTRIAXONE R
>=64
CIPROFLOXACIN R
>=4
ERTAPENEM S
<=0.5
GENTAMICIN I
8
LEVOFLOXACIN R
>=8
NITROFURANTOIN R
>=512
PIP/TAZ S
<=4
TOBRAMYCIN I
8
TRIM/SULFA R
>=320
___ ___ ___: negative
BCx: NGTD x2
Imaging:
Lower extremity Doppler
1. No evidence of deep venous thrombosis in the left lower
extremity veins.
2. Subcutaneous edema.
CT C-Spine ___ ___
FINDINGS: Degenerative changes cervical spine are
advanced. There
is stable minimal anterolisthesis C4 on C5, C7 on T1,
likely
degenerative. Alignment is otherwise stable. No fractures
are
identified.Multilevel degenerative changes, disc osteophyte
complexes,, posterior element hypertrophic changes. There
is
multilevel mild-to-moderate central canal narrowing, most
prominent
at C4-C5, C6-C7 levels. C5-C6 vertebral bodies are fused.
There is
multilevel moderate to severe foraminal narrowing. There
is no
prevertebral soft tissue swelling. There is no evidence of
infection
or neoplasm. Small focus of low attenuation involving C7
vertebral
body is residua of prior Schmorl's node.
IMPRESSION: No acute fracture.
CT Head ___ ___
IMPRESSION: Subacute on chronic left hemispheric subdural
hematoma,
no new hemorrhage since prior.
Right periorbital soft tissue swelling, no fracture.
Chronic right cerebellar small infarcts. Severe brain
parenchymal
atrophy.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Bisacodyl 10 mg PR QHS:PRN constipation
5. Metoprolol Succinate XL 25 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Finasteride 5 mg PO DAILY
8. Lactulose 30 mL PO BID
9. Vitamin D ___ UNIT PO 1X/WEEK (WE)
10. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
11. Milk of Magnesia 30 mL PO Q6H:PRN constipation
12. Senna 17.2 mg PO BID
13. Tamsulosin 0.8 mg PO QHS
14. Omeprazole 20 mg PO DAILY
15. Phenytoin Sodium Extended 300 mg PO 3X/WEEK (___)
16. Phenytoin Sodium Extended 400 mg PO 4X/WEEK (___)
Discharge Medications:
1. ertapenem 1 gram intramuscular DAILY Duration: 6 Days
___ through ___ for full ___onsider treating for
14 days if UA still positive or if pt is symptomatic.
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
3. Atorvastatin 80 mg PO QPM
4. Bisacodyl 10 mg PR QHS:PRN constipation
5. Docusate Sodium 100 mg PO BID
6. Finasteride 5 mg PO DAILY
7. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
8. Lactulose 30 mL PO BID
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Milk of Magnesia 30 mL PO Q6H:PRN constipation
11. Omeprazole 20 mg PO DAILY
12. Phenytoin Sodium Extended 400 mg PO 4X/WEEK (___)
13. Phenytoin Sodium Extended 300 mg PO 3X/WEEK (___)
14. Senna 17.2 mg PO BID
15. Tamsulosin 0.8 mg PO QHS
16. Vitamin D ___ UNIT PO 1X/WEEK (WE)
17. HELD- Aspirin 81 mg PO DAILY This medication was held. Do
not restart Aspirin until You meet with Dr. ___
___ Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Chronic stable Subdural hematoma, urinary tract
infection
Secondary: CAD s/p CABG in ___, NSTEMI, systolic CHF (EF
35-40%), PVD s/p bypass, CKD stage III, history of LLE DVT s/p
IVC filter, chronic SDH, 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
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: ___ man presenting after fall with left leg swelling.
Evaluate for DVT.
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the left lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the left common
femoral, femoral, and popliteal veins. Normal compressibility 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. Subcutaneous soft tissue
edema in the left thigh and calf is mild to moderate.
IMPRESSION:
1. No evidence of deep venous thrombosis in the left lower extremity veins.
2. Subcutaneous edema.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with fall// ?pna
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
There are low lung volumes. Patient is status post median sternotomy. There
is increased opacity in the left mid to lower chest, worrisome for pneumonia,
although in the setting of trauma, pulmonary contusion is not excluded. There
is likely a small left pleural effusion. Mild right base atelectasis is seen.
No definite pneumothorax. Cardiac and mediastinal silhouettes are stable.
IMPRESSION:
Interval increase in opacity in the left chest, particularly in the left mid
to lower chest; differential diagnosis includes pneumonia, but in the setting
of trauma, pulmonary contusion is not excluded. There is a probable small
left pleural effusion and some of the opacity may relate to overlying
atelectasis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SDH, UTI, Transfer
Diagnosed with Urinary tract infection, site not specified, Traum subdr hem w/o loss of consciousness, init, Fall on same level, unspecified, initial encounter
temperature: 97.6
heartrate: 92.0
resprate: 18.0
o2sat: 98.0
sbp: 144.0
dbp: 68.0
level of pain: 0
level of acuity: 2.0 | ___ y/o M with PMhx of CAD s/p CABG in ___, NSTEMI, systolic
CHF (EF 35-40%), PVD s/p bypass, CKD stage III,
history of LLE DVT s/p IVC filter, chronic SDH, dementia and
frequent falls transferred from ___ after a fall with
subacute on chronic SDH and UTI.
#Subacute on chronic SDH Patient presented with fall. Per
neurosurgery who reviewed the CT head: CT head stable with left
subacute on chronic SDH, no new hemorrhage,
no midline shift. They did not feel that he had an indication
for surgery. The neurosurgery team recommended follow up in
clinic with repeat head CT in ___ weeks with Dr. ___
(___). His aspirin is being held until he follows up
with neurosurgery.
#UTI
#Urinary Retention
Patient with admission in ___ for UTI, and was on CTX
until
___ for parapneumonic effusion. He had urinary retention and
had
catheter in place on admission. UTI may be catheter
associated though may have had urinary frequency. Given fall and
?change in mental status causing fall decision was made to treat
his UTI with Ceftriaxone. Unfortunately, micro data from ___
___ grew Proteus with ESBL profile, sensitive to Zosyn,
Ceftazadime, and Ertapenem, so decision was made to switch to
Ertapenem 1 g daily IM (IV access unavailable because patient
continues to rip out IV's) for total of ___ days (___). His Foley was discontinued on admission but in the
setting of likely catheter-associated UTI it was discontinued on
admission. He failed multiple voiding trials and a new Foley was
replaced on ___ prior to discharge. We also continued his
home Finasteride and tamsulosin
#Fall
He ___ had multiple falls recently with most recent fall
witnessed. Unclear if fall was syncope related or not per
history. ___ be vasovagal in setting of bathroom use. Other ddx
includes orthostasis and cardiogenic causes though very low
likelihood. Will discharge back to his long term rehab facility.
#Toxic metabolic encephalopathy
#Dementia/delirium
Patient uncooperative and agitated requiring Haldol at ___.
Per grandchildren, he is known to sundown and ___ difficulty
adjusting to new environments. His agitation was an issue during
last admission and psych was consulted who recommended 2.5mg
Haldol BID. He ___ not required this back at his SNF. His
current
encephalopathy is likely delirium related provoked by his UTI.
Required 1 dose of IV Haldol overnight ___ but stable without
any issues on ___. He required no other antipsychotics for
agitation. We suspect he will return to baseline after treatment
for UTI. AOx3 on discharge.
#LLL opacity
Likely related to his previous parapnemonic effusion. There was
no
indication to intervene on this radiographic finding as patient
was afebrile without dyspnea, cough, and leukocytosis and
imaging
findings can lag clinical resolution. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin
Attending: ___
Chief Complaint:
Poor PO intake
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx of parkinsons disease, HTN, DM, dementia who presents
from ___ with lethargy and dehydration.
History obtained from daughter at bedside. Patient minimally
communicative
Daughter ___ states her mother has been declining for past
few
months, has lost 10 lbs, has diminished PO intake. The past few
days even less interactive though she will speak short thoughts
to ___. Pt had an admission about ___ weeks ago at ___
(see below) and has never gotten back to her baseline. Minmially
eating though no signs aspiration, no c/o difficulty swallowing;
pt just seems uninterested in general but will eat some when she
wants. Does take Ensures. Nursing staff at ___ noted
decreased UOP with nothing after straight cath. Pt denies
dysuria
at present; no frequency or foul smell noted by daughter. Pt in
continent in diaper. Pt denies any other pain, or SOB at present
but cannot report on other recent Sx
Dtr reports that team at ___ has recently been
discussing pt's decline. There was a family meeting and pt's 5
daughters decided together to make her DNR/DNI, ok for NIV and
ok
to hospitalize. They would not want a PEG placed. There is a
MOLST that ___ provides that is signed by HCP (pt's other
daughter is HCP), though not signed by an MD. ___ at present is
bed or wheelchair bound and at this point cannot wheel herself.
___ states family recognizes that pt is in decline but this
has been a difficult process. Pt generally at baseline recently
cannot report on Sx but discusses old times and family often
with
daughters.
Past Medical History:
HTN
HLD
Type II diabetes
Dementia with Behavioral Sxs
Dysphagia
Stroke
Social History:
___
Family History:
Her family history is negative for colorectal cancer. She has a
brother with prostate cancer. There is no history of
inflammatory bowel disease.
Physical Exam:
GENERAL: NAD
EYES: Anicteric
HENT: Dry oral mucosa
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic tenderness.
MSK: Moves all extremities.
SKIN: No rashes.
NEURO: Alert, speaks very few words, responds to verbal
commands.
PSYCH: Calm
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 1132)
Temp: 98.0 (Tm 98.1), BP: 137/66 (137-146/66-85), HR: 60
(59-66), RR: 18 (___), O2 sat: 99% (96-99), O2 delivery: Ra
GENERAL: NAD
EYES: Anicteric
HENT: EOMI, face symmetric
CV: Heart regular, no murmur, no S3, no S4. No JVD.
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation. Bowel
sounds present.
GU: No suprapubic tenderness.
MSK: Moves all extremities.
SKIN: No rashes.
NEURO: Alert, speaks very few words, responds to verbal
commands.
PSYCH: Calm
Pertinent Results:
LAB RESULTS ON ADMISSION:
==========================
___ 03:09PM BLOOD WBC-9.1 RBC-3.14* Hgb-9.7* Hct-30.3*
MCV-97 MCH-30.9 MCHC-32.0 RDW-14.6 RDWSD-51.8* Plt ___
___ 03:03PM BLOOD Glucose-184* UreaN-35* Creat-1.1 Na-157*
K-4.8 Cl-122* HCO3-24 AnGap-11
___ 08:05PM BLOOD Calcium-9.3 Phos-2.9 Mg-2.6
___ 03:11PM BLOOD Lactate-1.2 Na-152*
RELEVANT INTERVAL LABS:
=======================
___ 06:35AM BLOOD 25VitD-34
___ 06:35AM BLOOD VitB12-408 Folate-7
LAB RESULTS ON DISCHARGE:
==========================
___ 07:24AM BLOOD WBC-4.5 RBC-3.02* Hgb-9.3* Hct-28.8*
MCV-95 MCH-30.8 MCHC-32.3 RDW-14.0 RDWSD-49.1* Plt ___
___ 07:24AM BLOOD Glucose-101* UreaN-13 Creat-0.8 Na-143
K-4.5 Cl-109* HCO3-23 AnGap-11
___ 07:24AM BLOOD Calcium-9.2 Phos-3.0 Mg-2.0
IMAGING:
=========
CXR ___: No acute findings. Limited due to low lung
volumes.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. amLODIPine 10 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. Bisacodyl 10 mg PO DAILY
5. Bisacodyl ___AILY:PRN Constipation - Second Line
6. Carbidopa-Levodopa (___) 1 TAB PO TID
7. Docusate Sodium 200 mg PO BID
8. QUEtiapine Fumarate 25 mg PO QHS
9. Valsartan 80 mg PO QAM
10. Melatin (melatonin) 3 mg oral QHS
11. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - First
Line
12. Multivitamins W/minerals 1 TAB PO DAILY
13. QUEtiapine Fumarate 12.5 mg PO DAILY
Discharge Medications:
1. QUEtiapine Fumarate 25 mg PO BID
2. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
3. amLODIPine 10 mg PO DAILY
4. Bisacodyl ___AILY:PRN Constipation - Second Line
5. Bisacodyl 10 mg PO DAILY
6. Carbidopa-Levodopa (___) 1 TAB PO TID
7. Docusate Sodium 200 mg PO BID
8. Melatin (melatonin) 3 mg oral QHS
9. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - First
Line
10. Multivitamins W/minerals 1 TAB PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Hypernatremia
Malnutrition
Failure to thrive
Advanced dementia
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with cough, weakness // Pneumonia, other acute process?
COMPARISON: Prior study from ___
FINDINGS:
AP upright and lateral views of the chest provided.
Low lung volumes. Allowing for this, the lungs are clear. No signs of
pneumonia, edema, effusion or pneumothorax. Cardiomediastinal silhouette is
stable. Aortic knob calcifications again seen. Bony structures are intact.
No free air is seen below the right hemidiaphragm. A rotatory dextroscoliotic
curvature of the lumbar spine is partially visualized.
IMPRESSION:
No acute findings. Limited due to low lung volumes.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Lethargy
Diagnosed with Altered mental status, unspecified
temperature: 37.2
heartrate: 64.0
resprate: 14.0
o2sat: 100.0
sbp: 118.0
dbp: 58.0
level of pain: 0
level of acuity: 2.0 | ___ year old lady with history of Parkinsons disease and
diabetes, who presented with fatigue, somnolence, poor oral
intake, failure to thrive found to have hypernatremia. Now with
plan to transition to comfort oriented care given advanced
dementia.
# Failure to thrive
# Weight loss
# Goals of care
Per review of notes, there has been outpatient discussion with
regard to goals of care "team at ___ has recently
been discussing pt's decline. There was a family meeting and
pt's 5 daughters decided together to make her DNR/DNI, ok for
NIV and ok to hospitalize. They would not want a PEG placed.
There is a MOLST that ___ provides that is signed by HCP
(pt's other daughter is HCP), though not signed by an MD....
___ states family recognizes that pt is in decline but this
has been a difficult process."
During her hospitalization with us, discussed advanced dementia,
patient's failure to thrive/weight loss. Ultimately, decision
was made by family to focus on patient's comfort, and in
particular reiterated that they would not want a feeding tube
placed. We discussed that that was consistent with geriatric
society recommendations: "feeding tubes are not recommended for
older adults with advanced dementia. Careful hand feeding should
be offered because hand feeding has been shown to be as good as
tube feeding for the outcomes of death, aspiration pneumonia,
functional status, and comfort. Moreover, tube feeding is
associated with agitation, greater use of physical and chemical
restraints, healthcare use due to tube-related complications,
and development of new pressure ulcers."
Family met with ___, and will be discharged on
hospice for advanced dementia.
# Hypernatremia
Na peaked at 160. Likely secondary to poor PO intake. Resolved
with D5W. Oral intake was continued to be encouraged in the
hospital. After goals of care discussion with family, it was
decided that tube feeding was not within her goals; please see
above.
# Atrial fibrillation: New diagnosis. CHADS-Vasc of 5. Rate
controlled in 50-70s without medications. Anticoagulation was
not started due to transition to comfort oriented care.
# Hypertension
Home valsartan was held. Home amlodipine was continued; SBP
120-140s on this medication. Please have ongoing discussion with
family with regard to this medication given transition to
hospice care.
# Parkinsons
Home Sinamet was continued. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PODIATRY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Right foot infection
Major Surgical or Invasive Procedure:
Right foot incision and drainage: ___
Right foot debridement vac application: ___
History of Present Illness:
This is a pleasant ___ y/o borderline DM female who presents
to the ED from the ___ for a 5 day history of
pain,swelling and redness. She states on ___ she dropped a
frozen chicken onto her bare right foot. Since then she has been
soaking her foot daily, and states that since ___ she is no
longer able to bear weight. Her foot has had an increase of
erythema/ edema and pain over the last couple days and she now
states that she feels warm. been getting
She states she is a borderline diabetic,but does not take any
medications. Today her glucose is 300, and her WBC is 18. She
had malodor and no other complaints at this time.
Past Medical History:
none
Social History:
___
Family History:
NC
Physical Exam:
Admission PE:
VSS, Afebrile
9 98.6 107 129/77 18 97%
Gen: NAD, AAOx3, pleasant and cooperative.
___:
VASCULAR:
DP and ___ Pulses [x] Palpable [] Non-palpable [] Dopplerable
Cap Refill Time: [x] < 3 sec. [] > 3 sec. [] Immediate
Edema: [x] pitting edema [] non-pitting edema [] Anasarc [] no
edema
Skin temperature is warm when compared to the contralateral
limb.
Digital hair is [x] Present [] Absent
NEUROLOGIC:
Protective Sensation [x] Intact [] Diminished [] Absent
Proprioception: [x] Intact []Diminished [] Absent
Sharp/dull and light touch sensation [] Intact []Diminished []
Absent
DERMATOLOGIC:
Hyperkeratosis [x] Not noted [ ] Present
Ulceration (s) [ ] Not present [x] Present as described below
Ulceration(s): [x] Full thickness [] Partial thickness
[] Pre/Post-ulcerative [] Absent
___ interspace, R foot
Drainage: [] Serous [] Sanguineous [x] Purulent
[] Absent
Base: [] Granular [] Fibrous [] Eschar
[x] Tendon/Capsule/Bone
Margins: [] Regular [x] Irregular [] Hyperkeratotic
[x] Macerated [] Thin/Atrophic
Qualities: [] Undermines [] Tracks [] Probes to bone
[x] Malodorous
Discharge PE:
VSS
NAD, pleasant
RLE focused exam:
Wet to dry dressing without strikethrough. ___ pulse palpable.
CFTs<5s ___ all digits. POP to dorsum of foot.
Pertinent Results:
Admission labs:
___ 02:01PM LACTATE-1.4
___ 01:45PM GLUCOSE-330* UREA N-9 CREAT-0.7 SODIUM-136
POTASSIUM-3.7 CHLORIDE-100 TOTAL CO2-24 ANION GAP-16
___ 01:45PM estGFR-Using this
___ 01:45PM WBC-18.3*# RBC-4.51 HGB-11.5* HCT-36.1
MCV-80* MCH-25.6* MCHC-32.0 RDW-12.9
___ 01:45PM NEUTS-82.2* LYMPHS-13.7* MONOS-3.0 EOS-1.0
BASOS-0.2
___ 01:45PM PLT COUNT-347
Discharge labs:
___ 05:55AM BLOOD Glucose-251* UreaN-7 Creat-0.6 Na-137
K-3.5 Cl-103 HCO3-25 AnGap-13
___ 05:55AM BLOOD Plt ___
___ 05:55AM BLOOD
___ 05:55AM BLOOD Glucose-251* UreaN-7 Creat-0.6 Na-137
K-3.5 Cl-103 HCO3-25 AnGap-13
Imaging:
___ R foot:
IMPRESSION:
No fracture or dislocation
Pathology:
pending
Microbiology:
**FINAL REPORT ___
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
SMEAR REVIEWED; RESULTS CONFIRMED.
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 BELOW, THEY ARE NOT
PRESENT ___
this culture..
BETA STREPTOCOCCUS GROUP B. MODERATE GROWTH.
ANAEROBIC CULTURE (Final ___:
MIXED BACTERIAL FLORA.
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.
___ 4:14 pm SWAB Source: R foot ___ interspace.
**FINAL REPORT ___
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
1+ (<1 per 1000X FIELD): GRAM POSITIVE 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 BELOW, THEY ARE NOT
PRESENT ___
this culture..
BETA STREPTOCOCCUS GROUP B. MODERATE GROWTH.
ANAEROBIC CULTURE (Final ___:
MIXED BACTERIAL FLORA.
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. SPARSE GROWTH.
BETA LACTAMASE POSITIVE.
IDENTIFICATION PERFORMED ON CULTURE # ___
___.
Time Taken Not Noted ___ Date/Time: ___ 9:32 pm
TISSUE RIGHT FOOT TISSUE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE ROD(S).
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
TISSUE (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 BELOW, THEY ARE NOT
PRESENT ___
this culture..
BETA STREPTOCOCCUS GROUP B. MODERATE GROWTH.
ANAEROBIC CULTURE (Final ___:
MIXED BACTERIAL FLORA.
Mixed bacteria are present, which may include anaerobes
and/or
facultative anaerobes. Bacterial growth was screened
for the
presence of B.fragilis, C.perfringenes, and C.septicum.
None of
these species was found.
___ 4:00 pm SWAB Site: FOOT
SOURCE: DORSAL RIGHT FOOT SWABS.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
WOUND CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
___ 4:10 pm TISSUE SOURCE: RIGHT DORSAL FOOT .
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
TISSUE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary):
Medications on Admission:
None
Discharge Medications:
1. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth q4-6h Disp #*30 Tablet
Refills:*0
2. Ciprofloxacin HCl 750 mg PO Q12H
RX *ciprofloxacin 750 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*20 Tablet Refills:*0
3. Clindamycin 300 mg PO Q8H
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every six (6)
hours Disp #*40 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
right foot infection
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Followup Instructions:
___
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL RIGHT
INDICATION: ___ year old woman with Rt foot pain.
TECHNIQUE: RightFoot, three views.
COMPARISON: None.
FINDINGS:
No fracture or dislocation is detected. The base of the fifth metatarsal is
intact. Spurring at the origin of the plantar fascia on the calcaneus is
noted. No obvious focal lytic or sclerotic lesion detected. No soft tissue
calcification or radio-opaque foreign body identified.
IMPRESSION:
No fracture or dislocation.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: R Foot pain
Diagnosed with CELLULITIS OF FOOT, OPEN WOUND FOOT-COMPL, STRUCK BY FALLING OBJECT
temperature: 98.6
heartrate: 107.0
resprate: 18.0
o2sat: 97.0
sbp: 129.0
dbp: 77.0
level of pain: 9
level of acuity: 3.0 | The patient presented to Emergency Room on ___. After
thorough evaluation, it was deemed necessary to admit the
patient to the podiatric surgery service and bring her to the OR
for a right foot I&D. For operative details, please see the op
note ___ OMR. Three days later, she was taken back to the OR for
a debridement, partial closure, and VAC placement. Afterward
each procedure, pt was taken to the PACU ___ stable condition,
then transferred to the ward for observation.
Post-operatively, the patient remained afebrile with stable
vital signs; pain was well controlled with IV pain medication
that was then transitioned into an entirly oral pain medication
regimen on a PRN basis. The patient remained stable from both a
cardiovascular and pulmonary standpoint. The patient received
subcutaneous heparin throughout admission; early and frequent
ambulation were strongly encouraged while remaining
nonweightbearin to her right foot.
The patient was subsequently discharged to home on HD5. She was
sent home on clindamycin and ciprofloxacin for 10 days. The
patient received discharge teaching and follow-up instructions
with understanding verbalized and agreement with the discharge
plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim
Attending: ___
Chief Complaint:
left arm pain
Major Surgical or Invasive Procedure:
Aspiration of fluid collection in the axial aspect of the graft
History of Present Illness:
___ yo man with HIV, HCV cirrhosis, s/p OLTx2, latent TB with
recent hospitalization for suspected graft infection (LUE
AVgraft placement ___ and fevers, found to have b/l psoas
fluid collections concerning for abcesses, treated with
vancomycin/zosyn terporarily, admitted to medicine service per
request of hepatologist in setting of hyperkalemia and worsening
left arm pain.
.
Pt. notes that over the past week, he has had intermitent
nausea, preventing him from taking his antiretrovirals and
immunosuppresants. Concominantly he has had chills but no
objective fevers. These have resolved by ___ and he resumed
his medication rregimen. Over the past week, he in addition has
been more withdrawn and fatigued. He also noted increasing
redness on the L arm fistula site. Although endorsed during
prior interview, he denied SOB, CP, diaphoresis. He notes
unchanged ___ edema. Also notes dry cough over the past month.
.
He was seen by Dr. ___ ___ and after a routine lab check,
noted to have potassium >10 in a hemolyzed specimen, thus was
called in to the ED. Please see NF note for ED course. In
summary, received 1g of Vancomycin. This AM was taken to HD,
however, did not undergo HD due to suspected cellulitis over the
L graft.
Past Medical History:
-HCV cirrhosis, genotype 4, grade 2 inflammation, stage 2
fibrosis ___, no varices on endoscopy ___
-S/p OLT ___ complicated by acute rejection ___, s/p repeat
transplantation, c/b recurrent HCV with most recent VL, 1.9
million
-HIV+, on HAART, CD4 of ___, a viral load of <48 copies
-IDDM c/b neuropathy
-hyperlipidemia
-h/o CVA ___
-CKD, etiology unknown
-Depression: followed by Dr. ___
-History of positive PPD, unable to tolerate INH therapy
-left front intraparenchymal hemorrhage and subdural hematoma in
setting of a fall (___)
Social History:
___
Family History:
Father died of ESRD. Mother is alive and
healthy. Siblings are healthy as well, living in ___. No
known history of DM, HTN, liver disease, heart disease, or
cancer.
Physical Exam:
VS - 98.4 125/69 74 19 97% RA
GENERAL - 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, crackles at left base, no rhonchi/wheeze,
unlabored
HEART - PMI non-displaced, RRR, ___ holosystolic murmur at base
with radiation to apex but not carotids, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, liver edge palpated 2 cm below
costal margin, no splenomegaly, surgical wounds c/d/i, no
rebound/guarding
EXTREMITIES - WWP, no c/c, 2+ pitting edema ___ b/l, 2+
peripheral pulses (radials, DPs), faint palpable thrill of LUE
AV graft
SKIN - no spiders, palmar erythema, or jaundice
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Pertinent Results:
___ 01:30PM BLOOD WBC-13.1* RBC-3.90*# Hgb-12.0*#
Hct-38.1*# MCV-98 MCH-30.8 MCHC-31.5 RDW-16.4* Plt ___
___ 07:00AM BLOOD WBC-13.7* RBC-3.40* Hgb-10.2* Hct-32.5*
MCV-96 MCH-30.1 MCHC-31.5 RDW-16.4* Plt ___
___ 01:30PM BLOOD Neuts-48.1* ___ Monos-9.8 Eos-1.4
Baso-0.6
___ 01:30PM BLOOD ___
___ 11:10PM BLOOD Glucose-249* UreaN-74* Creat-5.9* Na-128*
K-4.3 Cl-90* HCO3-26 AnGap-16
___ 07:00AM BLOOD Glucose-162* UreaN-36* Creat-3.8*#
Na-127* K-4.3 Cl-89* HCO3-29 AnGap-13
___ 01:30PM BLOOD ALT-86* AST-248* AlkPhos-175* TotBili-0.7
___ 09:25AM BLOOD ALT-55* AST-93* LD(LDH)-298* AlkPhos-156*
TotBili-0.8
___ 09:25AM BLOOD Albumin-2.8* Calcium-7.9* Phos-7.6*
Mg-2.0
___ 07:00AM BLOOD Mg-1.7
___ 09:25AM BLOOD Vanco-14.8
___ 07:15AM BLOOD Vanco-11.4
___ 08:15AM BLOOD Vanco-18.1
___ 09:25AM BLOOD rapmycn-4.1*
___
EBV PCR - negative
___
UCx - no growth
BCx - no growth
Imaging:
___ US:
IMPRESSION: Two similar-appearing, but separate collections, is
seen in the
left upper arm. Each of these could represent a hematoma or
seroma; however,
infection/superinfection cannot be excluded.
CT chest ___:
IMPRESSION:
1. Small nonhemorrhagic layering right pleural effusion. No
pneumonia.
2. Moderately severe centrilobular emphysema, predominantly
upper lobe.
Medications on Admission:
ABACAVIR [ZIAGEN] - 1 tab BID
NEPHROCAPS - 1 mg daily
CITALOPRAM - 40 mg daily
FENOFIBRATE NANOCRYSTALLIZED [TRICOR] - 145 mg daily
GABAPENTIN - 300 mg daily
INSULIN GLARGINE [LANTUS] - 10 units at night time
INSULIN LISPRO [HUMALOG] - ___ units QID
LABETALOL - 100 mg BID
LACTULOSE - 30 ml(s) TID for 3BM daily
LAMIVUDINE [EPIVIR HBV] - 25 mg daily
LOPINAVIR-RITONAVIR [KALETRA] - 50 mg-200 mg Tablet - 2 tabs
daily
METHADONE - 5 mg BID
MYCOPHENOLATE MOFETIL - 250 mg BID
OMEPRAZOLE - 20 mg daily
ONDANSETRON - 4 mg PRN
RIFAXIMIN [XIFAXAN] - 550 mg BID
SIROLIMUS [___] - 1 mg weekly on ___
CALCIUM CARBONATE - 500 mg TID
CHOLECALCIFEROL (VITAMIN D3) - 400 unit daily
DOCUSATE SODIUM - 100mg BID
SIMETHICONE - 80 mg q4H PRN
Discharge Medications:
1. abacavir 300 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
2. B complex-vitamin C-folic acid 1 mg Capsule Sig: One (1) Cap
PO DAILY (Daily).
3. citalopram 20 mg Tablet Sig: Two (2) Tablet PO DAILY (Daily).
4. Tricor 145 mg Tablet Sig: One (1) Tablet PO once a day.
5. gabapentin 300 mg Capsule Sig: One (1) Capsule PO Q48H (every
48 hours).
6. labetalol 100 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
7. lactulose 10 gram/15 mL Syrup Sig: Thirty (30) ML PO TID (3
times a day).
8. lamivudine 10 mg/mL Solution Sig: ___ (25) mg PO
DAILY (Daily).
9. lopinavir-ritonavir 200-50 mg Tablet Sig: Two (2) Tablet PO
BID (2 times a day).
10. methadone 5 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
11. mycophenolate mofetil 250 mg Capsule Sig: One (1) Capsule PO
BID (2 times a day).
12. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
13. rifaximin 550 mg Tablet Sig: One (1) Tablet PO BID (2 times
a day).
14. sirolimus 1 mg Tablet Sig: One (1) Tablet PO Every ___.
15. calcium carbonate 200 mg calcium (500 mg) Tablet, Chewable
Sig: One (1) Tablet, Chewable PO TID (3 times a day).
16. cholecalciferol (vitamin D3) 400 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
17. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID
(2 times a day).
18. simethicone 80 mg Tablet, Chewable Sig: One (1) Tablet,
Chewable PO QID (4 times a day) as needed for gas.
19. sevelamer carbonate 800 mg Tablet Sig: One (1) Tablet PO TID
W/MEALS (3 TIMES A DAY WITH MEALS).
Disp:*90 Tablet(s)* Refills:*2*
20. Zofran 4 mg Tablet Sig: One (1) Tablet PO three times a day
as needed for nausea.
21. Lantus 100 unit/mL Solution Sig: Ten (10) u Subcutaneous at
bedtime.
22. Humalog 100 unit/mL Solution Sig: as per home sliding scale
Subcutaneous four times a day.
23. vancomycin in 0.9% sodium Cl 1 gram/250 mL Solution Sig: One
(1) Intravenous with HD for 7 days.
24. Outpatient Lab Work
Please obtain CBC, Chem 7 and Rapamycin level on ___ in AM
before taking your dose of Rapamycin. Please fax resutls to
your Dr. ___ ___, Fax: ___.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Graft cellulitis AND seroma of graft
Secondary: End stage renal disease, HIV, liver transplatation.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: A ___ man with end-stage renal disease and liver
transplant and recent left arm AV fistula with concern for infection.
COMPARISON: Left arm ultrasound, ___.
FINDINGS: A complex fluid collection is seen at the site of the area marked
on the patient's skin, in the medial left upper arm. At this site, this
collection is avascular and measures 4.2 x 2.1 x 3.1 cm. A second complex
collection is also seen in the medial antecubital fossa measuring 1.7 x 2.2 x
1.8 cm. This collection is also avascular on color Doppler imaging.
IMPRESSION: Two similar-appearing, but separate collections, is seen in the
left upper arm. Each of these could represent a hematoma or seroma; however,
infection/superinfection cannot be excluded.
Radiology Report
INDICATION: ___ male with lightheadedness and chest pain. Evaluate
for pneumonia.
PA AND LATERAL CHEST RADIOGRAPHS
COMPARISONS: ___ and ___.
FINDINGS:
Since the prior examinations, there is increased opacification in the right
lower lobe compatible with pneumonia. There are no other areas of focal
consolidation. There are no large pleural effusions or pneumothorax. The
cardiomediastinal and hilar contours are stable demonstrating moderate
cardiomegaly. A large bore hemodialysis catheter has been removed. There is
stable engorgement of pulmonary vasculature without frank interstitial edema.
There are degenerative changes of thoracolumbar spine and the left
glenohumeral joint, partially imaged.
IMPRESSION: New right lower lobe opacification compatible with pneumonia.
Recommend followup to resolution.
Findings were discussed with Dr. ___ at 2:00 p.m. on ___ by
Dr. ___ telephone.
Radiology Report
INDICATION: ___ male with end-stage renal and liver disease, on
hemodialysis, with recent history of effusions and prior infiltrates, now with
focal right lower lobe opacification. Evaluate for further characterization.
EXAMINATION: CT of the chest without intravenous contrast.
COMPARISONS: Radiographs from ___ and CT from ___,
dating back to ___.
TECHNIQUE: MDCT of the chest was performed without intravenous contrast as
per departmental protocol. Axial images are provided at 1.25- and 5-mm
collimation. Coronal and sagittal reformations are provided for review.
FINDINGS:
A small nonhemorrhagic layering right pleural effusion can account for
opacification demonstrated on concurrent radiographs. There is no evidence
pneumonia. Chain sutures reflect prior resection in the right lower and
middle lobes. Centrilobular emphysema is moderately severe in the upper
lobes. There is no left effusion. There is no evidence of pneumothorax.
Sub-4-mm nodules in the right upper lobe (4:67; 4:77) are of unlikely clinical
significance. Stellate scarring within the left upper lobe (4:67) is stable
since at least ___.
The airways are patent to the subsegmental levels.
This is no axillary, hilar, or mediastinal lymphadenopathy. Mild
atherosclerotic calcification is demonstrated in the aortic arch and origins
of the great vessels. There is mild aortic and mitral valvular calcification.
Incidentally noted is bilateral gynecomastia.
This examination is not tailored for subdiaphragmatic evaluation. The patient
is status post liver transplantation. A splenule in the left upper quadrant
survived splenectomy.
BONE WINDOWS: There are no findings suspicious for malignancy or infection.
IMPRESSION:
1. Small nonhemorrhagic layering right pleural effusion. No pneumonia.
2. Moderately severe centrilobular emphysema, predominantly upper lobe.
Radiology Report
REASON FOR THE EXAMINATION: This is a ___ man with history of left AV
graft infection with fluid collection in the left antecubital fossa and fluid
collection in the left upper arm. The initial request was to aspirate both
collections; however, during the procedure, the request was changed to
aspirate only the left upper arm collection.
COMPARISON: Previous ultrasound examination from ___.
PROCEDURE: The risks and benefits of the procedure were explained to the
patient and written informed consent was obtained. A preprocedure timeout was
performed verifying patient identity using three patient identifiers and the
procedure to be performed. The aspiration site was selected using ultrasound.
The skin of the left upper arm was prepared and draped in standard sterile
fashion. Local anesthesia was achieved via subcutaneous injection of 1%
lidocaine buffered with bicarbonate. Under ultrasound guidance a 25-gauge
needle was advanced into the small liquefied portion of this lesion. Less
than 1 mL clear fluid was aspirated. The sample was sent for gram stain and
culture. The patient tolerated the procedure well with no complication evident
at the time of the procedure.
The attending radiologist, Dr. ___, was present throughout the procedure.
IMPRESSION: Technically successful aspiration of fluid from a left upper arm
collection.
Gender: M
Race: HISPANIC OR LATINO
Arrive by WALK IN
Chief complaint: ABNORMAL LABS
Diagnosed with DUE TO RENAL DIALYSIS DEVICE,IMPLANT,GRAFT, PAIN IN LIMB, SWELLING OF LIMB, ABN REACT-RENAL DIALYSIS, END STAGE RENAL DISEASE, LIVER TRANSPLANT STATUS
temperature: 100.1
heartrate: 71.0
resprate: 18.0
o2sat: 100.0
sbp: 130.0
dbp: 68.0
level of pain: 7
level of acuity: 2.0 | ___ yo man with HIV, HCV cirrhosis, s/p OLTx2, latent TB with
recent hospitalization for suspected graft infection (LUE
AVgraft placement ___ and fevers, found to have b/l psoas
fluid collections concerning for abcesses, treated with
vancomycin/zosyn terporarily, admitted to medicine service per
request of hepatologist in setting of hyperkalemia and worsening
left arm pain. Hyperkalemia was a spurious findging.
# LUE AV cellulitis at site of Left axilla. Site was
erythematous and TTP with thrill. Patient was started on
vancomycin 1g with HD for suspected cellulitis. Repeat US of
both AV sites in ___ showed shrunken fluid collections at AC
fossa, but increased in size in the axilla. Tenderness
progressed throughout hospitalization requiring increased pain
regimen. Patient had a difficult cannulation episode in the AC
graft with clot removal and successful subsequent HD session.
BCx remained negative and patient was afebrile while on
vancomycin IV. Throughout his stay, he was monitored by
Transplant Surgery Service, who felt his graft was not infected.
In agreement with infectious dsiease, there was significant
concern for endovascular infection given increasing fluid
collections as well as cellulitis over the graft.
Patient's proximal fluid collection was aspirated per discussion
with ID and Renal. This revealed 2+ PMNs, serous fluid w/
negative cultures consistent with a seroma. Patient's pain was
felt to be due to expansion of the seroma and improved with
drainage (self drainage occured prior to aspiration). Patient
was discharged home after completion of vancomycin IV with HD.
Pain improved at time of discharge.
Given episodes of clot aspiration from graft, patient was
arranged for outpatient evaluation of AV fistulogram per
discussion with renal.
# Cough, chest pressure, chronic. Was found to have an
incidental finding of RLL infiltrate on ED CXR. Started
empirically on cefepime for HCAP, CT chest revealed near
resolution of prior infiltrate and a small effusion. Cefepime
was discontinued.
# Hyponatremia/volume overload. While awaiting HD session over
the weekend, patient developed worsening hyponatremia (119) and
was found to be whole body volume overloaded (scrotal edema)
with mild encephalopathy. Infectious w/up was unrevealing. It
was felt, that patient had took in a grossly larger amount of
free water. As HD was performed, volume status normalized and
hyponatremia improved to baseline (high 120s). On day of d/c Na
was 125 prior to HD. Patient's scrotal edema resolved, ___ trace
edema was present bilaterally and encephalopathy had resolved.
He was discharged on 1.5L fluid restriction.
# ESRD on HD: ___. Maintained on home regimen, sevelamer
an low P diet was started for hyperphosphatemia and he was
started on Sevelamer. No other changes were made.
# HCV cirrhosis s/p OLT x2: HCV VL > ___. At this point no
evidence of cirrhosis clinically. Sirolimus level was 4.1 on
admission and 6.6 at discharge. He was maintained on current
dose, however timing had to be changed to ___ given changes in
HD schedule due to hyponatremia. Continued on other
immunosuppressants w/o changes in dose.
# HIV. Neg. VL and last CD4 count > 1000. Continued on home
ARV regimen. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Ibuprofen / dye
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with MM s/p auto transplant
___, more recently on Revlimid with a recent admission
___ for S. Pneumo pneumonia on
Ceftriaxone/doxycycline, then transitioned to levofloxacin on
discharge to complete 10 days of antibiotics (last day was to be
tomorrow), also extensive workup for PE given his hemopytsis
with V/Q scan and MRA/V chest, bilateral LENIs, all negative for
clots.
He reports a new chest pain which started the day of discharge,
"knife-like" per patient, which is worse with cough and
inspiration. This is the same pain he had experienced prior to
his first admission but it had resolved. The pain initially was
waxing and waning. This pain has been present for the past 2
days. It is not worsening. It is currently a ___ but worsens
significantly with deep inspiration or coughing. It is worse
with lying down and he had to sleep sitting up one night. He
denies worsening shortness of breath or DOE, fevers, chills,
night sweats, nausea, vomiting, abdominal pain, leg swelling. He
has no hemoptysis.
In the emergency department, initial vitals: 97.4 58 123/74 20
99%. CXR was unremarkable. ECG showed sinus bradycardia with a
RBBB, unchanged from baseline.
.
Review of systems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denied nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denied arthralgias or myalgias.
Past Medical History:
*Multiple Myeloma (h/o MGUS with transformation to MM in early
___, s/p high dose cytoxan, s/p autologous transplant in ___
and then on protocol treatment for refractory myeloma- treated
with Velcade and Dexamethasone), now on Revlimid
*Chronic Renal Insufficiency since ___ (baseline 1.5-2.0)
*H/o scarlet fever in childhood
*Varicose Vein corrective procedure as a child
*s/p Tonsillectomy
*h/o anal fissures and hemorrhoids with a fissure operative
procedure done ___.
*Rash, to torso/back area ___
*parainfluenza pnuemonia ___
*atrial flutter ___ with atrial flutter ablation ___.
*herpes zoster ___
*?recent TIA
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death; otherwise non-contributory. Father with
lung CA. No other family history of lung disease. No family
history of blood clots.
Physical Exam:
ADMISSION EXAM
VS: T98.0 BP 110/70 HR 61 RR 18 94%RA
GENERAL: alert and oriented, NAD
HEENT: No scleral icterus. PERRLA/EOMI. MMM. OP clear. Neck
Supple, No LAD.
CARDIAC: RR. Normal S1, S2. No m/r/g.
LUNGS: Breath sounds slightly decreased on the left. No crackles
or rales. Right rib area is non-tender on palpation.
ABDOMEN: NABS. Soft, NT, ND. No HSM
EXTREMITIES: No c/c/e, 2+ dorsalis pedis/ posterior tibial
pulses.
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Preserved
sensation throughout. ___ strength throughout. ___ reflexes,
equal ___. Gait assessment deferred
DISCHARGE EXAM
VS: Tc 97.8 Tm 98.3 104/64 49 (48-56) 18 96% RA
GENERAL: awake, alert, pleasant individual in NAD
HEENT: PERRLA, EOMI, no scleral icterus, MMM, OP clear without
lesions
CARDIAC: RRR, S1/S2, no m/r/g appreciated
LUNGS: CTABL with good air movement, no ttp over rib area
ABDOMEN: BS+, soft, nondistended, nontender, no r/g/r
EXTREMITIES: WWP, 1+ PE in ___ bilaterally
NEURO: A&Ox3. Appropriate. CN ___ grossly intact. Moves all
fours.
Pertinent Results:
ADMISSION LABS
___ 02:07PM COMMENTS-GREEN TOP
___ 02:07PM LACTATE-1.0
___ 01:55PM GLUCOSE-87 UREA N-37* CREAT-2.4* SODIUM-137
POTASSIUM-4.3 CHLORIDE-103 TOTAL CO2-23 ANION GAP-15
___ 01:55PM estGFR-Using this
___ 01:55PM WBC-5.3 RBC-3.71* HGB-13.6* HCT-39.8*
MCV-107* MCH-36.7* MCHC-34.2 RDW-15.2
___ 01:55PM NEUTS-69 BANDS-6* LYMPHS-10* MONOS-8 EOS-1
BASOS-1 ATYPS-1* METAS-3* MYELOS-1*
___ 01:55PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-2+ MICROCYT-NORMAL POLYCHROM-NORMAL
___ 01:55PM PLT SMR-NORMAL PLT COUNT-190
DISCHARGE LABS
___ 05:30AM BLOOD WBC-3.2* RBC-3.33* Hgb-11.7* Hct-35.5*
MCV-107* MCH-35.2* MCHC-33.1 RDW-14.7 Plt ___
___ 05:30AM BLOOD Neuts-69.0 ___ Monos-5.4 Eos-1.4
Baso-2.1*
___ 05:30AM BLOOD Glucose-87 UreaN-24* Creat-2.5* Na-140
K-4.3 Cl-105 HCO3-28 AnGap-11
___ 05:30AM BLOOD ALT-35 AST-26 LD(LDH)-120 AlkPhos-84
TotBili-0.2
___ 05:30AM BLOOD TotProt-5.4* Albumin-3.3* Globuln-2.1
Calcium-9.4 Phos-5.3* Mg-2.1
___ 05:30AM BLOOD PEP-ABNORMAL B Fr K/L-PND IgG-675*
IgA-58* IgM-27*
MICRO
___ BLOOD CULTURE Blood Culture, Routine-FINAL
___ 9:15 am BRONCHOALVEOLAR LAVAGE BRONCHIAL LAVAGE.
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): MULTIPLE ORGANISMS
CONSISTENT
WITH OROPHARYNGEAL FLORA.
RESPIRATORY CULTURE (Final ___:
10,000-100,000 ORGANISMS/ML. Commensal Respiratory Flora.
STREPTOCOCCUS PNEUMONIAE. ~1000/ML.
Isolates are considered potential pathogens in amounts
>=10,000
cfu/ml. SENSITIVITIES PERFORMED ON REQUEST..
Sensitivity testing per ___ ___.
Penicillin = 12 MCG/ML : Sensitivity testing performed
by Etest.
Note: For treatment of meningitis, penicillin G MIC
breakpoints
are <=0.06 ug/ml (S) and >=0.12 ug/ml (R).
Note: For treatment of meningitis, ceftriaxone MIC
breakpoints
are <=0.5 ug/ml (S), 1.0 ug/ml (I), and >=2.0 ug/ml
(R).
For treatment with oral penicillin, the MIC break
points are
<=0.06 ug/ml (S), 0.12-1.0 (I) and >=2 ug/ml (R).
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
STREPTOCOCCUS PNEUMONIAE
|
CEFTRIAXONE----------- =>4 R
ERYTHROMYCIN---------- =>1 R
LEVOFLOXACIN---------- 1 S
PENICILLIN G---------- R
TETRACYCLINE---------- =>16 R
TRIMETHOPRIM/SULFA---- 4 R
VANCOMYCIN------------ <=1 S
LEGIONELLA CULTURE (Final ___: NO LEGIONELLA
ISOLATED.
POTASSIUM HYDROXIDE PREPARATION (Final ___:
Test cancelled by laboratory.
PATIENT CREDITED.
This is a low yield procedure based on our in-house
studies.
if pulmonary Histoplasmosis, Coccidioidomycosis,
Blastomycosis,
Aspergillosis or Mucormycosis ___ Microbiology
Laboratory.
It has not been cleared or approved by.
Immunoflourescent test for Pneumocystis jirovecii (carinii)
(Final
___: NEGATIVE for Pneumocystis jirovecii
(carinii)..
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
NOCARDIA CULTURE (Preliminary): NO NOCARDIA ISOLATED.
ACID FAST SMEAR (Final ___:
NO ACID FAST BACILLI SEEN ON CONCENTRATED SMEAR.
ACID FAST CULTURE (Preliminary): NO MYCOBACTERIA ISOLATED.
REPORTS
CHEST (PA & LAT) Study Date of ___ 2:36 ___
FINDINGS:
Lung volumes are low. Heart size is mildly enlarged.
Mediastinal contours are unchanged. Linear and patchy bibasilar
airspace opacities likely reflect atelectasis, similar to the
prior exam. Pulmonary vascularity is not engorged. No pleural
effusion or pneumothorax is clearly identified. Mild biapical
pleural thickening is present. Clips are seen in the right
upper quadrant of the abdomen compatible with prior
cholecystectomy.
TTE (Complete) Done ___ at 9:00:05 AM FINAL
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. Left ventricular wall thickness,
cavity size, and global systolic function are normal (LVEF>55%).
Due to suboptimal technical quality, a focal wall motion
abnormality cannot be fully excluded. The diameters of aorta at
the sinus, ascending and arch levels are normal. The aortic
valve leaflets (3) appear structurally normal with good leaflet
excursion and no aortic stenosis or aortic regurgitation. The
mitral valve leaflets appear structurally normal. There is no
mitral valve prolapse. Mild to moderate (___) mitral
regurgitation is seen. There is borderline pulmonary artery
systolic hypertension. Significant pulmonic regurgitation is
seen. There is a trivial/physiologic pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild-moderate mitral
regurgitation with normal valve morphology. Normal biventricular
cavity sizes with preserved global biventricular systolic
function. Mild biatrial enlargement.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
CLINICAL IMPLICATIONS:
Based on ___ AHA endocarditis prophylaxis recommendations, the
echo findings indicate prophylaxis is NOT recommended. Clinical
decisions regarding the need for prophylaxis should be based on
clinical and echocardiographic data.
CT CHEST W/O CONTRAST Study Date of ___ 10:35 AM
IMPRESSION:
1. Small right pleural effusion with adjacent right lower lobe
atelectasis and/or pneumonia. The effusion has decreased since
___.
2. Other scattered foci of atelectasis, particularly at the
left lung base and in the inferior lingula.
3. Multiple osseous lucencies in keeping with myeloma are
unchanged from
___. No new dominant lesion. No acute rib fracture or
compression
deformity.
4. Coronary artery calcifications.
IMPRESSION:
Mild bibasilar atelectasis, relatively unchanged compared to the
prior study.
RIB, UNILAT (NO CXR) Study Date of ___ 10:38 AM
There is atelectasis and consolidation at the right lung base
consistent with previous studies. There is no pneumothorax.
Surgical clips are seen within the right upper abdomen. Lung
volumes are slightly decreased. There are no displaced rib
fractures.
CHEST (PA & LAT) Study Date of ___ 10:14 AM
Right basal consolidation and pleural effusion appear to be
present on the current study, improved since ___, but more
conspicuous as compared to ___. Only small amount of
pleural fluid currently seen. There is no pneumothorax. Left
cardiophrenic angle is unremarkable.
Those findings are most likely in consitency with developing
rounded
atelectasis at right lung base, but of note that this study
neither confirm no exclude the diagnosis of pulmonary embolism.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acyclovir 400 mg PO Q12H
2. Diltiazem Extended-Release 120 mg PO DAILY
3. Gabapentin 100 mg PO QAM
4. Gabapentin 200 mg PO HS
5. Lisinopril 2.5 mg PO DAILY
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Tamsulosin 0.4 mg PO HS
9. Aspirin 325 mg PO DAILY
10. Vitamin D 800 UNIT PO DAILY
11. Levofloxacin 250 mg PO Q24H
12. Lenalidomide 10 mg PO DAILY
13. Dexamethasone 10 mg PO 1X/WEEK (___)
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
2. Aspirin 325 mg PO DAILY
3. Diltiazem Extended-Release 120 mg PO DAILY
4. Gabapentin 100 mg PO QAM
5. Gabapentin 200 mg PO HS
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Tamsulosin 0.4 mg PO HS
9. Vitamin D 800 UNIT PO DAILY
10. Dexamethasone 10 mg PO 1X/WEEK (___)
11. Levofloxacin 750 mg PO Q48H Duration: 5 Days
RX *levofloxacin 750 mg 1 tablet(s) by mouth Q48H Disp #*3
Tablet Refills:*0
12. Lenalidomide 10 mg PO DAILY
13. OxycoDONE (Immediate Release) ___ mg PO QHS:PRN pain
do not take if sedated, do not take if driving
RX *oxycodone 5 mg ___ capsule(s) by mouth at bedtime Disp #*20
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: pneumonia
Secondary: multiple myeloma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: History of pneumonia with increased right chest pain.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: Chest CT ___ and chest radiograph ___.
FINDINGS:
Lung volumes are low. Heart size is mildly enlarged. Mediastinal contours
are unchanged. Linear and patchy bibasilar airspace opacities likely reflect
atelectasis, similar to the prior exam. Pulmonary vascularity is not
engorged. No pleural effusion or pneumothorax is clearly identified. Mild
biapical pleural thickening is present. Clips are seen in the right upper
quadrant of the abdomen compatible with prior cholecystectomy.
IMPRESSION:
Mild bibasilar atelectasis, relatively unchanged compared to the prior study.
Radiology Report
INDICATION: History of multiple myeloma presenting with worsening right
pleuritic chest pain.
COMPARISON: MRI ___, CT ___, chest radiograph ___.
TECHNIQUE: Volumetric multidetector CT acquisition of the chest was performed
without intravenous contrast. Images are presented for display in the axial
plane at 5-mm and 1.25-mm collimation. A series of multiplanar reformation
images are submitted for review.
FINDINGS: Multiple lucenct lesions in the vertebral bodies and ribs are
unchanged from the prior study, some of which enhance on MRI ___ (e.g.
4:47, 108, 133, 147, 195). For example, a lucency with cortical irregularity
in the right fifth rib and a lucency in the T7 vertebral body are unchanged.
No new dominant lucent lesion, rib fracture, or vertebral body compression
fracture is seen.
A small right pleural effusion is decreased from ___ but new from
___. Adjacent right lower lobe consolidation with volume loss is similar
to ___ and may represent atelectasis or pneumonia. Other smaller
scattered areas of atelectasis are seen, predominantly at the left lung base
and inferior lingula. Minimal emphysema is noted at the right lung apex.
The thoracic aorta and pulmonary artery are normal in caliber. No
pathologically enlarged axillary, mediastinal, or hilar lymph nodes are
identified. The heart is enlarged. Coronary artery calcifications in the
left anterior descending and left circumflex arteries are of unknown
hemodynamic significance.
This study is not tailored for subdiaphragmatic evaluation, but no acute
abnormality is seen. Surgical clips are noted.
IMPRESSION:
1. Small right pleural effusion with adjacent right lower lobe atelectasis
and/or pneumonia. The effusion has decreased since ___.
2. Other scattered foci of atelectasis, particularly at the left lung base
and in the inferior lingula.
3. Multiple osseous lucencies in keeping with myeloma are unchanged from
___. No new dominant lesion. No acute rib fracture or compression
deformity.
4. Coronary artery calcifications.
Radiology Report
STUDY: AP chest and rib series, ___.
CLINICAL HISTORY: ___ man with history of multiple myeloma and
ongoing right-sided chest pain.
Comparison is made to previous study from ___.
There is atelectasis and consolidation at the right lung base consistent with
previous studies. There is no pneumothorax. Surgical clips are seen within
the right upper abdomen. Lung volumes are slightly decreased. There are no
displaced rib fractures.
Radiology Report
REASON FOR EXAMINATION: Right-sided pleuritic chest pain in a patient with
history of multiple myeloma.
PA and lateral upright chest radiograph was reviewed in comparison to chest CT
from ___.
Right basal consolidation and pleural effusion appear to be present on the
current study, improved since ___, but more conspicuous as compared to
___. Only small amount of pleural fluid currently seen. There is
no pneumothorax. Left cardiophrenic angle is unremarkable.
Those findings are most likely in consitency with developing rounded
atelectasis at right lung base, but of note that this study neither confirm no
exclude the diagnosis of pulmonary embolism.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: RIGHT SIDED CHEST PAIN
Diagnosed with PLEURISY W/O EFFUS OR TB
temperature: 97.4
heartrate: 58.0
resprate: 20.0
o2sat: 99.0
sbp: 123.0
dbp: 74.0
level of pain: 7
level of acuity: 2.0 | ___ gentleman with a history of multiple myeloma s/p
auto transplant in ___, most recently on Revlimid, who
presents with ongoing pleuritic right sided chest pain in
setting of recent treatment for bacterial pneumonia.
# Chest pain: nonexertional, right sided, EKG was not suggestive
of cardiac ischemia. Patient underwent extensive workup for PE
during prior hospitalization (V/Q scan, MRA, LENIs) which were
negative. ECHO was done this hospitalization, negative for right
sided valve vegetations. Rib films were negative for fracture.
CT thorax showed persistent but resolving right sided pleural
effusion, likely due to recent pneumonia. Patient was placed
back on ceftriaxone/levofloxacin. His pain gradually improved
over hospital day ___. He did require nightly doses of
oxycodone for pain control. Given his ongoing pain, pulmonology
service was consulted who recommended pain control and incentive
spirometry. He completed 5d of ceftriaxone and will be
discharged with an additional 5d course of levofloxacin. His
pain was largely resolved by day of discharge, will go home with
small supply of oxycodone to take as needed.
# Multiple myeloma s/p transplant: currently treated with
revlimid and dexamethasone as an outpatient. Patient did not
continue revlimid while in house, further management as per
outpatient oncologist.
# CKD: Patient presented with Cr of 2.4, slightly increased from
his recent baseline of 2.0-2.2. His lisinopril was held on
discharge as his creatinine was still elevated to 2.5. This can
be restarted based on further assessment of kidney function.
# Hx. aflutter: patient was sinus on admission, continued
metoprolol and diltiazem
# HTN: lisinopril was held as above
TRANSITIONAL ISSUES
- patient has f/u with ___ clinic to address resolution of
pleuritic chest pain
- patient will complete 5d course of levofloxacin
- patient's lisinopril is on hold pending improvement in kidney
function
- patient remained full code |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Flagyl
Attending: ___.
Chief Complaint:
L hip pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ who tripped over a quilt and fell onto her left hip. She
noticed immediate pain and called ___. She was brought here by
ambulance. She denies numbess, paresthesias or weakness in her
left leg, but it is quite painful when it is moved. She denies
LOC, hitting head, other areas of pain. She has a history of
osteoporosis and has taken bisphosphonates in the past - though
she is not taking any now. Currently taking Vit D and calcium
supplements. She is followed by endocrinology at ___.
Past Medical History:
PMH/PSH:
COPD - doesn't require oxygen or medications
ADENOCARCINOMA OF BREAST, WITH RECURR. S/P MASTECOMY
RIGHT
CMF CYCLE 1
COLONIC POLYPS
DEPRESSION
GERD
OSTEOPOROSIS
THYROID NODULE
TONSILLECTOMY
H/O MASTECTOMY, RIGHT
L TKA done at ___ by Dr. ___ more recently followed
by
Dr. ___
___ History:
___
Family History:
non contributory
Physical Exam:
AFVSS
Gen: A&Ox3, No actue distress
Ext: LLE ___, SILT ___, WWP
Pertinent Results:
___ ___ left: IMPRESSION:
1. Comminuted fracture of the left proximal femur greater
trochanter, likely involving the gluteus tendon insertion sites.
2. No evidence of fracture traversing the femoral neck or
intertrochanteric portion of the left femur.
3. Only mild right hip degenerative changes.
4. Findings are concordant with the wet reading provided on
PACS which reads as follows "comminuted fracture of the left
greater trochanter without apparent extension into the femoral
neck. No additional left hip fracture. No dislocation of the
left hip, a joint effusion, or evidence of lipohemarthrosis. No
underlying lesion is suspected. Wet read in ___."
___ L hip 2 views: IMPRESSION:
1. Minimally displaced fracture of the superior portion of the
greater
trochanter of the left hip.
2. Calcification inferior to the greater trochanter is
consistent with
calcific tendinosis.
___ 06:30PM ___ PTT-32.6 ___
___ 06:30PM PLT COUNT-238
___ 06:30PM NEUTS-63.3 ___ MONOS-9.0 EOS-0.5
BASOS-2.5*
___ 06:30PM WBC-5.3 RBC-4.14* HGB-13.9 HCT-39.6 MCV-96
MCH-33.5* MCHC-35.0 RDW-13.1
___ 06:30PM estGFR-Using this
___ 06:30PM GLUCOSE-111* UREA N-16 CREAT-0.6 SODIUM-138
POTASSIUM-4.0 CHLORIDE-100 TOTAL CO2-23 ANION GAP-19
Medications on Admission:
1. Amlodipine 5 mg PO DAILY
2. BuPROPion (Sustained Release) 200 mg PO QAM
3. Loratadine 10 mg PO DAILY
4. Pantoprazole 40 mg PO Q24H
5. Vitamin D 400 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Amlodipine 5 mg PO DAILY
3. BuPROPion (Sustained Release) 200 mg PO QAM
4. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth Twice
daily as needed for constipation Disp #*20 Capsule Refills:*0
5. Loratadine 10 mg PO DAILY
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Every 4 hours as
needed for pain control Disp #*60 Tablet Refills:*0
7. Pantoprazole 40 mg PO Q24H
8. Vitamin D 400 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
L greater troch fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with fall on the left buttock and pain in the
left hip. Evaluate for pelvis or hip fracture.
COMPARISON: None available.
TECHNIQUE: Frontal view of the pelvis and two views of the left hip were
obtained.
FINDINGS:
There is a cortical disruption of the greater trochanter of the left femur
with a minimal upper displacement of the superior portion of the greater
trochanter. A calcific fragment inferior to the greater trochanter is
consistent with calcific tendinosis. There is no dislocation of the left hip.
There is no abnormal radiopaque foreign object. Mild bilateral degenerative
changes of both hips are present.
Degenerative changes of the lumbosacral spine are incompletely assessed.
There is no diastasis of the pubic symphysis.
IMPRESSION:
1. Minimally displaced fracture of the superior portion of the greater
trochanter of the left hip.
2. Calcification inferior to the greater trochanter is consistent with
calcific tendinosis.
These findings were communicated by Dr. ___ to Dr. ___ telephone
immediately after discovery on ___ at 3:25 p.m.
Radiology Report
HISTORY: Left hip fracture on x-ray. Evaluate extent.
TECHNIQUE: Contiguous thin section helically acquire axial images were
obtained from the supra-acetabular iliac bone through the proximal femoral
diaphysis and reconstructed using both bone and soft tissue algorithm.
Coronal and sagittal reformats were generated. Images are targeted to
evaluation of the left hip and proximal femur.
LEFT HIP CT WITHOUT CONTRAST:
There is a comminuted fracture of the left greater trochanter, which spares
the extreme anterior portion of the greater trochanter. There is slight
superior retraction of fragments with slight posterior displacement, but
overall anatomic alignment.
No fracture is detected traversing the femoral neck or intertrochanteric
portion of the proximal femur. The femoral head is intact. The
femoroacetabular joint is congruent, without gross effusion. There are only
mild degenerative changes about the hip joint. No underlying bone lesion is
identified at the fracture site. The fractured portion of the greater
trochanter does appear to involve the insertion site of gluteus minimus and
medius tendons. There is mild soft tissue edema and stranding about the
fracture site, but no focal discrete hematoma.
The calcification seen on the radiograph and described as calcific tendinitis
in fact represents calcification within the subcutaneous fat. This is of
uncertain etiology, but most likely represents an injection granuloma or other
focus fat necrosis. Incidental note is made of scattered vascular
calcification and likely calcified fibroid. Muscles about the hip are
otherwise within normal limits in signal intensity and morphology.
Assessment of the pelvis is quite limited, but no obvious free fluid or
thickening of the intrapelvic porton of the obturator internus musculature is
identified.
IMPRESSION:
1. Comminuted fracture of the left proximal femur greater trochanter, likely
involving the gluteus tendon insertion sites.
2. No evidence of fracture traversing the femoral neck or intertrochanteric
portion of the left femur.
3. Only mild right hip degenerative changes.
4. Findings are concordant with the wet reading provided on PACS which reads
as follows "comminuted fracture of the left greater trochanter without
apparent extension into the femoral neck. No additional left hip fracture.
No dislocation of the left hip, a joint effusion, or evidence of
lipohemarthrosis. No underlying lesion is suspected. Wet read in RISweb."
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FALL
Diagnosed with FX NECK OF FEMUR NOS-CL, UNSPECIFIED FALL
temperature: 98.4
heartrate: 72.0
resprate: 16.0
o2sat: 100.0
sbp: 180.0
dbp: 105.0
level of pain: 3
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have left greater troch fracture and was admitted to the
orthopedic surgery service. The injury was determined to be non
operative on initial imaging and assessment. The patient worked
with ___ and was able to bear weight and mobilize on the left
lower extremity so ___ determined that discharge to home with
home ___ was appropriate. The patients home medications were
continued throughout this hospitalization. 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, and the patient was
voiding/moving bowels spontaneously. The patient is weight
bearing as tolerated in the left lower extremity with
recommendations of minimal abduction of the leg until follow up
due to having the greater troch fractured. The patient will
follow up in two weeks per routine. A thorough discussion was
had with the patient regarding the diagnosis and expected
post-discharge course, and all questions were answered prior to
discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
oxybutynin / trazodone / Aleve
Attending: ___.
Chief Complaint:
rigors vs seizure
Major Surgical or Invasive Procedure:
LP
History of Present Illness:
___ Stroke Scale (performed within 6 hours of presentation)-
Total [20]
Date: ___
Time: 1735
1a. Level of Consciousness -2
1b. LOC Questions -1 (intubated)
1c. LOC Commands -2
2. Best Gaze -0
3. Visual Fields -0
4. Facial Palsy -0
5a. Motor arm, left -3
5b. Motor arm, right -3
6a. Motor leg, left -3
6b. Motor leg, right -3
7. Limb Ataxia -0 (cannot understand commands)
8. Sensory -0
9. Language -3
10. Dysarthria -UN
11. Extinction and Neglect -UN
HPI:
Pt is a ___ yr F w/ hx of frontal dementia, HTN, HLD, and
depression who presents due to concern for breakthrough seizure.
Hx obtained from son at bedside.
This afternoon around 1500, son was driving with pt to
sister-in-law's house when he noticed she was less interactive
than normal, responding with one word answers at best. Upon
arriving to house pt was seen to develop acute onset of shaking
while sitting on the couch. Of note, shaking described as
tonic-clonic by EMS while son displayed as more rigorous in
nature. Pt was laid on her side and EMS was called who upon
arrival gave 5mg Versed intranasally. EMS report that pt
displayed R head/gaze deviation, with shaking lasting for at
most
a few minutes before resolution. Pt was brought to BI ED where
Code Stroke was called.
Son denies any recent f/c or infectious sx. No recent head
trauma
or substance abuse. Of note, pt has had prior "drop attacks"
evaluated in ED, generally attributed to presyncope. Son is
unsure if she had any similar shaking during those episodes. On
one occasion in ___ pt was admitted to BI after being found
down
in her bathroom, with subsequent cardiac w/u negative.
Past Medical History:
Hypercholesterolemia
Hypertension, essential, benign
Primary hypothyroidism
osteoporosis, s/p alendronate ___, last DEXA ___
History of SCC (squamous cell carcinoma) - right jawline
___
Fibrothecoma s/p BSO ___
Generalized anxiety disorder
Osteoarthritis of both hands
PMR (polymyalgia rheumatica)
Urge incontinence of urine
Hemorrhoids
Frontal lobe dementia
Diverticulosis of large intestine without hemorrhage
GERD (gastroesophageal reflux disease)
Chronic bilateral low back pain without sciatica
Chronic constipation
Degenerative joint disease (DJD) of lumbar spine
Spondylolisthesis, lumbosacral region
Social History:
___
Family History:
Brother - MI at age ___
Brother - HTN
Mother - Heart disease
Father - HTN
Daughter - atrial fibrillation, HTN
Physical Exam:
Exam on admission:
==============
Vitals: T: HR: BP: RR: SaO2:
General: NAD, intubated and sedated
HEENT: NCAT, no oropharyngeal lesions, neck supple, ETT in
place
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination (off Propofol):
MS: Somnolent, opens eyes briefly to voice w/o regard/tracking.
Does not follow commands.
CN: PERRL 3->2mm, +VORs, corneals. BTT. Grimaces appropriately
to
noxious.
Sensorimotor: Intact bulk and tone b/l. Withdraws briskly to
tactile stimuli in all extremities b/l. Intermittent generalized
rigors noted.
DTRS:
___ and symmetric throughout. Plantar response flexor b/l.
Coordination/Gait: Deferred
DISCHARGE EXAM:
General: appears well, in no distress
HEENT: NC/AT
___: WWP
Pulmonary: Breathing comfortably on room air.
Extremities: Warm, no edema
Neurologic Examination
Neuro:
MS- Oriented to self, month, year, not date. Generally
appropriate but a times tangential.
CN- Pupils 2->1.5 mm, slight left nasolabial fold flattening
with
symmetric activation and left ptosis with strong eye closure
Sensory/Motor- Diffuse paratonia. Moves all extremities
symmetrically and anti-gravity. intact to light touch
throughout.
Pertinent Results:
___ 11:50PM BLOOD WBC-16.2* RBC-4.21 Hgb-12.7 Hct-40.7
MCV-97 MCH-30.2 MCHC-31.2* RDW-12.9 RDWSD-46.0 Plt ___
___ 12:13PM CEREBROSPINAL FLUID (CSF) TNC-1 RBC-4 Polys-4
___ Macroph-7
___ 12:13PM CEREBROSPINAL FLUID (CSF) TotProt-24 Glucose-73
IMAGING:
CT/CTA/CTP:
CT HEAD WITHOUT CONTRAST: No acute intracranial process.
CT PERFUSION: Symmetric mismatch in the bilateral occipital
lobes
is felt to be artifactual in nature. No definite evidence of
perfusional abnormality.
CTA HEAD: Patent circle of ___. No acute vascular occlusion.
CTA NECK: There is a short segment of caliber change in the
distal V2 segment of the right vertebral artery at the level of
C3 which may be due to noncalcified atherosclerotic plaque or a
focal dissection (04:127). MRA neck could be obtained for
further
evaluation. The more distal V3 and V4 segments of the right
vertebral artery, as well as the basilar artery, are normal in
caliber.
OTHER: There is a large consolidation in the posterior left
upper
lobe which may represent pneumonia or aspiration in the setting
of altered mental status.
EEG:
IMPRESSION: This continuous video-EEG monitoring study was
abnormal due to:
1) Occasional rhythmic delta activity in the left temporal
region, consistent
with LRDA and is associated with increased risk for seizures;
2) Intermittent polymorphic delta slowing over the left temporal
region,
indicative of left temporal focal cerebral dysfunction;
3) Diffuse background slowing and disorganization, indicative of
mild diffuse
cerebral dysfunction, which is nonspecific as to etiology.
There were no clinical events. There were no electrographic
seizures or
epileptiform discharges. Compared to prior day's recording,
there was no
significant change.
Medications on Admission:
Aspirin 81 mg PO DAILY
Donepezil 10 mg PO QHS
Levothyroxine Sodium 100 mcg PO DAILY
Omeprazole 40 mg PO DAILY
Simvastatin 40 mg PO QPM
Discharge Medications:
1. Cefpodoxime Proxetil 200 mg PO Q12H pneumonia
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*4
Tablet Refills:*0
2. LevETIRAcetam 1000 mg PO BID
RX *levetiracetam 1,000 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*5
3. Aspirin 81 mg PO DAILY
4. Donepezil 10 mg PO QHS
5. Levothyroxine Sodium 100 mcg PO DAILY
6. Omeprazole 40 mg PO DAILY
7. Simvastatin 40 mg PO QPM
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
seizure
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with intubated//eval for ETT placement, aspiration
TECHNIQUE: Single frontal view of the chest
COMPARISON: CTA head and neck performed earlier on same day on ___
at 18:05
FINDINGS:
An endotracheal tube terminates approximately 4.5 cm above the carina. An
enteric tube passes below the level of the diaphragm, the distal tip of which
is not visualized. Cardiac size is normal. There is an opacity in the left
upper lobe. There is no pneumothorax or pleural effusion.
IMPRESSION:
1. An endotracheal tube terminates approximately 4.5 cm above the carina.
2. Left upper lobe opacity better seen on CTA head and neck performed earlier
on same day, concerning for pneumonia or aspiration.
Radiology Report
EXAMINATION: CTA HEAD AND NECK WITH PERFUSION PQ149 CT HEADNECK
INDICATION: History: ___ with acute AMS*** WARNING *** Multiple patients with
same last name!// ?bleed
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 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.
CT perfusion images using the RAPID software also obtained.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
903.1 mGy-cm.
2) Sequenced Acquisition 19.2 s, 8.0 cm; CTDIvol = 314.2 mGy (Head) DLP =
2,513.8 mGy-cm.
3) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 43.6 mGy (Head) DLP =
21.8 mGy-cm.
4) Spiral Acquisition 4.7 s, 37.4 cm; CTDIvol = 31.9 mGy (Head) DLP =
1,190.4 mGy-cm.
Total DLP (Head) = 4,629 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of infarction,hemorrhage,edema,ormass.
The ventricles and sulci are normal in size and configuration.
There is fluid in the ___ and oropharynx, most likely related to intubation.
There is a small amount of fluid in the left sphenoid sinus. The remainder of
the paranasal sinuses appears clear. The visualized portion of the mastoid
air cells,and middle ear cavities are clear. The visualized portion of the
orbits are unremarkable.
CT PERFUSION:
Symmetric mismatch in the bilateral occipital lobes is felt to be artifactual
in nature. No definite evidence of perfusional abnormality.
CTA HEAD:
There are mild atherosclerotic changes along both carotid siphons without
high-grade stenosis. Note is made of a 3 mm saccular outpouching along the
left ICA ophthalmic segment (series 4, image 232) which could represent a
small ophthalmic artery versus carotid cave aneurysm. There is a small infant
tibial Um at the origin of the right foot tonic artery (series 4, image 230).
The vessels of the circle of ___ and their principal intracranial branches
appear otherwise unremarkable without evidence of stenosis or vessel
occlusion. A small right posterior communicating artery is visualized. The
dural venous sinuses are patent.
CTA NECK:
Normal 3 vessel aortic arch. There are mild atherosclerotic changes along the
aortic arch with extension into the great vessels but without significant
stenosis. There are mild atherosclerotic changes along both carotid
bifurcations but without evidence of internal carotid stenosis by NASCET
criteria.
There is atherosclerotic plaque at the origin of the right vertebral artery
which results in at least mild stenosis. The origin of the left vertebral
artery is unremarkable. Note is made of a short segment caliber change in the
distal V2 segment of the right vertebral artery (series 4, image 126) which
most likely reflect narrowing due to a noncalcified atherosclerotic plaque,
however, a small focal dissection is not entirely excluded. The remainder of
the cervical vertebral arteries is unremarkable.
OTHER: The patient is intubated and the ET tube terminates a couple cm above
the carina. Small amount of fluid is seen in the trachea, most likely due to
intubation. There is a large consolidation in the posterior left upper lobe
which may represent pneumonia or aspiration in the setting of altered mental
status. The visualized portion of the thyroid gland is within normal limits.
There is no lymphadenopathy by CT size criteria.
IMPRESSION:
1. No evidence of acute infarction, hemorrhage or intracranial mass.
2. Most likely artifactual symmetric perfusion mismatch involving the
bilateral occipital lobes.
3. Saccular 3 mm left ophthalmic artery versus carotid cave aneurysm.
4. Short-segment caliber change in the distal V2 segment of the right
vertebral artery, most likely related to a noncalcified atherosclerotic
plaque, however, a small focal dissection is not entirely excluded.
5. Atherosclerotic plaque at the origin of the right vertebral artery,
resulting in at least mild stenosis.
6. Otherwise patent cervical intracranial vasculature without evidence of
stenosis or occlusion.
RECOMMENDATION(S): Saccular 3 mm left ophthalmic artery versus carotid cave
aneurysm, neurosurgical consultation is suggested.
Radiology Report
EXAMINATION: MRI ROUTINE SEIZURE PROTOCOL WANDW/O CONTRAST ___ MR HEAD.
INDICATION: ___ year old woman with FTD and suspicion for seizure. EEG with
left temporal slowing.// Evaluate for anatomical focus.
TECHNIQUE: Sagittal T1, axial T1, and axial DTI images were obtained. After
the administration of 6 mL of Gadavist intravenous contrast, axial GRE, axial
FLAIR, axial T2, coronal T2, coronal MPRAGE, and axial T1 images were
obtained. Additional sagittal and axial reformatted images of the MPRAGE
images were then produced. All images were reviewed in the production of this
report. The examination was performed using a 1.5T MRI scanner.
COMPARISON: CTA head and neck with perfusion ___
FINDINGS:
Moderate motion degradation, limiting assessment. Within these confines:
There is bilateral grade 3 to grade 4 medial temporal lobe atrophy
bilaterally, with widening of the choroid fissures and temporal horns of the
lateral ventricles, and marked hippocampal height loss. There is suggestion
of a small focal T2 hyperintense signal within the hippocampal head laterally
on the right (12:39). No definite signal abnormality within the left
hippocampus, although evaluation for small areas of signal abnormality is
limited due to the degree of motion degradation.
The mammillary bodies are preserved in signal. There is no focal lobar
encephalomalacia. There are no focal cortical dysplasias or gray matter
heterotopia noted.
There is no evidence of infarction, hemorrhage, edema, mass, or mass effect.
The ventricles and sulci are prominent, compatible with global parenchymal
volume loss. Minimal periventricular and a few scattered small deep white
matter foci of T2/FLAIR signal hyperintensity are nonspecific but compatible
with mild changes of chronic white matter microangiopathy. There is no
abnormal enhancement after contrast administration.
IMPRESSION:
1. Moderate motion degradation, limiting assessment. Within these confines:
2. Possible small focus of T2 hyperintense signal in the right hippocampal
head, which is nonspecific but could represent a small focus of right
hippocampal gliosis. No definite left hippocampal signal abnormality, within
confines of motion degradation.
3. Bilateral grade 3 or 4 medial temporal lobe atrophy, including marked
hippocampal height loss.
4. No acute infarct, hemorrhage, or extra-axial collection.
5. Global parenchymal volume loss.
6. Mild changes of chronic white matter microangiopathy.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with presumed PNA// r/o progression of
consolidation r/o progression of consolidation
IMPRESSION:
Heart size is normal. Mediastinum is normal. Lungs overall clear. There is
no appreciable pleural effusion. There is no pneumothorax. No definitive
consolidation demonstrated.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Altered mental status
Diagnosed with Altered mental status, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ is a ___ year old woman with PMH of frontal dementia,
HTN, HLD, and depression who was admitted to the neuro ICU due
to
concern for seizure s/p intubation. CT/CTA/CTP only revealing
for potential PNA. MRI wuthout stroke.
Per discussion with daughter and review of EMS records,
patient's presentation could be consistent with a secondary
generalized seizure, but this is questionable as other "drop
attacks" reportedly may have been worked-up to be syncopal in
nature. LP reassuringly bland. She is now at neurological
baseline. Impression is seizure vs rigors provoked by community
acquired pneumonia vs progression of frontotemporal dementia.
Given the fact that she is certainly at risk for seizures, opt
to continue treatment with keppra indefinitely.
# Neuro:
- EEG IMPRESSION: Occasional rhythmic delta activity in the left
temporal region, consistent with LRDA. Intermittent polymorphic
delta slowing over the left temporal region, indicative of left
temporal focal cerebral dysfunction. Diffuse background slowing
and disorganization, indicative of mild diffuse cerebral
dysfunction. No electrographic seizures or epileptiform
discharges.
- Continue Keppra 1g PO BID
- She was continued on home Donepezil
- Memantine was held and in conjunction with OP neurologist,
plan to discontinue this medication as it has not been hepful.
# CV/Pulm:
- Continued on home ASA and statin
# ID:
- treated with CTX and azithromycin for community acquired PNA.
- She completed 5d of azithromycin in the hospital
- CTX was transitioned to cefpodoxime while inpatient, she has 2
days left to complete 7 day course. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
___ cerebral angiography
History of Present Illness:
___ F with hx reflux re-presenting ___ to ED with the worst
headache of her life on a history of known L MCA aneurysm
detected 2 days prior. On ___, patient initially presented with
sudden onset headache. She was with her father who was getting
admitted for a medical issue, when she suddenly developed an
acute sharp occipital headache associated with nausea. She has
never had migraines before and never had headaches like this in
the past. Normal CT, but concern for possible reversible
cerebral vasoconstriction syndrome in setting of beading seen on
CTA of L MCA (in addition to aneurysmal sac). CTA showed no
hemorrhage but did show a L MCA aneurysmal sac. LP was deferred.
MRI w/o contrast was performed and showed subtle hyperintense
signal in Right superior frontal sulcus possibly representing
subarachnoid hemorrhage; it also showed cortical gyriform
hyperintensity of Left medial parietal occipital lobe with no
evidence of hemorrhage on GRE nor restricted diffusion on DWI,
therefore likely representing subacute infarct. She was
discharged home on ___ after observation with follow-up with
neurosurgery for the incidental L MCA aneurysm.
Since that time she had continuous dull bioccipital headache
without associated symptoms. Then on day of admission ___ at
1500 she again developed severe sudden onset bioccipital
throbbing headache which progressed to involve her entire head.
It is associated w nausea and vomiting but no photophobia or
phonophobia. At onset she denied neck pain/discomfort, vision
changes, weakness, tingling/numbness, speech difficulty, or
confusion. On arrival to the ED she was reportedly
neurologically intact. She had another NCHCT which did not show
any hypodenstity or hemorrhage. She was again evaluated by
neurosurgery in the ED who recommended a LP for ruling out SAH.
CSF with WBC 57, RBC 11,451 in tube 1 and WBC 90, RBC 11,947 in
tube 4. There was reportedly no xanthochromia. At time of
neurology evaluation around ___, patient was still having
nausea and vomiting, but overall reported feeling somewhat
better (headache more dull and less severe). She notes loss of
right visual field around 6P but otherwise no weakness, tingling
or numbness. CT/CTA was done which showed a new left
parietal-occipital intraparenchymal hemorrhage measuring
approximately 3.8 x 2.7cm with a 1 cm rightward midline shift.
Patient admitted to neuro ICU for close neurological monitoring
and blood pressure management.
Past Medical History:
Hypothyroidism
GERD
Social History:
___
Family History:
No neurologic family history
Physical Exam:
ADMISSION EXAM
Vitals: HR 90-70s, BP 150-130/50-60, ___, 98% RA
General: Sitting in chair, comfortable appearing, awake
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: Soft, non-distended
Extremities: No ___ edema, right groin access site with dressing
in place, oozing small amount of blood, non tender, no hematoma.
2+ DP and ___ pulses. R arm with swelling at midline site
compared to L, mild pain.
Skin: No rashes or lesions noted, warm and well perfused
Neurologic:
-Mental Status: Opens her eyes to voice, oriented to self,
___, ___ and ___. No dysarthria. Follows
simple axial and appendicular commands
-Cranial Nerves:
R pupil 2->1, L pupil 1.5->1, EOMs, right homonymous hemianopia,
face symmetric at rest, L facial droop
-Motor: slight pronation on the right with some drift
RUE: able to lift hold, 4+/5 strength
LUE: able to lift hold, ___ strength
RLE: able to lift hold, ___ strength
LLE: able to lift hold, ___ strength
-Sensory: No deficits
-Reflexes: plantar response was flexor bilaterally
-Coordination: deferred
-Gait: deferred
++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++++
DISCHARGE EXAM
General: Sitting in chair, endorses mild headache, awake
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Pulmonary: Normal work of breathing
Cardiac: RRR, warm, well-perfused
Abdomen: Soft, non-distended
Extremities: No ___ edema, swelling in right upper arm improved
Skin: No rashes or lesions noted, warm and well perfused
Neurologic:
-Mental Status: awake and alert, attends examiner.
-Cranial Nerves:
PERRL, right homonymous hemianopia, face symmetric at rest, no
dysarthria, tongue midline
-Motor: no orbiting, no drift, ___ throughout b/l.
-Sensory: No deficits
-Coordination: no overt dysmetria but does undershoot
bilaterally but corrects
-Gait: Deferred
Pertinent Results:
Admission Labs
================
___ 10:00PM ALT(SGPT)-12 AST(SGOT)-17 ALK PHOS-66 TOT
BILI-0.6
___ 10:00PM ALT(SGPT)-12 AST(SGOT)-17 ALK PHOS-66 TOT
BILI-0.6
___ 03:30PM BLOOD WBC-8.2 RBC-4.35 Hgb-13.6 Hct-38.8 MCV-89
MCH-31.3 MCHC-35.1 RDW-14.6 RDWSD-47.8* Plt ___
___ 03:30PM BLOOD Neuts-43.3 ___ Monos-9.4 Eos-6.4
Baso-0.7 Im ___ AbsNeut-3.53 AbsLymp-3.27 AbsMono-0.77
AbsEos-0.52 AbsBaso-0.06
___ 03:30PM BLOOD ___
___ 03:30PM BLOOD Plt ___
___ 03:30PM BLOOD Glucose-110* UreaN-13 Creat-0.8 Na-141
K-3.9 Cl-102 HCO3-18* AnGap-21*
___ 10:00PM BLOOD ALT-12 AST-17 AlkPhos-66 TotBili-0.6
___ 10:00PM BLOOD ANCA-NEGATIVE B
___ 04:21AM BLOOD TSH-2.0
___ 10:00PM BLOOD RheuFac-<10 ___ CRP-3.0
___ 10:00PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 04:57PM BLOOD ___ pO2-68* pCO2-21* pH-7.57*
calTCO2-20* Base XS-0 Comment-GREEN TOP
___ 04:57PM BLOOD Lactate-2.2*
Discharge labs
================
___ 04:00AM BLOOD WBC-10.2* RBC-3.57* Hgb-10.9* Hct-32.8*
MCV-92 MCH-30.5 MCHC-33.2 RDW-15.9* RDWSD-53.5* Plt ___
___ 04:00AM BLOOD Plt ___
___ 09:52AM BLOOD Na-144
___ 04:00AM BLOOD CK(CPK)-93
___ 04:00AM BLOOD CK-MB-<1 cTropnT-<0.01
___ 04:00AM BLOOD Calcium-9.0 Phos-2.6* Mg-2.0
___ 09:52AM BLOOD Osmolal-296
Micro
=====
___ 3:33 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending): No growth to date ___.
Imaging
========
___ ___ 3pm
1. No evidence of acute infarction or intra-axial hemorrhage.
No CT correlate for findings seen on recent MRI.
2. Moderate paranasal sinus disease.
___ CT/CTA 10:30pm
CT HEAD WITHOUT CONTRAST:
New, intraparenchymal hemorrhage within the left
parietal-occipital region, measuring approximately 3.8 x 2.7 cm.
There is an approximately 1 cm rightward shift of normally
midline structures, with effacement of the left cerebral
hemisphere sulci, and mass effect on the left lateral ventricle
and basilar cisterns. Possible early left uncal herniation.
Subarachnoid blood is seen within the sulci of the left cerebral
hemisphere, along with mild subdural blood tracking along the
falx. Paranasal sinus disease is redemonstrated.
CTA HEAD:
The approximately 6 mm saccular aneurysm of the distal left M1
bifurcation is again seen. Mild focal narrowing of the left
proximal V4 segment (3:183). Otherwise, no evidence of stenosis,
occlusion, or aneurysm of the vessels of the circle of ___.
CTA NECK:
No evidence of stenosis or occlusion of the carotid or vertebral
arteries.
Final report pending.
___ NCHCT
1. No significant change in the known, left parieto-occipital
intraparenchymal hemorrhage, with subsequent mass effect,
including stable rightward shift of normally midline structures,
effacement of the left lateral ventricle, sulci of the left
cerebral hemisphere, and basilar cisterns. Stable probable left
uncal herniation. No evidence of new hemorrhage.
2. Stable left subdural hematoma, with subdural blood tracking
along the falx and tentorium.
3. Stable subarachnoid blood interdigitating between sulci of
the left cerebral hemisphere.
4. Redemonstrated paranasal sinus disease.
___ MRI
Again seen is a large left parietal and occipital all hematoma.
The lateral ___ of the hematoma appear to have enlarged
since the most recent head CT. There are small peripheral areas
of enhancement seen on the postcontrast images that were not
displaced on the CTA. These raise a concern of an underlying
vascular abnormality. In this location, the possibility of a
mycotic aneurysm should be considered. Alternatively, it is
possible that the enhancement seen reflects enlarged veins
associated with the hematoma itself and peripheral breakdown of
the blood-brain barrier due to the hematoma.
There is subarachnoid hemorrhage, superficial siderosis, or both
over the left convexity in the vicinity of the hematoma and in
the parasagittal right sulci. Again seen and unchanged is a
small convexity left subdural hematoma, unchanged. Also again
seen and unchanged is a small amount of subdural hematoma along
the falx and along the left tentorium. There is medial
displacement of the left uncus with deformity of the adjacent
cerebral peduncle.
___ Cerebral Angio:
Fusiform aneurysm of the left MCA bifurcation.
No evidence of vascular malformation to explain left occipital
intraparenchymal hematoma
___: TTE
IMPRESSION: No 2D echocardiographic evidence for endocarditis.
Normal biventricular wall
thicknesses, cavity sizes, and regional/global systolic
function.
Medications on Admission:
Medications - Prescription
LANSOPRAZOLE [PREVACID] - Prevacid 30 mg capsule,delayed
release.
one Capsule(s) by mouth once a day
Medications - OTC
FAMOTIDINE-CA CARB-MAG HYDROX [PEPCID COMPLETE] - Pepcid
Complete
10 mg-800 mg-165 mg chewable tablet. one Tablet(s) by mouth once
a day as needed for cough - (___)
Discharge Medications:
1. amLODIPine 10 mg PO DAILY
2. Levothyroxine Sodium 75 mcg PO DAILY
3. Lidocaine 5% Patch 1 PTCH TD DAILY
4. Lisinopril 7.5 mg PO DAILY
5. NiMODipine 60 mg PO Q4H
Last dose on ___.
6. Nystatin Oral Suspension 5 mL PO TID:PRN thrush
7. Ondansetron 4 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Reversible cerebral vasoconstriction syndrome
Intracranial Hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with worst headache of her life ___, N/V. Here
two days ago for same complaint with no bleed on CTA/MRI but with L MCA
anuerysmal sac// thunderclap headache
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.3 cm; CTDIvol = 49.3 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: ___ MRI head. Head CT from ___.
FINDINGS:
There is no evidence of acute large territorial infarction,hemorrhage,edema,
or mass. The ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. There is moderate mucosal thickening of the
bilateral maxillary sinus and bilateral ethmoid air cells, similar to prior MR
brain. There is there are aerosolized secretions within the left sphenoid
sinus. The remainder of 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 evidence of acute infarction or intra-axial hemorrhage. No CT correlate
for findings seen on recent MRI.
2. Moderate paranasal sinus disease.
Radiology Report
EXAMINATION: CT ANGIOGRAPHY HEAD AND NECK
INDICATION: History: ___ with new-onset right-side visual field deficit// New
onset right-sided visual field deficit while in ED. Please re-eval for
infarct/bleed
TECHNIQUE: CT of the head was acquired. Following contrast administration and
departmental protocol CT angiography of the head and neck was obtained. 3D
and curved reformatted images were obtained on the independent workstation.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.4 mGy-cm.
2) Spiral Acquisition 4.5 s, 35.7 cm; CTDIvol = 13.3 mGy (Body) DLP = 473.5
mGy-cm.
3) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
4) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 17.8 mGy (Body) DLP =
8.9 mGy-cm.
Total DLP (Body) = 484 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: None
FINDINGS:
CT HEAD WITHOUT CONTRAST:
New, intraparenchymal hemorrhage within the left parietal-occipital region,
measuring approximately 3.8 x 2.7 cm. There is an approximately 1 cm rightward
shift of normally midline structures, with effacement of the left cerebral
hemisphere sulci, and mass effect on the left lateral ventricle and basilar
cisterns. Possible early left uncal herniation. Subarachnoid blood is seen
within the sulci of the left cerebral hemisphere, along with mild subdural
blood tracking along the falx.
Paranasal sinus disease is redemonstrated.
CTA HEAD:
The approximately 6 mm saccular aneurysm of the distal left M1 bifurcation is
again seen. Mild focal narrowing of the left proximal V4 segment (3:183).
Otherwise, no evidence of stenosis, occlusion, or aneurysm of the vessels of
the circle of ___.
CTA NECK:
No evidence of stenosis or occlusion of the carotid or vertebral arteries.
IMPRESSION:
1. New intraparenchymal hemorrhage in the left parieto-occipital region
measuring 3.8 x 2.7 cm with midline shift and early uncal herniation.
Subarachnoid blood is also identified.
2. No significant change since the previous CT angiography examination.
Previously noted left MCA aneurysm is again noted. No new vascular occlusion
is seen.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old woman with recurrent thunderclap headache and now
right homonymous hemianopsia.// assess for hemorrhage, infarct, thrombus*Must
be scanned on West 3T with ICH protocol, MRV and MPRage * **WITH MPRAGE TO
ASSESS FOR VENOUS THROMBOSIS**
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
COMPARISON: CTA and head CT ___.
FINDINGS:
Again seen is a large left parietal and occipital all hematoma. The lateral
___ of the hematoma appear to have enlarged since the most recent head
CT. There are small peripheral areas of enhancement seen on the postcontrast
images that were not displaced on the CTA. These raise a concern of an
underlying vascular abnormality. In this location, the possibility of a
mycotic aneurysm should be considered. Alternatively, it is possible that the
enhancement seen reflects enlarged veins associated with the hematoma itself
and peripheral breakdown of the blood-brain barrier due to the hematoma.
There is subarachnoid hemorrhage, superficial siderosis, or both over the left
convexity in the vicinity of the hematoma and in the parasagittal right sulci.
Again seen and unchanged is a small convexity left subdural hematoma,
unchanged. Also again seen and unchanged is a small amount of subdural
hematoma along the falx and along the left tentorium.
There is medial displacement of the left uncus with deformity of the adjacent
cerebral peduncle.
IMPRESSION:
1. Findings concerning for enlargement of the left parietal and occipital
hematoma.
2. Several areas of peripheral enhancement that raise concern for possible
mycotic aneurysm. Alternatively, this may reflect enhancement or engorged
veins associated with the hematoma itself.
3. Subarachnoid hemorrhage, superficial cirrhosis or both in both hemispheres.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with ICH. Evaluate for stability.
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) = 844 mGy-cm.
COMPARISON: CTA head and neck ___. CT head ___.
FINDINGS:
Compared to the most recent prior study, the known, left parietooccipital
hematoma measures approximately 4.0 x 2.9 cm, not significantly changed from
prior. There is persistent approximately 0.9 cm rightward shift of normally
midline structures, with effacement of the left lateral ventricle, sulci of
the left cerebral hemisphere, and basilar cisterns. A left subdural
collection measures approximately 0.8 cm in greatest axial ___, with
subdural blood tracking along the falx and tentorium.
There is persistent subarachnoid blood over the left convexity as well as in
the sylvian fissures bilaterally, the quadrigeminal cistern and the ambient
cistern. Probable left uncal herniation appears stable. There is no evidence
of new hemorrhage. The ventricles are stable in size and configuration.
There is no evidence of fracture. Moderate mucosal thickening of the
bilateral maxillary sinuses and anterior ethmoid air cells. Aerosolized
secretions are seen within the right maxillary sinus and left sphenoid sinus,
similar to prior. Otherwise, the remainder of 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 significant change in the known, left parieto-occipital hematoma, with
subsequent mass effect, including stable rightward shift of normally midline
structures, effacement of the left lateral ventricle, sulci of the left
cerebral hemisphere, and basilar cisterns. Stable probable left uncal
herniation. No evidence of new hemorrhage.
2. Stable left subdural hematoma, with subdural blood tracking along the falx
and tentorium.
3. Stable subarachnoid blood interdigitating between sulci of the left
cerebral hemisphere.
4. Redemonstrated paranasal sinus disease.
Radiology Report
INDICATION: ___ year old woman with IPH// please obtain pre op CXR
TECHNIQUE: The chest AP
COMPARISON: ___
IMPRESSION:
Lungs are clear. Cardiomediastinal silhouette is stable. There is no pleural
effusion. No pneumothorax is seen. The aorta is unfolded and tortuous.
Radiology Report
EXAMINATION: Diagnostic cerebral angiogram
The following vessels were catheterized
Right common femoral artery
Right internal carotid artery
Right external carotid artery
Left vertebral artery
Left internal carotid artery
Left external carotid artery
INDICATION: Patient is a ___ female with a history of a left middle
cerebral artery aneurysm. Additionally she has developed a left occipital
lobe intraparenchymal hemorrhage. Plans were made for diagnostic cerebral
angiogram for further evaluation.
ANESTHESIA: Moderate sedation was provided by administering divided doses of
Versed and fentanyl throughout the total intra service time of 64 minutes
during which the patient's hemodynamic parameters were continuously monitored
by trained independent observer. Patient received a total of 50 micrograms of
fentanyl and 1.5 milligram of Versed was continuously supervised by the
attending physician.
TECHNIQUE: Dr. ___ Dr. ___ physician performed the
procedure. Dr. ___ supervised the trainee during the key
component to the procedure and has reviewed and agrees with the trainee's
findings.
COMPARISON: CT angio performed ___
PROCEDURE: The patient was identified and brought to the neuro radiology
suite. Patient was transferred to the fluoroscopic table supine. Moderate
sedation was administered. Bilateral groins were prepped and draped in the
standard sterile fashion. A time-out was performed to confirm the correct
patient and procedure. The right common femoral artery was identified using
radiographic anatomic and ultrasonographic data. The right common femoral
artery was accessed using standard micropuncture technique after infiltration
of local anesthetic. A short 5 ___ sheath was introduced connected to
continuous heparinized saline flush and secured with silk suture.
Next a soft ___ 2 diagnostic catheter was introduced. It was connected
to continuous heparinized saline flush as well as the power injector. The
catheter was advanced over an 038 glidewire through the aorta into the aortic
arch. The diagnostic catheter was reconstituted in the descending aorta. The
wire was removed. Using the puff technique under constant fluoroscopic
guidance the diagnostic catheter was navigated into the right common carotid
artery. A roadmap was performed. The wire was reintroduced into the
diagnostic catheter and used to select the right internal carotid artery.
Catheter was advanced over the wire into the right internal carotid artery.
Wire was removed and vessel patency was confirmed via hand injection.
Standard AP, oblique and lateral views were obtained. The diagnostic catheter
was then withdrawn into the common carotid artery. A roadmap was performed.
The wire was introduced into the diagnostic catheter and used to select the
right external carotid artery. Catheter was advanced over the wire into the
right external carotid artery. The wire was removed vessel patency confirmed
via hand injection. Standard AP and lateral views were obtained.
The diagnostic catheter was then pushed into the aortic arch. Using the puff
technique under constant fluoroscopic guidance the catheter was used to select
the left subclavian artery. A roadmap was performed. The catheter was
positioned at the origin of the left vertebral artery. Vessel patency was
confirmed via hand injection. Standard AP lateral and oblique views were
obtained.
The diagnostic catheter was then pushed into the aortic arch. Using the puff
technique under constant fluoroscopic guidance the catheter was navigated into
the left common carotid artery. A roadmap was performed. The wire was
introduced into the diagnostic catheter and used to select the left external
carotid artery. The catheter was positioned over the wire into the left
external carotid artery. The wire was removed vessel patency confirmed via
hand injection. Standard AP and lateral views were obtained. The catheter was
withdrawn into the left common carotid artery. A roadmap was performed. The
wire was introduced into the diagnostic catheter and used to select the left
internal carotid artery. The catheter was positioned over the wire into the
left internal carotid artery. The wire was removed vessel patency confirmed
via hand injection. Standard AP and lateral as well as 3 dimensional
rotational angiography were performed.
3 dimensional rotational angiography of the left internal carotid artery
circulation requiring post processing on an independent workstation and
concurrent attending physician interpretation review.
Next the diagnostic catheter was removed. Right common femoral angiogram was
performed via hand injection through the sheath. The sheath was removed and
the arteriotomy site closed using a 6 ___ Perclose device. The patient was
removed from the fluoroscopy table and remained at the patient's neurologic
baseline without any evidence of complication.
FINDINGS:
Ultrasound of the right groin demonstrates a pulsatile single-lumen
non-compressible vessel over the femoral head. There is evidence of needle
access into the arterial lumen.
Right internal carotid artery: Power injection of the right internal carotid
artery fills the carotid artery and its branches. Vessel walls are smooth
without evidence of dissection or stenosis. Branches are smooth and tapering.
A fetal PCOM is noted. No evidence of aneurysm or vascular malformation.
Arterial capillary venous phases are normal.
Right external carotid artery: Power injection of the right external carotid
artery fills the external carotid artery and its branches with flash filling
into the internal carotid artery. Vessel walls are smooth without evidence of
dissection or stenosis. Branches are smooth and tapering. No evidence of
aneurysm or vascular malformation. Arterial capillary and venous phases are
normal.
Left vertebral artery: Hand injection of the left vertebral artery fills the
left vertebral artery the basilar artery and its branches. Poor opacification
of the right posterior cerebral artery is consistent with the right-sided
fetal PCOM. Distal branches of the left posterior cerebral artery are
compressed medially consistent with patient's diagnosis of a intraparenchymal
hemorrhage. No evidence of aneurysm or vascular malformation. Arterial
capillary and venous phases are normal.
Left external carotid artery: Power injection of the left external carotid
artery fills the external carotid carotid artery and its branches. There is
flash filling into the internal carotid artery. Vessel walls are smooth
without evidence of dissection or stenosis. Branches are smooth and tapering.
No evidence of aneurysm or vascular malformation. Arterial capillary and
venous phases are normal.
Left internal carotid artery: Power injection of the left internal carotid
artery fills the internal carotid artery and its branches. Artery walls are
smooth without evidence of dissection or stenosis. Branches are smooth and
tapering. There is a paucity of filling in the occipital area in the arterial
capillary phases; this is consistent with patient's diagnosis of a occipital
intraparenchymal hematoma. No evidence of vascular malformation within or
near the hematoma site. The known left distal M1 aneurysmal dilatation is
noted. A small branch arises from the neck of the aneurysm. This anatomy is
best appreciated on the three-dimensional angiogram. The aneurysm was of
fusiform morphology and lacks a definitive neck. Venous phase is normal.
Right common femoral artery: Arteriotomy is above the bifurcation. There is
good distal runoff. There is no evidence of dissection. Vascular caliber is
appropriate for closure device.
IMPRESSION:
Fusiform aneurysm of the left MCA bifurcation.
No evidence of vascular malformation to explain left occipital
intraparenchymal hematoma.
RECOMMENDATION(S):
1. Will discuss aneurysm in vascular conference.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dizziness, Headache, N/V
Diagnosed with Headache
temperature: 97.6
heartrate: 74.0
resprate: 18.0
o2sat: 99.0
sbp: 163.0
dbp: 90.0
level of pain: 10
level of acuity: 3.0 | In brief, Mr. ___ is a ___ right-handed woman with a
past medical history of hypothyroidism and GERD who presented
with recurrent thunderclap headaches was found to have a new
left parietal intracranial hemorrhage and mass-effect on the
left ventricle and subarachnoid bleed. She was also noted to
have a 6 mm aneurysm of the left M1. Presentation is found to
be most consistent with reversible cerebral vasoconstriction
syndrome. Reversible cerebral vasoconstriction syndromes (RCVS)
are a group of conditions characterized by reversible narrowing
and dilatation of the cerebral arteries. The cause of this
syndrome is unknown, though the reversible nature of the
vasoconstriction suggests an abnormality in the control of
cerebrovascular tone. RCVS can cause intraparenchymal
hemorrhages, subarachnoid hemorrhages and cerebral edema.
Several other differential diagnoses were ruled out. An MRI
with MRV did not show any evidence of venous thrombus. A
cerebral angiography did not show any vascular spasms or
vascular malformation. Inflammatory markers were negative
making a vasculitis unlikely. A trans-thoracic echocardiogram
was negative for any cardioembolic source or evidence of
endocarditis.
Ms ___ received supportive therapy directed towards managing
her intracranial pressure, blood pressure and headaches. She was
started on oral calcium channel blockers to treat
vasoconstriction (nimodipine and amlodipine). She will finish a
20-day course of nimodipine on ___ and will continue
amlodipine. She was started on a prednisone taper which was
completed on ___. She was started on lisinopril with a goal
blood pressure in the normotensive range. For symptomatic
treatment of headaches and neck pain she received Tylenol,
lidocaine patches and Flexeril as needed. Zofran was given
scheduled to help mitigate nausea associated with taking
nimodipine.
+++++++++++++++++++++++++
Transitional issues
-Continue nimodipine until ___
-Continue amlodipine
-Continue other antihypertensive agents
-Consider starting a statin if LDL continues to be elevated
(here LDL was 155)
-Follow up in our stroke clinic
-Please call ___ for a Neurosurgery follow-up
appointment with Dr. ___ in 3 months.
+++++++++++++++++++++++++++
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No.
If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(bleeding risk, hemorrhage, etc.)
3. Smoking cessation counseling given? () Yes - () No [reason
(x) non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form?
(x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No. If no, why not? (I.e. patient at
baseline functional status) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Prazosin / ACE Inhibitors
Attending: ___.
Chief Complaint:
DYSPNEA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo male with CAD (cardiac catheterization in ___ showing
occluded LAD), CHF (normal EF, mild to moderate AR, increased
pulmonary artery systolic pressure), last echo ___,
atrial fibrillation since ___ (rate controlled and
anticoagulated) presents with dyspnea.
Patient's wife notes gradual ___ in dyspnea since ___
with new wheezing and increased work of breathing since early
___. Per atrius notes and corroborated by patient's wife,
patient presented for wheezing and SOB on ___. BNP 265
(prior levels around 250) and 2+ pitting bilateral leg edema to
mid calf. Lasix dose incrased from 40mg BID to 80mg BID for 3
days, which his wife says resulted in improvement in symptoms.
Per notes, Lasix increased to 80mg qAM and 40mg qPM ___ without improvement in symptoms. Patient evaluated by Dr.
___ ___ who advised uptitration of Lasix to 80mg BID.
Wife self discontinued this on ___ due only moderate
improvement in symptoms. On ___, wife notes patient awoke
with wheezing and increased work of breathing that improved to
baseline after nebulizer treatment. This morning, patient awoke
again with wheezing and increased work of breathing that did not
improve with nebulizer treatment. Patient originally with desire
for palliative care (palliative care nurse to visit ___ and no
rehospitalizations, but per wife, requested to come to the
hospital this morning.
Of note, wife reports patient fell out of bed on ___ morning.
Denies head strike or any other injury.
In the ED initial vitals were: T99.6 HR95 BP 120/50 R24 92%
Nasal Cannula (2L). VBG pH7.37 pCO2 51 pO2 24 HCO3 31 BaseXS.
Labs notable for lactate 3.2, Cr 1.1, BNP 3165, WBC 11.7, INR
3.5. UA with bacteruria. UCx and BCx x 2 pending. CXR showing
pulmonary edema with bibasilar atelectasis, pneumonia cannot be
excluded.
Patient placed on NIV (NIV/Invasive Mode:psv FiO2:50 PEEP: 5 PS:
5) with M mask, tolerating well, rr 21, VE 8, VT 435.
Subsequently noted to be more alert and orientated and feeling
better. Patient received IV MethylPREDNISolone Sodium Succ 125
mg.
Vitals priors to transfer: T97.1 HR105 BP101/87 RR24 95% Nasal
Cannula 2L.
On the floor, patient feeling better. Wife notes patient with
improved work of breathing. Denies fevers, chills, and feels
mental status is at baseline. Lower extremity edema at baseline.
Patient denies chest pain, shortness of breath, abdominal pain,
diarrhea, dysuria.
Past Medical History:
- HTN
- CAD
- GERD
- carotid artery stenosis, last duplex ___ with <50% stenosis R
ICA, 50-69% stenosis L ICA
- dCHF (LVEF 55% as of ___ ECHO)
- a-fib on coumadin
- dementia
- hx bladder cancer
Per atrius notes:
"Cardiac History: CAD
___: per record dates back to the early ___ at ___ Hosp.
___ - cath showed occluded LAD - unable to open by angioplasty.
On nitrates 40 mg TID w/o angina. Followed by Dr.
___. Last MIBI ___.
CHF: Echo ___ = EF 67%, ___ MR.
___ showed no significant change from
prior echo ___ Overall left ventricular ejection
fraction is normal with an EF of 55-60%. Mild aortic and
tricuspid regurgitation.
Received BCG plantar ___ with no fluid overload
Afib: atrial fibrillation in ___, cardioversion by Dr ___
___ patient ___ but it recurred, now in persistent atrial
fibrillation .
TIA: episode of leg weakness and garbled speech in ___.
Carotid stenosis"
Social History:
___
Family History:
Wife unsure.
Physical Exam:
Admission Exam:
========================
VS: T=98.0 BP=187/95 HR=105 RR=20 O2 sat=96%3L
GENERAL: NAD. Oriented x3 (person, place, date). Able to state
days of week backwards. Repeating stories
HEENT: Sclera anicteric. PERRL, EOMI.
NECK: Supple, JVP difficult to assess given body habitus.
CARDIAC: Irregularly irregular.
LUNGS: Decreased breath sounds throughout. No wheeze or crackles
appreciated.
ABDOMEN: Soft, NTND. +BS. Protruberant.
EXTREMITIES: 2+ pedal edema bilaterally. No skin breaks or
stasis dermatitis.
NEURO: ___ Strength in UE and ___ bilaterally. CNII-XII intact.
Discharge Exam:
========================
PHYSICAL EXAM:
VS: T=98.0 Tm= 98.6 HR79(78-55) BP 146/76 (113-155/69-91)
Wt: not recorded
I/O 8h - 270/600, 24h - 2360/2750
GENERAL: NAD
HEENT: NCAT. Sclera anicteric. PERRL.
NECK:= JVP difficult to assess.
CARDIAC: Irregularly irregular.
LUNGS: Decreased breath sounds throughout, no wheeze
appreciated.
ABDOMEN: Soft, +BS, nontender to palpation.
EXTREMITIES: Extremities warm and well perfused. DP pulses
palpable. No pedal edema. Air boots in place.
SKIN: Slight stasis hyperpigmentation bilaterally. No active
stasis dermatitis. L buttock region with cluster of erythematous
papules, two with overlying vesicles with clear fluid. Nontender
to palpation. Buttocks with pink to erythematous well defined
plaques. No clear satellite lesions.
Neuro: CNII-XII grossly intact. ___ strength in UE and ___
strength in ___, difficult to assess given some difficulty
following directions. AAOx3.
Pertinent Results:
Admission Labs:
========================
___ 08:17AM BLOOD WBC-11.7* RBC-3.65* Hgb-10.3* Hct-33.7*
MCV-92 MCH-28.2 MCHC-30.6* RDW-17.1* RDWSD-57.3* Plt ___
___ 08:17AM BLOOD Neuts-84.1* Lymphs-8.7* Monos-6.0
Eos-0.3* Baso-0.4 Im ___ AbsNeut-9.82* AbsLymp-1.02*
AbsMono-0.70 AbsEos-0.04 AbsBaso-0.05
___ 08:17AM BLOOD ___ PTT-38.1* ___
___ 08:17AM BLOOD Glucose-157* UreaN-20 Creat-1.1 Na-138
K-4.3 Cl-100 HCO3-25 AnGap-17
___ 08:17AM BLOOD proBNP-3165*
DIscharge Labs:
========================
___ 08:55AM BLOOD WBC-12.0* RBC-4.65 Hgb-12.9* Hct-42.8
MCV-92 MCH-27.7 MCHC-30.1* RDW-17.4* RDWSD-58.5* Plt ___
___ 08:55AM BLOOD Plt ___
___ 08:55AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.6
Imaging:
========================
___ ECHO
The left atrium is mildly dilated. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. Left ventricular wall thicknesses and cavity size
are normal. There is moderate regional left ventricular systolic
dysfunction with hypokinesis of the basal anterior septum,
severe hypokinesis/akinesis of the mid septum, dyskinesis of the
distal septum and apex, and hypokinesis of the distal anterior
and inferior segments. The remaining segments contract
vigorously (LVEF = 35-40 %). Tissue Doppler imaging suggests an
increased left ventricular filling pressure (PCWP>18mmHg). Right
ventricular chamber size is normal with mild global free wall
hypokinesis. The aortic valve leaflets are mildly thickened
(?#). There is no aortic valve stenosis. Mild to moderate (___)
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. There is no mitral valve prolapse. Mild
(1+) mitral regurgitation is seen. The tricuspid valve leaflets
are mildly thickened. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Moderate regional left ventricular systolic
dysfunction c/w CAD (LAD distribution). Increased PCWP. Mild to
moderate aortic regurgitation.
Findings discussed with Dr. ___ on the day of the study at
5:40PM.
___ CT CHEST
1. Small bilateral pleural effusions left greater than right
with associated
atelectasis. No evidence of pulmonary edema or aspiration
pneumonia.
2. Tracheomalacia.
3. Severely dilated main pulmonary arteries suspicious for
pulmonary
hypertension.
4. Severe Coronary artery calcifications.
CXR Study Date of ___ 8:47 AM
Comparison to ___. Moderate cardiomegaly persists.
Minimal left
pleural effusion. Moderate retrocardiac atelectasis. Mild
pulmonary edema.
No pneumonia.
CXRStudy Date of ___ 10:19 ___
___. Low lung volumes. Moderate cardiomegaly with
mild pulmonary
edema. No larger pleural effusions. Mild retrocardiac
atelectasis. No
pneumonia.
CXR Study Date of ___ 8:21 AM
Pulmonary edema with bibasilar atelectasis, pneumonia cannot be
excluded.
EKGs:
========================
ECGStudy Date of ___ 12:15:36 ___
Atrial fibrillation with rapid ventricular response. Anterior
wall myocardial
infarction of indeterminate age. Diffuse non-specific
repolarization changes.
Compared to the previous tracing of ___ lead placement is
slightly
different. Repolarization changes are slightly more pronounced,
although the
findings are similar.
___ QRS___
ECGStudy Date of ___ 8:27:08 AM
Atrial fibrillation with a rapid ventricular response. Tracing
is similar to
that recorded ___. There is evidence for a prior
anteroseptal myocardial
infarction. No diagnostic interim change.
P96 QRS82QT348QTc411
ECGStudy Date of ___ 12:21:18 AM
Atrial fibrillation. Compared to the previous tracing no clear
change.
TRACING #3
P92 QRS82QT356QTc412
ECGStudy Date of ___ 8:23:06 AM
Baseline artifact. Probable atrial fibrillation. Compared to the
previous
tracing no change.
TRACING #2
___ QRS78QT362QTc451
ECGStudy Date of ___ 8:20:52 AM
Baseline artifact. Atrial fibrillation is suggested. No previous
tracing
available for comparison.
TRACING #1
P78 QRS___
Microbiology:
========================
___ 1:48 pm SKIN SCRAPINGS
VARICELLA-ZOSTER CULTURE (Preliminary):
No Varicella-zoster (VZV) virus isolated.
___ 1:48 pm DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS
**FINAL REPORT ___
DIRECT ANTIGEN TEST FOR VARICELLA-ZOSTER VIRUS (Final
___:
UNINTERPRETABLE DUE TO INADEQUATE SPECIMEN.
Refer to culture results for further information.
Reported to and read back by ___ ___ ___ AT
10:43.
___ 9:13 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ 8:55 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 10:35 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 10:35 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:28 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 8:42 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
STAPHYLOCOCCUS, COAGULASE NEGATIVE. >100,000
ORGANISMS/ML..
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
_________________________________________________________
STAPHYLOCOCCUS, COAGULASE NEGATIVE
|
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN----------<=0.12 S
NITROFURANTOIN-------- <=16 S
OXACILLIN-------------<=0.25 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 1 S
___ 8:17 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. levalbuterol HCl 2 puffs inhalation Q4H:PRN sob
2. Finasteride 5 mg PO DAILY
3. Amlodipine 5 mg PO DAILY
4. Furosemide 40 mg PO BID
5. Donepezil 10 mg PO QHS
6. Metoprolol Succinate XL 125 mg PO DAILY
7. Warfarin 3.75 mg PO ___
8. Warfarin 2.5 mg PO ___,
___
9. Simvastatin 20 mg PO QPM
10. alendronate 70 mg oral 1X/WEEK
11. irbesartan 300 mg oral DAILY
12. Potassium Chloride 40 mEq PO DAILY
13. Acetaminophen 1000 mg PO Q4-6H:PRN pain
14. Vitamin D 1000 UNIT PO DAILY
15. Aspirin 81 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
17. Vitamin E 400 UNIT PO TWICE PER WEEK
18. Vitamin C (ascorbate Ca-multivit-min;<br>ascorbate
calcium;<br>ascorbic acid;<br>vit c-ascorbate Ca-ascorb sod) 500
mg oral Q24H
19. flaxseed oil 1,000 mg oral BID
Discharge Medications:
1. Acetaminophen 1000 mg PO Q4-6H:PRN pain
RX *acetaminophen 500 mg 2 tablet(s) by mouth q4-6h Disp #*60
Tablet Refills:*0
2. Donepezil 10 mg PO QHS
RX *donepezil 10 mg 1 tablet(s) by mouth at bedtime 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. Bumetanide 1 mg PO DAILY
Increase to 1mg twice a day if more short of breath. Decrease to
1mg if breathing improves
RX *bumetanide 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
5. Carvedilol 12.5 mg PO BID
RX *carvedilol 12.5 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
6. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN SOB
RX *ipratropium bromide [Atrovent HFA] 17 mcg/actuation 17 mcg
HFA every six hours as needed Disp #*1 Inhaler Refills:*0
7. Levofloxacin 500 mg PO Q48H
RX *levofloxacin 500 mg 1 tablet(s) by mouth every 48 hours Disp
#*2 Tablet Refills:*0
8. Potassium Chloride 20 mEq PO DAILY
RX *potassium chloride [Klor-Con] 20 mEq 1 packet(s) by mouth
daily Disp #*30 Packet Refills:*0
9. ValACYclovir 1000 mg PO Q12H
RX *valacyclovir 1,000 mg 1 tablet(s) by mouth every 12 hours
Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
Dyspnea
Secondary Diagnoses:
Atrial Fibrillation
Hypertension
Coronary Artery Disease
Dysphagia
Urinary Retention
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: Portable chest radiograph
INDICATION: ___ with dyspnea. Evaluate for pneumonia.
TECHNIQUE: Single AP portable chest radiograph
COMPARISON: Radiograph from ___
FINDINGS:
Again seen is generous heart size and widened mediastinum, not significantly
changed from prior exam. There is patchy fluffy opacities bilaterally, right
worse than left, in obscuration of the bilateral diaphragm. Degenerative
changes of the bilateral AC joints and of the spine are noted. Aortic
calcifications noted.
IMPRESSION:
Pulmonary edema with bibasilar atelectasis, pneumonia cannot be excluded.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ yo male with CAD (cardiac catheterization in ___ showing
occluded LAD), CHF (normal EF, mild to moderate AR, increased pulmonary artery
systolic pressure), last echo ___, atrial fibrillation since ___
(rate controlled and anticoagulated) presents with dyspnea. Lactate 3.1
increased to 6.4, agitated. // infectious process, progression from prior CXR
infectious process, progression from prior CXR
IMPRESSION:
___. Low lung volumes. Moderate cardiomegaly with mild pulmonary
edema. No larger pleural effusions. Mild retrocardiac atelectasis. No
pneumonia.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ___ yo male with CAD (cardiac catheterization
in ___ showing occluded LAD), CHF (normal EF, mild to moderate AR, increased
pulmonary artery systolic pressure), last echo ___, atrial
fibrillation since ___ (rate controlled and anticoagulated) presents with
dyspnea. Tachypnic. Lactate uptrending, troponin uptrending. // please assess
for interval change in pulmonary edema; any evidence of aspiration pna? please
assess for interval change in pulmonary edema; any evidence of aspiration pna?
IMPRESSION:
Comparison to ___. Moderate cardiomegaly persists. Minimal left
pleural effusion. Moderate retrocardiac atelectasis. Mild pulmonary edema.
No pneumonia.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with volume overload and questionable aspiration
pneumonia
TECHNIQUE: Multidetector helical scanning of the chest was performed without
intravenous contrast agent reconstructed as contiguous 5- and 1.25-mm thick
axial, 2.5-mm thick coronal and parasagittal, and 8 x 8 mm MIPs axial images
were obtained.
DOSE: DLP: 766 mGy-cm
COMPARISON: Chest radiograph dating back to ___
FINDINGS:
The thyroid is normal. Axillary and supraclavicular lymph nodes are not
enlarged. Mildly enlarged mediastinal lymph nodes measure up to 11 x 18 mm in
the lower right pretracheal station (series 2, image 24). Heart size is
enlarged. There is lipomatous hypertrophy of the interatrial septum.
Calcifications of the left ventricular papillary muscles are likely from prior
infarct. Coronary artery and aortic valvular calcifications are severe. Main
pulmonary trunk is severely dilated measuring up to 42 mm. There is severe
atherosclerotic calcification of a nondilated aorta.
Limited evaluation secondary to respiratory motion. There is significant
tracheal collapse on this expiration study. Airways are patent to the
segmental level bilaterally. There are small bilateral nonhemorrhagic pleural
effusions left greater than right with associated atelectasis. There is no
overt pulmonary edema. Two 2 mm right upper lobe pulmonary nodules are
present (series 4, image 80, 105).
The thoracic esophagus is mildly patulous. Limited views of the upper abdomen
OSSEOUS STRUCTURES: There are moderate to severe multilevel degenerative
changes of the thoracic spine. The bones are diffusely demineralized. There
are no suspicious bony lesions.
IMPRESSION:
1. Small bilateral pleural effusions left greater than right with associated
atelectasis. No evidence of pulmonary edema or aspiration pneumonia.
2. Tracheomalacia.
3. Severely dilated main pulmonary arteries suspicious for pulmonary
hypertension.
4. Severe Coronary artery calcifications.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Heart failure, unspecified, Chronic obstructive pulmonary disease w (acute) exacerbation, Unspecified atrial fibrillation
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 0
level of acuity: 1.0 | ___ yo male with CAD (cardiac catheterization in ___ showing
occluded LAD), CHF (normal EF, mild to moderate AR, increased
pulmonary artery systolic pressure), last echo ___,
atrial fibrillation since ___ (rate controlled and
anticoagulated) presents with dyspnea.
ACUTE ISSUES:
=============
#Goals of Care: Patient's family expressed desire to transition
to hospice care. Patient was discharged to hospice care.
#Rash: New rash noted on L buttocks on day of discharge. Papular
with rare vesicles concerning for zoster (slight dermatomal
distribution, initial report of pain) versus contact dermatitis
versus satellite lesions from candidate dermatitis. VZV swab and
culture were performed. Patient was discharged with empiric
treatment of acyclovir. After uninterpretable test results
resulted for VZV direct antigen test, patient was called to
discontinue treatment given absence of pain and thus lowered
suspicion for shingles, in light of potential renal adverse
effects of valacyclovir.
#Dyspnea: Patient reported to have increased dyspnea and
wheezing since ___. Had been evaluated at ___ for this
on multiple occasions prior to admission at which time diuretics
were intermittently increased with variable relief of symptoms.
Patient with new oxygen requirement at time of admission.
Dyspnea felt to be due to volume overload. Echocardiogram
revealed moderate regional left ventricular systolic dysfunction
c/w CAD (LAD distribution) with remaining segments contracting
vigorously (LVEF = 35-40 %) increased PCWP, and mild to moderate
aortic regurgitation. This was a newly depressed EF when
compared to ___ echocardiogram noted in ___ records
that reported EF of 55-60%. Patient was diuresed with IV
diuretics during hospital stay and discharged on bumetadine 1mg
daily in addition to carvedilol 12.5mg BID. Hydrazine 25mg TID,
imdur 20mg TID, amlodipine, ibesartan were discontinued given
palliative goals of care. Discharge weight was 95.2 kg. Patient
breathing on room air at time of discharge.
#Hypernatremia: Hospital stay was complicated by hypernatremia
that improved with slow administration of D5W.
#Urinary tract infection: Leukocytosis on admission to 11.7.
Patient denied dysuria but found to have coagulase negative
staphylococcus on urine culture. Initially was treated with
ceftriaxone/vancomycin that was broadened to
vanc/cefepime/flagyl after patient spiked temperature on initial
therapy. Given goals of care and based on culture sensitivities,
patient was transitioned to oral levofloxacin Q48H that patient
was to continue on discharge. Leukocytosis stable at 12.0 at
time of discharge. Blood cultures were all no growth final read.
#Atrial fibrillation: Occurring since ___. Atrial fibrillation
was rate controlled on metoprolol 125mg per day and
anticoagulated on warfarin. Warfarin was discontinued given
goals of care. Aspirin 81 mg was continued. Metoprolol was
discontinued and patient was discharged on carvedilol 12.5 BID.
#HTN: amlodipine, ibesartan, hydralazine 25mg TID and imdur 20mg
TID were discontinued given GOC. Patient was discharged on
carvedilol 12.5 BID
#CAD: Per atrius notes, cardiac catheterization in ___ showing
occluded LAD. Patient with rising troponin during hospital stay,
felt to be due to demand ischemia. Given that patient was
DNR/DNI and was not a candidate for catheterization, further
troponin checks were discontinued. Simvastatin was discontinued
at time of discharge. Aspirin 81mg was initially discontinued at
time of discharge but patient's wife was called following
discharge and told to continue it.
#CONCERN FOR DYSPHAGIA: Family and nurse note occasionally
coughing/having trouble swallowing salivary secretions. S/S
evaluated patient with video swallow ___ year ago at which time
had evidence of aspiration to thin liquids and nectar thick as
well. Discussion of risks/benefits with wife/HCP ___ was
performed with plan to continue feeding during hospital stay.
CHRONIC ISSUES:
===============
#PSYCH: Donepezil 10 mg PO/NG QHS
#URINARY RETENTION: Finasteride 5 mg PO DAILY
Transitional Issues:
======================
- needs Q48h levofloxacin until ___
- discharging on 1mg bumex daily. Should increase to 1mg BID if
patient noted to have increasing shortness of breath. Can return
to 1mg daily as breathing improves
- noted to have papulovesicular rash on buttocks. Swab and
culture for zoster were pending at time of discharge. Patient
was initiated on empiric treatment with valacylovir BID and will
be called with results. Treatment will be discontinued if
results are negative.
- dysphagia: risks of aspiration with po intake including both
thin and nectar thick liquids were discussed with patient's wife
and son and discussed need to balance this risk with patient's
comfort and goals of care at this time. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
oxycodone / Tylenol / Cymbalta / Glucophage
Attending: ___.
Chief Complaint:
Dyspnea, Agitation
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with a history of severe COPD (on ___ O2 at
home) with O2 destaturations with ambulation at baseline, OSA on
CPAP, history of panic attacks, insomnia, who presents with
several weeks of decreasing exercise tolerance and with
increasing agitation at home.
Several weeks ago while in ___ he found that his exercise
tolerance was worse than usual (can only walk 1000 feet now) and
went to see one of his doctors in ___. He was treated for a
possible COPD exacerbation with a prednisone taper (~ 2 weeks of
40mgPO and then tapered to off with last dose 2 days ago). He
flew home from ___ 2 days ago.
Since coming back from ___ his daughters report he's been
increasingly agitated, up all night, at times confused. The
night before admission he was hallucinating. Of note he's not
been sleeping much at night. He recently started using BIPAP
machine at night which he finds uncomfortable, but he says that
the insomnia preceded starting Bipap. Per his daughters he seems
terrified and in panic constantly except for when he takes
Xanax, which is a new med for him (0.25 per day). In this
setting his dyspnea has at times seemed slightly worse than
usual but home O2 requirement has not changed ___ L).
Of note while in ___ he had HRCT with ? findings reported in
LUL. He was scheduled to undergo PETCT, however he was unable to
complete this given elevated sugars while on prednisone. For his
severe COPD he is scheduled to see Dr. ___ consideration
of advanced therapeutic intervention and undergoing evaluation
for experimental procedure in ___ (one way valves).
In the ED, initial vitals: 6 97.6 96 121/68 28 92% Nasal Cannula
- Exam notable for anxious male unable to get comfortable moving
around in bed, tachycardic, poor air movement bilaterally though
no wheezing, no peripheral edema
- Labs were notable for: WBC 36. Chem panel unremarkable. UA
neg. Trop neg.
- Imaging: CXR with marked bullous emphysema, Patchy left upper
lobe and left basilar opacities may reflect infection, however
underlying neoplasm cannot be excluded in the left upper lobe.
CTA neg for PE, ?LUL infection vs neoplasm .
- EKG: RBBB, deeper TWI in V1 and V3 from prior, otherwise
unchanged from ___ EKG.
- Patient was given:
___ 13:10 IH Albuterol 0.083% Neb Soln 1 NEB
___ 13:10 IH Ipratropium Bromide Neb 1 NEB
___ 13:38 PO/NG PredniSONE 60 mg
___ 13:38 PO/NG Azithromycin 500 mg
___ 13:38 PO Phenazopyridine 100 mg
___ 15:02 IV LORazepam .25 mg
___ 15:06 TP Lidocaine Jelly 2% (Urojet) 1 Appl
On arrival to the MICU, he is accompanied by his daughters. He
endorses decreased exercise tolerance over past few weeks to
months but currently doesn't feel dyspneic. Cough has been
slightly worse recently. No fevers, +chills. No abdominal pain,
no diarrhea. Has been endorsing urinary frequency and urgency,
sometimes feels unable to urinate when he needs to.
Past Medical History:
-COPD: FEV1/FVC ratio 44 in ___
-Stable CAD w/ Hx of MI
-Diastolic dysfunction
-OSA on CPAP
-HTN
-PVD
-PERIPHERAL NEUROPATHY
-HLD
-Prior smoker
Social History:
___
Family History:
Father with pancreatic cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vitals: afebrile, HR ___ 110s/40s 22 90s on 6L
GENERAL: Alert, oriented, hard of hearing, slightly tachypneic
but in no distress resting close to flat
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Diminished breath sounds but fair air entry. bibasilar
crackles but otherwise clear to auscultation bilaterally, no
wheezes, rales, rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: no rash
NEURO: AOx3 but sometimes tangential, distracted appearing
ACCESS: PIVs
DISCHARGE PHYSICAL EXAM
=======================
VS: 98.0PO 137/59 63 24 93 5L NC
FSBS: 170's-270's
GEN: Alert, NAD
HEENT: NC/AT
CV: irreg irreg, no m/r/g
PULM: diminished air movement with bronchial BS at the left base
and diminished BS at the right base, otherwise CTA, breathing
comfortably
GI: S/NT/ND, BS present
EXT: No ___ edema
NEURO: Alert, Ox3
Pertinent Results:
Admission Labs:
___ 12:20PM BLOOD WBC-35.4*# RBC-5.02 Hgb-16.4# Hct-48.0
MCV-96 MCH-32.7* MCHC-34.2 RDW-13.4 RDWSD-46.9* Plt ___
___ 12:20PM BLOOD Neuts-89.2* Lymphs-3.9* Monos-5.2
Eos-0.1* Baso-0.3 Im ___ AbsNeut-31.64* AbsLymp-1.37
AbsMono-1.84* AbsEos-0.02* AbsBaso-0.10*
___ 12:20PM BLOOD Glucose-141* UreaN-27* Creat-0.9 Na-141
K-4.0 Cl-102 HCO3-26 AnGap-17
___ 02:25AM BLOOD ALT-21 AST-14 AlkPhos-83 TotBili-2.0*
___ 02:25AM BLOOD Albumin-4.1 Calcium-9.5 Phos-3.3 Mg-1.9
___ 01:15PM URINE Color-Yellow Appear-Clear Sp ___
___ 01:15PM URINE Blood-NEG Nitrite-NEG Protein-100
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-2* pH-6.5 Leuks-TR
___ 01:15PM URINE RBC-1 WBC-2 Bacteri-FEW Yeast-NONE Epi-<1
___ 12:20PM BLOOD VitB12-1086*
___ 12:20PM BLOOD TSH-0.46
___ 02:45PM BLOOD PARANEOPLASTIC AUTOANTIBODY
EVALUATION-PND
Urine Cx - mixed bacterial flora
Blood Cx - negative
RPR - non reactive
C.diff - negative
Discharge labs:
___ 07:35AM BLOOD WBC-14.7* RBC-4.36* Hgb-13.7 Hct-41.9
MCV-96 MCH-31.4 MCHC-32.7 RDW-13.1 RDWSD-46.9* Plt ___
___ 07:35AM BLOOD Glucose-149* UreaN-21* Creat-0.7 Na-144
K-3.5 Cl-106 HCO3-28 AnGap-14
==========================================================
Studies:
ECG (___) - Sinus tachycardia. Right bundle-branch block and
left anterior fascicular block. Atrial and ventricular ectopy,
frequent. Biatrial abnormality. Compared to the previous tracing
of ___ frequent atrial and occasional ventricular ectopy has
appeared. The P wave morphology has an increased prominence.
Followup and clinical correlation are suggested.
CXR (___) - IMPRESSION:
1. Marked bullous emphysema.
2. Patchy left upper lobe opacity, new in the interval, may
reflect infection, however underlying neoplasm cannot be
excluded. Additional patchy left lower lobe opacity may reflect
additional site of infection or atelectasis. Followup
radiographs after treatment are recommended, and if the finding
in the left upper lobe persists, dedicated chest CT is
suggested.
3. Pulmonary arterial hypertension.
CTA Chest (___) - IMPRESSION:
1. Somewhat limited exam due to respiratory motion artifact.
No evidence of pulmonary embolism to the segmental levels.
2. Left upper lobe opacity, concerning for infection.
3. Prominent hilar lymph nodes, likely reactive.
4. Severe emphysematous disease.
ECG (___) - Probable atrial flutter/tachycardia with variable
conduction. Right bundle-branch block with left anterior
fascicular block. Extensive ST-T wave changes. Prolonged Q-T
interval. Compared to the previous tracing of ___ the rhythm
has changed. Ventricular ectopy is absent.
ECG (___) - Sinus rhythm with premature atrial contractions.
Right bundle-branch block. Left anterior fascicular block.
Prolonged Q-T interval. Compared to tracing #1 sinus rhythm has
been restored.
CT Head (___) - IMPRESSION:
1. Allowing for streak artifact from embolization material at
the vertex, there is no evidence for acute hemorrhage or other
acute intracranial abnormalities.
2. Increased local parenchymal volume loss compared to ___.
CTA Head (___) - IMPRESSION:
1. No acute intracranial abnormality.
2. Interval progression of small vessel ischemic disease and
age-related into involutional changes.
3. Stable findings related to prior embolization of dural AV
fistula with associated streak artifact limiting the evaluation
of surrounding brain parenchyma.
4. Intracranial atherosclerosis involving cavernous,
supraclinoid ICAs resulting in mild stenosis.
5. Atherosclerosis involving V4 segments of bilateral vertebral
arteries resulting in moderate to severe luminal narrowing.
6. No aneurysm or occlusion is seen.
MRI Head (___) - IMPRESSION:
1. Interval progression of confluent FLAIR hyperintensity in the
periventricular, subcortical and deep white matter, nonspecific.
This is likely secondary to small vessel ischemic disease.
2. Age-related involutional changes.
3. No acute intracranial abnormality. Unchanged appearance of
posterior vertex embolization of dural AVF.
TTE (___) - The left atrium is normal in size. No left atrial
mass/thrombus seen (best excluded by transesophageal
echocardiography). Left ventricular wall thickness, cavity size,
and global systolic function are normal (LVEF>55%). Due to
suboptimal technical quality, a focal wall motion abnormality
cannot be fully excluded. Right ventricular chamber sizeis
grossly normal. The aortic valve leaflets are mildly thickened
(?#). There is no aortic valve stenosis. No aortic regurgitation
is seen. The mitral valve appears structurally normal with
trivial mitral regurgitation. There is no pericardial effusion.
IMPRESSION: Very suboptimal image quality. Normal biventricular
cavity sizes with preserved global biventricular systolic
function. No definite valvular pathology or pathologic flow
identified.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Hyoscyamine 0.125 mg PO BID
2. Centrum (multivit-iron-min-folic
acid;<br>multivit-mins-ferrous gluconat) 3,500-18-0.4 unit-mg-mg
oral DAILY
3. Aspirin 81 mg PO DAILY
4. NexIUM (esomeprazole magnesium) 40 mg oral BID
5. Clopidogrel 75 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. Coreg CR (carvedilol phosphate) 40 mg oral DAILY
8. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose
inhalation DAILY
9. Tudorza Pressair (aclidinium bromide) 400 mcg/actuation
inhalation BID
10. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
DAILY
11. glimepiride unknown oral Other
12. Zolpidem Tartrate 6.25 mg PO QHS
Discharge Medications:
1. Apixaban 5 mg PO BID
RX *apixaban [Eliquis] 5 mg one tablet(s) by mouth twice daily
Disp #*30 Tablet Refills:*2
2. Atorvastatin 40 mg PO QPM
3. Centrum (multivit-iron-min-folic
acid;<br>multivit-mins-ferrous gluconat) 3,500-18-0.4 unit-mg-mg
oral DAILY
4. Nicotine Patch 21 mg TD DAILY
RX *nicotine 21 mg/24 hour 1 patch daily Disp #*30 Patch
Refills:*0
5. Tamsulosin 0.4 mg PO QHS
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth at night Disp #*30
Capsule Refills:*0
6. QUEtiapine Fumarate 25 mg PO QHS
RX *quetiapine 25 mg 1 tablet(s) by mouth at night Disp #*30
Tablet Refills:*0
7. NexIUM (esomeprazole magnesium) 40 mg oral BID
8. Tudorza Pressair (aclidinium bromide) 400 mcg/actuation
inhalation BID
9. Incruse Ellipta (umeclidinium) 62.5 mcg/actuation inhalation
DAILY
10. Breo Ellipta (fluticasone-vilanterol) 100-25 mcg/dose
inhalation DAILY
11. glimepiride unknown ORAL Frequency is Unknown
Please resume the dose you were previously taking.
12. Metoprolol Tartrate 75 mg PO TID
RX *metoprolol tartrate 75 mg 1 tablet(s) by mouth three times a
day Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Encephalopathy
Central Sleep Apnea
Atrial Fibrillation
Benign Prostatic Hyperplasia
Chronic Obstructive Pulmonary Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with dyspnea
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: ___ chest radiograph and ___ chest CT
FINDINGS:
Heart size is normal. The mediastinal contours are unchanged with diffuse
atherosclerotic calcification of the thoracic aorta noted. Hilar contours are
similar with enlargement of the pulmonary arteries bilaterally suggestive of
underlying pulmonary arterial hypertension. Severe bullous emphysema is seen
with large bulla noted most pronounced in the right lung base. Patchy opacity
within the left upper lobe is new in the interval which may reflect an area of
infection though underlying neoplasm cannot be excluded. Patchy opacity in
the left lung base may also reflect an additional area of infection or
atelectasis. No pleural effusion or pneumothorax is seen. There are no acute
osseous abnormalities. Surgical anchor is noted in the right humeral head.
IMPRESSION:
1. Marked bullous emphysema.
2. Patchy left upper lobe opacity, new in the interval, may reflect infection,
however underlying neoplasm cannot be excluded. Additional patchy left lower
lobe opacity may reflect additional site of infection or atelectasis.
Followup radiographs after treatment are recommended, and if the finding in
the left upper lobe persists, dedicated chest CT is suggested.
3. Pulmonary arterial hypertension.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ year old man with severe COPD and worsening dyspnea // 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: Total DLP (Body) = 316 mGy-cm.
COMPARISON: Comparison is made with chest CTA from ___.
FINDINGS:
This exam is somewhat limited due to respiratory motion artifact.
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
segmental level without filling defect to indicate a pulmonary embolus.
Subsegmental levels are not well assessed due to motion. 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: Multiple enlarged mediastinal lymph nodes are
noted, the largest of which measures 13 mm in short axis, which are likely
reactive. No axillary or hilar lymphadenopathy is present. No mediastinal
mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Severe emphysematous disease is seen in the bilateral lungs.
Large bulla noted particularly in the right lower lobe as on prior. Opacity
is seen in the left upper lobe, concerning for infection. Calcified right
apical scarring is unchanged. 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: No suspicious osseous abnormality is seen.? There is no acute fracture.
Chronic right lateral rib fractures are noted.
IMPRESSION:
1. Somewhat limited exam due to respiratory motion artifact. No evidence of
pulmonary embolism to the segmental levels.
2. Left upper lobe opacity, concerning for infection.
3. Prominent hilar lymph nodes, likely reactive.
4. Severe emphysematous disease.
RECOMMENDATION(S): Recommend further imaging after treatment to assess for
underlying lesions.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ man with worsening agitation at night, history of
prior dural AV fistula embolization. Evaluate for any etiology of hemorrhage.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Stationary Acquisition 4.0 s, 15.1 cm; CTDIvol = 45.3 mGy (Head) DLP =
684.4 mGy-cm.
Total DLP (Head) = 684 mGy-cm.
COMPARISON: Head CT dated ___.
FINDINGS:
Evaluation at the vertex is limited secondary to streak artifact from
embolization material. Within this limitation, no evidence of hemorrhage,
edema, large vascular territorial infarction, or mass effect. Bilateral,
symmetric prominence of the ventricles and sulci has progressed since ___, indicating increased volume loss. Extensive bilateral periventricular,,
deep, and subcortical white matter hypodensities are nonspecific but please
secondary to small vessel ischemic disease, similar in appearance to the prior
CT . Cavernous and supraclinoid internal carotid artery as well as vertebral
artery calcifications are extensive bilaterally.
No evidence of fracture or concerning bone lesion. The visualized portion of
the paranasal sinuses and mastoid air cells are well aerated. The left
mastoid is underpneumatized, as seen previously.
IMPRESSION:
1. Allowing for streak artifact from embolization material at the vertex,
there is no evidence for acute hemorrhage or other acute intracranial
abnormalities.
2. Increased local parenchymal volume loss compared to ___.
Radiology Report
EXAMINATION: CTA HEAD WANDW/O C AND RECONS Q1213 CT HEAD
INDICATION: ___ year old man with COPD, acute agitation and microvascular
disease now with anisocoria concerning for possible stroke // Evaluate for
vascular malformation or vessel occlusion causing anisocria or stroke
occlusion
TECHNIQUE: Helical imaging of the head was performed prior to the
administration of intravenous contrast. This was followed by rapid axial
imaging was performed through the brain during the uneventful infusion of 70
mL of Omnipaque intravenous contrast material. Three-dimensional angiographic
volume rendered and segmented images were then generated on a dedicated
workstation. This report is based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 45.5 mGy (Head) DLP =
855.5 mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 14.6 mGy (Head) DLP = 2.9
mGy-cm.
3) Stationary Acquisition 15.1 s, 0.2 cm; CTDIvol = 405.1 mGy (Head) DLP =
81.0 mGy-cm.
4) Spiral Acquisition 3.7 s, 23.7 cm; CTDIvol = 32.7 mGy (Head) DLP = 753.2
mGy-cm.
Total DLP (Head) = 1,693 mGy-cm.
COMPARISON: Head CT from ___, MRI/MRA brain from ___
FINDINGS:
CT HEAD:
Again seen is high density material in the posterior vertex of the skull
related to prior embolization of dural AV fistula. There is associated streak
artifact limiting the evaluation of the underlying brain parenchyma.
There is prominence of the ventricles, sulci and cisterns, likely secondary to
age-related involutional changes, more advanced than the prior study from
___. Scattered hypodensities in the subcortical, periventricular and deep
white matter, nonspecific, likely secondary to small vessel ischemic disease.
There is intracranial atherosclerotic calcification.
No acute intracranial infarct, hemorrhage, mass or midline shift is seen.
The visualized paranasal sinuses, mastoid air cells are clear. The orbits are
unremarkable noting prior bilateral cataract surgeries.
CTA HEAD:
There is dense atherosclerosis involving bilateral V4 segments of the
vertebral arteries, right greater than the left resulting in moderate to
severe luminal narrowing.
Also seen is atherosclerosis involving bilateral cavernous and supraclinoid
ICAs resulting in mild luminal narrowing bilaterally. The vessels of the
circle of ___ and their principal intracranial branches appear normal with
no evidence of stenosis, occlusion, or aneurysm. The dural venous sinuses are
patent.
IMPRESSION:
1. No acute intracranial abnormality.
2. Interval progression of small vessel ischemic disease and age-related into
involutional changes.
3. Stable findings related to prior embolization of dural AV fistula with
associated streak artifact limiting the evaluation of surrounding brain
parenchyma.
4. Intracranial atherosclerosis involving cavernous, supraclinoid ICAs
resulting in mild stenosis.
5. Atherosclerosis involving V4 segments of bilateral vertebral arteries
resulting in moderate to severe luminal narrowing.
6. No aneurysm or occlusion is seen.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with acute encephalopathy, extensive small vessel
ischemic changes, prior history of dural AV malformation embolization //
evaluate for stroke, structural disease
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: Head CT from ___.
MRI/MRA brain from ___.
FINDINGS:
There is no evidence of hemorrhage, edema, masses, mass effect, midline shift
or infarction. The ventricles and sulci are patent and prominent in keeping
with age-related volume loss.
There is no abnormal enhancement on postcontrast images.
There are confluent areas of T2/FLAIR hyperintensity in the subcortical,
periventricular and deep white matter, nonspecific. This is slightly
progressed compared to the prior study.
There is susceptibility artifact in the posterosuperior vertex of the skull,
related to prior embolization of the dural AV fistula as seen on the CT scan.
There is a punctate focus of susceptibility in the right cerebellar hemisphere
on image 6:5, likely secondary to prior micro hemorrhage. An additional right
posterior pontine micro hemorrhage is unchanged from examination of ___
(series 6, image 8).
The orbits are unremarkable noting prior bilateral cataract surgeries. There
is mild mucosal thickening in bilateral anterior ethmoid air cells. The
remaining visualized paranasal sinuses are clear. Intracranial flow voids are
maintained.
IMPRESSION:
1. Interval progression of confluent FLAIR hyperintensity in the
periventricular, subcortical and deep white matter, nonspecific. This is
likely secondary to small vessel ischemic disease.
2. Age-related involutional changes.
3. No acute intracranial abnormality. Unchanged appearance of posterior
vertex embolization of dural AVF.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Dyspnea, unspecified
temperature: 97.6
heartrate: 96.0
resprate: 28.0
o2sat: 92.0
sbp: 121.0
dbp: 68.0
level of pain: 6
level of acuity: 2.0 | ___ yo M with history of COPD (On ___ O2 at baseline), OSA on
CPAP, CAD who presents with subacute agitation and nighttime
hallucinations and acute on chronic dyspnea.
#Agitation, anxiety, hallucinations: Has several week history
of agitation, particularly at night. During first 24 hours in
hospital he required 12 mg IV Haldol. Subseuqently his mental
status improved and he was calm/alert/oriented, however
subsequent exam was notable for pillrolling tremor, masked
facies, cogwheeling raising question of Parkinsonism. This
diagnosis was particularly interesting given that it could
explain central sleep apnea and autonomic dysfunction
(hypotension, changes in urinary fx) as well as intermittent
agitation and hallucinations. Neurology was consulted and felt
that the symptoms of cog-wheeling and pill-rolling were likely
related to heavy Haldol exposure on admission. They were
concerned for possible REM behavior sleep disorder. It was also
possible that progression of his central sleep apnea was causing
agitation/delirium particularly at night. A head CT was obtained
that showed no bleed but significant small vessel disease. MRI
head with and without contrast to evaluate for stroke revealed
no acute changes. B12 and TSH were normal. RPR was nonreactive.
Given possibility that polypharmacy (esp recent initiation of
benzos) was contributing, home benzos were stopped as was home
ambien. On HD2 given parkinsonism on exam he was changed from
Haldol to Seroquel for agitation. He had no further episodes of
agitation and no further notable Parkinsonian symtoms after
transfer to the floor.
# Leukocytosis
# LUL infiltrate
Presented with leukocytosis to 36 concerning for acute
infectious process, and with LUL opacity c/f PNA on CTA chest.
This LUL infiltrate had previously been noted on a ___t OSH. He had no other localizing s/s of infection aside from
dysuria (but only 2 WBC on UA) and diarrhea (c diff negative,
started after initiating abx). He was treated with ceftriaxone
x7 d and azithromycin x 5 d for CAP. Plan was for PET-CT as an
outpatient given possibility that LUL infiltrate represented
malignancy in this former cigarette smoker. Discussed with
radiology - will have to wait 1 month following resolution of
PNA to pursue PET scan.
#Atrial fibrillation: New diagnosis during this hospitalization,
possibly precipitated by infection. He was started on
metoprolol, which was uptitrated to provide adequate rate
control. Coreg was discontinued. Given his high CHADS2 score,
he was also initiated on Apixaban. Aspirin and Plavix were
stopped after discussion with his PCP and cardiologist to
decrease risk of bleeding while using Apixaban. TTE was done
which was limited study but largely unremarkable.
#Aniscoria: Patient noted to have aniscoria with possible mild
right sided weakness. He underwent CTA head to evaluate for AVM
which revealed none. MRI head with and without contrast showed
no acute changes.
#Lactatemia:
#Hypotension: He was hypotensive overnight ___. This was
most likely mild hypovolemia from poor intake while delirious
and from GI losses (diarrhea). Hypovolemia was further supported
by accompanying rise in BUN/Cr. BPs and lactate improved with
gentle IVF bolus.
#Acute on Chronic Dyspnea: Presentation was consistent with
progression of his COPD rather than exacerbation as no clear
worsening in dyspnea, no wheeze on exam or change in VBG,
slightly worse cough but no new sputum pdt. He was clinically
euvolemic pointing against CHF exacerbation. CT negative for PE.
Given leukocytosis and LUL CT findings, he was treated for CAP
as above. Suspect that anxiety was also contributing to
intermittent sensation of dyspnea. He remained stable on his
home O2 ___ L NC) throughout his stay. Pt seen by ___ who noted
that he desatted to the 70's with ambulation even with O2. Pt
noted that this is not far from his baseline given his
significant COPD and is insistent on d/c home. Discussed with
patient that our recommendations would be for rehab to build up
his strength and optimize his pulmonary status prior to going
home. Pt refuses rehab and opted for d/c home.
#Central sleep apnea: He had an incomplete sleep study in
___ that was most suggestive of a central (rather than
obstructive) etiology for sleep apnea. He was fitted for CPAP
but did not tolerate the mask, possibly b/c central OSA can be
worsened by CPAP. As above he underwent CT head and neurologic
eval to help w/u for neuro cause of central sleep apnea. While
inpatient he was put on NC rather than cpap at night. Plan is to
follow up with ___ (sleep specialist) who saw him
inpatient in the FICU regarding his sleep apnea.
#Voiding difficulty: Reports sensation of difficulty voiding
(sensation that he frequently needs to void but unable to pass
urine). This was of unclear chronicity but worse over past few
weeks. UA was negative. ___ represent progressive BPH or from
neurologic process as above with autonomic dysfunction. NPH
unlikely given CT head findings. Started on tamsulosin. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
levofloxacin / Anesthetics - Amide Type
Attending: ___.
Chief Complaint:
Dyspnea On Exertion, Abnormal Labs
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with h/o seronegative RA admitted with SOB in the setting of
pericardial and pleural effusions. Patient was seen by her PCP
at ___ on ___ for left sided pleuritic chest pain
and dry cough which began on ___. She notes that she never had
fever or productive cough, no sick contacts. CXR at that visit
showed minimal R basilar infiltrate vs atelectasis, WBC 16.6. Pt
was prescribed a Z pack for presumed CAP and returned to ___ ___
___ for continued dyspnea and left sided rib pain. Repeat CXR
showed possible L pleural effusion and associated atelectasis vs
PNA. Pt was prescribed doxycycline 100mg BID x 10 days and a CTA
chest was obtained which was negative for PE but showed small
left pleural effusion with associated atelectasis and/or
infiltrate and moderate pericardial effusion. Repeat WBC rose to
17.2 and doxycycline was changed to Augmentin on ___. Pt
reported continued cough, SOB and pleuritic pain and was advised
to report to ED for further work up. She initially declined to
go to ED, but agreed after phone discussion with PCP ___ ___
for worsening SOB. Pt reports that she has had intermittent
chest discomfort when laying flat for the last several weeks.
Of note, pt had been on MTX for several months, but this was put
on hold in the last few weeks due to concern for PNA.
Additionally, pravastatin was recently discontinued due to LFT
abnormalities.
In the ED initial vitals were:99.7 90 133/46 25 97%
- Pulsus <10
- Labs were significant for WBC 13.1, normal lactate, ALT 50,
AST 46, AP 477.
- CXR showed left pleural effusion
- Patient was given IV levofloxacin and admitted to medicine for
further management.
Vitals prior to transfer were: 99.7 90 133/46 25 97%
On the floor, pt reports that she is hungry but otherwise has no
complaints.
Past Medical History:
Seronegative RA
HLD
Osteoporosis
Erythema nodosum
DJD of hip
Social History:
___
Family History:
Pt does not know detailed family history, noting that she has no
living relatives at this point, but does recall that "all the
women had arthritis."
Physical Exam:
Admission exam:
Vitals - T: 99.5 154/61 101 RR 18 96% RA 76.9kg
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles, diminished breath sounds L
base
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose, second toes of both feet deviated
medially
PULSES: 2+ DP pulses bilaterally
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Discharge exam:
Vitals:98.5 150/75 82 18 100% RA pulsus 5
General: well-appearing elderly woman, no acute distress
HEENT: AT/NC, EOMI, PERRL, anicteric sclera
NECK: nontender supple neck
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission labs:
___ 12:05AM BLOOD WBC-13.1* RBC-2.96* Hgb-9.1* Hct-26.6*
MCV-90 MCH-30.9 MCHC-34.4 RDW-14.2 Plt ___
___ 12:05AM BLOOD Neuts-81.5* Lymphs-12.9* Monos-4.1
Eos-1.3 Baso-0.2
___ 12:05AM BLOOD ___ PTT-36.1 ___
___ 12:05AM BLOOD Glucose-103* UreaN-18 Creat-0.8 Na-135
K-4.6 Cl-96 HCO3-24 AnGap-20
___ 12:05AM BLOOD ALT-50* AST-46* AlkPhos-477* TotBili-0.4
___ 12:05AM BLOOD Albumin-3.7 Iron-24*
___ 12:05AM BLOOD proBNP-456*
___ 12:05AM BLOOD cTropnT-<0.01
Pertinent labs:
___ 10:40AM BLOOD RheuFac-16* CRP-247.9*
___ 05:35PM BLOOD C3-263* C4-51*
___ 07:35AM BLOOD GGT-335*
___ 12:05AM BLOOD calTIBC-241* Ferritn-1178* TRF-185*
___ 12:05AM BLOOD Albumin-3.7 Iron-24*
Discharge labs:
___ 07:00AM BLOOD WBC-11.6* RBC-3.17* Hgb-9.8* Hct-28.5*
MCV-90 MCH-30.8 MCHC-34.2 RDW-14.1 Plt ___
___ 07:00AM BLOOD Glucose-110* UreaN-13 Creat-0.8 Na-139
K-5.1 Cl-101 HCO3-27 AnGap-16
___ 07:00AM BLOOD ALT-36 AST-30 AlkPhos-367* TotBili-0.3
___ 07:00AM BLOOD Calcium-10.0 Phos-4.3 Mg-2.5
Imaging:
___ CXR: IMPRESSION: No evidence for current pneumonia.
Hyperexpanded, but clear lungs. No pleural effusions.
___ RUQ u/s: IMPRESSION: Mild central intrahepatic biliary
dilatation, status post cholecystectomy, which is nonspecific
given lack of prior imaging.
___ Echo:
Conclusions
The left atrium is mildly 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%). Tissue
Doppler imaging suggests an increased left ventricular filling
pressure (PCWP>18mmHg). Right ventricular chamber size and free
wall motion are normal. The diameters of aorta at the sinus,
ascending and arch levels are normal. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. No
aortic regurgitation is seen. The mitral valve leaflets are
mildly thickened. There is no mitral valve prolapse. There is
borderline pulmonary artery systolic hypertension. There is a
very small circumferential pericardial effusion without
echocardiographic evidence for hemodynamic compromise.
IMPRESSION: Suboptimal image quality. Small circumferential
pericardial effusion without evidence for hemodynamic
compromise. Normal biventricular cavity sizes with preserved
regional and global biventricular systolic function. Increased
PCWP.
___ foot xray: IMPRESSION: No acute bony injury. Medial
subluxation of the second toe in relation to the second
metatarsal heads bilaterally. Mild degenerative changes of
bilateral first MTP joints, left side worse than right.
___ MRCP: IMPRESSION: Minimal intra and extrahepatic bile duct
dilation is within the acceptable range post cholecystectomy. No
obstructing stone or mass lesion is identified. Known complex
pericardial effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Desipramine 250 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Methocarbamol 750 mg PO BID:PRN pain
5. Aspirin 325 mg PO DAILY
6. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
Discharge Medications:
1. Aspirin 650 mg PO TID
RX *aspirin 650 mg 1 tablet(s) by mouth three times a day Disp
#*36 Tablet Refills:*0
2. Desipramine 250 mg PO DAILY
3. FoLIC Acid 1 mg PO DAILY
4. Methocarbamol 750 mg PO BID:PRN pain
5. Omeprazole 20 mg PO DAILY
6. Outpatient Lab Work
Please check CBC, chem-7, and LFTs including: Na, K, Cl, HCO3,
BUN, Cr, Glc, AST, ALT, ALP, tbili
Fax results to: ___. fax #: ___
7. Colchicine 0.6 mg PO BID Duration: 48 Hours
RX *colchicine [Colcrys] 0.6 mg 1 tablet(s) by mouth twice a day
Disp #*28 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
viral pericarditis
Secondary diagnosis:
rheumatoid arthritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old woman with h/o seronegative RA p/w pericardial
effusion and elevated ALP/GGT with mild dilation of intrahepatic biliary ducts
seen on RUQ u/s // evaluate for strictures, potential causes of biliary
ductal dilation
TECHNIQUE: T1 and T2 weighted multiplanar images of the abdomen were acquired
within a 1.5 T magnet, including 3D dynamic sequences obtained prior to,
during, and following the administration of Gadavist intravenous contrast.
The patient also received oral contrast of 1 cc of Gadavist diluted in 50 cc
of water.
COMPARISON: Right upper quadrant ultrasound dating ___.
FINDINGS:
The liver is normal in size and contour. There is no focal parenchymal lesion
or hepatic steatosis. The patient is status post cholecystectomy. There is
mild diffuse dilation of the central intrahepatic and extrahepatic bile ducts.
The maximum diameter of the extrahepatic biliary tree is measured at 9 mm
(9:1). This is seen to taper smoothly to the level of the ampulla, with no
choledocholithiasis or extrinsic obstructing mass visualized.
The pancreatic parenchyma is notable for significant atrophy and fatty
replacement. There is no focal lesion or ductal abnormality. No peripancreatic
inflammation or fluid is identified.
The spleen, adrenal glands and kidneys are unremarkable.
Arterial vascular anatomy of the upper abdomen is conventional. The venous
structures are widely patent. There is no lymphadenopathy or ascites.
Note is made of the known pericardial effusion with maximum thickness of
approximately 1 cm anteriorly. Surrounding pericardium is hyperenhancing
(1202:30). Best seen on the T2 weighted imaging, the nonenhancing pericardial
fluid is quite complex with multiple septations (03:29).
The osseous structures are notable for an S-shaped scoliosis of the
thoracolumbar spine. No concerning osseous lesion is identified.
IMPRESSION:
Minimal intra and extrahepatic bile duct dilation. Post cholecystectomy could
contribute, but cannot exclude additional ampullary stenosis or sphincter of
Oddi dysfunction. No obstructing stone or mass lesion is identified.
Known complex pericardial effusion. Physiologic effects of this effusion on
cardiac function would be best assessed with echocardiography
Radiology Report
EXAMINATION: FOOT AP,LAT AND OBL BILATERAL
INDICATION: ___ year old woman with h/o seronegative RA with toe deformities
possibly not consistent with RA, please evaluate for bony erosions in the ___
and ___ metatarsals, bilaterally. // please evaluation for bony erosions
COMPARISON: None.
FINDINGS:
Left foot: No acute fractures or dislocations are seen.There are moderate
degenerative changes of the first MTP joint. There is also subluxation of the
second toe medially in relation to the second metatarsal head. Clawtoe
deformity of the second toe is also seen. There is normal osseous
mineralization.No bony erosions are seen.
Right foot: No acute fractures or dislocations are seen.There are mild
degenerative changes of the first MTP joint. Similar to the left foot, there
is medial subluxation of the second toe at the MTP joint. Clawtoe deformity of
the second toe is also present. There is some soft tissue swelling and
irregularity at the fifth metatarsal head.There is normal osseous
mineralization.Small plantar spur is present.
IMPRESSION:
No acute bony injury. Medial subluxation of the second toe in relation to the
second metatarsal heads bilaterally. Mild degenerative changes of bilateral
first MTP joints, left side worse than right.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old woman with elevated alk phos // biliary obstruction
or other acute abnormality?
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. Main portal vein is patent with
hepatopetal flow. There is no ascites.
BILE DUCTS: There is mild central intrahepatic biliary dilation. The CBD
measures 5 mm.
GALLBLADDER: The gallbladder is surgically absent.
PANCREAS: Imaged portion of the pancreas appears within normal limits, without
masses or pancreatic ductal dilation, with portions of the pancreatic tail
obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 11 cm.
Single views of each kidney are remarkable.
IMPRESSION:
Mild central intrahepatic biliary dilatation, status post cholecystectomy,
which is nonspecific given lack of prior imaging.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea on exertion, Abnormal labs
Diagnosed with SHORTNESS OF BREATH, PERICARDIAL DISEASE NOS, PLEURAL EFFUSION NOS
temperature: 99.7
heartrate: 90.0
resprate: 25.0
o2sat: 97.0
sbp: 133.0
dbp: 46.0
level of pain: 0
level of acuity: 2.0 | Impression: Ms. ___ is a ___ lady with h/o seronegative
RA presenting with DOE and cough in the setting of recently
diagnosed pleural and pericardial effusions, most likely due to
viral process.
# Pericardial effusion: Outpatient CTA showed moderate-sized
pericardial effusion and patient presented with pleuritic,
positional chest discomfort suggestive of pericarditis. There
were no EKG changes c/w pericarditis and patient remained stable
with normal BP and pulsus. Echo showed a small pericardial
effusion without any tamponade physiology. Given the presence of
both a pericardial effusion and pleural effusion, rheumatology
was consulted for possibility of serositis complicating an
underlying rhematologic disorder. They did not believe her
symptoms were consistent with either RA or lupus. Diagnostic
tests were sent and pending at discharge, including ___, anti-Sm
Ab, anti-dsDNA Ab, RNP Ab, anti-CCP Ab, Ro & La. Patient treated
with aspirin 650mg TID and colchicine 0.6 BID and will continue
these for 2 weeks and 3 months respectively.
# Dyspnea: Outpatient CTA noted a small left-sided pleural
effusion and patient had persistent dyspnea for 3 weeks. She
completed a course of azithromycin and trial doxycycline and
augmentin and was started on levofloxacin in the ED. Antibiotics
were held and repeat CXR as well as bedside ultrasound did not
show any effusion. Dyspnea most likely multifactorial from body
habitus, pericardial effusion, and atelectasis.
# LFT abnormalities: Patient presented with mild transaminitis
with markedly elevated alkaline phosphatase and GGT on
admission. RUQ ultrasound showed mild central intrahepatic
biliary dilatation and thus, MRCP was performed. This study
showed minimal intra and extrahepatic bile duct dilation without
any obstructing stones or mass lesions. ALT/AST/ALP trending
down at discharge.
# Leukocytosis: Patient with increasing leukocytosis as
outpatient to peak of 17.2 and on admission was 13.1. Most
likely due to a viral process such as ___ virus, leading
to systemic inflammation and pericarditis. CRP also elevated to
250 and ferritin as high as 1100. Leukocytosis downtrending on
discharge to 11.
# Chronic Normocytic Anemia: HGB on admission noted to be 9.4 on
___ from prior baseline 10.7 as of ___ per ___ records. Iron
studies consistent with iron deficiency but patient refused iron
supplementation.
# Rheumatoid arthritis: Patient with history of seronegative RA
followed by ___ Rheumatologist ___. She was previously
on methotrexate which is being in the setting of PNA.
Rheumatologic evaluation recommended x-rays of the foot to
evaluate for bony erosions, but only showed mild degenerative
changes. Per our rheumatology colleagues, we would recommend
re-evaluation of the diagnosis of RA. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
codeine / Lipitor / oxycodone / pneumoncoccal vaccines /
pravastatin
Attending: ___.
Chief Complaint:
intra-peritoneal bleed
Major Surgical or Invasive Procedure:
___: Laparoscopic reexploration with washout and
fulguration of the gallbladder fossa.
History of Present Illness:
___ year old female who had acute abdominal pain today, POD10
from elective
laparoscopic cholecystectomy at ___ ___.
History
of atrial fibrillation, mechanical mitral valve (St. ___ in
___ - she was bridged to enoxaparin perioperatively without any
untoward events in that time period. On POD8 she saw her PCP
and
her INR was in the low 2 range - she was advised to discontinue
the enoxaparin. Today, after her pain began, she presented to
___ where a CT abdomen pelvis with IV contrast
revealed an enhancing focus / contrast blush adjacent to the
surgical clips in the gallbladder fossa. She was given 1u PRBC,
1u FFP, PCC, vitamin K.
On arrival here, she is comfortable after being given pain
medication. She previously had much more abdominal pain. Her
heart rate was 80 on arrival here but has since increased to
110-120 since then. She previously had some lightheadedness but
has now resolved.
ROS:
(+) per HPI
(-) Denies fevers chills, night sweats, unexplained weight
loss, fatigue/malaise/lethargy, changes in appetite, trouble
with
sleep, pruritis, jaundice, rashes, headache, vertigo, syncope,
weakness, paresthesias, nausea, vomiting, hematemesis, bloating,
cramping, melena, BRBPR,dysphagia, chest pain, shortness of
breath, cough, edema, urinary
frequency, urgency
Past Medical History:
CAD
aortic stenosis/insufficiency s/p TAVR
mitral stenosis / insufficiency s/p mitral commissurotomy ___,
MVR mechanical ___ valve ___
ovarian cancer s/p lap TAH-BSO ___
pacemaker
GERD
cholelithiasis s/p lap cholecystectomy
sciatica
SA node dysfunction
Social History:
___
Family History:
Non contributory
Physical Exam:
Physical Exam on Admission:
Vitals:
T 97.4
BP 103/63
HR 88
RR 20
SaO2 97% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, slight tenderness to RUQ / right
lateral
abdomen, no peritonitis
Physical examination upon discharge: ___
GENERAL: NAD
CV: ns1, s2
LUNGS: clear
ABDOMEN: hypoactive BS, soft, non-tender
EXT: no pedal edema bil, no calf tenderness bil
NEURO: alert and oriented x 3, speech clear
Pertinent Results:
___ 07:30AM BLOOD WBC-5.1 RBC-2.77* Hgb-8.1* Hct-26.1*
MCV-94 MCH-29.2 MCHC-31.0* RDW-16.4* RDWSD-55.9* Plt ___
___ 06:15AM BLOOD WBC-5.8 RBC-2.94* Hgb-8.6* Hct-27.5*
MCV-94 MCH-29.3 MCHC-31.3* RDW-16.6* RDWSD-55.6* Plt ___
___ 06:03AM BLOOD WBC-5.5 RBC-2.65* Hgb-7.9* Hct-24.3*
MCV-92 MCH-29.8 MCHC-32.5 RDW-16.7* RDWSD-54.8* Plt ___
___ 06:14AM BLOOD WBC-6.4 RBC-2.78* Hgb-8.2* Hct-25.5*
MCV-92 MCH-29.5 MCHC-32.2 RDW-17.1* RDWSD-55.9* Plt ___
___ 01:50AM BLOOD WBC-11.6* RBC-2.93* Hgb-9.1* Hct-27.5*
MCV-94 MCH-31.1 MCHC-33.1 RDW-13.0 RDWSD-44.8 Plt ___
___ 01:50AM BLOOD Neuts-83.0* Lymphs-7.1* Monos-8.6
Eos-0.3* Baso-0.3 Im ___ AbsNeut-9.61* AbsLymp-0.82*
AbsMono-0.99* AbsEos-0.03* AbsBaso-0.04
___ 07:30AM BLOOD Plt ___
___ 07:30AM BLOOD ___ PTT-99.8* ___
___ 03:40PM BLOOD PTT-80.1*
___ 06:15AM BLOOD Plt ___
___ 06:15AM BLOOD ___ PTT-77.9* ___
___ 11:09PM BLOOD PTT-69.7*
___ 03:12PM BLOOD PTT-90.6*
___ 06:03AM BLOOD ___ PTT-57.7* ___
___ 06:03AM BLOOD Glucose-108* UreaN-7 Creat-0.6 Na-144
K-3.9 Cl-107 HCO3-25 AnGap-12
___ 09:30AM BLOOD Glucose-87 UreaN-6 Creat-0.6 Na-140 K-4.0
Cl-105 HCO3-26 AnGap-9*
___ 04:35PM BLOOD CK-MB-3 cTropnT-<0.01
___ 06:03AM BLOOD Calcium-8.3* Phos-3.9 Mg-1.8
___ 01:24PM BLOOD freeCa-1.14
CTA abdomen/pelvis ___
1. No evidence of active arterial extravasation or
pseudoaneurysm formation.
2. Moderate to large volume hyperdense intra-abdominal and
intrapelvic fluid, consistent with hemorrhage, appears increased
in size compared to recent outside CT abdomen pelvis performed
___.
3. Mild intrahepatic biliary ductal dilatation.
___ CTA ABD/PELVIS:
1. Laceration of the inferior medial right liver surface
extending to the
surgical bed. No CTA evidence of active arterial extravasation
or
pseudoaneurysm formation.
2. Moderate to large volume hyperdense intra-abdominal and
intrapelvic fluid,
consistent with hemorrhage, appears increased in size compared
to recent
outside CT abdomen pelvis performed ___.
3. Mild periportal edema.
___ PSEUDOANEURYSM EMBO
1. Right common femoral artery access in appropriate location
above the
bifurcation at the mid femoral head.
2. Replaced right hepatic arteriogram demonstrating no evidence
of
pseudoaneurysm or active extravasation.
3. Common hepatic arteriogram demonstrating small possible
blush at the level of the clips therefore selective left hepatic
arteriogram was performed.
4. Left hepatic arteriogram demonstrated no evidence of active
extravasation or pseudoaneurysm.
___ LIVER US:
1. Perihepatic hematoma as on recent CT exam, appears similar in
overall
volume and distribution.
2. Status post cholecystectomy.
___ CTA AB/PELVIS:
1. Right hepatic laceration with no signs of active
extravasation.
2. Interval worsening of the hemoperitoneum, now severe.
3. Small linear focus of enhancement adjacent to the
cholecystectomy surgical
clips, which is concerning for a pseudoaneurysm.
___ CXR:
No comparison. The lung volumes are normal. Correct alignment
of sternal
wires. Status post valvular replacement. Left pectoral single
lead pacemaker is in correct position, the lead is in the right
ventricle. No pleural effusions. No pulmonary edema. No
pneumonia. Mild elongation of the descending aorta. The
abnormalities mentioned in the referring note are not visible on
the chest x-ray.
___ CXR:
New right lateral subcutaneous emphysema likely sequelae of
recent procedure. Otherwise, no significant interval change in
the appearance of the lungs compared to the exam performed 23
hours prior.
Medications on Admission:
metoprolol tartrate 100 mg tablet oral 1 tablet(s) Once Daily
Coumadin 5 mg tablet oral 1 tablet(s) Once Daily
verapamil -- Unknown Strength 1 solution(s) Twice Daily
Lasix 20 mg tablet oral 1 tablet(s) Once Daily
Crestor -- Unknown Strength 1 tablet(s) 3 times a week
Calcium 500 + D 500 mg (1,250 mg)-400 unit tablet oral 1
tablet(s) Once Daily
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
2. Docusate Sodium 100 mg PO BID
3. Sodium Chloride Nasal ___ SPRY NU DAILY:PRN dry nasal mucosa
4. Furosemide 20 mg PO DAILY
5. Metoprolol Succinate XL 100 mg PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Oxazepam 10 mg PO QHS:PRN imnsonia
8. Verapamil 20 mg PO Q8H
9. Warfarin 2.5 mg PO ONCE Duration: 1 Dose
follow-up with PCP for repeat ___ and dosing of coumadin
10. ___ MD to order daily dose PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
Hemoperitoneum status post laparoscopic cholecystectomy.
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 obtain venous and arterial phases, portal venous. post
op pt chole 10 days ago. Evaluate for bleeding.
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast
images were acquired through the abdomen and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.1 s, 47.6 cm; CTDIvol = 6.1 mGy (Body) DLP = 289.3
mGy-cm.
2) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 21.3 mGy (Body) DLP =
10.6 mGy-cm.
3) Spiral Acquisition 6.1 s, 47.8 cm; CTDIvol = 17.2 mGy (Body) DLP = 822.0
mGy-cm.
4) Spiral Acquisition 6.1 s, 47.8 cm; CTDIvol = 17.2 mGy (Body) DLP = 822.3
mGy-cm.
Total DLP (Body) = 1,944 mGy-cm.
COMPARISON: Outside hospital CT abdomen pelvis performed ___.
FINDINGS:
VASCULAR:
There is moderate calcium burden in the abdominal aorta and great abdominal
arteries. The celiac axis and SMA appear patent without evidence of
pseudoaneurysm formation or definite imaging signs to suggest active arterial
extravasation particularly in the region of blush seen on the recent
comparison study. There is a replaced right hepatic artery. Hyperdense fluid
is seen tracking along the right abdomen and into the pelvis. High-density
fluid is also demonstrated within the postsurgical resection bed in the
gallbladder fossa. The volume of this hyperdense fluid appears increased in
size compared to recent CT abdomen pelvis performed ___.
There is no abdominal aortic aneurysm.
LOWER CHEST: Minimal atelectasis is noted in the lung bases. There is no
pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: There is a laceration of the inferior medial right liver
surface which appears to extend into the surgical bed, series 604, image 55
and series 5, image number 58. The laceration measures up to 2.5 cm in
length. There is mild periportal edema. No evidence of extrahepatic or
intrahepatic biliary ductal dilatation. The gallbladder is surgically absent
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
A 1.1 x 1.0 cm left lower pole renal cyst is identified (604:57). There is no
evidence of stones, concerning focal renal lesions, or hydronephrosis. There
are no urothelial lesions in the kidneys or ureters. There is no perinephric
abnormality.
GASTROINTESTINAL: Intraluminal contrast material from prior CT scan is noted.
Small bowel loops demonstrate normal caliber, wall thickness and enhancement
throughout. Colon and rectum are within normal limits. Hyperdense focus
measuring up to 9 mm in the gallbladder fossa is unchanged on all phases and
likely represents a small periportal lymph node (05:56).
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy.
REPRODUCTIVE ORGANS: The uterus is not definitively visualized. No adnexal
abnormality is seen.
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. Laceration of the inferior medial right liver surface extending to the
surgical bed. No CTA evidence of active arterial extravasation or
pseudoaneurysm formation.
2. Moderate to large volume hyperdense intra-abdominal and intrapelvic fluid,
consistent with hemorrhage, appears increased in size compared to recent
outside CT abdomen pelvis performed ___.
3. Mild periportal edema.
NOTIFICATION: The findings were discussed with Dr. ___. by ___
___, M.D. on the telephone on ___ at 12:31 pm, 10 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ year old woman with hepatic pseudoaneurysm// Local control of
bleed.
COMPARISON: CT from outside hospital on CTA from this admission
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
50mcg of fentanyl and 1 mg of midazolam throughout the total intra-service
time of 30 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: As above
CONTRAST: 20 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 6.9, 139 mGy
PROCEDURE:
1. Right common femoral artery access
2. Right common femoral artery arteriogram
3. SMA arteriogram
4. Replaced right hepatic arteriogram
5. Celiac arteriogram
6. Common hepatic artery arteriogram
7. Left hepatic artery arteriogram
8. Cone beam CT of left hepatic artery
9. Angio-Seal closure of right common femoral artery access site
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.
Utilizing palpatory guidance, micropuncture needle was advanced into the right
common femoral artery. This was after line marks were identified on
fluoroscopy to assure mid femoral head access. This Micropuncture was upsized
to a 5 ___ sheath and a right common femoral artery angiogram was
performed.
Then, a C2 catheter was introduced into the SMA. The SMA was selectively
catheterized small run was performed. Then, a Transcend wire and high flow
microcatheter used to selectively cannulae eyes the right hepatic artery. The
microcatheter was advanced into the right hepatic artery confirmed by contrast
injection. A digital subtraction angiography was performed.
The catheter was then retracted and the C2 catheter was then advanced into the
celiac artery. A small celiac injection was performed. Then, the Transcend
wire and high flow microcatheter were introduced into the common hepatic
artery. A common hepatic arteriogram was performed. Then, the Transcend wire
and microcatheter were advanced into the left hepatic artery after was
selectively cannulated. Digital subtraction angiography was performed. Based
on these findings, cone beam CT was performed. Rotational cone-beam CT
angiography was performed to help delineate the anatomy. Multiplanar CT
images were reconstructed and 3D volume-rendered images of the arterial
anatomy required post-processing on an independent workstation under direct
physician ___. These images were used in the interpretation, decision
making for intervention and reporting of this procedure.
All the above arteriograms were medically necessary given need for
localization of the bleed and potential embolization site.
Then, the catheters were removed. An Angio-Seal device was deployed at the
right common femoral artery access site along with manual pressure until
hemostasis was achieved..
FINDINGS:
1. Right common femoral artery access in appropriate location above the
bifurcation at the mid femoral head
2. Replaced right hepatic arteriogram demonstrating no evidence of
pseudoaneurysm or active extravasation.
3. Common hepatic arteriogram demonstrating small possible blush at the level
of the clips therefore selective left hepatic arteriogram was performed.
4. Left hepatic arteriogram demonstrated no evidence of active extravasation
or pseudoaneurysm.
IMPRESSION:
Diagnostic angiography as above without evidence of active extravasation or
pseudoaneurysm.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ y/o F who presented on POD ___ s/p lap ccy with post-operative
bleed, now with RUQ pain// eval for any e/o blood in abdomen
TECHNIQUE: Right upper quadrant ultrasound
COMPARISON: CT abdomen pelvis from ___
FINDINGS:
Large perihepatic hematoma again noted. The liver parenchyma appears normal.
No discrete intrahepatic liver lesion. No intrahepatic biliary ductal
dilation is seen. Main portal vein is patent with hepatopetal flow. CBD is
normal measuring 4 mm. Gallbladder is surgically absent. The spleen measures
8 cm. Small volume perisplenic simple fluid is noted. Complex fluid in the
right lower quadrant likely represents hemoperitoneum. Simple appearing fluid
in the left lower quadrant is noted.
IMPRESSION:
1. Perihepatic hematoma as on recent CT exam, appears similar in overall
volume and distribution.
2. Status post cholecystectomy.
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: ___ year old woman with afib, s/p mitral mechanical valve and
aortic valve replacement, COPD, hx of CCY POD10, liver lac noted on previous
CTA.// peritoneal bleed hx, now tender concerning for rebleed. also needs CTV.
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast
images were acquired through the abdomen and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.2 s, 50.2 cm; CTDIvol = 3.7 mGy (Body) DLP = 183.7
mGy-cm.
2) Spiral Acquisition 3.8 s, 50.2 cm; CTDIvol = 7.7 mGy (Body) DLP = 388.5
mGy-cm.
3) Spiral Acquisition 3.8 s, 50.2 cm; CTDIvol = 7.7 mGy (Body) DLP = 388.5
mGy-cm.
4) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 2.1 mGy (Body) DLP = 1.1
mGy-cm.
5) Stationary Acquisition 3.0 s, 0.5 cm; CTDIvol = 10.6 mGy (Body) DLP =
5.3 mGy-cm.
Total DLP (Body) = 967 mGy-cm.
COMPARISON: CT abdominal pelvis from ___
FINDINGS:
VASCULAR:
There is no abdominal aortic aneurysm. There is minimal calcium burden in the
abdominal aorta and great abdominal arteries.
The portal vein, hepatic veins and portal confluence are patent.
There is a replaced right hepatic artery originating from the SMA. In the
surgical bed, near the cholecystectomy surgical clips, there is a linear
arterial foci that persists on portal phase (series 301, image 55) measuring
approximately 1 cm not well previously demonstrated on previous CT.
LOWER CHEST: Minimal atelectasis is noted in the lung bases. There is no
pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: Again seen is a laceration of the inferior medial right liver
surface that extends into the cholecystectomy surgical bed. No biliary duct
dilatation.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidney's are unremarkable besides a 1 cm left lower pole renal
cyst. No hydronephrosis.
GASTROINTESTINAL: No bowel obstruction. Sigmoid diverticulosis without
evidence of diverticulitis..
RETROPERITONEUM: No abdominal pelvis adenopathy.
Interval increase in size of the hemoperitoneum that is now severe with fluid
levels. For example, the right perihepatic hematoma now measures 13.6 x 11.5
cm, previously measuring 10 x 6.7 cm.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy.
REPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal abnormality.
BONES: There are no suspicious osseous lesions. There are moderate multilevel
degenerative changes of the spine with grade 1 anterolisthesis of L4 on L5.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Right hepatic laceration with no signs of active extravasation.
2. Interval worsening of the hemoperitoneum, now severe.
3. Small linear focus of enhancement adjacent to the cholecystectomy surgical
clips, which is concerning for a pseudoaneurysm.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 9:02 pm, 1 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with hemoperitoneum s/p cholecystectomy.//
?pulm edema vs multifocal PNA seen on CT scan by rads. Eval for abnormalities.
?pulm edema vs multifocal PNA seen on CT scan by rads. Eval for abnormalities.
IMPRESSION:
No comparison. The lung volumes are normal. Correct alignment of sternal
wires. Status post valvular replacement. Left pectoral single lead pacemaker
is in correct position, the lead is in the right ventricle. No pleural
effusions. No pulmonary edema. No pneumonia. Mild elongation of the
descending aorta. The abnormalities mentioned in the referring note are not
visible on the chest x-ray.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with COPD, volume resuscitation// pulm edema?
TECHNIQUE: Portable supine radiograph of the chest.
COMPARISON: Radiograph of the chest performed 23 hours prior.
FINDINGS:
Heart size is normal. Hilar and mediastinal contours are unchanged. Mild
bibasilar atelectasis is seen. No evidence of pneumothorax. Extensive new
right lateral subcutaneous emphysema is seen. There is no large pleural
effusion.
IMPRESSION:
New right lateral subcutaneous emphysema likely sequelae of recent procedure.
Otherwise, no significant interval change in the appearance of the lungs
compared to the exam performed 23 hours prior.
NOTIFICATION: The findings were discussed with Dr. ___. by ___
___, M.D. on the telephone on ___ at 9:03 am, 10 minutes after
discovery of the findings.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: PSEUDOANEURYSM, Transfer
Diagnosed with Aneurysm of other specified arteries
temperature: 97.4
heartrate: 88.0
resprate: 20.0
o2sat: 97.0
sbp: 103.0
dbp: 63.0
level of pain: 8
level of acuity: 2.0 | Ms. ___ is a ___ year old was admitted to ___ ___ post-operative day 10 from a laparoscopic cholecystectomy
at ___ ___ with concern for a post-operative
bleed. She originally presented to ___ prior to
___ where a CT was performed and showed an enhancing
focus/contrast blush adjacent to her surgical clips within the
gallbladder fossa and given blood products to stabilize her
bleeding. At ___ she underwent an ___ that showed
no evidence of pseudoaneurysm or active extravasation. She
underwent serial H/H checks while in the ICU that were stable
and was subsequently started on a heparin gtt 24 hours after
last known administration of blood products. On ___ the
patient was hemodynamically stable and transferred to the
surgical floor.
Her heparin drip was titrated to goal PTT and Coumadin therapy
was resumed on ___. On ___ she had sudden onset abdominal
pain radiating to her back and repeat hematocrit showed a
significant drop in hemoglobin/hematocrit. During this event she
also had increased heart rate to 130 in atrial fibrillation and
hypotension to the 80's systolic. She was given IV fluid bolus
and 1 unit packed red blood cells. The patient was then
transferred to the ICU for close hemodynamic monitoring and
management of acute bleed.
On ___ patient was transferred back to the ___ with RUQ
pain, hypotension, A-fib w/ RVR, decreased HCT, and radiologic
findings significant for perihepatic hematoma. CTA showed no
active extravasation from previously noted hepatic laceration or
interval worsening of hemoperitoneum. ___ was notified with
concern for venous bleed however ___ decided to take patient to
OR ___ for ex-lap/washout where a small arterial bleed was
found and controlled. ___ patient HCT has remained stable and
was restarted on a clear liquid diet and heparin drip. ___ her
HCT was stable and the decision was made to transfer her out of
the ICU, begin a regular diet, and transition over to home
Warfarin.
The patient was hemodynamically stable on continuous telemetry
monitoring during the remainder of her hospital course. Her
Coumadin was dosed daily while maintaining therapeutic
anticoagulation with heparin drip. On POD4 surgical drain was
removed. She tolerated a regular diet and had adequate pain
control. She was voiding adequate amounts of urine without
difficulty. She was encouraged to mobilize out of bed and
ambulate as tolerated, which she was able to do independently.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. Her INR at discharge was 2.3 and
heparin drip was discontinued. The patient was instructed to
resume 2.5 mg Coumadin at home and follow-up with PCP ___ 24
hours for ___ monitoring. The patient was tolerating a
regular diet, ambulating, voiding without assistance, and pain
was well controlled. The patient was discharged home without
services. The patient received discharge teaching and follow-up
instructions with understanding verbalized and agreement with
the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Tetracycline / ciprofloxacin / prednisone / Reglan
Attending: ___.
Chief Complaint:
Nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
According to the Emergency Department, the patient is a
___ woman without significant medical history presents
with intractable nausea/vomiting. Transfer from ___
___. Her N/V began ___, around the time she began
prozac (though she took prozac before with no effects). She has
had constant nausea since that time, vomits bilious fluid. Has
also had constant diarrhea. Her workup has included a
cholecystectomy for chronic cholecystitis on ___, which relieved
N/V for 5 days, a normal EGD, an MRCP which showed a liver
hemangioma, multiple normal CT scans of abd, a normal CT head, a
normal HIDA scan, neg C.diff, neg ciliac dz w/u. She has been
hospitalized two times with an unyielding workup. Scheduled for
gastric emptying study soon.
Since her cholecystectomy, she has also had pain in varying
areas of abd, including RUQ and periumbilical. Today had severe
RUQ pain which brought her to ___ again. Pain and nausea
has persisted here in the ED. Has never had fever/chills. No
travel or sick contacts. Labs only been significant for mildly
elevated ast/alt.
In the ED, initial vs were 4 98.5 82 101/63 18 99% RA. Received
Zofran and Dilaudid in the Emergency Department. Transfer VS
were 0 97.7 66 93/52 16 96%.
On my interview, the patient reports that her nausea began on
___ and was consomitant with sinus congestion. She was
treated for the sinusitis with Augmentin (which resulted in
diarrhea and had to be stopped early), but she had some
resolution of her nausea. On ___, she sent her son off
to boot camp during the day. In the evening, she began to
experience the nausea that has plagued her since. She reported
to the Emergency Department at ___ multiple times.
Evetually, sludge was discovered in her gallbladder and she
underwent cholecystectomy on ___. On ___ or ___,
she experienced nausea, this time accompanied by pain in her RUQ
and below her belly button. The patient has since had extensive
work-up, including two EGDs, which has been negative. She
reports weight loss of 30 pounds and loss of appetite. She has
not had more dairy than usual, and typically does not have much,
as her son is lactose-intolerant. The patient was scheduled for
gastric emptying study next week and still has celiac work-up
pending from ___. Two days ago she began to vomit
blood during her episodes of nausea. She also has diarrhea. She
describes her current pain as ___ knife-like pain under her
ribs on right and pain shallow in a periumbilical distribution.
Her pain is almost completely relieved when given IV Dilaudid.
Finally, the patient mentiones that she has not had her period
since the end of ___ and has negative pregnancy tests.
Past Medical History:
Depression
GERD
Allergies
Anxiety
Cholecystectomy (___)
C-section ___ years ago
Uterine fibroid removal
Social History:
___
Family History:
Mother and father both required cholecystectomy. Mother has
GERD.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS T 97.5 BP 80/46 (rechecked by me as 92/48), HR 65, RR 18 97%
RA
GEN: Alert, oriented, no acute distress
HEENT: NCAT, MMM, PERRL, EOMI, sclera anicteric, OP clear
NECK: supple, no LAD, no thyromegaly
PULM: Good aeration, CTAB, no wheezes, rales, rhonchi
CV: RRR, normal S1/S2, no murmurs auscultated
ABD: soft, non-tender, ND, normoactive bowel sounds, healing
scars from recent cholecystectomy
BACK: no spinal tenderness, no CVA tenderness, two
hyperpigmented patches in area of right scapula
EXT: WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO: CNs ___ intact, motor function grossly normal
DISCHARGE PHYSICAL EXAM
VS Tc 98.2 Tm 98.9 HR 60-66 BP 98-108/53-62 RR 18 SpO2 98%RA
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, CTAB no wheezes, rales, ronchi
CV RRR normal S1/S2, no mrg
ABD soft minimally ttp in RUQ and periumbilically, ND
normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
Pertinent Results:
ADMISSION LABS
___ 08:30PM BLOOD WBC-12.3* RBC-4.42 Hgb-12.5 Hct-38.9
MCV-88 MCH-28.4 MCHC-32.3 RDW-13.1 Plt ___
___ 08:30PM BLOOD Glucose-82 UreaN-5* Creat-0.5 Na-141
K-3.7 Cl-107 HCO3-23 AnGap-15
___ 08:30PM BLOOD ALT-55* AST-31 AlkPhos-66 TotBili-0.3
___ 08:30PM BLOOD HCG-<5
___ 08:30PM BLOOD Lactate-0.7
BAS/UGI AIR/SBFT ___: FINDINGS: Barium passes freely to the
stomach with normal primary and secondary peristaltic
contractions. No hiatal hernia is seen and there is no evidence
of narrowing or stricture within the esophagus. No
gastroesophageal reflux was noted during the exam and even after
reflux inducing maneuvers. Multiple fluoroscopic spot views of
the stomach showing the cardia, fundus, body, antrum and pyloric
portions are unremarkable. Barium passes freely through the
small bowel reaching the cecum in approximately 130 minutes.
The small bowel was normal in caliber, contour, and mucosal
pattern. The terminal ileum is unremarkable. IMPRESSION:
Normal upper GI and small bowel follow-through. Intestinal
transit was approximately 130 minutes.
GASTRIC EMPTYING STUDY ___: INTERPRETATION:
Residual tracer activity in the stomach is as follows:
At 45 mins 76% of the ingested activity remains in the stomach
At 131 mins 40% of the ingested activity remains in the stomach
At 186 mins 25% of the ingested activity remains in the stomach
At 4 hours 4% of the ingested activity remains in the stomach
There is no evidence of reflux and the slope of the remaining
ingested tracer activity in the stomach is normal through out
the study, consistent with normal gastric emptying.
IMPRESSION: Normal gastric emptying study.
___ 1:52 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
C. difficile DNA amplification assay (Final ___:
This test was cancelled because a FORMED stool specimen
was received,
and is NOT acceptable for the C. difficle DNA
amplification testing..
FECAL CULTURE (Preliminary):
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O VIBRIO (Preliminary):
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
DISCHARGE LABS:
___ 06:45AM BLOOD WBC-5.6 RBC-4.42 Hgb-12.4 Hct-38.5 MCV-87
MCH-28.1 MCHC-32.3 RDW-12.8 Plt ___
___ 06:45AM BLOOD Glucose-87 UreaN-5* Creat-0.5 Na-140
K-3.6 Cl-103 HCO3-28 AnGap-13
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from Patient.
1. Fluoxetine 20 mg PO DAILY Start: In am
2. Omeprazole 20 mg PO BID Start: In am
3. Multivitamins 1 TAB PO DAILY Start: In am
4. Acidophilus *NF* (L.acidoph &
___ acidophilus) unknown Oral
DAILY
5. Lorazepam Dose is Unknown PO Frequency is Unknown
6. HYDROmorphone (Dilaudid) Dose is Unknown PO Frequency is
Unknown
Discharge Medications:
1. Fluoxetine 20 mg PO DAILY
2. Lorazepam 0.5 mg PO Q4H:PRN nausea
RX *lorazepam 0.5 mg 1 tab(s) by mouth every four (4) hours Disp
#*20 Tablet Refills:*0
3. Multivitamins 1 TAB PO DAILY
4. Omeprazole 20 mg PO BID
5. Acetaminophen 1000 mg PO TID
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*60 Tablet Refills:*0
6. Acidophilus *NF* (L.acidoph &
___ acidophilus) 1 capsule ORAL
DAILY
As directed
7. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron 8 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*45 Tablet Refills:*0
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain, nausea, vomiting
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with persistent nausea and vomiting for two
and half months of unclear etiology. Please evaluate gastric emptying, GI
transit time, or any other abnormalities.
COMPARISON: CT abdomen from outside institution on ___.
TECHNIQUE: Double contrast upper GI with small bowel follow-through.
FINDINGS: Barium passes freely to the stomach with normal primary and
secondary peristaltic contractions. No hiatal hernia is seen and there is no
evidence of narrowing or stricture within the esophagus. No gastroesophageal
reflux was noted during the exam and even after reflux inducing maneuvers.
Multiple fluoroscopic spot views of the stomach showing the cardia, fundus,
body, antrum and pyloric portions are unremarkable.
Barium passes freely through the small bowel reaching the cecum in
approximately 130 minutes. The small bowel was normal in caliber, contour,
and mucosal pattern. The terminal ileum is unremarkable.
IMPRESSION: Normal upper GI and small bowel follow-through. Intestinal
transit was approximately 130 minutes.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: N/V
Diagnosed with NAUSEA
temperature: 98.5
heartrate: 82.0
resprate: 18.0
o2sat: 99.0
sbp: 101.0
dbp: 63.0
level of pain: 4
level of acuity: 3.0 | The patient is a ___ woman with a recent history of
nausea, vomting, and diarrhea who is presenting for continued
work-up of these chronic symptoms after extensive work-up at
outside hospital failed to yield diagnosis.
#) ABDOMINAL PAIN with NAUSEA, VOMITING, DIARRHEA: Patient has
had extensive work-up at ___, which appears to
rule out pancreatic, liver, and biliary etiologies, although the
transaminases are still elevated (may by sequelae of
cholecystectomy). Tissue transglutaminase reportedly performed
there as well. Patient has yet to have gastric emptying study,
and presentation is suggestive of gastroparesis. Abdominal
migraine and cyclic vomiting still on the differential, however.
In addition, it is unclear if gynecological causes of abdominal
pain, outside of pregnancy, have been worked up. Multiple
attempts were made to secure a full copy of her workup from ___
___, but only a portion of the record was obtained. GI
was consulted for their input into remaining components of her
workup that could be investigated during this hospital course.
Stool studies were sent to rule out occult infectious sources,
and were negative. The patient was kept NPO and her opiate
analgesia discontinued leading into HD#3 in preparation for
obtaining a barium swallow with small bowel follow through on
HD#3 and gastric emptying study on HD#4. Both of these studies
were reported as normal. Throughout her hospital course, she did
not develop any fevers, vomiting, peritoneal signs, or diarrhea.
Her nausea was controlled on ondansetron IV with lorazepam IV
for breakthrough nausea. Her pain was controlled initially on
hydromorphone IV, which was discontinued in preparation for her
GI studies. At that time she was controlled on around the clock
acetaminophen and toradol. After her studies were completed she
was restarted on oxycodone PO with adequate relief of her pain.
On HD#4 discussion was had with ___ that there were no further
components of her workup requiring hospital admission, and that
further testing could be completed as an outpatient. At this
time it is unclear what is causing Ms. ___ symptoms, and
she will potentially need further workup as an outpatient. She
is to follow up this coming week with her gastroenterologist in
___ for ongoing symptomatic management, and our GI service
will coordinate follow up for her in clinic with one of the
Fellows. At the time of discharge, she was afebrile with stable
vital signs, her nausea was controlled with ondansetron and
lorazepam as needed, her pain controlled with oxycodone as
needed, and she was able to tolerate adequate PO intake.
#LEUKOCYTOSIS: The patient had a leukocytosis on admission lab
testing. Subsequent testing showed that this resolved. She
remained afebrile throughout her hospital course.
#DEPRESSION/ANXIETY: The patient was continued on her home dose
of Prozac.
TRANSITIONAL ISSUES
The patient is to follow up this coming week with her
gastroenterologist in ___ for ongoing symptomatic
management, and our GI service will coordinate follow up for her
in clinic with one of the Fellows.
She has been instructed to attempt to collect her pertinent
records from ___ in order to expedite her future
workup and ongoing management. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
sulfa
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Laparoscopic appendectomy
History of Present Illness:
___ began having generalized crampy abdominal pain yesterday.
By the evening it localized to right lower abdomen. He woke up
during the night with rigors, nausea, diaphoresis, and
subjective fever. He endorses anorexia today.
Past Medical History:
Past Medical History:
healthy
Past Surgical History:
none
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission Physical Exam:
Vitals:
T 100.7
BP 108/76
HR 96 - 109
RR 18
SaO2 99% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Diffuse guarding and tenderness to palpation RLQ. Soft.
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
IMAGING:
___: US Appendix:
Acute, uncomplicated appendicitis.
LABS:
___ 12:00PM GLUCOSE-101* UREA N-13 CREAT-1.0 SODIUM-139
POTASSIUM-4.4 CHLORIDE-97 TOTAL CO2-27 ANION GAP-15
___ 12:00PM ALT(SGPT)-15 AST(SGOT)-16 ALK PHOS-58 TOT
BILI-2.7*
___ 12:00PM LIPASE-19
___ 12:00PM ALBUMIN-4.7
___ 12:00PM WBC-18.2* RBC-5.30 HGB-16.3 HCT-46.1 MCV-87
MCH-30.8 MCHC-35.4 RDW-12.1 RDWSD-38.5
___ 12:00PM NEUTS-90.5* LYMPHS-4.2* MONOS-4.1* EOS-0.2*
BASOS-0.3 IM ___ AbsNeut-16.43* AbsLymp-0.77* AbsMono-0.74
AbsEos-0.04 AbsBaso-0.05
___ 12:00PM PLT COUNT-211
___ 11:57AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 11:57AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 11:57AM URINE RBC-2 WBC-2 BACTERIA-FEW* YEAST-NONE
EPI-0
___ 11:57AM URINE MUCOUS-OCC*
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen ___ mg PO Q8H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID
Hold for loose stool
3. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: Alternating agents for
similar severity
Wean as tolerated. Patient may request partial fill.
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*10 Tablet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: US APPENDIX
INDICATION: ___ with right lower quadrant abdominal pain, anorexia,
subjective fevers and chills. Evaluate for appendicitis.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
A tubular, blind-ending structure is compatible with the appendix. The
appendix is noncompressible, with a thickened wall, and dilated to
approximately 1.2 cm in transverse diameter. The lumen is distended, and the
appendiceal wall layers are distinct, creating a target like appearance. No
significant periappendiceal fluid is seen. Of note, the patient experienced
tenderness over the area of examination with compression using the ultrasound
probe.
IMPRESSION:
Acute, uncomplicated appendicitis.
Gender: M
Race: PORTUGUESE
Arrive by WALK IN
Chief complaint: Fever, Lightheaded, RLQ abdominal pain
Diagnosed with Unspecified acute appendicitis
temperature: 98.4
heartrate: 109.0
resprate: 18.0
o2sat: 99.0
sbp: 134.0
dbp: 84.0
level of pain: 7
level of acuity: 3.0 | Mr. ___ is a ___ y/o M who was admitted to the General Surgical
Service on ___ for evaluation and treatment of abdominal
pain. Admission abdominal US revealed acute, uncomplicated
appendicitis, WBC was elevated at 18.2. 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 on IV fluids, and oxycodone and acetaminophen.
for pain control. The patient was hemodynamically stable.
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:
Chest pain, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old M w/ PMH diet-controlled DM, HTN,
chronic Afib on apixaban, HFrEF (EF 35%), moderate to severe MR,
HLD, s/p ischemic CVA, severe mixed sleep-disordered breathing,
CKD; and OA who presents with left-sided chest pain, dyspnea,
and dizziness. The pain is worse with breathing. He hadn't taken
his home medications in 4 days. His daughter also stated that
he has been somewhat confused for a few days.
Past Medical History:
CVA
AFib
HFrEF
Type II DM
HTN
H/o Left atrial thrombus
Obstructive Sleep Apnea
Peripheral Vascular Disease
Osteoarthritis
CHF
CKD
Asthma
Social History:
___
Family History:
Father had CAD and MIs, does not know how old he was when had
his first MI.
Physical Exam:
GENERAL: NAD, oriented to location, cooperative with exam
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
HEART: Irregular rhythm, normal S1/S2, II/VI holosystolic murmur
heard best in left axilla, no gallops or rubs, JVD not
appreciated
LUNGS: Crackles in right middle lobe and base, minimal crackles
on left side
ABDOMEN: Nondistended, nontender, no hepatojugular reflex
EXTREMITIES: No edema in lower extremities
NEURO: Moving all 4 extremities with purpose
SKIN: Warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
Admission labs:
___ 06:30PM BLOOD WBC-8.0 RBC-4.59* Hgb-13.0* Hct-41.0
MCV-89 MCH-28.3 MCHC-31.7* RDW-15.9* RDWSD-51.8* Plt ___
___ 06:30PM BLOOD Neuts-71.6* Lymphs-18.0* Monos-5.3
Eos-4.5 Baso-0.3 Im ___ AbsNeut-5.74 AbsLymp-1.44
AbsMono-0.42 AbsEos-0.36 AbsBaso-0.02
___ 06:30PM BLOOD ___ PTT-28.7 ___
___ 06:30PM BLOOD Glucose-145* UreaN-14 Creat-1.3* Na-135
K-4.8 Cl-101 HCO3-23 AnGap-11
___ 06:30PM BLOOD ALT-20 AST-25 AlkPhos-108 TotBili-0.4
___ 06:30PM BLOOD Albumin-3.3*
___ 03:40PM BLOOD TSH-1.2
___ 06:30PM BLOOD Lactate-2.1*
Discharge labs:
___ 07:59AM BLOOD WBC-8.7 RBC-4.67 Hgb-13.0* Hct-40.7
MCV-87 MCH-27.8 MCHC-31.9* RDW-15.5 RDWSD-49.2* Plt ___
___ 07:59AM BLOOD Glucose-132* UreaN-29* Creat-1.4* Na-135
K-4.5 Cl-96 HCO3-25 AnGap-14
___ 07:59AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.9
Medications on Admission:
1. Simvastatin 40 mg PO QPM
2. Metoprolol Succinate XL 100 mg PO DAILY
3. Lisinopril 10 mg PO DAILY
4. Eplerenone 25 mg PO DAILY
5. Eliquis (apixaban) 2.5 mg oral BID
6. Acetaminophen 500 mg PO Frequency is Unknown
7. Furosemide 20 mg PO DAILY
8. ProAir HFA (albuterol sulfate) 108 mcg inhalation prn
9. Fluticasone Propionate 110mcg 1 PUFF IH BID
Discharge Medications:
1. Simvastatin 40 mg PO QPM
2. Metoprolol Succinate XL 125 mg PO DAILY
3. Lisinopril 10 mg PO DAILY
4. Eplerenone 25 mg PO DAILY
5. Eliquis (apixaban) 2.5 mg oral BID
6. Acetaminophen 500 mg PO Frequency is Unknown
7. Furosemide 20 mg PO DAILY
8. ProAir HFA (albuterol sulfate) 108 mcg inhalation prn
9. Fluticasone Propionate 110mcg 1 PUFF IH BID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
Acute on chronic heart failure with reduced ejection fraction
Exacerbation
Dyspnea
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with chest pain, dyspnea, dizziness// CHF?
COMPARISON: Multiple prior chest radiographs most recently dated ___
FINDINGS:
PA and lateral views of the chest provided.
In comparison with prior study there is interval increase in now moderate to
severe pulmonary edema with unchanged moderate cardiomegaly. No pleural
effusion or pneumothorax is identified there is no definite superimposed focal
consolidation. The mediastinal silhouette is unchanged. No acute osseous
abnormalities identified.
IMPRESSION:
Interval increase in, now moderate to severe, pulmonary edema with stable
moderate cardiomegaly.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with HFrEF presenting with pulmonary edema,
improving after diuresis// interval changes from presenation, concerns for
retrocardiac opacity
IMPRESSION:
In comparison with study of ___, there has been some decrease in the
degree of pulmonary edema, which still remains quite prominent. Continued
enlargement of the cardiac silhouette. Otherwise, little change.
Gender: M
Race: BLACK/CAPE VERDEAN
Arrive by AMBULANCE
Chief complaint: Chest pain, Dizziness
Diagnosed with Heart failure, unspecified, Chest pain, unspecified, Dizziness and giddiness
temperature: 98.6
heartrate: 74.0
resprate: 20.0
o2sat: 99.0
sbp: 128.0
dbp: 71.0
level of pain: 5
level of acuity: 2.0 | Mr. ___ is a ___ year old M w/ PMH diet-controlled DM, HTN,
chronic Afib on apixiban, HFrEF (EF 35%), moderate to severe MR,
HLD, s/p ischemic CVA, severe mixed sleep-disordered breathing,
CKD; and OA who presented with chest pain and dyspnea I/s/o
medication non-adherence, who was found to have acute
decompensation of his heart failure s/p IV diuresis, now
euvolemic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Exploratory laparotomy, lysis of adhesions.
History of Present Illness:
___ w IDDM, CAD c/b STEMI (___) s/p BMS to RCA, CHF (EF 30%)
p/w syncope in setting recurrent nausea, vomiting, abdominal
discomfort x 12H. Patient in usual state of health until
yesterday late afternoon when he developed vague abdominal
discomfort and associated anorexia. Took in small amount soup
for
dinner. Approximately 11pm felt light headed and went to
bathroom where he had episode of emesis followed by syncopal
event witnessed by wife. +Fall without head strike. Came to and
had additional episode bilious emesis. Wife called EMS who
brought patient to ___ ED for further evaluation. Had
self-limited
episode bradycardia w hypotension en route. Surgery consult
obtained.
On surgery eval, patient c/o mild lower abdominal pain and
persistent nausea despite NGT placement. No flatus this evening.
Last BM yesterday afternoon. No additional complaints. Denies
fever, chills, chest pain, shortness of breath, dysuria.
Past Medical History:
PMH: CAD c/b STEMI (___) s/p BMS to RCA, CHF (TTE ___: EF
30%, Mild AR, Moderate MR, borderline pulm HTN), IDDM, RA, BPH,
Hx colonic polyps, HLD, disequilibrium, multiple pancreatic
cysts, Hx BCC
PSH: Open appendectomy, TURP, laparoscopic converted to open
cholecystectomy (___), R IHR w mesh (___)
Social History:
___
Family History:
*Mother - ___
*Father - ___ and lung cancer
*Sisters (3) - 1. Breast cancer and thyroid nodule excision 2.
Oral/pharyngeal cancer 3. Unknown thyroid problem
*Cousins - One with unknown thyroid problems
Physical Exam:
Admission Physical Exam:
VS: 97.6 66 127/56 18 99% RA
GEN: WD, frail M in mild distress
HEENT: NCAT, anicteric
CV: RRR
PULM: non-labored, no respiratory distress
ABD: soft, mild tenderness RLQ, mildly distended, no
rebound/guarding, no mass, large, reducible L inguinal hernia w
bowel in scrotum
PELVIS: deferred
EXT: WWP, +B/L ___ compression stockings, ruborous feet B/L
NEURO: A&Ox3, no focal neurologic deficits
Discharge Physical Exam:
VS: T: 97.3, BP: 114/54, HR: 94, RR: 18, O2: 94% RA
General:A+Ox3, NAD
CV: RRR
PULM: CTA b/l
ABD: midline incision with staples OTA, skin well-approximated.
mild erythema at lower portion of staple line, but no induration
or s/s infection. abd soft, non-distended, non-tender
EXT: +3 b/l ___ edema, +pulses to palpation b/l
Pertinent Results:
___ 09:36PM GLUCOSE-125* UREA N-34* CREAT-1.0 SODIUM-140
POTASSIUM-4.8 CHLORIDE-105 TOTAL CO2-25 ANION GAP-15
___ 09:36PM CALCIUM-9.2 PHOSPHATE-3.1 MAGNESIUM-1.7
___ 09:36PM WBC-3.3* RBC-3.71* HGB-11.6* HCT-35.4* MCV-95
MCH-31.3 MCHC-32.8 RDW-14.3 RDWSD-49.7*
___ 09:36PM PLT COUNT-69*
___ 03:43PM GLUCOSE-191* UREA N-31* CREAT-0.8 SODIUM-138
POTASSIUM-4.2 CHLORIDE-105 TOTAL CO2-25 ANION GAP-12
___ 03:43PM CALCIUM-9.2 PHOSPHATE-3.4 MAGNESIUM-1.7
___ 03:43PM WBC-4.7 RBC-3.38* HGB-10.7* HCT-31.9* MCV-94
MCH-31.7 MCHC-33.5 RDW-14.2 RDWSD-48.5*
___ 03:43PM PLT COUNT-73*
___ 06:50AM URINE COLOR-Yellow APPEAR-Clear SP
___
___ 06:50AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 06:50AM URINE RBC-5* WBC-0 BACTERIA-NONE YEAST-OCC
EPI-<1
___ 06:50AM URINE MUCOUS-RARE
___ 02:49AM LACTATE-1.4
___ 02:30AM GLUCOSE-182* UREA N-30* CREAT-0.9 SODIUM-139
POTASSIUM-4.1 CHLORIDE-103 TOTAL CO2-25 ANION GAP-15
___ 02:30AM ALT(SGPT)-27 AST(SGOT)-27 ALK PHOS-143* TOT
BILI-1.5
___ 02:30AM LIPASE-10
___ 02:30AM cTropnT-<0.01 proBNP-1755*
___ 02:30AM ALBUMIN-3.7
___ 02:30AM WBC-7.8 RBC-4.16* HGB-13.0* HCT-39.5* MCV-95
MCH-31.3 MCHC-32.9 RDW-14.1 RDWSD-48.7*
___ 02:30AM NEUTS-83.1* LYMPHS-9.2* MONOS-6.8 EOS-0.3*
BASOS-0.3 IM ___ AbsNeut-6.45* AbsLymp-0.71* AbsMono-0.53
AbsEos-0.02* AbsBaso-0.02
___ 02:30AM PLT COUNT-85*
Imaging:
___:
EKG: Sinus rhythm. Premature ventricular contractions. Compared
to the previous tracing of ___ there were no significant
changes.
___: Chest (PA&Lat):
No acute intrathoracic abnormality.
___: CT Head:
1. No acute intracranial abnormality.
2. No evidence of acute intracranial hemorrhage or fracture.
3. Atrophy, probable small vessel ischemic changes, and
atherosclerotic
vascular disease as described.
4. Paranasal sinus disease concerning for acute sinusitis and
polyposis as described.
___: CT ABD&Pel:
1. 3 abrupt cut offs in small bowel caliber in the right lower
quadrant (Se 601b, Im 39) is consistent with a Closed loop
distal small bowel obstruction with transition point in the
riqht lower quadrant: Short segment of small bowel in the
closed loop is fluid filled. The small bowel proximal to the
loop is distended with fluid and has fecalization. No evidence
of pneumatosis or free air. The bowel wall in the closed loop
and remaining small bowel appear to enhance normally. However,
there is edema and free fluid around the short closed loop
segment (Se 2, Im 104) and proximal bowel loop (Se 2, Im 123)
that may suggest complication such as ischemia. Major vessels
appear patent. No portal venous gas or mesenteric gas seen.
2. Left inguinal hernia with interval increased herniation of a
large segment of distal large bowel/sigmoid colon into the
scrotal sac but no evidence of complication.
3. Unchanged 3.5-cm infrarenal abdominal aortic aneurysm.
4. Multiple hepatic and renal cysts.
5. Prostatomegaly.
6. Persistent pancreatic duct dilation and cystic lesions,
unchanged.
7. Small hiatal hernia.
___: CT C-Spine:
1. No evidence of traumatic fracture.
2. Extensive multilevel degenerative changes of the cervical
spine as
described, with narrowing of the spinal canal from C4-C7 and
narrowing of
foraminal recesses at multiple levels.
3. Please note MRI of the cervical spine is more sensitive for
the evaluation of spinal cord or ligamentous injury.
___: EKG:
Artifact is present. Sinus rhythm. Frequent ventricular ectopy.
Left axis
deviation. Left bundle-branch block. Compared to the previous
tracing
of ___ ventricular actopy is new.
Medications on Admission:
ATORVASTATIN [LIPITOR] - Lipitor 80 mg tablet. 1 Tablet(s) by
mouth at bedtime
FINASTERIDE - finasteride 5 mg tablet. 1 Tablet(s) by mouth at
bedtime - (Prescribed by Other Provider)
INSULIN GLARGINE [LANTUS SOLOSTAR] - Lantus Solostar 100 unit/mL
(3 mL) subcutaneous insulin pen. 7 units qam before breakfast
KNEE HIGH COMPRESSION HOSE LIGHT - knee high compression hose
light . please measure wear daily
METOPROLOL SUCCINATE - metoprolol succinate ER 25 mg
tablet,extended release 24 hr. 1 tablet(s) by mouth once a day
MULTIVITAMINS - MULTIVITAMINS . ONE EVERY DAY
NITROGLYCERIN [NITROSTAT] - Nitrostat 0.3 mg sublingual tablet.
1
tablet(s) sublingually q5min prn CP x 3 - (Prescribed by Other
Provider)
Medications - OTC
ASPIRIN - aspirin 81 mg chewable tablet. 1 tablet(s) by mouth
once a day - (Prescribed by Other Provider: ___
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Docusate Sodium 100 mg PO BID
please hold for loose stool
5. Finasteride 5 mg PO DAILY
6. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
7. Glucose Gel 15 g PO PRN hypoglycemia protocol
8. Insulin SC
Sliding Scale
Fingerstick q6h
Insulin SC Sliding Scale using REG Insulin
9. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain, fever
do NOT drink alcohol or drive while taking this medication
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
10. Polyethylene Glycol 17 g PO DAILY:PRN constipation
11. Senna 8.6 mg PO BID:PRN constipation
12. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Closed loop bowel obstruction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ man with syncope/fall with head strike d/t ___
pain/vomiting // ? traumatic injury (head/neck).
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph dated ___. Chest radiograph dated ___.
FINDINGS:
No significant interval change overall. The lungs remain hyperinflated. Left
lower lobe atelectasis is re- demonstrated. The cardiomediastinal silhouette
unchanged. No pleural effusion common pneumothorax, edema, or focal
consolidation. No definite rib fracture. No subdiaphragmatic free air is
visualized. Appearance of the thoracic spine, including loss of vertebral
body height, is overall similar to ___.
IMPRESSION:
No acute intrathoracic abnormality.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ male status post syncope and fall with head strike,
now with abdominal pain and vomiting. Evaluate for acute intracranial
hemorrhage or 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) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 16.0 s, 16.9 cm; CTDIvol = 47.6 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. There is
prominence of the ventricles and sulci suggestive of involutional changes.
There are periventricular and subcortical lucencies, which may represent small
vessel ischemic changes. No shift of normally midline structures.
There is partial opacification of the right predominantly anterior ethmoidal
air cells, complete opacification of the right frontal sinus, and aerosolized
deep tendon secretions in the right sphenoid sinus. The right ostiomeatal
recess appears somewhat narrowed. The left paranasal sinuses are clear. The
right mastoid air cells appear under pneumatized, but no fluid is identified.
The left mastoid air cell are aerated. The middle ear cavities are clear.
The orbits are unremarkable. No evidence of a fracture.
IMPRESSION:
1. No acute intracranial abnormality.
2. No evidence of acute intracranial hemorrhage or fracture.
3. Atrophy, probable small vessel ischemic changes, and atherosclerotic
vascular disease as described.
4. Paranasal sinus disease concerning for acute sinusitis and polyposis as
described.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: ___ male status post fall and syncope with head strike,
now with abdominal pain and vomiting. Evaluate for cervical spine 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: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 5.5 s, 21.6 cm; CTDIvol = 37.1 mGy (Body) DLP = 801.9
mGy-cm.
Total DLP (Body) = 802 mGy-cm.
COMPARISON: None.
FINDINGS:
Study is limited secondary to patient positioning. There is slight widening
of the anterior aspect of the intervertebral disc space at C2-C3 without
associated prevertebral soft tissue swelling or splaying of the transverse
prostheses, suggestive of degenerative change. Vertebral body alignment is
otherwise grossly preserved. No definite fracture is identified. The
visualized osseous structures are osteopenic. Multiple areas of spinal canal
narrowing secondary to posterior osteophytes are noted, particularly at the
C4-C5 and C5-C6 level. Multilevel degenerative changes in the cervical spine
are extensive with loss of intervertebral disc height, endplate sclerosis,
prominent posterior and anterior osteophytes, and subchondral cysts. There
is narrowing of the foraminal recesses at multiple levels. No prevertebral
soft tissue swelling.
IMPRESSION:
1. No evidence of traumatic fracture.
2. Extensive multilevel degenerative changes of the cervical spine as
described, with narrowing of the spinal canal from C4-C7 and narrowing of
foraminal recesses at multiple levels.
3. Please note MRI of the cervical spine is more sensitive for the evaluation
of spinal cord or ligamentous injury.
Radiology Report
EXAMINATION: CT Abdomen and Pelvis
INDICATION: ___ man with syncope/fall with head strike d/t ___ pain;
evaluate for acute intra-abdominal 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: 100 mL Omnipaque.
Oral contrast was not administered per request of the referring team.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Spiral Acquisition 6.1 s, 47.9 cm; CTDIvol = 14.2 mGy (Body) DLP = 678.8
mGy-cm.
4) Spiral Acquisition 0.9 s, 6.9 cm; CTDIvol = 11.7 mGy (Body) DLP = 80.8
mGy-cm.
5) Spiral Acquisition 0.9 s, 6.9 cm; CTDIvol = 11.0 mGy (Body) DLP = 75.8
mGy-cm.
6) Spiral Acquisition 0.8 s, 6.4 cm; CTDIvol = 9.0 mGy (Body) DLP = 57.2
mGy-cm.
Total DLP (Body) = 893 mGy-cm.
COMPARISON: CT abdomen pelvis dated ___.
FINDINGS:
LOWER CHEST: Other than bibasilar atelectasis, the visualized lung fields are
within normal limits. No pleural or pericardial effusion. The heart is
mildly enlarged.
ABDOMEN:
HEPATOBILIARY: Multiple hypodense lesions in the liver are overall unchanged
and most consistent with hepatic cysts. The liver parenchyma otherwise
demonstrates homogenous attenuation throughout. No concerning focal lesions.
No evidence of intrahepatic biliary dilatation. Prominence of the common bile
duct up to 9 mm is noted, within normal limits for the patient's age and
absence of the gallbladder.
PANCREAS: There is extensive fatty atrophy of the pancreas, overall
unchanged. Previously described cystic lesions in the pancreas are also
overall unchanged. Mild dilatation of main pancreatic duct is unchanged. No
peripancreatic stranding.
SPLEEN: The spleen is mildly enlarged measuring up to 14 cm. The spleen is
normal in 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 nephrograms.
Multiple renal cortical hypodensities are too small to accurately characterize
on CT but are likely, unchanged. No evidence of concerning focal renal
lesions. No hydronephrosis. No perinephric abnormality.
GASTROINTESTINAL: Small hiatal hernia is unchanged. The stomach distended
with fluid. 3 abrupt cut offs in small bowel caliber in the right lower
quadrant (Se 601b, Im 39) is consistent with a closed loop distal small bowel
obstruction with a transition point in the riqht lower quadrant: Short
segment of small bowel in the closed loop is filled with fluid. The small
bowel proximal to the transition point is distended with fluid all the way out
to the left upper quadrant with fecalization in the a fairly long segment of
bowel immediately proximal to the transition (series 601b, image 50). No
evidence of pneumatosis or free air. The bowel wall in the closed loop and
remaining small bowel appear to enhance normally. However, there is what
appears to be edema and free fluid around the short closed loop segment (Se 2,
Im 104) that may suggest complication. Small amount of free fluid is also in
the pelvis around the loop of bowel (series 2, image 123). Major vessels
appear patent. No portal venous gas or mesenteric gas seen. No
pneumoperitoneum. The terminal ileum just proximal to the IC junction is
collapsed.
There is a left inguinal hernia with herniation of a large segment of distal
large bowel/sigmoid colon into the scrotal sac. The degree of herniation it
is greater than on the prior exam (series 2, image 147; series 601b, image
35). There is stool in the bowel but the wall is thin and appears
unobstructed. The colonic walls appear to enhance normally.
PELVIS: The urinary bladder and distal ureters are unremarkable.
REPRODUCTIVE ORGANS: The prostate is heterogeneous and enlarged.
LYMPH NODES: No retroperitoneal or mesenteric lymphadenopathy by CT size
criteria. No pelvic or inguinal lymphadenopathy.
VASCULAR: An approximately 3.5 cm infrarenal abdominal aortic aneurysm with
noncalcified thrombus is overall unchanged (series 601b, image 57). Extensive
atherosclerotic calcifications are again noted.
BONES: No evidence of worrisome osseous lesions or acute fracture. Extensive
multilevel degenerative changes of the visualized lumbar spine, SI joints, and
hips are again noted. Mild levoconvex scoliosis of the lumbar spine is
unchanged.
SOFT TISSUES: Left inguinal hernia as above containing wall loop of distal
colon.
IMPRESSION:
1. 3 abrupt cut offs in small bowel caliber in the right lower quadrant (Se
601b, Im 39) is consistent with a Closed loop distal small bowel obstruction
with transition point in the riqht lower quadrant: Short segment of small
bowel in the closed loop is fluid filled. The small bowel proximal to the
loop is distended with fluid and has fecalization. No evidence of pneumatosis
or free air. The bowel wall in the closed loop and remaining small bowel
appear to enhance normally. However, there is edema and free fluid around the
short closed loop segment (Se 2, Im 104) and proximal bowel loop (Se 2, Im
123) that may suggest complication such as ischemia. Major vessels appear
patent. No portal venous gas or mesenteric gas seen.
2. Left inguinal hernia with interval increased herniation of a large segment
of distal large bowel/sigmoid colon into the scrotal sac but no evidence of
complication.
3. Unchanged 3.5-cm infrarenal abdominal aortic aneurysm.
4. Multiple hepatic and renal cysts.
5. Prostatomegaly.
6. Persistent pancreatic duct dilation and cystic lesions, unchanged.
7. Small hiatal hernia.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Syncope, Abd pain
Diagnosed with Syncope and collapse
temperature: 97.6
heartrate: 66.0
resprate: 18.0
o2sat: 99.0
sbp: 127.0
dbp: 56.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ year-old male who presented to ___ on
___ with complaints of abdominal pain. He was found on
imaging to have a small bowel obstruction. He was admitted to
the Acute Care Surgery team for further medical management.
On HD1, the patient was taken to the operating room and
underwent an exploratory laparotomy with lysis of adhesions.
The patient tolerated this procedure well and there were no
adverse events (reader, please see operative note for details).
The patient was extubated and transferred to the PACU. The
patient was noted to have low urine output and was hypotensive
with systolic blood pressure in the ___ and he was bloused
with 500ml IVF with good effect. Once stabilized in the PACU,
was transferred to the surgical floor for pain control and to
await return of bowel function.
The Medicine team was consulted to evaluate the patient for his
syncopal episode prior to his hospital admission. His EKGs were
unconcerning and he remained stable from a cardiovascular
standpoint. His syncopal episode was most likely vasovagal from
an episode of emesis. It was recommended he receive an ECHO with
his outpatient cardiologist.
The remainder of the ___ hospital stay is summarized by
systems below:
Neuro: The patient was alert and oriented throughout
hospitalization; pain was managed with oral pain medication once
tolerating a diet.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. His home
metoprolol was held as he was normotensive.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirometry were
encouraged throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO. On POD2, the
patient had +flatus. On POD3, he had a bowel movement and was
advanced to a regular diet which was well tolerated. Patient's
intake and output were closely monitored. His foley catheter was
removed and he voided independently.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: The patient received subcutaneous heparin and ___
dyne boots were used during this stay and was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
ambulating, voiding without assistance, and pain was well
controlled. The patient worked with Physical Therapy who
recommended his discharge to rehab. The patient declined a
prescription for oxycodone as he stated his pain was
well-controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. A follow-up appointment was
scheduled with the Acute Care Surgery team. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
aspirin / Sulfa (Sulfonamide Antibiotics) / risperidone /
Abilify
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with PMHx significant for cirrhosis secondary to hepatitis C
infection, schizophrenia, and seizure disorder who presents with
3 days of worsening chest pain and shortness of breath. Three
days prior to admission he noted some difficulty breathing,
particularly with exertion. He also had right-sided chest pain
that was worse with inspirationa and cough. These symptoms
progressively worsened. he also reports a non-productive cough,
no hemoptysis. No fevers, chills, nausea, vomiting, diarrhea. He
had not traveled recently, no recent surgery, no leg swelling or
pain. He is rather sedentary at home most days. He has a
35-pack-year history of smoking.
In the ED intial vitals were: 99.4 ___ 20 95% ra. Labs
notable for d-dimer of 1492 and AST of 55. Trop < 0.01. CTA with
R lobar and segmenal PE, wedge-shaped opacity concerning for
pulmonary infarction and segmental LLL PE. Pt guiac negative.
Patient started on heparin gtt.
On arrival to the floor, vitals 98.1 135/92 94 18 95% on RA. He
reports improved breathing at rest, has not ambulated. Continued
mild right-sided chest pain worse with inspiration.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, palpitations, abdominal
pain, nausea, vomiting, diarrhea, constipation, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
1. Hepatitis C genotype 1A.
2. Osteoarthritis.
3. Peptic ulcer disease.
4. Traumatic brain injury.
5. Hypertension.
6. COPD.
7. Mild cognitive impairment.
8. Schizophrenia.
9. Seizure disorder.
10. Type 2 diabetes.
11. H/o SBP
12. H/o MI in ___ with ICU stay (in ___
Social History:
___
Family History:
Both parents died in airplane accident.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- 98.1 135/92 94 18 95% on RA
General- Alert, oriented, no acute distress, lying comfortably
in bed
HEENT- PERRL, EOMI, sclera anicteric, no conjunctival injection,
MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV- Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen- obese, soft, non-tender, normoactive bowel sounds
present, no rebound tenderness or guarding, no organomegaly
appreciated, no masses appreciated
GU- no foley
Ext- warm, well perfused, 2+ ___ pulses, no clubbing or
cyanosis, no edema, no calf tenderness or palpable cords
Neuro- CNs ___ intact, ___ strength throughout extremities
DISCHARGE PHYSICAL EXAM:
unchanged
Pertinent Results:
ADMISSION LABS
===================
___ 02:00AM BLOOD WBC-10.6 RBC-4.80 Hgb-15.1 Hct-46.0
MCV-96 MCH-31.4 MCHC-32.8 RDW-12.7 Plt ___
___ 02:00AM BLOOD Neuts-49.7* ___ Monos-10.8
Eos-0.8 Baso-0.9
___ 02:00AM BLOOD Glucose-108* UreaN-13 Creat-0.8 Na-140
K-3.7 Cl-98 HCO3-29 AnGap-17
___ 02:00AM BLOOD ALT-39 AST-55* AlkPhos-59 TotBili-0.6
___ 02:00AM BLOOD Lipase-45
___ 02:00AM BLOOD cTropnT-<0.01
___ 02:00AM BLOOD Albumin-4.0
___ 02:55AM BLOOD D-Dimer-1492*
STUDIES/IMAGING
===================
___ CXR PA AND LAT
The cardiomediastinal and hilar contours are within normal
limits. Lungs are well expanded and clear. There is mild
blunting of the right costophrenic angle which could relate to
small pleural effusion. There is no focal consolidation or
pneumothorax.
IMPRESSION: Blunting of the right costophrenic angle could
relate to a small right pleural effusion.
___ CTA CHEST
IMPRESSION: Filling defect in the lobar and segmental portions
of the
pulmonary artery in the right upper lung c/w pulmonary emboli
___ ECG
Sinus tachycardia to 114, no ST segement or T wave changes,
normal axis, S1Q3T3 pattern but unchanged from prior ECG dated
___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diazepam 10 mg PO HS
2. Divalproex (EXTended Release) 1500 mg PO DAILY
3. Doxepin HCl 20 mg PO HS
4. esomeprazole magnesium 40 mg oral DAILY
5. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
6. Hydrochlorothiazide 25 mg PO DAILY
7. Ibuprofen 800 mg PO Q8H:PRN arthritis pain
8. ipratropium-albuterol ___ mcg/actuation inhalation Q6H:PRN
sob, wheeze
9. Lisinopril 40 mg PO DAILY
10. Lithium Carbonate CR (Eskalith) 900 mg PO DAILY
11. Lorazepam 1 mg PO DAILY:PRN anxiety
12. lurasidone 80 mg oral DAILY
13. MetFORMIN (Glucophage) 500 mg PO BID
14. QUEtiapine Fumarate 400 mg PO QAM
15. QUEtiapine Fumarate 800 mg PO QPM
16. Tiotropium Bromide 1 CAP IH DAILY
Discharge Medications:
1. Diazepam 10 mg PO HS
2. Divalproex (EXTended Release) 1500 mg PO DAILY
3. Doxepin HCl 20 mg PO HS
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Hydrochlorothiazide 25 mg PO DAILY
6. Ibuprofen 800 mg PO Q8H:PRN arthritis pain
7. Lisinopril 40 mg PO DAILY
8. Lithium Carbonate CR (Eskalith) 900 mg PO DAILY
Eskalith CR
9. Lorazepam 1 mg PO DAILY:PRN anxiety
10. lurasidone 80 mg oral DAILY
11. QUEtiapine Fumarate 400 mg PO QAM
12. QUEtiapine Fumarate 800 mg PO QPM
13. Tiotropium Bromide 1 CAP IH DAILY
14. Enoxaparin Sodium 110 mg SC Q12H Start: ___, First
Dose: Next Routine Administration Time
RX *enoxaparin 120 mg/0.8 mL 120 mg SQ Two (2) times a day Disp
#*20 Syringe Refills:*0
15. Warfarin 5 mg PO DAILY16
Take as directed by the ___ clinic.
RX *warfarin 5 mg 1 tablet(s) by mouth daily as directed by your
___ clinic Disp #*30 Tablet Refills:*0
16. esomeprazole magnesium 40 mg oral DAILY
17. ipratropium-albuterol ___ mcg/actuation inhalation
Q6H:PRN sob, wheeze
18. MetFORMIN (Glucophage) 500 mg PO BID
19. Warfarin 2 mg PO DAILY16
Take as directed by the ___ clinic
RX *warfarin 2 mg 1 tablet(s) by mouth daily as directed by the
anticoagulation clinc Disp #*30 Tablet Refills:*0
20. Outpatient Lab Work
Pulmonary Embolism
ICD-9 415.19
___ to be drawn on ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: lobar and segmental pulmonary emboli
Secondary: hepatitis C, schizophrenia, seizure disorder
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Chest pain on inspiration. Rule out acute process.
COMPARISON: None available.
TECHNIQUE: PA and lateral chest radiographs.
FINDINGS:
The cardiomediastinal and hilar contours are within normal limits. Lungs are
well expanded and clear. There is mild blunting of the right costophrenic
angle which could relate to small pleural effusion. There is no focal
consolidation or pneumothorax.
IMPRESSION: Blunting of the right costophrenic angle could relate to a small
right pleural effusion.
Radiology Report
HISTORY: Pleuritic chest pain, positive D-dimer. Rule out pulmonary embolism.
COMPARISON: Prior chest radiograph from ___ and prior
abdominal/pelvic CT from ___.
TECHNIQUE: Axial helical MDCT images were obtained from the suprasternal
notch to the upper abdomen in early arterial phase scanning after the
administration of 100 cc of Omnipaque IV contrast. Multiplanar reformatted
images in coronal, sagittal and oblique axes were generated.
Total exam DLP: 651 mGy-cm.
CTDI: 43 mGy.
FINDINGS:
CTA THORAX: The aorta and main thoracic vessels are well opacified. The
aorta demonstrates normal caliber throughout the thorax without intramural
hematoma or dissection. There is a filling defect in the lobar and segmental
portions of the pulmonary artery in the right upper lung (3:75-77). There is
no filling defect in the main, right or left pulmonary arteries. No
arteriovenous malformation is seen.
CT OF THE THORAX: 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. An area of
focal ground glass opacity at the minor fissure likely relates to atelectasis.
No additional focal consolidation, pleural effusion or pneumothorax.
Although this study is not designed for assessment of intra-abdominal
structures, the visualized solid organs and stomach are unremarkable. Patient
is status post splenectomy and there is redemonstration of splenosis in the
left upper quadrant, not fully imaged.
OSSEOUS STRUCTURES: No focal osseous lesion concerning for malignancy.
IMPRESSION: Filling defect in the lobar and segmental portions of the
pulmonary artery in the right upper lung c/w pulmonary emboli.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain, Dyspnea
Diagnosed with PULM EMBOLISM/INFARCT
temperature: 99.4
heartrate: 117.0
resprate: 20.0
o2sat: 95.0
sbp: 149.0
dbp: 102.0
level of pain: 7
level of acuity: 3.0 | Mr. ___ was admitted with chest pain and dsypnea and
found to have lobar and segmental pulmonary emboli, likely in
setting of immobility at home. No ECG changes or evidence of
right heart strain, was started on a heparin drip, transitioned
to enoxaparin to bridge to warfarin for at least 3 months of
anticoagulation. He was discharged without chest pain or
dyspnea.
ACTIVE ISSUES
# Pulmonary Emboli
Only risk factor is being completely sedentary while at home -
no known malignancy, no weight loss or night sweats, no recent
surgery, no history of blood clots. ECG without evidence of
right heart strain, TropT negative. Was initially started on a
heparin drip, but transitioned to enoxaparin to take while
bridging to warfarin. He will continue anticoagulation for at
least 3 months. He will be followed at the ___
clinic.
# Dyspnea
Most consistent with pulmonary emboli. No evidence of PNA on CT,
no fevers or elevated WBC either, not typical cardiac chest pain
and TropT negative. Does not seem consistent with COPD
exacerbation given no productive sputum. Clinically not
consistent with heart failure. Not anemic. Treatment for PE as
above, discharged without pulmonary sypmtoms.
CHRONIC ISSUES
# Schizophrenia/TBI/seizure d/o
No acute changes in mental status. Is establishing outpatient
care with a new psychiatrist. Continued quetiapine, lithium,
divalproex, lorazepam,
diazepam, doxepin, and lurasidone.
# Hepatitis C
No stigmata of cirrhosis on exam, no evidence decompensation.
Seeing GI/liver as an outpatient.
# Hypertension
Normotensive. Continued HCTZ, lisinopril.
# Diabetes
Continued metformin.
# PUD
Not active, continued PPI.
# COPD
Not active. Continued tiotropium, fluticasone-salmeterol,
albuterol/ipratropium PRN.
TRANSITIONAL ISSUES
- Patient to have ___ checked at ___ on ___ to take 5mg
warfarin from ___ ___s enoxaparin BID
- Was supposed to have a tooth extraction on ___ but high risk
given initiation of anticoagulation. Told patient to defer this
and needs anticoagulation for at least 1 month before we can
bridge again to lovenox and hold for extraction
- Warfarin/divalproex interaction can potentiate warfarin, but
will monitor INR closely during the initiation of warfarin |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Tetracycline / Grapefruit / Amoxicillin / Tegaderm
/ diazepam
Attending: ___.
Chief Complaint:
Nausea, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ w/ h/o DM2, idiopathic axonal sensorimotor
polyneuropathy, SBO, coronary vasospasm who presents with one
day of N/V. She began vomiting evening prior to presentation
(she says too many to count), accompanied by chills, body aches,
lower abdominal pain, and substernal left chest pain immediately
after her vomiting episodes without associated symptoms. She
took nitro. The pain resolved within 5 minutes. None since. No
URI symptoms. Lives in assisted living, several other residents
with similar symptoms.
She does note ongoing issues with constipation, though has had
several loose BMs in the last couple of days.
In the ED, initial vitals: 96.7 67 180/72 18 95% RA
Labs and CT abd/pelvis reassuring. EKG wnl, trops neg x2.
Pt received:
___ 01:50 IV Ondansetron 4 mg
___ 01:50 IVF 1000 mL NS 1000 mL
___ 02:15 IV Metoclopramide 10 mg
___ 03:00 PO Aspirin
___ 03:00 IH Albuterol 0.083% Neb Soln
___ 03:00 IH Ipratropium Bromide Neb
___ 03:41 IV Lorazepam 1 mg
___ 09:01 IV Diazepam 10 mg
___ 12:06 IV Prochlorperazine 10 mg
___ 12:06 IV DiphenhydrAMINE 25 mg
Briefly apneic after receiving 10 mg valium but quickly
recovered. She was unable to tolerate POs.
Vitals prior to transfer: 99.0 72 143/98 22 96% RA
Currently, the patient notes mild lower back pain that started
during the present episode without other associated symptoms.
Past Medical History:
- Severe idiopathic axonal sensorimotor polyneuropathy
* initial sx in ___ (weakness and sensory loss in legs -->
abdomen --> arms)
* responsive to plasmapheresis ~yearly, last ___
- Vitamin B12 deficiency
- Partial SBO, managed conservatively, ___
- DM2 (not on medication)
- HTN
- GERD
- Depression
- Diverticulosis
- Coronary vasospam on amlodipine
PAST SURGICAL HISTORY:
- c-section x 2
- hysterectomy for leiomyomata
- left breast lumpectomy
- bilateral knee replacements
- portacath (since removed)
- surgery related to recent abdominal hematoma related to sc
heparin
Social History:
___
Family History:
from OMR
- negative for neurological conditions
- positive for DM (mother, brother), malignancy (mother - liver,
cervical, colon; father - lung), CAD (mother)
Physical Exam:
ON ADMISSION:
=============
Vitals- 98.8 150/77 68 18 96% RA
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, systolic murmur at the ___
Abdomen- Obese, soft, mild ttp in the bilateral lower quadrants,
bowel sounds present, no rebound tenderness or guarding, no
organomegaly
GU- no foley
Ext- warm, well perfused, no clubbing, cyanosis or edema
Neuro- CNs2-12 grossly intact, moving all extremities
ON DISCHARGE:
=============
VS: 98.2 134/76 70 20 97RA
GENERAL: Well appearing, alert, oriented, no acute distress.
HEENT: MMM, oropharynx clear.
NECK: Supple, JVD not elevated
CV: RRR, normal S1, S2. Systolic murmur at ___.
RESP: Clear to auscultation bilaterally.
ABD: +BS, soft, nondistended, nontender to palpation.
GU: No foley
EXT: Warm and well perfused. No edema.
SKIN: No rashes.
Pertinent Results:
ON ADMISSION:
======================================
___ 01:20AM PLT COUNT-178
___ 01:20AM NEUTS-77.7* LYMPHS-12.4* MONOS-6.5 EOS-3.3
BASOS-0.1
___ 01:20AM WBC-5.8 RBC-4.76 HGB-14.9 HCT-43.2 MCV-91
MCH-31.3 MCHC-34.5 RDW-13.9
___ 01:20AM ALBUMIN-3.9
___ 01:20AM cTropnT-<0.01
___ 01:20AM LIPASE-21
___ 01:20AM ALT(SGPT)-18 AST(SGOT)-24 ALK PHOS-89 TOT
BILI-0.5
___ 01:20AM estGFR-Using this
___ 01:23AM LACTATE-1.6
___ 02:40AM URINE MUCOUS-RARE
___ 02:40AM URINE RBC-<1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 02:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 02:40AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 02:40AM URINE UHOLD-HOLD
___ 02:40AM URINE HOURS-RANDOM
___ 07:45AM cTropnT-<0.01
ON DISCHARGE:
============================
___ 05:26AM BLOOD WBC-4.4 RBC-4.73 Hgb-14.6 Hct-42.2 MCV-89
MCH-30.8 MCHC-34.5 RDW-14.1 Plt ___
___ 05:26AM BLOOD Glucose-113* UreaN-20 Creat-1.0 Na-139
K-3.7 Cl-101 HCO3-26 AnGap-16
___ 05:26AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.1
MICRO:
========================
Urine Culture: No growth
Blood Culture: Pending, no growth to date
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay
STUDIES:
CT ABD/PELVIS (___)
1. Diverticulosis throughout the colon without signs of
diverticulitis.
2. No convincing evidence of small bowel obstruction. Tortuous
colon with cecum positioned in the midline, and mild prominence
of distal small bowel, but no focal zone of transition.
3. Stable right adrenal nodule dating back to ___.
4. Slight thickening of the distal sigmoid colon may be due to
collapsed segment. Suggest followup nonemergent endoscopy.
CXR ___:
No acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO DAILY
2. Artificial Tears 2 DROP BOTH EYES Q6H:PRN dry eyes
3. Aspirin 81 mg PO DAILY
4. Docusate Sodium 100 mg PO BID
5. Bisacodyl 5 mg PO DAILY:PRN constipation
6. Lactulose 15 mL PO TID
7. Lorazepam 0.5 mg PO Q6H:PRN anxiety
8. Polyethylene Glycol 17 g PO Q12H
9. Multivitamins 1 TAB PO DAILY
10. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
11. Reguloid (psyllium husk;<br>psyllium seed (sugar)) 0.52 gram
oral BID
12. Cyanocobalamin 1000 mcg PO DAILY
13. Vitamin D 1000 UNIT PO DAILY
14. BuPROPion 100 mg PO BID
15. Sertraline 100 mg PO DAILY
16. Amlodipine 2.5 mg PO DAILY
17. Gabapentin 100 mg PO BID
18. Ondansetron 4 mg PO Q6H:PRN nausea
19. Simvastatin 20 mg PO DAILY
20. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
Discharge Medications:
1. Acetaminophen 1000 mg PO DAILY
2. Amlodipine 2.5 mg PO DAILY
3. Artificial Tears 2 DROP BOTH EYES Q6H:PRN dry eyes
4. Aspirin 81 mg PO DAILY
5. BuPROPion 100 mg PO BID
6. Cyanocobalamin 1000 mcg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. Gabapentin 100 mg PO BID
9. Lactulose 15 mL PO TID
10. Lorazepam 0.5 mg PO Q6H:PRN anxiety
11. Multivitamins 1 TAB PO DAILY
12. Polyethylene Glycol 17 g PO Q12H
13. Sertraline 100 mg PO DAILY
14. TraMADOL (Ultram) 50 mg PO Q6H:PRN pain
15. Vitamin D 1000 UNIT PO DAILY
16. Bisacodyl 5 mg PO DAILY:PRN constipation
17. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
18. Ondansetron 4 mg PO Q6H:PRN nausea
19. Reguloid (psyllium husk;<br>psyllium seed (sugar)) 0.52 gram
oral BID
20. Atorvastatin 10 mg PO QPM
RX *atorvastatin 10 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
Viral gastroenteritis
Acute kidney injury
Constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with chest pain.
TECHNIQUE: Frontal and lateral chest radiographs were obtained with the
patient in the upright position.
COMPARISON: Chest radiograph from ___ and ___.
FINDINGS:
There is no focal consolidation, pleural effusion or pulmonary edema. The
heart is top-normal in size. The mediastinal contours are normal.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ female with vomiting, left lower quadrant pain.
TECHNIQUE: Axial MDCT images were obtained through the abdomen and pelvis
following the administration of 150 cc of Omnipaque intravenous contrast
material and without oral contrast material. Reformatted coronal and sagittal
images were obtained.
DOSE: DLP: 951 mGy-cm.
CTDIvol: 29 mGy.
COMPARISON: CT from ___.
FINDINGS:
THORAX: The visualized lung bases are clear with no pleural effusions,
pneumothorax or focal opacities. The visualized heart and pericardium are
normal.
LIVER: There is a subcentimeter segment VI/VII hypodensity that is stable
from prior CT scans and is too small to characterize but statistically likely
to represent a cyst (2:29). The portal and hepatic veins are patent, and there
is no intra or extrahepatic biliary duct dilatation.
GALLBLADDER: The gallbladder is unremarkable and contains no radiopaque
gallstones.
SPLEEN: The spleen is normal in size and shape.
PANCREAS: The pancreas enhances homogeneously without ductal dilation or
peripancreatic fat stranding.
ADRENALS: A 3.5 x 1.9 cm right adrenal gland nodule is stable from prior CT
exams dating back to ___ (2:26), and the left adrenal gland is normal.
KIDNEYS: The kidneys are normal in size and shape. The kidneys have
appropriate contrast enhancement and excretion bilaterally. There is no
hydronephrosis or perinephric stranding.
BOWEL: The stomach is mildly distended and unremarkable. The small bowel does
not have signs of obstruction or focal wall thickening. The appendix is
normal. The large bowel does not have wall thickening or evidence of
obstruction. Colon appears tortuous, with the cecum orientated transversely in
the midline. There is mild prominence of the distal small bowel, but no focal
zone of transition to suggest mechanical obstruction. Diverticulosis is noted
throughout the colon without evidence of diverticulitis. Slight thickening of
the distal sigmoid (series 2, image 70) may be due to collapsed segment. There
is no intraperitoneal free air or free fluid.
LYMPH NODES: There are no pathologically enlarged retroperitoneal or
mesenteric lymph nodes by CT size criteria.
PELVIS: The bladder is moderately distended without focal wall thickening.
There is no pelvic free fluid. There are no pathologically enlarged pelvic
sidewall or inguinal lymph nodes by CT size criteria. The rectum is
unremarkable.
VESSELS & SOFT TISSUE: There is moderateatherosclerotic disease without
aneurysmal dilatation of the abdominal aorta. The aorta and its major branches
are patent. SMA supplying hepatic and splenic arteries again noted. There are
no hernias.
BONES: There are no suspicious lytic or sclerotic osseous lesions to suggest
malignancy. Degenerative changes are noted in the lumbar spine without acute
fracture.
IMPRESSION:
1. Diverticulosis throughout the colon without signs of diverticulitis.
2. No convincing evidence of small bowel obstruction. Tortuous colon with
cecum positioned in the midline, and mild prominence of distal small bowel,
but no focal zone of transition.
3. Stable right adrenal nodule dating back to ___.
4. Slight thickening of the distal sigmoid colon may be due to collapsed
segment. Suggest followup nonemergent endoscopy.
NOTIFICATION: #4 of the impression above was entered by Dr. ___ on
___ at 11:42 into the Department of Radiology critical communications
system for direct communication to the referring provider.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: n/v/d
Diagnosed with CHEST PAIN NOS, NONINF GASTROENTERIT NEC
temperature: 96.7
heartrate: 67.0
resprate: 18.0
o2sat: 95.0
sbp: 180.0
dbp: 72.0
level of pain: 7
level of acuity: 3.0 | ___ with PMH significant for DM2, idiopathic axonal
sensorimotor polyneuropathy, SBO, coronary vasospasm who
presents with one day of nausea, vomiting, and loose stools.
# VIRAL GASTROENTERITIS:
Given sick contacts, chills, body aches, the patient's symptoms
were felt to be secondary to viral gastroenteritis. She did not
have any URI symptoms or myalgias to suspect influenza. CT
ABD/PELVIS showed diverticulosis and slight thickening of the
distal sigmoid colon, which may be due to a collapsed segment.
Blood cultures with no growth to date. C difficile was negative.
The patient was treated with IVF and anti-emetics. Her diet was
advanced slowly. Her symptoms improved by day 2 of
hospitalization.
# ACUTE KIDNEY INJURY:
Cr was elevated at 1.8 on day 2 of hospitalization, from
baseline of 0.8. FENa was 0.08%, which was consistent with a
pre-renal etiology. She did not have any episodes of
hypotension. She was not on nephrotoxic medications. She was
treated with IVF.
# CHEST PAIN:
Suspect this may be esophageal irritation in the setting of
vomiting given temporality. Troponins were negative x 2. EKG was
also reassuring. The patient was given omeprazole. She was
continued on medications for CAD/coronary vasospasm. Simvastatin
was switched to atorvastatin given drug interaction with
amlodipine.
# DM2:
HbA1c was 5.4% in ___ without therapy. Her glucose with daily
chemistries were normal.
# CHRONIC PAIN:
She was continued on tramadol and gabapentin.
# SENSIROMOTOR NEUROPATHY:
She will have outpatient follow up with plasmapheresis as
planned.
# DEPRESSION:
She was continued on sertraline.
# HOME MEDICATIONS:
- Continued eye drops.
- Held psyllium. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Sulfadiazine / diltiazem / clonidine
Attending: ___.
Chief Complaint:
code stroke
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
Neurology at bedside for evaluation after code stroke activation
within: 5 minutes
Time (and date) the patient was last known well: ___ (24h
clock)
___ Stroke Scale Score: 4
t-PA given:
X No Reason t-PA was not given or considered: mild deficits with
rapid improvement
I was present during the CT scanning and reviewed the images
instantly within 20 minutes of their completion.
___ Stroke Scale score was: 4
1a. Level of Consciousness: 0
1b. LOC Question: 1
1c. LOC Commands: 0
2. Best gaze: 0
3. Visual fields: 0
4. Facial palsy: 1
5a. Motor arm, left: 0
5b. Motor arm, right: 0
6a. Motor leg, left: 0
6b. Motor leg, right: 0
7. Limb Ataxia: 0
8. Sensory: 1
9. Language: 1
10. Dysarthria: 0
11. Extinction and Neglect: 0
*History gathered via pt's daughter at the bed side*
Mrs ___ is a ___ woman with PMH signficant for ESRD on
HD, HTN, DM, HLD who presents as a code stroke for ? aphasia.
The
patient was in her usual state of health until ___ during
her HD session. The nurse saw her well at 7:15 and moments later
noticed a glazed look on her face. The patient was not speaking
at all. The nurse went to get her daughter who was waiting out
side. The patient did not respond verbally to anything said to
her. The daughter did not notice any asymmetry in the patients
face or movements at that point. She did think that the patient
looked very pale. The patient was then sent to our ED and a code
stroke was activated. No NIHSS was acquired prior to my arrival.
According to the patient's daughter her color and behavior were
slowly returning to normal at the time of my interview. By the
end of her evaluation the patient was behaving and talking in
her
usual manner - per the daughter.
The patient was complaining of headache. Apparently she gets a
headache after most of her dialysis sessions. The patient was
recently taken off of her clonidine patch and has since had
elevated BPs at home - to the 180s at times - with associated
dizziness.
On neuro ROS: the pt denies loss of vision, blurred vision,
diplopia, oscilopsia, dysarthria, dysphagia, or hearing
difficulty. Denies focal weakness, numbness, paresthesias. No
bowel or bladder incontinence or retention.
On general ROS: the pt denies recent fever or chills. No night
sweats or recent weight loss or gain. Denies cough, shortness of
breath. Denies chest pain or tightness, palpitations. Denies
nausea, vomiting, diarrhea, constipation or abdominal pain. No
recent change in bowel or bladder habits. No dysuria. Denies
arthralgias or myalgias. Denies rash.
Past Medical History:
Hypercholesterolemia
Hypertension
Osteoporosis
Diabetes Mellitus type 2 Diagnosed ___
Microalbuminuria
s/p Appendectomy
Benign essential tremor
CKD Now on HD
Normocytic anemia ___ CKD
Social History:
___
Family History:
NC
Physical Exam:
MEDICAL EXAMINATION
97.8 100 199/77 14 99% RA
GENERAL MEDICAL EXAMINATION:
General appearance: alert, in no apparent distress, frail
elderly
woman
HEENT: Neck is supple, Sclera are non-injected. Mucous membranes
are moist.
CV: Heart rate is regular
Lungs: Breathing comfortably on RA
Abdomen: soft, non-tender
Extremities: No evidence of deformities. No contractures. No
Edema.
Skin: No visible rashes. Warm and well perfused.
NEUROLOGICAL EXAMINATION:
Mental Status: Awake and alert. Oriented to self and hospital.
Does not reply question re date. Minimal verbal output but
without dysarthria per family. Able to name 2 items on stroke
card (chair and glove) Able to follow both midline and
appendicular commands.
Cranial Nerves:
I: not tested
II: BTT in all quadrants
III-IV-VI: pupils equally round, reactive to light. Normal
conjugated, extra-ocular eye movements in all directions of
gaze.
No nystagmus or diplopia.
V: Symmetric perception of LT in V1-3
VII: Left NLF attenuation at rest. decreased speed and excursion
with smile (new per family)
VIII: Hearing intact to finger rub bl
IX-X: Palate elevates symmetrically
XI: Shoulder shrug and head rotation ___ bl
XII: No tongue deviation or fasciculations
Motor: decreased muscle bulk throughout. normal tone. No
pronator
drift
Strength: diffusely 4+/5 in the bl upper extremities (concerning
for poor effort) ___ in the ___
Reflexes:
Bi Tri ___ Pat Ach
L 2 2 2 2 1
R 2 2 2 2 1
Toes are down going bilaterally.
Sensory: "small" reduction in LT and PP on the left arm and leg.
Coordination: Finger to nose without dysmetria bilaterally. No
intention tremor. RAM were symmetric and slow bl
Gait: could not test.
DISCHARGE EXAMINATION:
Waxing and waning of her language function, at times she is able
to answer simple questions in ___, at other times she will
respond with short answers in ___ only. However, on formal
testing in ___ her language is always fluent with intact
naming and repetition. Follows commands consistantly in ___.
Facial droop resolved. Strength is ___ throughout with diffuse
wasting but no true pattern of weakness.
Pertinent Results:
___ 08:00PM CREAT-1.4*#
___ 08:00PM GLUCOSE-106* UREA N-10 CREAT-1.2*# SODIUM-143
POTASSIUM-3.9 CHLORIDE-103 TOTAL CO2-28 ANION GAP-16
___ 08:00PM estGFR-Using this
___ 08:00PM estGFR-Using this
___ 08:00PM ALT(SGPT)-10 AST(SGOT)-20 ALK PHOS-74 TOT
BILI-0.5
___ 08:00PM cTropnT-0.05*
___ 08:00PM ALBUMIN-3.7
___ 08:00PM GLUCOSE-98 LACTATE-0.9 NA+-141 K+-3.8 CL--99
TCO2-29
___ 08:00PM WBC-10.7* RBC-3.43* HGB-10.3* HCT-32.4*
MCV-95 MCH-30.0 MCHC-31.8* RDW-16.2* RDWSD-56.2*
___ 08:00PM NEUTS-74.9* LYMPHS-12.8* MONOS-9.5 EOS-1.9
BASOS-0.3 IM ___ AbsNeut-8.03* AbsLymp-1.37 AbsMono-1.02*
AbsEos-0.20 AbsBaso-0.03
___ 08:00PM PLT COUNT-143*
___ 08:00PM ___ PTT-31.9 ___
___ 06:50AM BLOOD %HbA1c-5.1 eAG-100
___ 06:50AM BLOOD Triglyc-100 HDL-47 CHOL/HD-2.7 LDLcalc-58
___ 06:50AM BLOOD TSH-0.88
___ 07:30AM BLOOD CRP-5.3*
___ 12:10PM BLOOD SED RATE-6
___ 02:08AM URINE Color-Straw Appear-Cloudy Sp ___
___ 02:08AM URINE Blood-SM Nitrite-NEG Protein-600
Glucose-TR Ketone-NEG Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG
___ 02:08AM URINE RBC-24* WBC->182* Bacteri-MOD Yeast-NONE
Epi-0
___ 2:08 am URINE Source: ___.
**FINAL REPORT ___
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 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
cefepime sensitivity testing confirmed by ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- 16 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ 4 S
TRIMETHOPRIM/SULFA---- <=1 S
EEG showed slowing in the frontal regions and R side but no
seizure activity
CXR: Persistent left base opacity raises concern for
consolidation, underlying pleural effusion with atelectasis may
also be present. Pulmonary vascular congestion.
CTA head and neck:
1. Atherosclerosis of bilateral cavernous, clinoid and
supraclinoid ICAs and bilateral V4 segments of the vertebral
arteries.
2. No stenosis by NASCET criteria in the neck.
3. Tight stenosis of the left external carotid artery near its
origin
secondary to atherosclerosis.
4. No acute intracranial abnormality.
DISCHARGE LABS:
___ 07:00AM BLOOD WBC-8.5 RBC-2.67* Hgb-8.2* Hct-26.3*
MCV-99* MCH-30.7 MCHC-31.2* RDW-16.5* RDWSD-59.4* Plt ___
___ 07:00AM BLOOD Glucose-88 UreaN-12 Creat-2.3*# Na-139
K-4.3 Cl-100 HCO3-28 AnGap-15
___ 07:00AM BLOOD Calcium-8.6 Phos-3.6# Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO EVERY ___ AFTER DIALYSIS
2. Labetalol 100 mg PO BID:PRN SBP>160
3. HydrOXYzine 10 mg PO BID:PRN Itch
4. Nephrocaps 1 CAP PO DAILY
5. Aspirin 81 mg PO DAILY
6. Vitamin D 1000 UNIT PO BID
7. Docusate Sodium 100 mg PO BID
8. Senna 8.6 mg PO QHS:PRN constipation
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Aspirin 81 mg PO DAILY
3. Amlodipine 10 mg PO EVERY ___ AFTER DIALYSIS
4. Nephrocaps 1 CAP PO DAILY
5. Senna 8.6 mg PO QHS:PRN constipation
6. HydrOXYzine 10 mg PO BID:PRN Itch
7. Vitamin D 1000 UNIT PO BID
8. Ciprofloxacin HCl 500 mg PO Q24H
9. Labetalol 200 mg PO TID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Multifactorial hypertensive and toxic/metabolic encephalopathy
ESRD on HD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: History: ___ with aphasia. Evaluate for CVA .
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) CT Localizer Radiograph
2) CT Localizer Radiograph
3) Sequenced Acquisition 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
897.1 mGy-cm.
4) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 38.1 mGy (Head) DLP =
19.1 mGy-cm.
5) Spiral Acquisition 4.9 s, 38.5 cm; CTDIvol = 32.0 mGy (Head) DLP =
1,233.5 mGy-cm.
Total DLP (Head) = 2,150 mGy-cm.
COMPARISON: Head CT from ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of no evidence of infarction, hemorrhage, edema, or mass.
The ventricles and sulci are patent and prominent in keeping with age-related
volume loss.
Extensive hypodensities in the periventricular, subcortical and deep white
matter, nonspecific, likely secondary to small vessel ischemic changes.
Intracranial atherosclerotic calcification.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable
noting prior bilateral cataract surgeries. .
CTA HEAD:
Atherosclerotic calcification of bilateral V4 segments of the vertebral
arteries, right greater than left. Also seen is atherosclerotic calcification
with luminal irregularity of bilateral cavernous, clinoid and supraclinoid
segments of internal carotid arteries, right greater than left. The vessels
of the circle of ___ and their principal intracranial branches appear
normal without stenosis, occlusion or aneurysm formation. The dural venous
sinuses are patent.
CTA NECK:
There is focal high-grade stenosis at the origin of right vertebral artery.
Minimal atherosclerosis involving bilateral carotid bulbs without significant
stenosis.
The remaining carotid and vertebral arteries and their major branches
otherwise appear unremarkable. There is no evidence of internal carotid
stenosis by NASCET criteria.
All it least 50% atherosclerotic narrowing of the origin of left external
carotid artery near the bifurcation with of clot as seen on image ___: 60.
Incidentally seen is medialized retropharyngeal course of bilateral carotid
arteries.
OTHER:
There is layering left-sided pleural effusion, partially visualized. The
visualized portion of the lungs are otherwise clear. There is enlarged
thyroid with multiple low-attenuation nodules with foci of calcification, the
largest is a partially calcified 1.1 cm nodule in the left lobe of thyroid.
Further evaluation with ultrasound of the thyroid can be performed as
clinically indicated. There is no lymphadenopathy by CT size criteria.
Atherosclerosis of the aortic arch with calcified and soft plaque.
IMPRESSION:
1. Atherosclerosis of bilateral cavernous, clinoid and supraclinoid ICAs and
bilateral V4 segments of the vertebral arteries.
2. No stenosis by NASCET criteria in the neck.
3. Tight stenosis of the left external carotid artery near its origin
secondary to atherosclerosis.
4. No acute intracranial abnormality.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with acute onset aphasia // eval for consolidation
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
There is persistent left base opacity which could be due to consolidation due
to infection or aspiration. Underlying left pleural effusion with atelectasis
could be present. The right lung is grossly clear aside from pulmonary
vascular congestion. No right pleural effusion is seen. There is no evidence
of pneumothorax. The heart remains mildly enlarged. The aortic knob is
calcified. Large-bore dual-lumen right central venous catheter terminates at
the cavoatrial junction/right atrium.
IMPRESSION:
Persistent left base opacity raises concern for consolidation, underlying
pleural effusion with atelectasis may also be present. Pulmonary vascular
congestion.
Gender: F
Race: ASIAN - CHINESE
Arrive by AMBULANCE
Chief complaint: Altered mental status, Headache
Diagnosed with Aphasia, Essential (primary) hypertension
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: unable
level of acuity: 1.0 | Ms ___ is a ___ woman with PMH signficant for ESRD on HD
___, HTN, DM, HLD who presented with episode of
behavioral/speech arrest during dialysis and a possible facial
droop which resolved. Her mental status waxed and waned in the
hospital (sometimes speaking in ___ some, other times
responding slowly in ___ but language exam showed fluent
speech with intact repetition and naming. TIA or stroke appeared
to be very unlikely given her presentation so MRI was not
obtained. EEG was preformed and showed slowing but no seizures.
The patient and was found to have a UTI, which was the most
likely etiology of her symptoms. CXR showed a questionable
consolidation, but she had no clinical signs or symptoms of PNA.
She was initially treated with CTX/Vanc to cover both possible
etiologies, but when urine culture returned showing a resistant
UTI and she continued to have no respiratory symptoms, she was
narrowed to Cipro on ___ for a 10 day course (last day ___.
Her BP was very high on admission with SBP > 200. HTNsive
encephalopathy was another possible etiology of her symptoms.
She had previously been on a clonidine patch but developed a
rash so the patch was discontinued prior to this presentation.
Thus she likely was having rebound hypertension in response to
stopping clonidine abruptly. Her HTN was treated with
uptitrating labetalol slowly during admission. Her BPs improved
to SBP 160s-180s at the time of discharge. The team was not
overly aggressive in treating HTN at this time given concern for
continued rebound HTN from clonidine, and the potential to drop
lower once this acute period is over. Her BP should be monitored
at rehab and adjusted as needed with input from the Renal team.
Her Nutritional status appeared to be poor and she was started
on supplementation. Swallow felt she required a ground diet with
nectar thickened liquids. Her Nutrition and Swallow function
should continued to be monitored at rehab. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
head and neck swelling, dyspnea
Major Surgical or Invasive Procedure:
___ venoplasty, thrombectomy, and port removal w/ ___ on ___
Skin biopsy ___
History of Present Illness:
Ms. ___ is a ___ year old female with CLL complicated by
transformation to DLBCL who underwent allo SCT on ___ who
presents with dyspnea and headache.
Of note, the patient underwent a bronchoscopy as an outpatient
on
___ for the evaluation of progressive dyspnea on exertion which
grew no organisms after which her symptoms began to resolve.
The patient was in her usual state of health until about 1 week
ago when she noticed the gradual onset of progressive dyspnea on
exertion. This continued throughout the week until 1 day prior
to
admission when she noticed the gradual onset of chest fullness
radiating across her chest, in addition to neck and facial
fullness. She stated that in addition, she had positional
dizziness and headache that is exacerbated with bending forward.
She then presented to her oncologist's office who referred her
to
the ED for further management.
In the ED, the initial vital signs were:
T 99 HR 83 BP 133/86 R 16 SpO2 100% RA
Laboratory data was notable for:
Normal Chem10 aside from HCO3 21
Normal LFTs
WBC 2.0 ANC 960 Hgb 10.8 plt 127
trop <0.01
BNP 174
The patient received:
___ 19:38 PO OxyCODONE (Immediate Release) 5 mg
Imaging demonstrated:
___ 14:31 Cta Chest
IMPRESSION:
- Right upper and right lower lobe segmental pulmonary emboli.
No
CT evidence of right heart strain.
-Intrinsic substantially occlusive thrombus surrounding the
Port-A-Cath in the SVC. Venous return from the head and neck
vessels occurs via small mediastinal veins and the azygos system
draining to the IVC. A custom, hand injected venogram via the
port can be considered to assess whether infusion port catheter
is patent. Of note, contrast could not be injected mechanically
via the port at the time of study.
-Interval increase in axillary and mediastinal lymphadenopathy,
resulting in further narrowing of the left brachiocephalic just
peripheral to the origin of the SVC.
-New sclerotic lesions in the T10 through T12 vertebral bodies,
concerning for progression of metastatic disease.
-Resolving right lower lobe consolidation.
-Minimal interval increase in pericardial effusion.
-2 new subcentimeter nodules in the left upper lobe are
nonspecific, and may be inflammatory.
___ 10:56 Chest (Pa & Lat)
IMPRESSION:
No focal consolidation to suggest pneumonia. Grossly stable
cardiomediastinal silhouette.
___ Imaging CT HEAD W/O CONTRAST
IMPRESSION:
No CT evidence of intracranial hemorrhage or acute process.
Upon arrival to 8S, the patient endorses the above history. She
states that her facial and neck fullness is stable. She is
without diploplia or vision changes. No difficulty breathing,
wheezing, drooling or dysphagia. No palpitations. No n/v/d. No
constipation or dysuria.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___: ___ was incidentally found to have CLL, presenting with
leukocytosis 19,000.
- ___: CT scan ___ confirms adenopathy in the
neck, axillary, retroperitoneal, and inguinal regions averaging
roughly 3 cm.
- ___: Excisional biopsy of the lymph node consistent
with chronic leukocytic leukemia. ___ confirmed 13q deletion.
Anemia was thought to be from iron deficiency and not CLL; she
was considered Rai Stage I at that time. She remained without
issue for the next ___ years and was followed by ___, MD
___ oncology).
- ___ - Diagnosed with PMR and started on
prednisone/plaquenil
with some improvement in shouler aching
- ___ - patient presents to ___ with progressive
dyspnea, possible night sweats and left sided abdominal pain.
Stress test and CTA were negative; she had new-onset anemia and
thrombocytopenia. CT scan shows massive splenomegaly with
extensive lymphadenopathy.
- ___ - ___ - Hospitalization ___ for the above issues.
She
is trialed on IVIG/prednisone for ?ITP; no response in
platelets.
___- PET suggestive of progressive CLL and she starts
treatment with fludarabine/cyclophosphamide (rituxin held ___
bulky disease).
- ___ biopsy returns with population of DLBCL,
indicating Richter's Transformation
- ___: C1D1 da-EPOCH, dose level 1, uncapped vincristine.
- ___: C1 rituximab.
- ___: C2D1 da-EPOCH-R, dose level 2, uncapped vincristine.
- ___: PET:2 shows a mixed response with improvement in
retroperitoneal adenopathy and splenic involvement but increased
osseous FDG avidity and a new right hilar lymphadenopathy.
- ___: C3D1 da-EPOCH-R, dose level 3, uncapped vincristine.
- ___: C4D1 da-EPOCH-R, dose level 3, uncapped vincristine.
- ___: PET:4 shows ___ 4, given diffuse osesous
uptake
greater than the liver; however, it is also noted that bone
marrow recovery is difficult to distinguish from active disease.
- ___: Targeted left iliac bone biopsy demonstrates
trabecular bone marrow with focal minimal involvement by her
known CLL/SLL; there was no evidence of large cell lymphoma.
- ___: MRI shoulder for left shoulder pain reveals
supraspinatus tendon tear.
- ___: C5D1 da-EPOCH-R, dose level 4, uncapped vincristine.
- ___: Pre-transplant bone marrow biopsy reveals a markedly
hypercellular marrow with myeloid dominant trilineage
hematopoiesis and no evidence of large cell lymphoma. There were
no mutations on lymphoid sequencing, normal karyotype, and
normal
CLL FISH panel.
- ___: Pre-transplant PET scan shows stable axillary,
mediastinal, retroperitoneal, pelvic sidewall and inguinal
lymphadenopathy, as well as unchanged diffuse osseous FDG
avidity, all thought to represent residual CLL, with no evidence
of recurrent DLBCL.
- ___: Sibling donor found to be ineligible.
- ___: Admitted for C6D1 da-EPOCH-R, dose level 2, uncapped
vincristine, as a bridge to identifying an unrelated donor.
- ___: Pre-transplant PFTs reveal an FEV1/FVC 0.81, FEV1 98%
of predicted. DLCO corrected for hemoglobin 116% of predicted.
- ___: Pre-transplant TTE shows an LVEF of 60%.
- ___: Pre-transplant PET again reveals stable axilary,
mediastinal, retroperitoneal, pelvic sidewall, and inguinal
adenopathy with diffuse marrow avidity, most likely reflective
of
underlying CLL.
- ___: Admitted for transplant.
- ___: Undergoes matched, unrelated donor myeloablative
[fludarabine and busulfan conditioning] peripheral blood
allogeneic hematopoietic stem cell transplant, with day 0:
___. Transplant is complicated by possible brief and mild
episode of GVHD of the gut (flexible sigmoidoscopy with biopsy
negative on ___, for which she was treated briefly with
methylprednisolone, quickly tapered to off. In addition, she had
severe mucositis and esophagitis that resolved with neutrophil
engraftment. Found to have mild erythematous rash on bilateral
axillae and inguinal regions, thought to be contact dermatitis
by
Dermatology, treated with topical triamcinolone. She also did
have asymptomatic pyuria on ___, for which she was treated with
cefpodoxime for a 3 day course.
- ___: Discharged to home.
- ___: Day +39 peripheral blood lineage specific chimerism
reveals 100% donor in the myeloid lineage and 66% donor in the
lymphoid lineage.
- ___: Initiates treatment for mild acute cutaneous GVHD
with
topical betametasone, with subsequent resolution of rash.
- ___: Undergoes bronchoscopy for persistent dyspnea on
exertion. Culture shows no organisms.
- ___: Bactrim held because of neutropenia and mild
thromboctyopenia, atovaquone initiated for pneumocystis
prophylaxis.
- ___: Neutropenia and thrombocytopenia resolve.
PAST MEDICAL HISTORY:
CLL (13q-) with Richter Transformation to DLBCL, as above
Mild acute cutaneous GVHD
BK Viruria
Left supraspinatus tendon tear
Asthma
GERD
Depression
Morbid obesity s/p gastric bypass
B12 deficiency
Iron deficiency anemia
PMR
Eczema
L Uveitis c/b blindness in left eye
Social History:
___
Family History:
Sister: ___
Father: CAD, PVD, Colon CA
Mother: ___ Cell Carcinoma
Physical Exam:
ADMISSION PHYSICAL EXAM:
==========================
VITALS: T 98.4 BP 129/90 HR 97 R 18 ___ NC
GENERAL: Sitting comfortably in bed, NAD
HEENT: Noted facial flushing and edema. Tongue midline and not
protruding. No pooled secretions. No wheezing on ausculation
EYES: PERRL, anicteric R pupil >L pupil (baseline)
NECK: Noted flushing with distended JVD
RESP: No increased WOB, no wheezing, rhonchi or crackles
___: Regular, no MRG
GI: soft, non-tender, no rebound or guarding
EXT: warm, no edema, no palpable cord
SKIN: dry, no obvious rashes. distended veins over right
posterior back
NEURO: Alert, fluent speech. CN II-XII intact. R pupil > L as
above
ACCESS: R POC not accessed, PIV
DISCHARGE PHYSICAL EXAM
==========================
24 HR Data (last updated ___ @ 544)
Temp: 97.6 (Tm 98.4), BP: 115/74 (113-124/71-79), HR: 73
(73-97), RR: 19 (___), O2 sat: 99% (97-100), O2 delivery: Ra,
Wt: 168.5 lb/76.43 kg
GENERAL: Well appearing woman in NAD.
HEENT: MMM, R > L pupil, no facial flushing/plethora, no
pharyngeal erythema or exudates
EYES: Pupils reactive to light, anicteric, anisocoria (R pupil >
L pupil)
NECK: Supple, non-tender, no elevated JVP
RESP: No increased WOB, no wheezing, rhonchi or crackles
___: Regular rate and rhythm, no murmurs, rubs or gallops.
GI: Soft, non-tender, no rebound or guarding
EXT: Warm, no edema
SKIN: Skin type II. RLE with firm, immobile, 3mm rosy
erythematous nodule proximal to medial malleolus, 2mm purpuric
nodule on the distal RLE. Biopsy site distal to knee with
dressing c/d/I.
NEURO: Alert, fluent speech. R pupil > L as above
ACCESS: R POC not accessed, PIV
Pertinent Results:
ADMISSION LABS
=================
___ 12:00PM BLOOD WBC: 2.0* RBC: 3.99 Hgb: 10.8* Hct: 34.3
MCV: 86 MCH: 27.1 MCHC: 31.5* RDW: 17.0* RDWSD: 52.9* Plt Ct:
127*
___ 12:00PM BLOOD Neuts: 48 Lymphs: ___ Monos: 18* Eos: 2
Baso: 0 AbsNeut: 0.96* AbsLymp: 0.64* AbsMono: 0.36 AbsEos: 0.04
AbsBaso: 0.00*
___ 12:00PM BLOOD Glucose: 101* UreaN: 17 Creat: 0.8 Na:
139
K: 4.4 Cl: 108 HCO3: 21* AnGap: 10
___ 12:00PM BLOOD ALT: 10 AST: 11 AlkPhos: 103 TotBili: 0.2
___ 12:00PM BLOOD Calcium: 8.6 Phos: 4.1 Mg: 2.2 UricAcd:
3.6
DISCHARGE LABS
=================
___ 06:05AM BLOOD WBC-6.5 RBC-3.66* Hgb-9.6* Hct-30.3*
MCV-83 MCH-26.2 MCHC-31.7* RDW-17.8* RDWSD-53.7* Plt ___
___ 06:05AM BLOOD Neuts-62 Bands-9* Lymphs-8* Monos-15*
Eos-0* ___ Metas-1* Myelos-3* Promyel-1* NRBC-0.3*
AbsNeut-4.62 AbsLymp-0.52* AbsMono-0.98* AbsEos-0.00*
AbsBaso-0.07
___ 06:05AM BLOOD Anisocy-1+* Poiklo-1+* Spheroc-1+*
Ovalocy-2+* Schisto-1+* RBC Mor-SLIDE REVI
___ 06:05AM BLOOD ___ PTT-44.0* ___
___ 06:05AM BLOOD Glucose-101* UreaN-11 Creat-0.7 Na-143
K-4.0 Cl-107 HCO3-24 AnGap-12
___ 06:05AM BLOOD Calcium-8.4 Phos-4.8* Mg-1.9
NUTRITION LABS
=================
ZINC (SPIN NVY/EDTA)
Test Result Reference
Range/Units
ZINC 55 L 60-130 mcg/dL
COPPER (SPIN NVY/NO ADD)
Test Result Reference
Range/Units
COPPER 126 70-175 mcg/dL
MICROBIOLOGY
=================
HERPES VIRUS 6 DNA, PCR
Test Result Reference
Range/Units
SOURCE Whole Blood
HERPESVIRUS 6 DNA, QN PCR <500 <500 copies/mL
___ 17:20
PARVOVIRUS B19 DNA
Test Result Reference
Range/Units
SOURCE Serum
PARVOVIRUS B19 DNA, QL REAL Not Detected Not Detected
TIME PCR
___ RSV panel negative
___ 6:04 am SEROLOGY/BLOOD
**FINAL REPORT ___
CRYPTOCOCCAL ANTIGEN (Final ___:
CRYPTOCOCCAL ANTIGEN NOT DETECTED.
(Reference Range-Negative).
___ 5:15 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ Bone Marrow Biopsy
===========================
HEMATOPATHOLOGY REPORT - Final
PATHOLOGIC DIAGNOSIS:
============= DIAGNOSIS =============
SPECIMEN: BONE MARROW ASPIRATE AND CORE BIOPSY.
DIAGNOSIS:
HYPOCELLULAR, ERYTHROID DOMINANT BONE MARROW WITH MILD
DYSERYTHROPOEISIS, INCREASED MEGAKARYOCYTES, AND FOCAL STROMAL
DAMAGE.
FINDINGS MAY BE COMPATIBLE WITH GRAFT-VERSUS-HOST-DISEASE
(GVHD).SEE NOTE.
Note: the biopsy and aspirate exhibit marked megaloblastic
changes, left shift and only mild dyspoiesis. Numerous mitoses
are present. Focally, there is cell dropout and some apoptotic
cells. Spaces vacated by hemopoietic cells contain fibrinous
material. There is not evidence
of hemophagocytosis. Conditions than can cause the changes
evidenced in this marrow include viral infections, particularly
CMV infection, drug/medication toxicity, immunosuppressive
drugs, and ___. Please correlated with
other clinical, imaging and laboratory findings. By
immunohistochemistry, Ki-___ highlights mildly increased number
of positive cells. CD33 highlight decreased myeloid precursors;
E-cadherin show increased proerythroblasts; glycophorin-A show
increased polychromatophilic and orthochromatic erythroblasts;
myeloperoxidase stain myeloid precursors which represent
approximately 30% of the overall cellularity. CD34 stain show
rare, scattered, less than 5% blasts. BCL6 is negative. BCL2
stains numerous cells. PAX5 (BSAP) highlight rare, scattered,
individual cells.There is no evidence of leukemia or lymphoma.
IMAGING
==========
___ CXR
iMPRESSION:
No focal consolidation to suggest pneumonia. Grossly stable
cardiomediastinal
silhouette.
___ CTA NECK
- Right upper and right lower lobe segmental pulmonary emboli.
No CT evidence of right heart strain.
-Intrinsic substantially occlusive thrombus surrounding the
Port-A-Cath in the SVC. Venous return from the head and neck
vessels occurs via small
mediastinal veins and the azygos system draining to the IVC. A
custom, hand injected venogram via the port can be considered to
assess whether infusion port catheter is patent. Of note,
contrast could not be injected mechanically via the port at the
time of study.
-Interval increase in axillary and mediastinal lymphadenopathy,
resulting in further narrowing of the left brachiocephalic just
peripheral to the origin of the SVC.
-New sclerotic lesions in the T10 through T12 vertebral bodies,
concerning for progression of metastatic disease.
-Resolving right lower lobe consolidation.
-Minimal interval increase in pericardial effusion.
-2 new subcentimeter nodules in the left upper lobe are
nonspecific, and may be inflammatory.
___ CT NECK WITH CONTRAST
1. Diffusely enlarged cervical, mediastinal and axillary lymph
nodes,
increased in size from examination of ___.
Associated diffuse surrounding inflammatory stranding is noted.
2. Retropharyngeal edema measuring approximately 5 mm in
greatest thickness. This may be reactive in nature or secondary
to venous congestion.
3. No focal peripherally enhancing fluid collection to suggest
abscess.
4. Additional findings described above.
___ ___
IMPRESSION:
No CT evidence of intracranial hemorrhage or acute process.
___ venous recannulation
IMPRESSION:
Successful SVC recannulization, mechanical and suction
thrombectomy. Right port removal.
RECOMMENDATION(S):
1. Restart heparin
2. Monitor for SVC syndrome symptoms. Repeat intervention may
be considered if there are any additional symptoms in the
short-term
3. ___ to follow in house as well as as an outpatient to assess
for need of any further interventions
___ TTE
IMPRESSION: Subaortic membrane causing a mild left ventricular
outflow tract obstruction (18 mmHg). Mild symmetric left
ventricular hypertrophy with normal cavity size, and
hyperdynamic regional/global systolic function. No valvular
pathology or pathologic flow identified.
Indeterminate pulmonary artery systolic pressure. Very small
pericardial effusion without echocardiographic evidence of
tamponade.
Compared with the prior TTE ___ , the subaortic membrane
is newly recognized (present previously but not commented upon).
___ PET
IMPRESSION:
1. Overall, similar appearance of cervical, axillary,
mediastinal, retroperitoneal, pelvic, and inguinal
lymphadenopathy without significantly changed FDG uptake as
compared to the exam in ___. ___ 3.
2. Known sclerotic lesions in the thoracic lower spine are less
conspicuous on today's PET study, and better appreciated on the
CTA from ___.
3. There has been interval removal of a right Port-a-Cath.
4. Stable top normal spleen, measuring 12.9 cm.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion XL (Once Daily) 450 mg PO DAILY
2. Cyanocobalamin 250 mcg PO DAILY
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. FLUoxetine 80 mg PO DAILY
5. Senna 8.6 mg PO BID:PRN constipation
6. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
7. Ursodiol 300 mg PO BID
8. Fluconazole 400 mg PO Q24H
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Tacrolimus 1 mg PO Q12H
11. Acyclovir 400 mg PO Q8H
12. Atovaquone Suspension 1500 mg PO DAILY
13. LORazepam 0.5-1 mg PO Q8H:PRN anxiety
14. Prochlorperazine ___ mg PO Q6H:PRN nausea/vomiting
15. Magnesium Oxide 400 mg PO BID
Discharge Medications:
1. Clobetasol Propionate 0.05% Ointment 1 Appl TP DAILY
RX *clobetasol 0.05 % Apply to erythematous lesions twice a day
Refills:*0
2. Enoxaparin Sodium 80 mg SC Q12H
3. FoLIC Acid 5 mg PO DAILY
RX *folic acid 1 mg 5 tablet(s) by mouth once a day Disp #*150
Tablet Refills:*0
4. LevoFLOXacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth once a day Disp #*5
Tablet Refills:*0
5. PredniSONE 60 mg PO DAILY
RX *prednisone 20 mg 3 tablet(s) by mouth once a day Disp #*90
Tablet Refills:*0
6. Tacrolimus 0.5 mg PO QPM
RX *tacrolimus 0.5 mg 1 capsule(s) by mouth at bedtime Disp #*30
Capsule Refills:*0
7. Tacrolimus 1 mg PO QAM
RX *tacrolimus 0.5 mg 2 capsule(s) by mouth QAM Disp #*60
Capsule Refills:*0
8. Acyclovir 400 mg PO Q8H
9. Atovaquone Suspension 1500 mg PO DAILY
10. BuPROPion XL (Once Daily) 450 mg PO DAILY
11. Cyanocobalamin 250 mcg PO DAILY
12. Docusate Sodium 100 mg PO BID:PRN constipation
13. Fluconazole 400 mg PO Q24H
14. FLUoxetine 80 mg PO DAILY
15. LORazepam 0.5-1 mg PO Q8H:PRN anxiety
16. Magnesium Oxide 400 mg PO BID
17. Multivitamins W/minerals 1 TAB PO DAILY
18. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
19. Prochlorperazine ___ mg PO Q6H:PRN nausea/vomiting
20. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
=======
- Superior vena cava syndrome
- Pulmonary emboli
SECONDARY
=========
- DLBCL s/p allogenic SCT
- Neutropenia
- Erythema nodosum
Discharge Condition:
.
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: ___ year old woman with lymphoma status-post transplant, now with
dyspnea, ? pneumonia// ___ year old woman with lymphoma status-post transplant,
now with dyspnea, ? pneumonia
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: Chest radiographs from ___ and chest CT
from ___.
FINDINGS:
Right-sided Port-A-Cath terminates in the mid to low SVC, without evidence of
pneumothorax.No focal consolidation is seen. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes are grossly
stable compared to ___, with mild prominence of the left upper
mediastinum, which may relate to underlying lymph nodes..
IMPRESSION:
No focal consolidation to suggest pneumonia. Grossly stable cardiomediastinal
silhouette.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ yo woman with lymphoma s/p allogeneic stem cell transplant.
Two day h/o chest and neck pain, with new onset SOB/DOE. Rule out PE.// ___ yo
woman with lymphoma s/p allogeneic stem cell transplant. Two day h/o chest
and neck pain, with new onset SOB/DOE. Request CTA with contrast to rule out
PE.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 8.8 mGy (Body) DLP = 1.8
mGy-cm.
2) Stationary Acquisition 5.2 s, 0.2 cm; CTDIvol = 82.1 mGy (Body) DLP =
16.4 mGy-cm.
3) Spiral Acquisition 4.8 s, 30.9 cm; CTDIvol = 11.9 mGy (Body) DLP = 360.9
mGy-cm.
Total DLP (Body) = 379 mGy-cm.
COMPARISON: Chest CT dated ___
FINDINGS:
HEART AND VASCULATURE: There are small, nonocclusive filling defects in the
right upper and right lower lobe segmental pulmonary arteries. The thoracic
aorta is normal in caliber without evidence of dissection or intramural
hematoma. A right chest Port-A-Cath terminates in the cavoatrial junction.
There has been interval increase in moderate narrowing of the left
brachiocephalic vein due to mass effect from adjacent mediastinal
lymphadenopathy. Otherwise, the heart is within normal limits. There has
been slight interval increase in a small pericardial effusion.
Reflux of contrast is seen in the chest, some of which enters into the right
brachiocephalic vein. Distal to the origin of the SVC there is severe luminal
narrowing and irregularity secondary to thrombosis, not extrinsic compression
by mediastinal adenopathy. Venous return from the head and neck appears to be
via small mediastinal veins and collaterals from the azygos vein draining to
the IVC.
AXILLA, HILA, AND MEDIASTINUM: There has been significant interval increase in
axillary lymphadenopathy bilaterally. For example a left axillary lymph node
now measures 1.2 cm, previously 0.6 cm and a right axillary lymph node now
measures up to 1.5 cm, previously 0.9 cm. There is also been interval
increase in the mediastinal lymphadenopathy. For example a 9 mm right
paratracheal node (04:21) is new. Retrocrural adenopathy appears stable
measuring up to 1.6 cm, previously 1.5 cm (4:93). A small right hilar lymph
node measures up to 7 mm (04:58).
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: 2 mm nodules in the left upper lobe (04:56, 62) are new, but
nonspecific. Evidence of resolving right lower lobe consolidation is noted
(4:66). There is mild diffuse bronchial wall thickening. The airways are
patent to the level of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is notable for a subcentimeter
hypodensity in the right hepatic lobe, which is incompletely characterized but
likely represents a hepatic cyst or biliary hamartoma and is unchanged. There
are expected postsurgical changes related to previous partial gastrectomy.
BONES: There is increased sclerosis in the T11 and T12 vertebral bodies and
spinal process as well as in the spinal process of T10 (08:39), which is
concerning for metastatic disease (08:41). There is no acute pathologic or
compression fracture. Multilevel degenerative changes are moderate.
IMPRESSION:
- Right upper and right lower lobe segmental pulmonary emboli. No CT evidence
of right heart strain.
-Intrinsic substantially occlusive thrombus surrounding the Port-A-Cath in the
SVC. Venous return from the head and neck vessels occurs via small
mediastinal veins and the azygos system draining to the IVC. A custom, hand
injected venogram via the port can be considered to assess whether infusion
port catheter is patent. Of note, contrast could not be injected mechanically
via the port at the time of study.
-Interval increase in axillary and mediastinal lymphadenopathy, resulting in
further narrowing of the left brachiocephalic just peripheral to the origin of
the SVC.
-New sclerotic lesions in the T10 through T12 vertebral bodies, concerning for
progression of metastatic disease.
-Resolving right lower lobe consolidation.
-Minimal interval increase in pericardial effusion.
-2 new subcentimeter nodules in the left upper lobe are nonspecific, and may
be inflammatory.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 4:57 pm, 5 minutes
after discovery of the findings.
Radiology Report
EXAMINATION: CT NECK W/CONTRAST (EG:PAROTIDS) Q22 CT NECK
INDICATION: ___ yo woman with lymphoma s/p allogeneic stem cell transplant.
Two day h/o chest and neck pain, with new onset SOB/DOE. Rule out PE.// ___ yo
woman with lymphoma s/p allogeneic stem cell transplant. Two day h/o chest
and neck pain, with new onset SOB/DOE. Rule out PE.
TECHNIQUE: Imaging was performed after administration of Omnipaque
intravenous contrast material.
MDCT acquired helical axial images were obtained from the thoracic inlet
through the skull base.
Coronal and sagittal multiplanar reformats were then produced and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.0 s, 25.9 cm; CTDIvol = 16.2 mGy (Body) DLP = 408.8
mGy-cm.
2) Spiral Acquisition 2.1 s, 3.2 cm; CTDIvol = 8.4 mGy (Body) DLP = 24.3
mGy-cm.
3) Spiral Acquisition 2.1 s, 3.2 cm; CTDIvol = 8.4 mGy (Body) DLP = 24.3
mGy-cm.
Total DLP (Body) = 457 mGy-cm.
COMPARISON: PET-CT of ___.
FINDINGS:
When compared to PET-CT of ___, interval development of diffusely
enlarged cervical, mediastinal and axillary lymph nodes, many of which
demonstrate surrounding inflammatory stranding.
There is retropharyngeal edema measuring approximately 5 mm in greatest
thickness.
Evaluation of the aerodigestive tract demonstrates no mass and no areas of
focal mass effect.
The major salivary glands are within expected limits, however the intraparotid
lymph nodes do appear enlarged. A few speckled calcifications in the left
lobe of the thyroid. Otherwise the thyroid is unremarkable.The cervical
vessels are patent.
Visualized lungs are clear.There are no osseous lesions. Incidental note is
made of ossification of the posterior longitudinal ligament at the C5-C6
level. Incidental note is made of a 7 mm sclerotic lesion in the left
mandibular symphysis, compatible with cemento-osseous dysplasia (a benign
finding).
IMPRESSION:
1. Diffusely enlarged cervical, mediastinal and axillary lymph nodes,
increased in size from examination of ___. Associated diffuse
surrounding inflammatory stranding is noted.
2. Retropharyngeal edema measuring approximately 5 mm in greatest thickness.
This may be reactive in nature or secondary to venous congestion.
3. No focal peripherally enhancing fluid collection to suggest abscess.
4. Additional findings described above.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with headache, has PE on imaging, cancer hx// r/o
SDH and mass prior to heparin
TECHNIQUE: Contiguous axial images from skullbase to vertex were obtained
without intravenous contrast. Coronal and sagittal reformations and bone
algorithms reconstructions were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 17.2 cm; CTDIvol = 46.7 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: Brain MRI from ___
FINDINGS:
There is no evidence of infarction, hemorrhage, edema, or mass. The ventricles
and sulci are normal in size and configuration. Previously described pre
ventricular white matter changes are not well visualized on this study. No
osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
No CT evidence of intracranial hemorrhage or acute process.
Radiology Report
INDICATION: ___ year old woman with Lymphoma status-post transplant, now with
SVC Syndrome from Port-a-Cath related thrombosis. Please perform angioplasty
for venous recanalization. This plan was discussed in detail with Dr. ___
___// ___ year old woman with Lymphoma status-post transplant, now with
SVC Syndrome from Port-a-Cath related thrombosis. Please perform angioplasty
for venous recanalization. This plan was discussed in detail with Dr. ___
___.
COMPARISON: CT scan from 1 day prior
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___
performed the procedure.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
175mcg of fentanyl and 3.5 mg of midazolam throughout the total intra-service
time of 60 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: Heparin was discontinued at the start of the procedure, IV
antibiotics per nursing sheet
CONTRAST: 60 ml of OPTIRAY contrast
FLUOROSCOPY TIME AND DOSE: 13 min, 168 mGy
PROCEDURE: 1. Right internal jugular access under ultrasound guidance
2. SVC venogram
3. Recannulization of SVC
4. Removal of right-sided double-lumen port
5. Angioplasty of SVC with 12 and 14 mm balloons
6. Suction thrombectomy of SVC thrombus
7. Mechanical cleaner thrombectomy of SVC thrombus
8. Post intervention SVC venogram
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The right internal jugular was prepped and draped in the usual
sterile fashion along with the port. At this time, under ultrasound guidance
the patent right internal jugular vein was accessed with a micropuncture
needle. A micropuncture sheath was then placed and a SVC venogram performed,
the results of which are below. Then, utilizing a Glidewire, the SVC was
recannulated. The Glidewire was parked in the IVC. A Kumpe catheter was then
placed and this was exchanged for a Amplatz wire. Then, an 8 ___ sheath
was placed in the right IJ. At this time, the right-sided double-lumen port
was removed. After installation of lidocaine and lidocaine with epinephrine,
an incision was made and blunt dissection was utilized to remove the existing
port. The port pocket was packed while the remainder of the procedure was
performed.
Angioplasty of the SVC was performed with 12 and 14 mm balloons. Residual
thrombus was noted therefore a penumbra CAT 8 device was utilized for suction
thrombectomy of the SVC thrombus followed by a 6 ___ cleaner device for
mechanical thrombectomy. Post these interventions, there was substantially
less thrombus as outlined below with resolution of the large collaterals. At
this time, the port pocket was closed with ___ interrupted Vicryl and ___
subcuticular Vicryl stitches. A layer of Dermabond was also applied. A
Neptune hemostatic pad was used at the internal jugular site after manual
pressure was applied for 10 minutes.
Sterile dressings were applied. The patient tolerated the procedure well and
postprocedure artery reported improvement in her facial swelling and
symptomatology.
FINDINGS:
1. initial venogram with complete, abrupt occlusion of the SVC at the level
of the distal catheter.
2. Post catheter removal, mild improvement in the SVC thrombus, but
significant thrombus still remaining therefore mechanical and suction
thrombectomy as well as venoplasty was performed.
3. Post interventions, substantial improvement in the SVC thrombus. Mild
residual narrowing noted, but not further intervened upon at this time given
the complete resolution of collaterals.
IMPRESSION:
Successful SVC recannulization, mechanical and suction thrombectomy. Right
port removal.
RECOMMENDATION(S): 1. Restart heparin
2. Monitor for SVC syndrome symptoms. Repeat intervention may be considered
if there are any additional symptoms in the short-term
3. ___ to follow in house as well as as an outpatient to assess for need of
any further interventions
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, Headache, Neck pain
Diagnosed with Other pulmonary embolism without acute cor pulmonale
temperature: 99.0
heartrate: 83.0
resprate: 16.0
o2sat: 100.0
sbp: 133.0
dbp: 86.0
level of pain: 7
level of acuity: 2.0 | ___ is a ___ year old woman with CLL c/b DLBCL
transformation s/p Allo SCT on ___ complicated by mild,
cutaneous GVHD who presents from clinic with progressive
headache, dizziness and dyspnea who was found to have a port
associated DVT, PE and potential SVC syndrome. Course
complicated by neutropenia and erythema nodosum.
#PULMONARY EMBOLISM
#PORT ASSOCIATED DVT
#POSSIBLE SVC SYNDROME
#ACUTE HYPOXIC RESPIRATORY FAILURE:
Worsening dyspnea and CT demonstrating right sided PE and
occlusive thrombus by the patient's port-a-cath with findings
concerning for SVC occlusion. Reviewed imaging with radiology
and appears that her obstruction is from thrombus rather than
tumor. After discussion with primary oncologist, ___, and IV
access team, patient underwewnt Port removal, Mechanical and
suction thrombectomy of SVC thrombus, SVC venoplasty w/ ___ on
___ with improvement in symptoms. Patient started on enoxaparin
on admission; transitioned to heparin periprocedurally. Switched
back to enoxaparin thereafter. Underwent TTE ___ did not reveal
intracardiac thrombus, but did show a subaortic membrane.
#DLBCL
#S/P ALLO SCT
#CUTANEOUS GVHD:
Post transplant course complicated by mild, cutaneous GVHD and
BK viruria which have resolved with treatment. CT showed new
T10-12 sclerotic lesions and mediastinal lymphadenopathy
initially concerning for recurrent lymphoma. Continued ACV,
atovaquone, and fluconazole ppx. Stopped ursodiol for VOD ppx.
Obtained PET on ___, which was unchanged from prior; no new FDG
avidity. BM biopsy ___ w/o evidence of lymphoma recurrence or
leukemia but did show some megaloblastic features, so increased
increased dose of b12/folate. MMA level was pending at time of
discharge. Tacrolimus was tapered to 1mg QAM, 0.5 mg QPM.
#NEUTROPENIA
#THROMBOCYTOPENIA:
Previously attributed to Bactrim, which was transitioned to
atovaquone. Developed severe neutropenia of unclear etiology
during admission. Dosed neupogen while ANC < 500. Counts
recovered. Etiology of neutropenia was not clear but though most
likely to be secondary to a viral illness though respiratory
viral panel without detection of common pathogens. A full
infectious workup was sent and pending at time of discharge as
below.
#ERYTHEMA NODOSUM
New erythematous leg lesions noted ___. Biospied ___: c/w
erythema nodosum. Broad ddx, including autoimmune/inflammatory,
infections (viral, bacterial, fungal), and malignant. Given low
suspicion for infection, patient was started on
methylprednisolone 1 mg/kf on ___ and tapered to prednisone 60mg
daily for discharge. Applied topical steroid with occlusive
dressing to EN lesions for symptomatic relief. Infectious
disease was consulted and recommended obtaining
quant gold, viral panel (negative), endemic mycosis labs, ASO
which were pending at time of discharge.
#HYPOTENSION (c/f sepsis; resolved)
Hypotensive to ___ on ___ with sensation
lightheadedness/unsteadiness. Initially started vancomycin and
cefepime (___). Stopped vanco ___ and cefepime ___. Was
prescribed levofloxacin upon discharge.
#DEPRESSION: patient tearful on admission given acute illness.
-continued bupropion
-continued fluoxetine
#H/O GASTRIC BIPASS C/B B12 DEFICIENCY:
-continued home B12
#CANCER ASSOCIATED PAIN: Chronic and stable
-continued home oxycodone
#HCP/CONTACT:
Relationship: Husband
Phone number: ___
Cell phone: ___
#CODE STATUS: Full, presumed
TRANSITIONAL ISSUES:
[] Determine prednisone taper, discharged on prednisone 60mg
daily
[] Skin biopsy sutures should be removed on ___, please ensure
follow up for removal
[] TTE showed subaortic membrane, should have surveillance TTE
[] follow up pending quantiferon gold, endemic mycosis labs,
ASO, MMA, B-glucan, galactomannan |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
gluten / egg
Attending: ___.
Chief Complaint:
Nausea and vomiting
Major Surgical or Invasive Procedure:
Exploratory laparotomy, left salpingo-oophorectomy
History of Present Illness:
HPI: ___ G0 who presented to ___ ED yesterday after
developing persistent n/v/d and abd pain which persisted. Was
unable to tolerate any po since ___. Otherwise denies f/c,
uri sx, dysuria, joint/muscle pains outside of her usual.
Prior to ___, had actually been feeling very well since
starting rituximab. Has been walking and much more active than
prior. Does report 6 pound weight loss and possibly slightly
less than normal apetite but was actively calorie counting and
dieting over this past month (eating 1200-1500 calories) per
day.
AT ___ was found to have ___ with Cr 2.9 and started on
IVF. Non-contract CT scan showed a 25cm cystic abdominal mass
and she was transferred to ___ for further workup.
Here her pain is relatively well controlled with po meds,
creatinine is improving with IVF, at 1.9 this am. Continues to
deny f/c. N/V/D also currently resolved.
ROS otherwise negative
Past Medical History:
OB/Gyn hx:
-G0
-amenorrheic on mirena
-denies hx STI, fibroids, ovarian cysts or other gyn issues
PMH:
-RA on rituximab since ___
-eosinophilic esophagitis
-hypothyroid
-bipolar
PSH:
-OMFS surgery to correct jaw alignment
Social History:
___
Family History:
Father with CAD, possible UC, possible RA
Mother with A-fib
Grandmother died of melanoma
Physical Exam:
Admission PE
VS: 98 70 118/86 16 100% RA
Gen: NAD, resting comfortably in bed
HEENT: EOMI, PERRLA, MMM, OP clear
CV: RRR nl s1s2 no m/r/g
Resp: CTAB no w/r/r
Abd: soft, diffuse mild tenderness, no rebound or guarding, ND,
+BS
Ext: no c/c/e
Neuro: CN II-XII intact, ___ strength throughout
Skin: warm, dry no rashes
On day of discharge:
Afebrile, vitals stable
No acute distress
CV: regular rate and rhythm
Pulm: clear to auscultation bilaterally
Abd: soft, appropriately tender, nondistended, incision
clean/dry/intact, no rebound/guarding
___: nontender, nonedematous
Pertinent Results:
___ 07:25PM GLUCOSE-101* UREA N-19 CREAT-2.2*# SODIUM-140
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-21* ANION GAP-18
___ 07:25PM CALCIUM-9.4 PHOSPHATE-4.1 MAGNESIUM-2.7* URIC
ACID-8.8*
___ 07:25PM CEA-1.5 CA125-11
___ 07:25PM LITHIUM-1.7*#
Pelvic US ___:
IMPRESSION:
1. Normal-sized bilateral ovaries, with normal flow. Only the
right ovary was identified by transvaginal ultrasound. The left
ovary was seen by transabdominal approach.
2. Large predominantly anechoic cystic structure in the mid to
left upper
abdomen, correlating with findings on the earlier outside
hospital CT. It is unclear if this structure originates from
the ovaries, but no direct
connection to either ovary was identified on this study.
MRI pelvis ___:
IMPRESSION:
Large simple appearing cystic lesions which appears to be
arising from the
pelvis extending into the abdomen, likely from the left ovary.
Its
characteristics are most consistent with an ovarian serous
cystadenoma. Given the lack of complex features, a serous
cystadenocarcinoma is thought to be less likely. The other
differential consideration is a benign mesenteric cyst.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 100 mcg PO DAILY
2. Lithium Carbonate SR (Lithobid) 900 mg PO QHS
3. LaMOTrigine 200 mg PO QHS
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN pain
do not exceed 4000 mg in 24 hours
RX *acetaminophen [Acetaminophen Extra Strength] 500 mg ___
tablet(s) by mouth every 6 hours Disp #*40 Tablet Refills:*0
2. Docusate Sodium 100 mg PO BID
take while using oxycodone for pain
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*40 Capsule Refills:*0
3. Ibuprofen 400 mg PO Q8H:PRN Pain
RX *ibuprofen 400 mg 1 tablet(s) by mouth every 8 hours Disp
#*20 Tablet Refills:*0
4. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
do not drive while taking, use with a stool softener
RX *oxycodone [Oxecta] 5 mg ___ tablet(s) by mouth every 4 hours
Disp #*35 Tablet Refills:*0
5. LaMOTrigine 200 mg PO QHS
6. Levothyroxine Sodium 100 mcg PO DAILY
7. Lithium Carbonate SR (Lithobid) 900 mg PO QHS
Lithobid SR
Discharge Disposition:
Home
Discharge Diagnosis:
Mesosalpinx inclusion cyst
Final pathology pending
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: PELVIS U.S., TRANSVAGINAL
INDICATION: ___ year old woman with large pelvic mass. OB discussed patient
w/medicine team and concerned about possible ovarian mass and want to r/o
torsion. Please assess bilateral ovaries and blood flow. Assess ovaries
bilaterally.
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach followed by transvaginal approach for further
delineation of uterine and ovarian anatomy.
COMPARISON: Outside hospital CT abdomen pelvis of ___.
FINDINGS:
The uterus is anteverted and measures 8.0 x 2.2 x 3.5 cm. The endometrium is
homogenous and measures 3 mm. An IUD is identified within the uterine fundus.
On transvaginal ultrasound, the right ovary measures 3.0 x 2.4 x 1.7 cm, and
demonstrates normal blood flow. The left ovary was not identified on
transvaginal approach. By transabdominal approach, the left ovary measures
3.4 x 2.1 x 1.4 cm, and also demonstrates normal blood flow.
In the midline to left upper abdomen, there is a predominantly anechoic cystic
structure with faint internal echoes, which is difficult to measure due to the
size. It is not clear if this originates from either ovary, but no direct
connection is identified. The cystic structure itself appears separate from
the visualized pancreas and kidneys.
IMPRESSION:
1. Normal-sized bilateral ovaries, with normal flow. Only the right ovary
was identified by transvaginal ultrasound. The left ovary was seen by
transabdominal approach.
2. Large predominantly anechoic cystic structure in the mid to left upper
abdomen, correlating with findings on the earlier outside hospital CT. It is
unclear if this structure originates from the ovaries, but no direct
connection to either ovary was identified on this study.
Radiology Report
INDICATION: History of rheumatoid arthritis on Rituximab, presenting with
abdominal pain, nausea, and vomiting. Found to have a large pelvic cyst.
Please evaluate.
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen and pelvis
were acquired in a 1.5 T magnet. Intravenous contrast: 7 mL Gadavist.
COMPARISON: CT of the abdomen and pelvis from ___, obtained at
an outside hospital. Pelvic ultrasound from ___.
FINDINGS:
There is a 17.4 cm (transverse) x 3.1 cm (anterior-posterior) x 23.3 cm
(cranial caudal) cystic lesion located superior to the bladder, extending
upward in the mid lower abdomen, and into the left upper quadrant, with its
most superior point at the level of the upper kidney. The cyst itself appears
simple. It is hyperintense on the T2 weighted images, hypointense on the T1
weighted images, and there is no nodularity or septation. The wall is thin
and has non-measurable, though perceptible, enhancement.
It is difficult to assess from which organ this is arising, though the left
ovary is immediately adjacent to the left lateral wall of the cystic lesion
(7, 36), suggesting it is likely arising from the ovary. Alternatively, it
may just be so close due to mass effect. The left ovary itself otherwise
appears to be within normal limits with several follicles.
The right ovary is normal. This is separate from the cystic lesion. There
are multiple follicles.
The uterus is normal measuring 5.9 x 2.7 x 4.8 cm. There are no fibroids.
The enodmetrium measures 4 mm, which is normal in a patient of this age. An
IUD is noted to be in satisfactory position. The cervix and vaginal canal are
within normal limits.
There is a small amount of free fluid in the pelvis, as well as in the
bilateral pericolic gutters.
The bladder is unremarkable. There is no pelvic or inguinal lymphadenopathy.
The imaged portions of the liver, spleen, and kidneys are normal. The
abdominal and pelvic vasculature is normal in caliber without evidence of an
aneurysm or significant atherosclerotic plaque. The pelvic veins are patent
without evidence of a thrombus.
The rectum is within normal limits. Evaluation the bowel is limited due to
bowel motion. It appears grossly normal. There is no evidence of
obstruction. Of note, the large cystic lesion has mass effect on multiple
loops of small bowel.
There are no concerning osseous lesions. There is mild anterolisthesis and
disc degeneration at L5-S1 with a small disc bulge. Note, this exam is not
optimized for evaluation of the spine. The soft tissues are unremarkable.
IMPRESSION:
Large simple appearing cystic lesions which appears to be arising from the
pelvis extending into the abdomen, likely from the left ovary. Its
characteristics are most consistent with an ovarian serous cystadenoma. Given
the lack of complex features, a serous cystadenocarcinoma is thought to be
less likely. The other differential consideration is a benign mesenteric
cyst.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED, HYPOVOLEMIA, ABDOM/PELV SWELL/MASS UNSP SITE
temperature: 97.8
heartrate: 81.0
resprate: 16.0
o2sat: 100.0
sbp: 128.0
dbp: 79.0
level of pain: 5
level of acuity: 3.0 | ___ year old female with PMH of rheumatoid arthritis on
rituximab, bipolar disorder and hypothyroidism admitted to
medicine after presenting with 5 days of nausea, vomiting,
diarrhea, poor PO intake and crampy lower abdominal pain found
to have large pelvic cystic mass. Patient transferred to Gyn-Onc
for exploratory laparotomy and left salpingoo-phorectomy for
mesosalpinx inclusion cyst. Please see operative note for
details.
Pre-operative:
*) Pelvic mass/nausea/vomiting: 22 cm abdominopelvic mass. ACS
general surgery and Gyn consulted. Abd/Pelvic MRI and PUS -
likely peritoneal inclusion cyst or a large left ovarian cyst
with plan for removal given patients symptoms. Nausea and pain
improved with IVF, pain meds and anti-emetics.
*) ___: Pre-renal acute kidney injury due to dehydration. Had
very limited PO intake over 4 days prior to presenting with
slightly elevated lithium level potentially contributing to ___.
No evidence of obstruction on CT. Creatinine 2.9 on admission,
improved to 0.9 on day of discharge after IV fluid
resuscitation.
*) RA: Currently asymptomatic, last received rituximab on
___. Patient discharged with instructions to f/u with
rheumatology.
Post-operative:
Her post-operative course is detailed as follows. Immediately
postoperatively, her pain was controlled with IV dilaudid and
toradol. Her diet was advanced without difficulty and she was
transitioned to oxycodone, acetaminophen, and ibuprofen. On
post-operative day #1, her urine output was adequate so her
Foley catheter was removed and she voided spontaneously.
By post-operative day #1, she was tolerating a regular diet,
voiding spontaneously, ambulating independently, and pain was
controlled with oral medications. She was then discharged home
in stable condition with outpatient follow-up scheduled. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Statins-Hmg-Coa Reductase Inhibitors
Attending: ___.
Major Surgical or Invasive Procedure:
none
attach
Pertinent Results:
ADMISSION LABS
===============
___ 02:30PM BLOOD WBC-5.2 RBC-3.43* Hgb-10.1* Hct-31.9*
MCV-93 MCH-29.4 MCHC-31.7* RDW-13.2 RDWSD-44.5 Plt ___
___ 02:30PM BLOOD Neuts-63.5 Lymphs-16.2* Monos-18.9*
Eos-0.2* Baso-0.4 Im ___ AbsNeut-3.29 AbsLymp-0.84*
AbsMono-0.98* AbsEos-0.01* AbsBaso-0.02
___ 02:30PM BLOOD ___ PTT-30.1 ___
___ 02:30PM BLOOD Glucose-326* UreaN-35* Creat-1.6* Na-138
K-4.7 Cl-98 HCO3-24 AnGap-16
___ 02:30PM BLOOD ALT-23 AST-33 AlkPhos-57 TotBili-0.2
___ 02:30PM BLOOD Albumin-4.5 Calcium-8.8 Phos-2.7 Mg-2.1
OTHER PERTINENT LABS/MICRO
==========================
___ 02:30PM BLOOD Iron-19* calTIBC-472* Ferritn-62 TRF-363*
___ 02:30PM BLOOD proBNP-3101*
___ 02:30PM BLOOD cTropnT-0.04*
___ 05:30PM BLOOD cTropnT-0.05*
___ 08:50PM BLOOD cTropnT-0.04*
___ 01:15AM BLOOD %HbA1c-10.2* eAG-246*
___ 11:15 am URINE Source: ___.
**FINAL REPORT ___
Legionella Urinary Antigen (Final ___:
NEGATIVE FOR LEGIONELLA SEROGROUP 1 ANTIGEN.
IMAGING
========
CT HEAD ___
1. No evidence of acute intracranial process.
2. Inflammatory changes in the ethmoid and sphenoid sinuses
including a small
air-fluid level in the sphenoid sinus. These findings are
nonspecific but
acute or chronic sinus disease is not excluded.
CTA CHEST ___
1. Multifocal opacities in the left lung suggesting
bronchopneumonia.
2. No evidence of pulmonary embolism.
3. Finding suggesting a mild inflammatory process involving the
jejunum,
perhaps an infectious form of enteritis.
CHEST (PORTABLE AP) ___
IMPRESSION:
In comparison with the study of ___, there are slightly
improved lung volumes. Continued enlargement of the cardiac
silhouette with engorgement of ill defined pulmonary vessels
consistent with pulmonary vascular congestion. Retrocardiac
opacification with obscuration of the hemidiaphragm is
consistent with volume loss in left lower lobe and pleural
fluid. Single lead pacer again extends to the right ventricle.
There is an area of increased opacification in the left mid zone
that would be worrisome for developing aspiration/pneumonia in
the appropriate clinical setting
DISCHARGE LABS
===============
___ 06:28AM BLOOD WBC-3.9* RBC-2.95* Hgb-8.6* Hct-26.6*
MCV-90 MCH-29.2 MCHC-32.3 RDW-12.6 RDWSD-41.4 Plt ___
___ 06:28AM BLOOD Glucose-211* UreaN-18 Creat-1.1 Na-140
K-4.1 Cl-102 HCO3-24 AnGap-14
___ 06:28AM BLOOD Calcium-8.5 Phos-2.3* Mg-2.1
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Aspirin 81 mg PO DAILY
2. Carvedilol 6.25 mg PO BID
3. Citalopram 40 mg PO DAILY
4. Omeprazole 40 mg PO DAILY
5. Pregabalin 200 mg PO BID
6. Rosuvastatin Calcium 20 mg PO QPM
7. Tamsulosin 0.4 mg PO QHS
8. TraZODone 100 mg PO QHS
9. Acetaminophen 1000 mg PO Q8H
10. Docusate Sodium 100 mg PO BID
11. Furosemide 40 mg PO BID
12. Lisinopril 40 mg PO DAILY
13. MetFORMIN (Glucophage) 1000 mg PO BID
14. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
15. linaGLIPtin 5 mg oral daily
16. Ferrous Sulfate 325 mg PO BID
17. dulaglutide 1.5 mg/0.5 mL subcutaneous q week
Discharge Medications:
1. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 2 Doses
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*2
Tablet Refills:*0
2. OSELTAMivir 75 mg PO BID Duration: 9 Doses
RX *oseltamivir [Tamiflu] 75 mg 1 capsule(s) by mouth twice a
day Disp #*2 Capsule Refills:*0
3. Acetaminophen 1000 mg PO Q8H
4. Aspirin 81 mg PO DAILY
5. Carvedilol 6.25 mg PO BID
6. Citalopram 40 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
8. dulaglutide 1.5 mg/0.5 mL subcutaneous q week
9. Ferrous Sulfate 325 mg PO BID
10. Furosemide 40 mg PO BID
11. linaGLIPtin 5 mg oral daily
12. Lisinopril 40 mg PO DAILY
13. MetFORMIN (Glucophage) 1000 mg PO BID
14. Omeprazole 40 mg PO DAILY
15. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
16. Pregabalin 200 mg PO BID
17. Rosuvastatin Calcium 20 mg PO QPM
18. Tamsulosin 0.4 mg PO QHS
19. TraZODone 100 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
#Pneumonia
#Influenza
#Hypoxia
#Diarrhea
#Nausea
#HFrEF
#Elevated Troponin
#Elevated Pro-BNP
#Acute kidney injury
#Insomnia
#DMII
#Microscopic Hematuria
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph, AP upright and lateral views.
INDICATION: Chest pain.
COMPARISON: Prior study from ___.
FINDINGS:
Single lead pacemaker lead terminates in the right ventricle. Heart is
moderately enlarged. Predominant central interstitial process of moderate
severity is most suggestive of congestive heart failure. Dense left basilar
opacification may indicate an additional process, atelectasis versus
pneumonia. Coinciding pleural effusion on the left is difficult to exclude
but is substantial pleural effusion seems doubtful (the medial left
hemidiaphragm is fairly well visualized. No definite pleural effusion on the
right. No pneumothorax. Bony structures are unremarkable.
IMPRESSION:
Finding suggest mild-to-moderate congestive heart failure. Left lateral
basilar opacity, possible pneumonia. The site is also typical for
atelectasis, however.
RECOMMENDATION(S): Follow-up radiographs are recommended to show clearance of
the left base and exclude any other alternative underlying process such as a
mass lesion.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111
INDICATION: History: ___ with shortness of breath, pleuritic chest pain,
midepigastric abdominal pain, fevers, lethargy and somnolence overall
clinically unwell // Presence of PE, characterized the consolidation seen on
chest x-ray, evaluate for evidence of stroke (symptom onset 2 days ago) or
intracranial hemorrhage, evaluate for intra-abdominal pathology given
abdominal pain in the midepigastric region
TECHNIQUE: Multidetector CT images of the head were obtained with out
intravenous contrast. Sagittal and coronal reformations were also performed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.1 cm; CTDIvol = 49.9 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 5.0 s, 10.0 cm; CTDIvol = 49.9 mGy (Head) DLP =
501.7 mGy-cm.
Total DLP (Head) = 1,304 mGy-cm.
COMPARISON: None are available.
FINDINGS:
Age-related involutional changes are mild. There is no mass effect,
hydrocephalus or shift of normally midline structures. Gray-white matter
distinction appears preserved. No evidence of acute intracranial hemorrhage.
Surrounding soft tissue structures are unremarkable. There is a small
air-fluid level in the maxillary sinus. Patchy opacification is noted among
ethmoid air cells including mild mucosal thickening. Mastoid air cells appear
clear. No evidence of fracture or bone destruction.
IMPRESSION:
1. No evidence of acute intracranial process.
2. Inflammatory changes in the ethmoid and sphenoid sinuses including a small
air-fluid level in the sphenoid sinus. These findings are nonspecific but
acute or chronic sinus disease is not excluded.
Radiology Report
EXAMINATION: CTA CHEST AND CT ABDOMEN AND PELVIS PQ45
INDICATION: NO_PO contrast; History: ___ with shortness of breath, pleuritic
chest pain, midepigastric abdominal pain, fevers, lethargy and somnolence
overall clinically unwellNO_PO contrast // Presence of PE, characterized the
consolidation seen on chest x-ray, evaluate for evidence of stroke (symptom
onset 2 days ago) or intracranial hemorrhage, evaluate for intra-abdominal
pathology given abdominal pain in the midepigastric region
TECHNIQUE: Multidetector CT images of the chest were obtained with
intravenous contrast in the pulmonary arterial phase. In addition to standard
sagittal coronal reformations of the chest, bilateral oblique MIP reformations
were also performed. More delayed contrast enhanced images were also obtained
of the abdomen and pelvis, including construction of sagittal and coronal
reformats.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 10.6 mGy (Body) DLP =
5.3 mGy-cm.
2) Spiral Acquisition 4.4 s, 34.8 cm; CTDIvol = 17.2 mGy (Body) DLP = 600.0
mGy-cm.
3) Spiral Acquisition 6.8 s, 53.6 cm; CTDIvol = 26.0 mGy (Body) DLP =
1,394.2 mGy-cm.
Total DLP (Body) = 2,000 mGy-cm.
COMPARISON: No relevant prior study is available.
FINDINGS:
Chest:
Single lead pacemaker/ICD device lead terminates in the right atrium.
Heart is moderately enlarged. Coronary artery calcification is moderately
severe.
There is trace a very small pericardial effusion. There is no pleural
effusion.
The aorta is normal in caliber. Mild mixed type atherosclerotic changes are
found along the thoracic aorta. No evidence of acute aortic syndrome.
No filling defects are found among pulmonary arterial branches.
There are several mildly prominent but subcentimeter mediastinal lymph nodes
which are probably reactive. Bilateral hilar lymph nodes are small. A right
subcarinal lymph node measures up to 27 x 13 mm in axial ___ (3:65),
which is at the upper limits of normal size. A second largest node is a
prevascular node measuring up to 15 by 10 mm, which is borderline (3:40).
Mild septal thickening at the lung bases suggesting vascular congestion. Mild
wall thickening of central airways may also be due to congestion versus
possibility of inflammation of lower airways. Small calcification in the left
lower lobe.
Patchy bronchovascular ground-glass nodules in the left lower lobe are found
with ___ opacities in the superior segment, and in the left upper
lobe, there are patchy but more confluent mixed type bronchovascular
opacities, mostly in the lingula, suggesting bronchopneumonia.
Abdomen:
There is no biliary dilatation. No focal liver lesions are identified. The
gallbladder appears normal. This is pancreas is unremarkable. Spleen is
normal in size and appearance. Adrenals are also unremarkable appear within
normal limits. Subcentimeter hypodense focus in the mid left kidney is too
small to characterize but doubtful in clinical significance. No evidence for
stones, solid masses, perfusion defects or hydronephrosis.
The stomach is unremarkable. Duodenum is mildly distended with fluid, its
caliber measuring up to is 36 mm in diameter. Although not well depicted due
to underdistension, imaging appearance of the proximal jejunum suggests mild
wall thickening. Mid jejunal loops shows borderline dilatation to 27 mm in
diameter with somewhat prominent fluid content. However there is no abrupt
transition point to suggest an obstructing process. Colon is unremarkable.
Pelvis:
Prostate is moderately enlarged with central hypertrophy. Seminal vesicles
appear normal. Bladder is also unremarkable. Bladder is mildly distended.
Atherosclerotic changes in the abdomen and pelvis are mild-to-moderate. Major
vascular structures appear widely patent. There is no lymphadenopathy, free
air, or free fluid. Moderate-sized fat containing inguinal hernia on the
right.
Bones:
Bones appear demineralized. There are no suspicious bone lesions. There is a
nonunited but subacute or older fracture involving the left posterior tenth
rib. Moderate degenerative change affects the L3-L4 interspace of the lumbar
spine.
IMPRESSION:
1. Multifocal opacities in the left lung suggesting bronchopneumonia.
2. No evidence of pulmonary embolism.
3. Finding suggesting a mild inflammatory process involving the jejunum,
perhaps an infectious form of enteritis.
IMPRESSION:
1. Multifocal opacities in the left lung suggesting bronchopneumonia.
2. No evidence of pulmonary embolism.
3. Finding suggesting a mild inflammatory process involving the jejunum,
perhaps an infectious form of enteritis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with HFrEF, recent PNA now w/ worsening
substernal CP. // evaluation for pulmonary opacities, effusions
IMPRESSION:
In comparison with the study of ___, there are slightly improved lung
volumes. Continued enlargement of the cardiac silhouette with engorgement of
ill defined pulmonary vessels consistent with pulmonary vascular congestion.
Retrocardiac opacification with obscuration of the hemidiaphragm is consistent
with volume loss in left lower lobe and pleural fluid.. Single lead pacer
again extends to the right ventricle.
There is an area of increased opacification in the left mid zone that would be
worrisome for developing aspiration/pneumonia in the appropriate clinical
setting
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, ILI, Weakness
Diagnosed with Chest pain, unspecified
temperature: 100.3
heartrate: 100.0
resprate: 18.0
o2sat: 95.0
sbp: 126.0
dbp: 74.0
level of pain: 0
level of acuity: 2.0 | Patient summary statement for admission:
=========================================
___ year old male with PMHx of HFrEF (EF ___ w/ ICD/AID,
HLD,
HTN, CAD s/p CABG, T2DM, obesity, depression/anxiety, GERD,
psoriasis presenting with dyspnea, malaise in the setting of
influenza with superimposed bacterial pneumonia. Patient
clinically improved with treatment of above infections and was
able to be discharged with plan to complete a PO antibiotic
course. Hospital course complicated by insomnia and long qtc
interval. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / Feraheme / atenolol
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
Foley catheter (___)
History of Present Illness:
___ with history of HTN, HLD, polyvalvular disease, and anemia
who presents with one week of shortness of breath. She was in
her usual state of health until one week ago when she started
developing nausea and shortness of breath with acute worsening
on the morning of admission. She has noticed difficulty walking
up stairs and around the block, activities she was able to do
without getting short of breath prior to last week. She endorses
PND and orthopnea (using 2 pillows in past week compared to 1
pillow prior to that). Furthermore, she has noticed increased
swelling in her legs and has felt fatigued. She did have a cough
this prior ___ but it resolved the same day. She denies any
fever, chills, vomiting, diarrhea, chest pain, lightheadedness,
or diaphoresis.
Of note, she has been reported to have exertional shortness of
breath in the past, which has been attributed to her worsened
anemia from chronic GI blood loss. She receives iron sucrose
infusions every 4 weeks. She has had an extensive evaluation for
her low-grade chronic Gi bleeding and only vessel ectasia has
been found.
In the ED, initial vitals: 98.0 102 177/66 20 98% 4L. Labs were
notable for Cr 1.6 (baseline past ___ years), BNP 1887, and Hgb
6.1 Hct 19.8. Exam was notable for diminished lung sounds in R
base without wheezes or crackles and trace foot edema. Rectal
exam was negative. She received IV Zofran 4 mg for nausea and IV
Ceftriaxone 1 gm and IV Azithromycin 500 mg for possible
pneumonia. Vitals prior to transfer: 98.8 82 151/53 26 94% 1L
NC.
Currently, she is on 1L NC without any respiratory distress,
resting comfortably in bed. Although her O2 sat remains stable
on RA, she subjectively becomes short of breath.
Past Medical History:
-Anemia secondary to iron deficiency with question of
myelodysplastic syndrome. Patient had endoscopoies and capsule
studies ___ years ago that showed no source of bleeding. On
monthly iron infusions
-s/p total abdominal hysterectomy with oophorectomy.
-lung cancer in ___ with surgery and removal of part of her
left lung. She had no chemo. She smoked one pack per day for
___ years, but not now.
-sickle cell trait
-benign breast lesions
-polyvalvular disease (2+ MR/2+ TR)
Social History:
___
Family History:
Both parents are deceased, one sister, one brother alive and
well. She had a total of six brothers and four sisters, a
nephew died of sickle cell disease, it is her sister's son. She
has three children. Her daughter had cancer of the breast. She
has five grandchildren alive and well.
Physical Exam:
At admission:
VS: 98.8 150/64 94 18 94% 1L NC 93% RA
GENERAL: Alert, oriented, no acute distress, pleasant and
well-appearing
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: supple, JVP elevated, no LAD
RESP: diminshed breath sounds with absent sounds in R base,
crackles heard at bases, no wheezes or rhonchi
CV: RRR, Nl S1, S2, +S4, ___ systolic murmur heard at apex
ABD: Soft, NT/ND 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
SKIN: No excoriations or rash.
At discharge:
VS: 100.3 98.6 70-100s 130-160s/40-70s 18 94%RA
Wt: 64.7 kg (65.2 kg yesterday, admission 69 kg)
I/O's: incomplete but at least p24H ___ pMN NR/350
GENERAL: Alert, oriented, no acute distress, pleasant and
well-appearing
HEENT: Sclerae anicteric, MMM, oropharynx clear
NECK: stiff to flexion and rotation, JVP not elevated, no LAD
RESP: Diminshed breath sounds at bilateral bases, no crackles,
wheezes, or rhonchi
CV: RRR, Nl S1, S2, ___ holosystolic murmur heard at apex
ABD: Soft, NT/ND bowel sounds present, no rebound tenderness or
guarding, no organomegaly
GU: foley in place
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; mild L knee pain now improving, able to passively flex
and extend, no erythema/swelling/effusion noted
NEURO: CNs2-12 intact, motor function grossly normal
SKIN: No excoriations or rash
Pertinent Results:
Labs at admission:
___ 11:25AM ___ PTT-27.3 ___
___ 11:25AM PLT COUNT-266
___ 11:25AM NEUTS-72.0* ___ MONOS-5.7 EOS-2.1
BASOS-0.4
___ 11:25AM WBC-4.0 RBC-2.49* HGB-6.1* HCT-19.8* MCV-80*
MCH-24.3* MCHC-30.5* RDW-17.8*
___ 11:25AM ALBUMIN-3.6 CALCIUM-9.2 PHOSPHATE-3.2
MAGNESIUM-2.2
___ 11:25AM proBNP-1887*
___ 11:25AM LIPASE-34
___ 11:25AM ALT(SGPT)-10 AST(SGOT)-32 ALK PHOS-64 TOT
BILI-0.3
___ 11:25AM estGFR-Using this
___ 11:25AM GLUCOSE-90 UREA N-19 CREAT-1.6* SODIUM-141
POTASSIUM-4.9 CHLORIDE-108 TOTAL CO2-23 ANION GAP-15
___ 11:42AM LACTATE-1.9
Labs at discharge:
___ 05:37AM BLOOD WBC-7.8 RBC-2.83* Hgb-7.0* Hct-23.5*
MCV-83 MCH-24.7* MCHC-29.8* RDW-16.8* RDWSD-51.4* Plt ___
___ 05:37AM BLOOD Plt ___
___ 05:37AM BLOOD Glucose-100 UreaN-46* Creat-1.7* Na-136
K-4.3 Cl-102 HCO3-25 AnGap-13
___ 05:37AM BLOOD Calcium-9.4 Phos-4.1 Mg-2.9*
Micro:
BLOOD CULTURE (___): NO GROWTH.
BLOOD CULTURE (___): pending
BLOOD CULTURE (___): pending
BLOOD CULTURE (___): pending
BLOOD CULTURE (___): pending
BLOOD CULTURE (___): pending
URINE CULTURE (Final ___: NO GROWTH.
C. difficile DNA amplification assay (Final ___: Negative
for toxigenic C. difficile by the Illumigene DNA amplification
assay.
Imaging:
CXR (___):
1. Findings consistent with moderate congestive heart failure
including
pleural effusions with suspected left basilar atelectasis.
Pneumonia is not
excluded, however.
2. Possible developing opacity at the right lung base versus
regional edema.
In addition to that, right hilum appears enlarged. Although
these findings
may be congestive in nature, re-evaluation in follow-up
radiographs is
recommended after treatment.
TTE (___):
Moderate to severe mitral regurgitation. Moderate pulmonary
artery hypertension. Normal left ventricular cavity size with
preserved regional and global systolic function. Mild right
ventricular cavity dilation with preserved free wall motion.
Moderate tricuspid regurgitation.
Compared with the report of the prior study (images unavailable
for review) of ___, the severity of mitral regurgitation
and the estimated PA systolic pressure have both increased. The
right ventricle is now mildly dilated.
CXR (___):
No relevant change as compared to the previous image. Known
left postoperative changes with missing left rib. Elevation of
the left hemidiaphragm with small left pleural effusion. Mild
pulmonary edema. Mild cardiomegaly. Atelectasis at both the
left and the right lung bases.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amitriptyline 10 mg PO QHS
2. Omeprazole 20 mg PO DAILY
3. Pravastatin 40 mg PO QPM
4. NIFEdipine CR 30 mg PO DAILY
5. Venofer (iron sucrose) 200 mg/10 mL iron injection q4week
Discharge Medications:
1. TraMADOL (Ultram) 25 mg PO Q6H:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every 6
hours as needed Disp #*10 Tablet Refills:*0
2. Acetaminophen 500 mg PO Q6H:PRN pain
3. Amitriptyline 10 mg PO QHS
4. Omeprazole 20 mg PO DAILY
5. Pravastatin 40 mg PO QPM
6. Venofer (iron sucrose) 200 mg/10 mL iron INJECTION Q4WEEK
7. Lidocaine 5% Patch 1 PTCH TD QPM knee pain
8. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
stomach discomfort
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Congestive Heart Failure
Polyvalvular Heart Disease
Acute on Chronic Kidney Disease
Chronic Anemia
Mechanical Left Knee Pain
Neck Muscle Stiffness
SECONDARY DIAGNOSES:
Hypertension
Hyperlipidemia
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 RADIOGRAPHS
INDICATION: Shortness of breath.
TECHNIQUE: Chest, AP upright and lateral.
COMPARISON: ___ and ___.
FINDINGS:
There again surgical clips in the mediastinum. The heart appears mildly
enlarged. There is increased prominence in the aortopulmonary window which is
suggestive of enlarged left atrial appendage. On the right there is probably
a trace pleural effusion. On the left, there is a small to moderate pleural
effusion with associated opacity probably due to atelectasis in the posterior
left lower lobe. More generally, a moderate interstitial abnormality is most
suggestive of congestive heart failure. Fissures are thickened. The right
hilum appears more prominent than before and in addition there is the
possibility of developing focal opacity at the right lung base. Streaky
opacities in the lingula appear unchanged suggesting background scarring and
mild volume loss, as depicted on prior studies.
IMPRESSION:
1. Findings consistent with moderate congestive heart failure including
pleural effusions with suspected left basilar atelectasis. Pneumonia is not
excluded, however.
2. Possible developing opacity at the right lung base versus regional edema.
In addition to that, right hilum appears enlarged. Although these findings
may be congestive in nature, re-evaluation in follow-up radiographs is
recommended after treatment.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with clinically volume overloaded undergoing
diuresis, now with acute hypoxia to 79%on room air // eval pleural effusions,
pulm edema
COMPARISON: ___
IMPRESSION:
No relevant change as compared to the previous image. Known left
postoperative changes with missing left rib. Elevation of the left
hemidiaphragm with small left pleural effusion. Mild pulmonary edema. Mild
cardiomegaly. Atelectasis at both the left and the right lung bases.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ former smoker with history of HTN, HLD, and anemia presenting
with dyspnea. Now with fever // please eval for pneumonia
COMPARISON: ___.
IMPRESSION:
As compared to the previous image, there is evidence of increasing
radiodensity in the right lung apex. Part of this observation might be caused
by rotation of the patient. However, coexisting developing pneumonia might
also be present. Short term radiographic followup is recommended. Otherwise,
the radiograph is unchanged. Mild cardiomegaly and postoperative appearance
of the left lung base is constant.
Radiology Report
INDICATION: Evaluate for fracture or other abnormality in a patient with
acute knee pain.
COMPARISON: None available.
FINDINGS:
AP and lateral left knee radiographs demonstrate no acute fracture,
dislocation, or joint effusion. There are mild degenerative changes in the
lateral and patellofemoral compartments, without significant loss of joint
space. Chondrocalcinosis in the lateral compartment is noted, as are vascular
calcifications. There is no focal lytic or sclerotic lesion.
IMPRESSION:
1. No acute fracture or dislocation.
2. Mild degenerative changes of the lateral and patellofemoral compartments,
with chondrocalcinosis in the lateral compartment as well as vascular
calcifications.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with acute on chronic renal failure in setting
of diuresis. Please evaluate for hydronephrosis or other abnormalities.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT from ___.
FINDINGS:
The right kidney measures 9.2 cm. The left kidney measures 10.0 cm. There is
no hydronephrosis, stones, or masses bilaterally. The kidneys are echogenic
bilaterally, consistent with medical renal disease. There are multiple small
bilateral cysts similar to the prior study. The cyst in the upper pole of the
right kidney appears minimally complex with internal echoes and/or septations.
The bladder is moderately well distended and normal in appearance.
IMPRESSION:
Echogenic kidneys consistent with medical renal disease. No evidence of
urinary obstruction.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with new fevers to 101.9 and previous x-rays
suggesting pneumonia // Please eval for interval change
COMPARISON: ___
IMPRESSION:
As compared to the previous radiograph, a pre-existing right basal parenchymal
opacity has completely cleared. The left hemi thorax is unchanged, the
postoperative lesions at the level of the hilus and the costophrenic sinus are
constant. No new focal parenchymal opacities suggesting pneumonia.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with ANEMIA NOS, SHORTNESS OF BREATH
temperature: 98.0
heartrate: 102.0
resprate: 20.0
o2sat: 98.0
sbp: 177.0
dbp: 66.0
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a previously highly functional ___ year old female
with history of HTN, HLD, polyvalvular heart disease, and
chronic anemia who presented with worsening dyspnea over the
past week. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
seizures
Major Surgical or Invasive Procedure:
Intubation
History of Present Illness:
The pt is a ___ y/o woman with a history of of TBI (MVA in ___
with right and left frontal encephalomalacia. She had some
seizures during that time ( not much known about it, someone
documented Ativan withdraw). She was placed on dilantin for 6
months and no seizures after that. Today around 4 am she woke up
with a headache and took some ibuprofen and went to sleep. She
later woke up feeling ill with a headache. She thought it was
the flu. She was with her grandparents and was found with
generalized convulsions around 4 pm. Grandparents are not
available now so not much known around that time. EMS was
called. She was given Ativan (not sure how much) and on arrival
at OSH was intubated. There she was given another round of
Ativan (not documented how
much). No AED's were given and after a head CT she was
transferred here. Here she was on a midazolam gtt, intubated.
She was not responsive on midaz wean.
ROS: per above. pt intubated, sedated.
Past Medical History:
TBI ___ - resulted in frontal skull fracture, R>L
encephalomalacia, anosmia, anisocoria and ageustia
Seizures following TBI - ?in context of Ativan w/d, was treated
with dilantin for 6 months and had no further seizures
Social History:
___
Family History:
No history of seizures, otherwise noncontributory
Physical Exam:
Physical Exam on Admission:
Vitals: T:101.6 P: 105 R: 24 BP:110/70 SaO2:100%
General: intubated,sedated
HEENT: nuchal rigidity, nasal trumpet in place.
Pulmonary: Lungs CTA bilaterally
Cardiac: tachycardic
Abdomen: soft.
Extremities: No edema or deformities.
Skin: no rashes or lesions noted.
Neurologic:
Intubated, sedated. With midazolam off she kept here eyes
closed.
did not open to sternal rub. Eyes held open, roving eye
movements. Looked conjugate. No blink to threat. + corneal
reflex. + gag and cough. Arms held flexed. Some spontaneous
movements of the extremities. localized with LUE. Reflexes were
brisk. Clonus at the ankles L>R. Toes downgoing.
Physical Exam on Transfer:
General Physical exam is normal. MSK notable for back and quad
tenderness.
Neuro exam: AOx3, interactive. Mild disinhibition and
perseveration, but performs well on memory, and attention tasks.
CNs: PERRL, EOMI, mild left facial weakness.
Motor: Upper motor neuron pattern of weakness on the R>L. ___
also has mild ___ weakness.
Sensory: Normal
Coordination: ataxic in bilateral upper extremities, improves
with eyes open.
Gait: is slow, wide based, with mild unsteadiness.
Pertinent Results:
___ 11:59PM TYPE-ART TEMP-39.4 RATES-___/ TIDAL VOL-450
PEEP-5 O2-50 PO2-204* PCO2-31* PH-7.44 TOTAL CO2-22 BASE XS--1
-ASSIST/CON INTUBATED-INTUBATED
___ 10:23PM LACTATE-3.2*
___ 10:16PM CEREBROSPINAL FLUID (CSF) PROTEIN-670*
GLUCOSE-1
___ 10:16PM CEREBROSPINAL FLUID (CSF) WBC-29 RBC-61*
POLYS-98 ___ ___ 10:16PM CEREBROSPINAL FLUID (CSF) WBC-39 RBC-63*
POLYS-96 ___ ___ 10:00PM GLUCOSE-138* UREA N-14 CREAT-0.7 SODIUM-137
POTASSIUM-3.3 CHLORIDE-102 TOTAL CO2-25 ANION GAP-13
___ 10:00PM estGFR-Using this
___ 10:00PM WBC-14.7*# RBC-3.79* HGB-11.8* HCT-36.4
MCV-96 MCH-31.1 MCHC-32.3 RDW-12.7
___ 10:00PM NEUTS-92* BANDS-3 LYMPHS-4* MONOS-1* EOS-0
BASOS-0 ___ MYELOS-0
___ 10:00PM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 10:00PM PLT COUNT-214
___ 10:00PM ___ PTT-31.3 ___
___ 10:00PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 10:00PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-TR KETONE-40 BILIRUBIN-NEG UROBILNGN-2* PH-6.0 LEUK-NEG
___ 10:00PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 10:00PM URINE AMORPH-RARE
___ 10:00PM URINE MUCOUS-FEW
CT head (OSH): R>L encephalomalacia. Ethmoid mucosal thickening,
frontal
non-displaced fracture, left orbital fx.
CXR ___: IMPRESSION: ET and NG tubes positioned appropriately.
Possible left lower lobe mild atelectasis.
CXR ___: IMPRESSION: No acute intrathoracic process.
Brain MRI on ___ - IMPRESSION: 1. Diffuse enhancement of the
leptomeninges and along the margins of the lateral ventricles
with fluid-fluid levels in the occipital horns showing slow
diffusion. Findings are concerning for leptomeningitis with
ventriculitis and intraventricular pus.
2. Encephalomalacic changes in the frontal lobes bilaterally,
likely from prior trauma.
EEG (___): This is an abnormal continuous ICU monitoring
study because of a mild diffuse encephalopathy. There were no
clear focal or
lateralized features. There were no interictal epileptic
discharges nor
were there any recorded events.
Medications on Admission:
None
Discharge Medications:
1. CeftriaXONE 2 gm IV Q 12H
2. Tizanidine 4 mg PO TID
3. traZODONE 50 mg PO HS:PRN insomnia
4. LeVETiracetam 1000 mg PO BID
5. Nicotine Patch 14 mg TD DAILY
6. Ibuprofen 600 mg PO Q6H:PRN pain
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
if not responding to ibuprofen or tizanidine
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1) Streptococcus pneumoniae bacterial meningitis, 2) Status
epilepticus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Neuro Exam: MS notable for disinhibition, Mild UMN weakness in
UE and ___ L > R.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
Comparison with an outside hospital study from three hours earlier.
CLINICAL HISTORY: Outside hospital intubated, confirm ET tube position.
FINDINGS: AP supine portable chest radiograph is obtained. Endotracheal tube
tip resides 2.5 cm above the carina. NG tube courses into the left upper
abdomen, tip not included in field of imaging. The lungs appear mostly clear
bilaterally. There may be a tiny retrocardiac atelectasis. No large effusion
is seen. Cardiomediastinal silhouette appears normal. No bony abnormalities
are detected.
IMPRESSION: ET and NG tubes positioned appropriately. Possible left lower
lobe mild atelectasis.
Radiology Report
INDICATION: ___ with seizures, assess for respiratory status after
intubation.
COMPARISONS: ___.
Endotracheal tube terminates in the mid trachea, 3.1 cm above the carina.
Nasogastric tube courses into the stomach and out of view. Otherwise, the
lungs appear clear aside from minimal left basal atelectasis. without pleural
effusion or pneumothorax. The heart is normal in size with normal
cardiomediastinal contours.
IMPRESSION: No acute intrathoracic process.
Radiology Report
INDICATION: Evaluate line placement in patient with meningitis.
COMPARISON: Most recent radiograph from earlier today, ___ at
04:20.
FINDINGS: Bedside semi-upright AP radiograph of the chest demonstrates a new,
appropriately-positioned, left subclavian central venous catheter, terminating
in the lower portion of the superior vena cava. There is no pneumothorax or
other evidence of immediate complication. The endotracheal tube terminates
3.9 cm above the carina, also appropriate. An OGT courses into the stomach
and inferior beyond the field of view. Aside from a new, small focus of
linear atelectasis at the right costophrenic angle, the remainder of the
examination is unchanged from approximately 9 hours earlier.
IMPRESSION:
1. Appropriate positioning of new left subclavian central line terminating in
the low SVC, without evidence of complication. All other tubes and lines are
well-positioned.
2. New minimal right basilar atelectasis, stable minimal left basilar
atelectasis. Otherwise unchanged from this morning.
Radiology Report
INDICATION: History of traumatic brain injury with prior skull fractures
presenting with seizures, fever and headache.
COMPARISON: Outside hospital CT head from ___ and CT head from
___.
TECHNIQUE: MRI of the head was obtained before and after administration of
contrast per department protocol.
FINDINGS: There is diffuse leptomeningeal enhancement and enhancement along
the margins of the ventricles. An area of slow diffusion seen within the
occipital horns bilaterally, left more than right. There is no acute
intracranial hemorrhage or infarction. Encephalomalacic changes are seen in
bilateral frontal lobes. On the gradient echo images, there are multiple
areas of abnormal susceptibility scattered in bilateral cerebral hemispheres,
may represent old blood products. There is no hydrocephalus or midline shift.
Major intracranial flow voids are preserved. There is polypoid mucosal
thickening in the sphenoid sinus. Mild mucosal thickening is seen in
bilateral maxillary sinuses with fluid levels on the left. There is mild
fluid signal in bilateral mastoid air cells.
IMPRESSION:
1. Diffuse enhancement of the leptomeninges and along the margins of the
lateral ventricles with fluid-fluid levels in the occipital horns showing slow
diffusion. Findings are concerning for leptomeningitis with ventriculitis and
intraventricular pus.
2. Encephalomalacic changes in the frontal lobes bilaterally, likely from
prior trauma.
Findings discussed by Dr ___ with Dr ___ over phone on
___ at 11:50 am.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST
REASON FOR EXAM: Assess line.
Comparison is made with prior study, ___.
Right PICC tip is in the lower SVC. There is no pneumothorax.
Cardiomediastinal contours are normal. Bibasilar opacities larger on the
right side have increased, consistent with increasing atelectasis and pleural
effusion.
PICC location was discussed with IV nurse, ___, at the time of the
interpretation of the study at 3:00 p.m.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: FEVER SZ
Diagnosed with GRAND MAL STATUS, FEVER, UNSPECIFIED, PERSONAL HISTORY OF TRAUMATIC BRAIN INJURY
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ yo woman with a history of TBI from an MVA in ___ with
resultant R frontal encephalomalacia and prior seizures (on
dilantin for 6 months following TBI, none since then), who
presents in status epilepticus in the context of fever and
headache. She developed a headache and some flu-like symptoms on
the am of ___ but appeared well throughout the day until she
was found around 4pm with generalized convulsions. EMS was
called and she was given ativan en route to an OSH. She received
further ativan there and was intubated. A head CT showed stable
R>L encephalomalcia, ethmoidal sinus mucosal thickening, and a
frontal skull fracture consistent with her prior TBI. She was
transferred to ___ and started on a midazolam drip. Initial
exam was significant for fever to 101.6 and nuchal rigidity. Off
sedation she did not open her eyes to sternal rub and had roving
eye movements when eyelids held open. Corneal, gag, and cough
were present. She had some spontaneous movements of all
extremities but localized only with LUE. Hyperreflexia L>R, toes
downgoing.
An LP was performed and she was started on vancomycin,
ceftriaxone, and acyclovir for empiric meningitis coverage. She
was also placed on decadron 8mg Q6hrs in addition to Rifampin
600mg daily. ID was consulted. She was loaded with Dilantin and
admitted to the neuro ICU. She was connected to EEG monitoring,
which initially showed burst-suppression pattern. Occasional
bifrontal sharp transients but no definitive epileptic
discharges.
CSF returned with a protein 670, glucose 1, WBC 29 (98% polys),
RBC 61, consistent with bacterial meningitis. Gram stain grew
out streptococcus pneumoniae, sensitive to ceftriaxone. Her
antibiotics were narrowed. Blood cx from the outside hospital
also grew strep pneumoniae.
She was continued on Dilantin 100mg IV Q8hrs. Levels were
monitored with a goal of ___. An MRI brain was performed on
___ and showed diffuse enhancement of the leptomeninges and
along the margins of the lateral ventricles with fluid-fluid
levels in the occipital horns showing slow diffusion, concerning
for intraventricular pus.
She was extubated on ___ and did well. She was transferred to
the Neurology floor. She was monitored on tele and was initially
hypotensive to 80's/50's but improved with IVF. A TTE was
performed which was normal without vegetations.
The patient did well on the floor and received ___ who deamed her
an appropriate rehab candidate. Her AEDs were switched from
Dilantin to Keppra as the patient had previously developed a
rash while on the Dilantin. She was continued on ceftriaxone to
complete a 14 day course. She had some pain associated with
meningeal irritation with head and back pain that was treated
symptomatically with ibuprofen and muscle relaxants. Her pain
was specifically increased in the late afternoon and
prophylactic treatment with tizanidine should be considered
around that time.
Of note her LFTs were mildly elevated, this was attributed to
the high doses of tylenol she was receiving as they drifted down
when the tylenol was removed. On discarge her AST was 113 (down
from 141) and ALT was 47 (down from 75).
She is being discharged to ___ for a short rehab
stay. She will continue the ceftriaxone through ___,
afterwhich her PICC line can be removed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Left inguinal hernia repair with mesh.
History of Present Illness:
Patient is a ___ with history of AL amyloidosis s/p autologous
stem cell transplant ___ years ago, DM2 who presents with left
groin pain. He reports that he has had a reducible right
inguinal hernia for years which has always been easily reducible
and has never been stuck out. He has never had a hernia on the
left that he is aware of. Starting yesterday morning he had a
sudden left inguinal bulge which increased in discomfort
throughout the day with severe pain starting at approximately 3
___. He left work and went home and tried to take a nap to see
if
it would get better but it did not, so he came to the emergency
department. He reports he had a bowel movement yesterday
morning
but has not passed any gas or had a bowel movement since. He
denies nausea/vomiting. He denies fever/chills, chest pain,
dyspnea.
Past Medical History:
1. CKD
2. Diabetes type 2
3. Hyperlipidemia
4. Chronic mild thrombocytopenia
5. Diverticulosis
6. AL amyloidosis s/p autologous stem cell transplant
Social History:
___
Family History:
He has five siblings; three older sisters, one
younger sister and one younger brother, all of whom are well and
healthy to his knowledge.
Physical Exam:
Admission Physical Exam:
Vitals:
99.4 95 122/71 16 95% RA
GEN: A&Ox3, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: regular, mildly tachycardic
PULM: Breathing comfortably on room air
ABD: Soft, nondistended, moderately tender in the lower
quadrants
with voluntary guarding, left inguinal hernia palpated with hard
bulge, very tender, mild overlying erythema.
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
VS: 98.0 BP: 112/71 HR: 89 RR: 18 O2: 95% ra
Gen: A&O x3
Pulm: LS ctab
CV: HRR
Abd: soft NT/ND. Left groin hernia repair site CDI no swelling
or erythema
Ext: WWP no edema
Pertinent Results:
___ 01:40AM BLOOD WBC-10.4* RBC-4.02* Hgb-13.0* Hct-37.1*
MCV-92 MCH-32.3* MCHC-35.0 RDW-12.3 RDWSD-41.5 Plt Ct-92*
___ 01:40AM BLOOD Neuts-65 Bands-22* Lymphs-4* Monos-4*
Eos-0* Baso-0 Atyps-5* AbsNeut-9.05* AbsLymp-0.94* AbsMono-0.42
AbsEos-0.00* AbsBaso-0.00*
___ 01:40AM BLOOD Glucose-167* UreaN-21* Creat-0.9 Na-138
K-3.9 Cl-107 HCO3-22 AnGap-9*
Imaging:
CT Abd/Pelvis:
Left inguinal hernia with heterogeneous indeterminate
components.
There does
appear to be a tubular structure within the hernia sac with a
hyperenhancing
rim concerning for incarceration/strangulation
Medications on Admission:
Acyclovir
Atorvastatin
Lisinopril
Metformin
Aspirin
Cholecalciferol
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*25 Tablet Refills:*0
2. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
RX *oxycodone 5 mg 1 tablet(s) by mouth every six (6) hours Disp
#*5 Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 17 gram/dose 17 g by mouth once a
day Refills:*0
4. Acyclovir 400 mg PO Q12H
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 40 mg PO QPM
7. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Left incarcerated inguinal hernia
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 concern for incarcerated and
strangulated herniaNO_PO contrast // Strangulation, perforation?
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 6.5 s, 0.5 cm; CTDIvol = 31.3 mGy (Body) DLP =
15.6 mGy-cm.
2) Spiral Acquisition 6.7 s, 53.1 cm; CTDIvol = 12.6 mGy (Body) DLP = 666.4
mGy-cm.
3) Spiral Acquisition 1.8 s, 14.3 cm; CTDIvol = 12.0 mGy (Body) DLP = 171.4
mGy-cm.
Total DLP (Body) = 853 mGy-cm.
COMPARISON: No recent imaging available for comparison
FINDINGS:
LOWER CHEST: Dependent atelectasis bilaterally. Visualized lung fields are
within normal limits. There is no evidence of pleural or pericardial
effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
Calcified granulomas noted. There is no evidence of focal lesions. There is
no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder contains gallstones without wall thickening or surrounding
inflammation.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of solid renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. A left inguinal hernia is noted with a small
amount of sigmoid colon herniating into the inguinal canal. Inflammatory
changes is noted in the left inguinal canal with fluid present within a patent
processes vaginalis with peritoneal enhancement. Appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
There is degenerative changes in the L4-L5 vertebral body.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
A left inguinal hernia is noted with a small amount of sigmoid colon
herniating into the inguinal canal. Inflammatory changes are noted in the
left inguinal canal with fluid present within a patent processes vaginalis
with peritoneal enhancement.
No evidence of obstruction.
Gender: M
Race: ASIAN
Arrive by WALK IN
Chief complaint: L Inguinal pain
Diagnosed with Unil inguinal hernia, w obst, w/o gangr, not spcf as recur
temperature: 99.0
heartrate: 105.0
resprate: 16.0
o2sat: 97.0
sbp: 143.0
dbp: 78.0
level of pain: 9
level of acuity: 3.0 | ___ with hx of AL amyloidosis s/p autologous stem cell
transplant, chemotherapy in remission, DM2, presenting with an
incarcerated left inguinal hernia, unable to be reduced at
bedside. The patient was hemodynamically stable. The patient
underwent left inguinal hernia repair with mesh, 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: NEUROSURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
L1 superior wedge fracture
Major Surgical or Invasive Procedure:
N/A
History of Present Illness:
___ year old gentleman transferred from OSH after MVC with L1
burst fracture. The patient swered his vehicle to avoid a deer
in
the road. The patient was able to walk away from the scene but
noted immediate low back pain. He presented to an OSH where a CT
of the L spine showed an L1 burst fracture. He was transferred
to
___ for further neurosurgery evaluation.
Past Medical History:
Kidney Stones
Renal Stents
Social History:
___
Family History:
Family Hx: NC
Physical Exam:
T: 97.1 BP: 118/68 HR: 100 R:22 O2Sats:97%RA
Gen: WD/WN, comfortable, NAD.
HEENT: NC/AT Pupils: PERRL
Neck: Supple.
Abd: Soft, NT, BS+
Extrem: Warm and well-perfused.
WWP:
Motor:
D B T Grip IP Q H AT ___ G
On Discharge:
___: Aox3, PERRL ___, ___, SILT, brusing to right ankle
(Able to bear weight)
Motor:
D B T Grip IP Q H AT ___ G
Pertinent Results:
PELVIS (AP ONLY) Study Date of ___ 9:12 AM
IMPRESSION:
No acute fracture identified.
CHEST (SINGLE VIEW) Study Date of ___ 9:12 AM
IMPRESSION:
No comparison. Lung volumes are low. Borderline size of the
heart. No
pneumonia, no pulmonary edema, no pleural effusions.
MR ___ SPINE W/O CONTRAST Study Date of ___ 1:32 ___
IMPRESSION:
1. Acute compression burst fracture of the L1 vertebral body
with prevertebral soft tissue edema and edema in the T12-L1
interspinous ligament.
2. The visualized fibers of the anterior longitudinal ligament
appear intact. The posterior longitudinal ligament appears
intact intact.
3. There is an apparent defect in the ligamentum flavum.
4. Posterior disc bulge at L5-S1 resulting in mild spinal canal
and bilateral neural foraminal narrowing.
L-SPINE (AP & LAT) Study Date of ___ 5:20 ___
IMPRESSION:
L1 fracture.
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Diazepam 5 mg PO Q8H:PRN muslce spasm
3. Docusate Sodium 100 mg PO BID
4. Gabapentin 300 mg PO TID
5. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
6. Senna 8.6 mg PO BID:PRN constiaption
7. Allopurinol ___ mg PO DAILY
8. Famotidine 20 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
L1 superior wedge fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (SINGLE VIEW)
INDICATION: History: ___ s/p MVC crash // ? fractures ? fractures
IMPRESSION:
No comparison. Lung volumes are low. Borderline size of the heart. No
pneumonia, no pulmonary edema, no pleural effusions.
Radiology Report
EXAMINATION: PELVIS (AP ONLY)
INDICATION: History: ___ s/p MVC crash // ? fractures ? fractures
TECHNIQUE: Single AP view of the pelvis was obtained.
COMPARISON: None.
FINDINGS:
No acute fracture is identified. The femoral heads are well aligned with the
acetabula. No significant degenerative changes are noted at the sacroiliac
joints or at the hips bilaterally.
IMPRESSION:
No acute fracture identified.
Radiology Report
EXAMINATION: MR ___ SPINE W/O CONTRAST ___ MR SPINE
INDICATION: ___ year old man with L1 burst fracture. Evaluate for ligamentous
injury
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique,
followed by axial T2 imaging.
COMPARISON: ___ lumbar spine CT
FINDINGS:
The images are degraded by motion.
There is compression burst fracture of L1 with extensive bone marrow edema in
the L1 vertebral body extending into the pedicles. There is approximately 20%
loss of height anteriorly, similar to the prior study. There is minimal, if
any, retropulsion of the superior endplate. There is prevertebral soft tissue
edema, but the visualized fibers of anterior anterior longitudinal ligament
appear intact. The posterior longitudinal ligament is intact. There is a
possible defect in the ligamentum flavum, best seen on image 11 of series 4.
There is mild edema in the T12-L1 interspinous ligament, suggesting injury to
the posterior ligamentous complex.
The remaining vertebral bodies are normal in height and signal intensity.
Alignment is maintained.
The lower spinal cord is normal in morphology and signal intensity. Nerve
roots of the cauda equina are unremarkable. Conus medullaris terminates at
L1-2.
At L5-S1, there is a broad posterior disc bulge that results in mild narrowing
of the spinal canal and mild left neural foraminal narrowing.
IMPRESSION:
1. Acute compression burst fracture of the L1 vertebral body with prevertebral
soft tissue edema and edema in the T12-L1 interspinous ligament.
2. The visualized fibers of the anterior longitudinal ligament appear intact.
The posterior longitudinal ligament appears intact intact.
3. There is an apparent defect in the ligamentum flavum.
4. Posterior disc bulge at L5-S1 resulting in mild spinal canal and bilateral
neural foraminal narrowing.
Radiology Report
EXAMINATION: L-SPINE (AP AND LAT)
INDICATION: ___ year old man s/p MVC now with Lumbar Spine L1 burst fracture.
AP and Lateral X-Rays in standing position WITH TLSO brace on in place. *Brace
MUST be on for X-Rays. // ___ year old man s/p MVC now with Lumbar Spine L1
burst fracture. AP and Lateral X-Rays in standing position WITH TLSO brace on
in place. *Brace MUST be on for X-Rays.
TECHNIQUE: Lumbar spine two views
COMPARISON: MRI lumbar spine ___.
FINDINGS:
There is mild to moderate compression fracture of L1 vertebral body, similar
compared with MRI exam. There is minimal posterior displacement of L1
posterior vertebral body line into the spinal canal, contributing mechanically
small degree to central canal narrowing. Otherwise alignment is maintained.
There mild degenerative changes in the lower lumbar spine. No evidence of
fracture through pedicles. Transverse processes appear intact.
IMPRESSION:
L1 fracture.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: MVC, Transfer
Diagnosed with Unsp fracture of first lumbar vertebra, init for clos fx, Car driver injured in collision w car in traf, init
temperature: 97.1
heartrate: 100.0
resprate: 22.0
o2sat: 97.0
sbp: 118.0
dbp: 68.0
level of pain: 10
level of acuity: 2.0 | Mr. ___ is a ___ who presented with a L1 superior wedge
fracture after an MVC on ___. Neurosurgery was consulted
for further recommendations or evaluation. He was admitted to
the floor for TLSO brace fitting, but was unable to be fitted
for a brace due to his body habitus. Due to holiday, pt was
unable to be fitted until ___. Pt was made strict bed rest
until brace fitting on ___. He remained neuro intact
throughout his hospital stay. He received his brace on the
evening of ___ and had AP/Lateral X-rays performed while
standing in the brace. Prior to discharge he ambulated
independently with the RN. He was cleared for safe discharge to
home and instructed to follow up in 6 weeks w/ a CT scan w/o
contrast of his lumbar spine prior to his visit. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/prior PE, esophageal cancer, presents w/SOB. Pt reports
dyspnea on exertion worsening over the last 3 weeks. Took
symbicort, flonase and albuterol w/out relief. Had similar
symptoms w/ prior PE ___ years ago. Also with dizziness and left
knee/calf pain w/radiation down L leg for 6 weeks of knee calf
pain. No falls.
Denies hematuria, no black/blood stool. No ___ swelling, no
recent weight gain.
In ED pt found to have ___ PE. Started on heparin gtt.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
PAST ONCOLOGIC HISTORY:
History of left-sided breast cancer (T1b, grade 2, ER/PR
positive, and HER-2/neu amplification
negative by FISH) s/p excision and partial breast radiation
followed by endocrine therapy.
___: pain with swallowing and noted pain along her
mid chest that radiated to her back with occasional gagging. New
pain along the lower aspect of her right breast. PMD started BID
dosing of PPI for acid reflux.
___: CT scan of the chest demonstrated right lower
lobe ground glass peribronchiolar opacities along with
midesophagus circumferential wall thickening.
___: Pt underwent an upper endoscopy on ___
that demonstrated an ulcerated lesion in the upper third of the
esophagus that was concerning for carcinoma. Biopsies of the
lesion were taken that demonstrated predominantly
fibrinopurulent
exudate and fungal forms of single tissue fragment with features
that were suspicious for squamous cell carcinoma. Upper
endoscopic ultrasound on ___ showed a large
esophageal
ulcer that measures approximately 5 cm and was stage T3 by
endoscopic ultrasound criteria. Furthermore, a 1.7 cm celiac
node was seen along with the 8-mm mediastinal node were noted,
both of which underwent FNA biopsies. ___, PET/CT showed
"Esophageal cancer metastatic to mediastinal, thoracic
paraspinal, celiac, and para-aortic nodes."
___: Port-a-cath placed on ___ however, feeding tube
could not be placed.
The patient started chemotherapy on ___ since it was
difficult to access the port, the patient was unable to start
treatment on ___ as origionally planned. The patient
started
radiation therapy on ___.
Cycle #: 1 Day 1: ___ Cycle end: ___
Fluorouracil/Carboplatin
Cycle #: 2 Day 1: ___ Cycle end: ___ Today is Day#: 12
PAST MEDICAL HISTORY:
1. Left-sided breast cancer diagnosed in ___, status post
excision and radiation therapy, previously on tamoxifen;
however,
now, the patient is on exemestane.
2. Bilateral PEs diagnosed in ___. The patient was on Lovenox
BID dosing for six months. (The patient PE is attributed to
possible tamoxifen use and thus the patient was switched from
tamoxifen therapy to exemestane after having PEs).
3. Right hiatal hernia.
4. Spinal injury with chronic low back pain.
5. GERD
Social History:
___
Family History:
Mother passed away in her ___ secondary to cancer. The patient
is unclear of which cancer, possibly abdominal or pelvic cancer.
Physical Exam:
Vitals: T:98.2 BP:122/92 P:86 R:18 O2:100%ra
PAIN: 6
General: nad
EYES: anicteric
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
MSK: no joint effusion
Skin: no rash
Neuro: alert, follows commands
Pertinent Results:
___ 05:55PM GLUCOSE-123* UREA N-22* CREAT-1.4* SODIUM-139
POTASSIUM-4.0 CHLORIDE-103 TOTAL CO2-23 ANION GAP-17
___ 05:56PM LACTATE-2.2*
___ 05:55PM ALT(SGPT)-22 AST(SGOT)-19 ALK PHOS-80 TOT
BILI-0.2
___ 05:55PM LIPASE-17
___ 05:55PM ALBUMIN-4.1
___ 05:55PM WBC-8.3# RBC-3.77* HGB-11.3 HCT-36.8 MCV-98#
MCH-30.0 MCHC-30.7* RDW-17.2* RDWSD-61.7*
___ 05:55PM NEUTS-64.9 ___ MONOS-7.5 EOS-1.5
BASOS-0.4 IM ___ AbsNeut-5.36 AbsLymp-2.09 AbsMono-0.62
AbsEos-0.12 AbsBaso-0.03
___ 05:55PM PLT SMR-NORMAL PLT COUNT-150
# L ___ (___): No evidence of deep venous thrombosis in the
left lower extremity veins
# CXR (___): No acute cardiopulmonary process
# L knee x-ray (___): No evidence of acute fracture or
dislocation is seen. There is minimal to no suprapatellar joint
effusion is seen.
# Chest CTA (___): Extensive bilateral pulmonary emboli are
seen involving the right, and left main, lobar, segmental, and
subsegmental branches. No definite evidence of right heart
strain, however if there is further clinical concern, an
echocardiogram may be helpful for further evaluation.
# L knee MRI (___): 1. Horizontal tear of the body of the
lateral meniscus. 2. Intact medial meniscus, cruciate ligaments,
and collateral ligaments. 3. Mild degenerative changes of the
lateral compartment with partial thickness cartilage loss.
# Abd/pelvic CT (___): 1. No evidence of intra-abdominal or
intrapelvic malignancy or metastatic disease. Visualized
esophagus is unchanged appearance since ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. exemestane 25 mg Oral daily
4. Lorazepam 2 mg PO QHS:PRN insomnia
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
6. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. Gabapentin 600 mg PO TID
9. Omeprazole 20 mg PO DAILY
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
11. Ranitidine 300 mg PO QHS
12. Senna 8.6 mg PO BID:PRN constipation
13. Guaifenesin-CODEINE Phosphate 5 mL PO Q8H:PRN cough
Discharge Medications:
1. Enoxaparin Sodium 110 mg SC Q12H
Start: ___, First Dose: Next Routine Administration Time
RX *enoxaparin 100 mg/mL ___very twelve (12) hours Disp
#*60 Syringe Refills:*5
2. Outpatient Physical Therapy
please evaluate and treat
3. Albuterol Inhaler 2 PUFF IH Q4H:PRN SOB
4. Aspirin 81 mg PO DAILY
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. exemestane 25 mg Oral daily
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. Gabapentin 600 mg PO TID
9. Guaifenesin-CODEINE Phosphate 5 mL PO Q8H:PRN cough
10. Lorazepam 2 mg PO QHS:PRN insomnia
11. Omeprazole 20 mg PO DAILY
12. Ranitidine 300 mg PO QHS
13. Senna 8.6 mg PO BID:PRN constipation
14. Hydrocodone-Acetaminophen (5mg-325mg) ___ TAB PO Q6H:PRN
pain
RX *hydrocodone-acetaminophen 5 mg-325 mg ___ tablet(s) by mouth
every six (6) hours Disp #*60 Tablet Refills:*0
15. Ibuprofen 400 mg PO Q8H:PRN knee pain Duration: 3 Days
Please use sparingly
16. Symbicort (budesonide-formoterol) 80-4.5 mcg/actuation
inhalation BID
Discharge Disposition:
Home
Discharge Diagnosis:
Acute pulmonary embolism
Left lateral meniscus tear
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: MR KNEE W/O CONTRAST LEFT
INDICATION: ___ year old woman with significant acute knee pain evaluate for
meniscal tear.
TECHNIQUE: Imaging performed at 1.5 Tesla using the knee coil. Sequences
include axial fat sat proton density, sagittal fat sat proton density,
sagittal T2 fat sat, and coronal fat-sat proton density.
COMPARISON: Left knee radiograph ___.
FINDINGS:
There is no joint effusion.
In the medial compartment, the meniscus is intact. Hyaline cartilage is
preserved. No subchondral marrow edema.
In the lateral compartment, there is a horizontal tear extending from the
anterior to the posterior body of the lateral meniscus with an associated
parameniscal cyst (series 7, image 19). In addition, there is degenerative
intermediate intensity signal within the posterior horn. There is partial
thickness cartilage loss involving the lateral tibial plateau. There is
probable full-thickness cartilage loss deep to the posterior horn. There is
no underlying marrow edema.
In the patellofemoral compartment, cartilage is preserved. No subchondral
marrow edema.
The cruciate and collateral ligaments are intact. There is intermediate
signal within the femoral attachment of the fibular collateral ligament
(series 6, image 20), consistent with a small focus of degeneration. There is
associated surrounding interstitial soft tissue edema.
The quadriceps and patellar tendons are intact, within normal limits.
Muscles are within normal limits.
There is no ___ cyst.
Single popliteal lymph node that is top-normal in short axis diameter, but
with preserved fatty component (5:15, 6:14, 4:14).
IMPRESSION:
1. Horizontal tear of the body of the lateral meniscus.
2. Intact medial meniscus, cruciate ligaments, and collateral ligaments.
3. Mild degenerative changes of the lateral compartment with partial thickness
cartilage loss and probably some areas of full-thickness cartilage loss.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old woman h.o esophageal, breast CA admitted with acute
PE. Assess for recurrence in setting of PE
TECHNIQUE: MDCT axial images were acquired through the abdomen and pelvis
following intravenous contrast administration with a single bolus technique.
Coronal and sagittal reformations were performed and reviewed on PACS.
Oral contrast was administered.
DOSE: Total DLP (Body) = 1,324 mGy-cm.
IV Contrast: 150 mL Omnipaque
COMPARISON: CTA chest from ___, CT abdomen pelvis from ___, and ___.
FINDINGS:
LOWER CHEST: Lung bases are clear without pleural effusions. Please refer to
the CTA chest from 2 days prior for complete intrathoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The nondistended gallbladder is
unremarkable in appearance.
PANCREAS: Pancreas demonstrates moderate fatty infiltration, as seen on the
study from ___. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: A 0.9 x 0.9 cm left adrenal gland nodule has been previously
described as an adenoma, and is unchanged in size since at least ___.
The right adrenal gland is unremarkable.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesion or hydronephrosis.
GASTROINTESTINAL: The visualized distal esophagus is unchanged in appearance
since ___, and unremarkable. The stomach demonstrates intramural
fat, as seen in ___. The colon and rectum are within normal limits.
There is no evidence of mesenteric lymphadenopathy.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is minimal calcium
burden in the abdominal aorta and great abdominal arteries.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: Large heterogeneously enhancing and partially calcified
masses in the uterus, compatible fibroids, are similar in appearance to the
study from ___.
BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions.
Moderate degenerative changes of the lumbar spine are again seen, and most
pronounced at L4-L5 and L5-S1. Mild soft tissue stranding and foci of air in
the right anterior abdominal wall are likely due to recent subcutaneous
injections (4:31, 36).
IMPRESSION:
1. No evidence of intra-abdominal or intrapelvic malignancy or metastatic
disease. Visualized esophagus is unchanged appearance since ___.
2. Please refer to the CTA chest from 2 days prior for intrathoracic
findings.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: L Calf pain, L Knee pain, Dyspnea
Diagnosed with PULM EMBOLISM/INFARCT, HX-ESOPHAGEAL MALIGNANCY
temperature: 97.8
heartrate: 93.0
resprate: 18.0
o2sat: 100.0
sbp: 115.0
dbp: 79.0
level of pain: 6
level of acuity: 2.0 | ASSESSMENT & PLAN: ___ h/o breast CA on hormone therapy,
esophageal CA s/p chemo/XRT, prior PE admitted w/SOB due to
acute PE.
# SOB/Dyspnea, cough: Ms. ___ was admitted with SOB and chest
CTA showed extensive bilateral pulmonary emboli with negative L
LENIs. During this stay, there was no O2 requirements: no
desaturations with ambulation, no hypotension or concern for RV
strain (based on CT scan). This episode represented her ___ PE
- as a result there was concern for a hypercoagulable state in
setting of adenoCA x2.
For this reason, she was treated with lovenox BID and will
likely need this medication indefinitely. To evaluate for a
possible recurrence of cancer as an etiology, an abd/pelvic CT
scan was performed. It showed no evidence of recurrence. She
may obtain a PET scan as an outpt to further delineate the need
for lovenox (if negative for recurrence then possibly
coumadin?).
She was seen by ___ and she was mildly orthostatic by pressure
(but asymptomatic). She was cleared for home with ___. There
was no drop in O2 with ambulation.
# L knee pain: Ms. ___ had L knee pain. LLENI and knee x-ray
revealed no dislocation, effusion or fracture. The exam was
suggestive of possible infrapatellar tenderness possibly ___
___ disease, infrapatellar bursitis/tendinitis. Ultimatley,
L MRI knee was obtained and this showed a tear in lateral
meniscus. It was otherwise unremarkable. She was treated with
NSAIDs, ice pack, vicodin PRN with good effect. Again, she
should continue with home ___
# Esophageal and Breast Cancers: no active treatment
- cont exemestane
- abd/pelvic CT scan without any signs of recurrence
# Chronic Back Pain: cont home meds
# OTHER ISSUES AS OUTLINED.
#FEN: [] IVF [X] Oral [] NPO [] Tube Feeds []
Parenteral
#DVT PROPHYLAXIS: on Lovenox
#LINES/DRAINS: [X] Peripheral [] PICC [] CVL [] Foley
#PRECAUTIONS: [X] Fall [] Aspiration []
MRSA/VRE/CDiff/ESBL/Droplet /Neutropenic
#COMMUNICATION: pt
#CONSULTS: ___
#CODE STATUS: [X]full code []DNR/DNI
.
#DISPOSITION: d/c home with home ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Pentothal / Lipitor / lovastatin / Adult Low Dose Aspirin /
simvastatin / aspirin / Keflex / acetaminophen
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with PMH of COPD, HTN, DM2, and multiple psychiatric
comorbidities who presents with several days of dyspnea worse
than baseline. Associated with productive cough, rhinorrhea,
and pleuritic chest pain. Patient has also had lightheadedness
that is worse on standing and some post-tussive N/V. Subjective
fever. Does not use oxygen at home. Baseline O2 sats in low ___
per patient. Notably, patient has not been using her inhalers
for the last few days and has been smoking more than her usual 1
pack of cigarettes per day.
Patient recently at patient at ___. Went home last ___.
Since that time she has had cravings for drugs and has used
cocaine one time. She has not had chest or jaw pain since
cocaine use. Patient denies SI at this time.
In the ED, vital signs were 99.1, 114, 156/75, 24, 96% 4L (91%
RA). Labs notable for WBC 3.4 and otherwise stable CBC and
electrolytes with troponin negative x1, lactate 2.0, and normal
coags. CXR was concerning for pneumonia vs. COPD exacerbation.
Patient was given albuterol and ipratropium nebs, Solumedrol 125
mg IV x1, and levofloxacin and was admitted to Medicine for
further management.
Past Medical History:
- COPD
- Morbid obesity
- Hypertension
- Hyperlipidemia
- Type 2 diabetes
- Diabetic neuropathy
- Bipolar disorder vs. schizophrenia
- Depression with multiple suicide attempts
- PTSD
- Anxiety
- Substance abuse
- Glaucoma
- DJD
- DVT and pulmonary embolism
- Lower GI bleed
- Cholecystectomy
- Shoulder arthroscopies
- Endometriosis
- Hysterectomy
Social History:
___
Family History:
- Father: CAD, MI, CHF, and polymyalgia rheumatica
- Mother: CAD and RA
- Siblings: Brother with ___ disease
Physical Exam:
Admission Exam
Vitals: 98, 98, 119/70, 20, 97% 3L
General: AAOx3, NAD, unkempt
HEENT: EOMI, MMM, oropharynx clear
Neck: Supple, no LAD
CV: Tachycardic, nl S1/S2, no MRG
Lungs: CTAB, no wheezes/rhonchi/rales
Abdomen: Soft, NTND, positive bowel sounds
GU: No Foley
Ext: Warm and well perfused. 1+ lower extremity edema
bilaterally.
Neuro: CN II-XII grossly intact
Skin: Facial bruising/lesions
Discharge Exam
Vitals: 98, 86, 123/66, 20, 98% RA
General: AAOx3, NAD, unkempt
HEENT: MMM, oropharynx clear
CV: Tachycardic, nl S1/S2, no MRG
Lungs: Coughing, CTAB, no wheezes/rhonchi/rales
Abdomen: Soft, NTND, positive bowel sounds
Ext: Warm and well perfused. 1+ lower extremity edema
bilaterally.
Neuro: CN II-XII grossly intact
Skin: Facial and lower extremity bruising/lesions
Pertinent Results:
Admission Labs
___ 12:25PM BLOOD WBC-3.4*# RBC-5.06 Hgb-14.6 Hct-42.8
MCV-85 MCH-29.0 MCHC-34.2 RDW-14.6 Plt ___
___ 12:25PM BLOOD ___ PTT-28.4 ___
___ 12:25PM BLOOD Glucose-304* UreaN-13 Creat-0.8 Na-135
K-4.6 Cl-97 HCO3-25 AnGap-18
___ 12:37PM BLOOD Lactate-2.0
Discharge Labs
___ 06:55AM BLOOD ___-4.2 RBC-4.62 Hgb-13.8 Hct-40.1 MCV-87
MCH-29.9 MCHC-34.4 RDW-14.5 Plt ___
___ 06:55AM BLOOD Glucose-193* UreaN-13 Creat-0.6 Na-139
K-4.2 Cl-100 HCO3-27 AnGap-16
Imaging
CXR (___): Portable AP chest radiograph was provided. The study
is slightly limited due to patient's body habitus. Opacity at
the left base may be due to overlying soft tissue or
atelectasis. There is no focal consolidation, pleural effusion
or pneumothorax. The cardiomediastinal silhouette is normal.
Left shoulder arthroplasty is noted. There are no displaced
fractures.
CT chest (___): No evidence of acute pulmonary process nor
pulmonary embolism. Ground glass opacities in the lingula along
with atelectasis. These may be related to resolved infection.
Numerous prominent mediastinal lymph nodes, increased in size
and number from prior studies. These may be related to a post
infectious process in the lingula but should be followed in ___
months with a CT scan to assure resolution.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. RISperidone 1 mg PO QAM
2. RISperidone 4 mg PO HS
3. Multivitamins 1 TAB PO DAILY
4. Ferrous Sulfate 325 mg PO QAM
5. Lisinopril 30 mg PO DAILY
6. Omeprazole 20 mg PO BID
7. Gabapentin 1200 mg PO TID
8. Tizanidine 4 mg PO TID
9. TraZODone 150 mg PO HS:PRN insomnia
10. Rosuvastatin Calcium 10 mg PO HS
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Docusate Sodium 100 mg PO BID:PRN constipation
14. Citalopram 40 mg PO QAM
15. glimepiride *NF* 2 mg Oral QAM
16. Clindamycin 1 Appl TP BID
17. Glargine 50 Units Bedtime
18. Victoza 2-Pak *NF* (liraglutide) 1.2 mg Subcutaneous QPM
19. HydrOXYzine 25 mg PO Q6H:PRN itch
20. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
21. Promethazine 25 mg PO BID:PRN nausea
22. Fluticasone Propionate 110mcg 2 PUFF IH BID:PRN SOB
23. ammonium lactate *NF* 12 % Topical BID
Apply to lower extremities
24. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB
RX *albuterol sulfate 2.5 mg/3 mL (0.083 %) 1 neb IH every six
(6) hours Disp #*1 Unit Refills:*1
2. Citalopram 40 mg PO QAM
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Ferrous Sulfate 325 mg PO QAM
5. Gabapentin 1200 mg PO TID
6. HydrOXYzine 25 mg PO Q6H:PRN itch
7. Glargine 50 Units Bedtime
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
9. Lisinopril 30 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Omeprazole 20 mg PO BID
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Promethazine 25 mg PO BID:PRN nausea
14. RISperidone 1 mg PO QAM
15. RISperidone 4 mg PO HS
16. Rosuvastatin Calcium 10 mg PO HS
17. Tizanidine 4 mg PO TID
18. TraZODone 150 mg PO HS:PRN insomnia
19. Azithromycin 500 mg PO Q24H Duration: 3 Days
RX *azithromycin 500 mg 1 tablet(s) by mouth Q24H Disp #*3
Tablet Refills:*0
20. PredniSONE 60 mg PO DAILY Duration: 3 Days
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*6 Tablet
Refills:*0
21. ammonium lactate *NF* 12 % Topical BID
22. Clindamycin 1 Appl TP BID
23. Fluticasone Propionate 110mcg 2 PUFF IH BID
24. glimepiride *NF* 2 mg Oral QAM
25. MetFORMIN (Glucophage) 1000 mg PO BID
26. Victoza 2-Pak *NF* (liraglutide) 1.2 mg Subcutaneous QPM
27. Nebulizer
Please provide patient with 1 nebulizer.
28. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
Only use if albuterol nebulizer is not working.
RX *albuterol 2 puffs IH every six (6) hours Disp #*1 Inhaler
Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: COPD exacerbation
Secondary: Diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ woman with diabetes, COPD and new onset shortness of
breath for 1 week. Rule out pneumonia.
COMPARISON: Chest radiograph from ___.
FINDINGS:
Portable AP chest radiograph was provided. The study is slightly limited due
to patient's body habitus. Opacity at the left base may be due to overlying
soft tissue or atelectasis. There is no focal consolidation, pleural effusion
or pneumothorax. The cardiomediastinal silhouette is normal. Left shoulder
arthroplasty is noted. There are no displaced fractures.
IMPRESSION:
Limited due to patient body habitus. No acute cardiopulmonary process.
Radiology Report
HISTORY: Pleuritic chest pain, tachycardia. Question PE.
COMPARISON: Multiple prior studies, most recently ___.
TECHNIQUE: CT of the chest was performed per departmental PE protocol
including maximum intensity projection images in the oblique reformats.
FINDINGS:
MEDIASTINUM: Numerous prominent mediastinal lymph nodes are once again
present and slightly more prominent and numerous than on prior studies. For
example, a precarinal lymph node measures up to 13 mm is new. Elsewhere,
subcarinal lymphadenopathy measuring up to 15 mm more prominent than earlier.
There is no axillary or hilar lymphadenopathy.
HEART: The heart is of normal size. There is a small stable pericardial
effusion. There is no significant coronary disease.
AORTA: Aorta and the great vessels are unremarkable and normal in the
caliber.
PULMONARY VASCULATURE: There is no evidence of pulmonary arterial filling
defect to the segmental level. Further evaluation is limited by the patient's
body habitus and bolus timing.
LUNGS: No parenchymal opacities concerning for infection or malignancy are
present. Left lingular scarring and atelectasis has been present on multiple
prior studies but is somewhat progressed concerning for a resolving infectious
process. There is also bibasilar atelectasis but overall this is minimal.
BONES: Prominent flowing anterior osteophytes are found throughout the
veterbral bodies. No fracture is identified.
IMPRESSION:
1. No evidence of acute pulmonary process nor pulmonary embolism.
2. Ground glass opacities in the lingula along with atelectasis. These may be
related to resolved infection.
3. Numerous prominent mediastinal lymph nodes, increased in size and number
from prior studies. These may be related to a post infectious process in the
lingula but should be followed in ___ months with a CT scan to assure
resolution.
Updated findings discussed with ___ at 9:19 AM via telephone.
-___
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: DYSPNEA
Diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION, PNEUMONIA,ORGANISM UNSPECIFIED, HYPERTENSION NOS
temperature: 99.1
heartrate: 114.0
resprate: 24.0
o2sat: 96.0
sbp: 156.0
dbp: 75.0
level of pain: 7
level of acuity: 2.0 | ___ yo F with PMH of COPD, HTN, DM, and multiple psychiatric
comorbidities who presents with worsening dyspnea c/w pneumonia
vs. COPD exacerbation.
Acute Issues
# COPD exacerbation: Given tachycardia and hypoxia on admission
there was concern for PE for which CTA chest was obtained. It
showed no thrombosis or pneumonia making COPD exacerbation most
likely diagnosis. Patient was started on prednisone,
azithromycin, standing albuterol/ipratropium, and albuterol nebs
PRN. Supplementary oxygen was titrated to baseline of 92% on RA.
These interventions resulted in rapid improvement in patient's
symptoms. By HD#2 she had no SOB. Ambulatory O2 sats were
obtained to assess readiness for discharge. O2 sats consistently
above 95% with ambulation. Patient was discharged with
prescriptions for home inhalers and with instructions to
follow-up with ___ pulmonary clinic.
# Cocaine abuse: Since recent discharge from psychiatric
hospital patient endorsed one use of cocaine. She had no
symptoms that were concerning for cardiac ischemia. Troponin on
admission was negative and remained negative on cycling.
Chronic Issues
# Hypertension: Continued home lisinopril.
# Hyperlipidemia: Continued home rosuvastatin.
# Diabetes, type 2 uncontrolled: Patient hyperglycemic to 417 on
transfer to floor for which she was given Humalog 10 units.
Continued home Lantus and managed sugars with low dose Humalog
sliding scale. Oral hypoglycemics were held.
# Bipolar/Depression/PTSD: Continue home psychiatric regimen.
# Anemia: Continued home ferrous sulfate.
# Glaucoma: Continued home eye care regimen.
Transitional Issues
# Patient needs follow-up in ___ pulmonary clinic. Given phone
number but it is unlikely she will call to make appointment. Is
scheduled to see PCP ___ ___ who can help facilitate f/u in
pulmonary clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fall
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Ms. ___ is a ___ F with severe dementia and history of
a-fib who presents from ___ after witnessed fall,
also found to have probable UTI.
The patient is not able to provide a history; history was
obtained from chart and from HCP ___ (___).
Per HCP the patient fell while in the cafeteria at ___
in ___, and hurt her head/face. She was brought to ___
___, where initial head CT was concerning for
possible intracranial hemorrhage. She was subsequently
transferred to ___.
In the ED, initial VS were 98.1 HR: 94 BP: 136/61 Resp: 24
O(2)Sat: 99 Normal.
ED exam was notable for large hematoma around swollen left eye.
Exam was limited by patient cooperation.
Labs were significant for Lactate 2.2. Urine was cloudy,
+nitrite, 30 protein, lg leuks, 21 RBC, >182 WBC, few bacteria.
She was given olanzapine 5mg IM x2, as well as ceftriaxone 1g
IV. She was sent to the floor for further management.
Notably she has had Alzheimers for ___ years, acutely worse for ___
years. She is combative at baseline, inconsistently able to
localize symptoms, unable to recognize people around her. She
does not know her HCP ___ , ___, lives in ___ at
baseline. She is able to ambulate with a walker at her nursing
facility (___ in ___, but per HCP is often sedated.
ECG (from ED):
Heart Rate: 105
Note(s): Sinus tachycardia, lateral
ST-T wave changes, incomplete LBBB, QRS 114
Rhythm: Sinus
Past Medical History:
Dementia
A-fib
CHF
Breash ca
PVD
Weakness
Social History:
___
Family History:
Noncontributory.
Physical Exam:
***ADMISSION EXAM***
VS: T 96.7 (Tmax 98.1) 136/36 95 18 99%RA
General: Elderly woman sitting in bed, verbalizing, appears
confused.
HEENT: Large hematoma around swollen left eye. Sutures over L
temporal region. Neck supple, oropharynx within normal limits
Chest: No respiratory distress, good air movement bilaterally.
Cardiovascular: RRR, normal s1/s2, no m/r/g.
Abdominal: Soft, nondistended, +BS
Extr/Back: No cyanosis, clubbing or edema.
Skin: Warm and dry
Neuro: Moves all extremities with full strength, Speech
fluent. Responds to name, otherwise not alert/oriented.
Perseverates about "need to go to bathroom / I just went to the
bathroom", responds "not today, go do it in the corner" when
asked questions and during exam maneuvers. During conversation
unable to respond to questions but says "You're nice." Actively
resisting all exam maneuvers.
***DISCHARGE EXAM***
VS: T 97.0 150/50 80 21 96%RA
General: Elderly woman lying in bed, responds to provider,
confused.
HEENT: Large hematoma around swollen left eye. Sutures over L
temporal region. Neck supple, oropharynx within normal limits
Chest: No respiratory distress, good air movement bilaterally.
Cardiovascular: RRR, normal s1/s2, no m/r/g.
Abdominal: Soft, nondistended, +BS
Extr/Back: No cyanosis, clubbing or edema.
Skin: Warm and dry
Neuro: Moves all extremities with full strength, speech fluent.
Responds to name, unable to identify location or date. Says "Go
away." Actively resisting all exam maneuvers.
Pertinent Results:
___ 05:59AM LACTATE-2.2*
___ 04:14AM URINE COLOR-Yellow APPEAR-Cloudy SP ___
___ 04:14AM URINE BLOOD-SM NITRITE-POS PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-LG
___:14AM URINE RBC-21* WBC->182* BACTERIA-FEW
YEAST-NONE EPI-0
___ 09:24PM ___ PTT-31.9 ___
___ 08:40PM GLUCOSE-127* UREA N-25* CREAT-0.9 SODIUM-143
POTASSIUM-5.0 CHLORIDE-110* TOTAL CO2-25 ANION GAP-13
___ 08:40PM WBC-13.8* RBC-4.13* HGB-12.1 HCT-36.3 MCV-88
MCH-29.1 MCHC-33.2 RDW-14.0
___ 08:40PM NEUTS-84.6* LYMPHS-10.1* MONOS-4.2 EOS-0.9
BASOS-0.2
IMAGING:
OSH head CT:
Soft tissue hematoma over left orbit/frontal bone. Small
hemorrhagic cortical contusion in R frontal lobe. L temporal
focus could be hemorrhagic contusion or small extra-axial
hemorrhage.
CT HEAD W/O CONTRAST:
1. Density in the right caudate, putamen and
anterior limb of the internal capsule reflects calcification
rather than hemorrhage
2. Subcutaneous hematoma in the left periorbital and
frontotemporal scalp.
Evaluation for fracture is limited by motion artifact.
CT ORBIT, SELLA & IAC W/O CONTRAST:
No fracture
CT C-SPINE W/O CONTRAST:
1. No evidence of acute fracture or subluxation within
limitations of motion
artifact.
2. A large, heterogeneous thyroid gland containing multiple
hypodense nodules. This can be further evaluated with
ultrasound if clinically indicated.
Soft Tissue Ultrasound:
No cellulitis, abscess, or foreign body.
MICRO: Blood and urine cultures pending.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 25 mcg PO DAILY
2. OLANZapine (Disintegrating Tablet) 5 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Artificial Tears 1 DROP BOTH EYES QAM
5. Aspirin 162 mg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Furosemide 20 mg PO DAILY
8. Magnesium Oxide 400 mg PO DAILY
9. Cyanocobalamin 500 mcg PO DAILY
10. Vitamin D 400 UNIT PO DAILY
11. Oxcarbazepine 300 mg PO BID
12. Mirtazapine 37.5 mg PO HS
13. Senna 17.2 mg PO HS
14. Acetaminophen 650 mg PO Q8H
15. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO Q4H:PRN
indigestion
16. Loratadine 10 mg PO DAILY:PRN itch
17. Milk of Magnesia 30 mL PO Q6H:PRN constipation
18. Nitroglycerin SL 0.3 mg SL PRN PAIN Q5MIN chest pain
19. OLANZapine 2.5 mg PO DAILY:PRN agitation
20. Guaifenesin 15 mL PO Q4H:PRN cough
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H
2. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO Q4H:PRN
indigestion
3. Artificial Tears 1 DROP BOTH EYES QAM
4. Aspirin 162 mg PO DAILY
5. Cyanocobalamin 500 mcg PO DAILY
6. FoLIC Acid 1 mg PO DAILY
7. Furosemide 20 mg PO DAILY
8. Guaifenesin 15 mL PO Q4H:PRN cough
9. Levothyroxine Sodium 25 mcg PO DAILY
10. Loratadine 10 mg PO DAILY:PRN itch
11. Magnesium Oxide 400 mg PO DAILY
12. Milk of Magnesia 30 mL PO Q6H:PRN constipation
13. Mirtazapine 37.5 mg PO HS
14. OLANZapine 2.5 mg PO DAILY:PRN agitation
15. OLANZapine (Disintegrating Tablet) 5 mg PO DAILY
16. Omeprazole 20 mg PO DAILY
17. Oxcarbazepine 300 mg PO BID
18. Senna 17.2 mg PO HS
19. Vitamin D 400 UNIT PO DAILY
20. Nitroglycerin SL 0.3 mg SL PRN PAIN Q5MIN chest pain
21. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 2 Doses
RX *sulfamethoxazole-trimethoprim [Bactrim DS] 800 mg-160 mg 1
tablet(s) by mouth twice a day Disp #*2 Tablet Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Urinary tract infection
Secondary: Dementia
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with reported intracranial hemorrhage.
COMPARISON: None.
TECHNIQUE: Non-contrast axial multidetector CT images through the head with
coronal and sagittal reformats.
DLP: 1604 mGy-cm.
CTDIvol: 81 mGy.
FINDINGS: There is a right basal ganglia hemorrhage which involves the
caudate, lentiform nucleus and anterior limb of the internal capsule.
Prominent ventricles and sulci likely reflect age-related atrophy.
Periventricular and subcortical white matter hypodensities, are non-specific,
but likely sequelae of chronic small vessel ischemic disease. There is no
shift of normally midline structures. Basilar cisterns are patent.
Gray-white matter differentiation is preserved.
Soft tissue hematoma is present in the left periorbital and frontotemporal
scalp. The globes are intact.
Assessment of the bones is limited by motion artifact; however, no definite
displaced fracture is identified. Paranasal sinuses, mastoid air cells and
middle ear cavities are largely clear.
IMPRESSION:
1. Intraparenchymal hemorrhage involving the right caudate, lentiform nucleus
and anterior limb of the internal capsule.
2. Subcutaneous hematoma in the left periorbital and frontotemporal scalp.
Evaluation for fracture is limited by motion artifact.
NOTE ADDED AT ATTENDING REVIEW: The density in the right caudate, putamen and
anterior limb of the internal capsule reflects calcification, rather than
hemorrhage. The density is far too high for hemorrhage, there is no mass
effect, and no edema. Given the high density of the calcification, it is not
possible to exclude a small amount of hemorrhage, but the findings can be
entirely explained by calcification.
The ED neurosurgery conslut note recognized this as calcification, so Dr.
___ not enter a follow communication about this revised report.
Radiology Report
INDICATION: ___ woman with left eye hematoma, evaluate for
entrapment.
COMPARISON: None.
TECHNIQUE: Non-contrast axial multidetector CT images from the orbits through
the mandible with coronal and sagittal reformats.
DLP: 1068 mGy-cm.
CTDIvol: 52 mGy.
FINDINGS: Examination is limited by motion artifact. Within this limitation,
there is no evidence of fracture. Paranasal sinuses, mastoid air cells and
middle ear cavities are clear. A left periorbital and frontotemporal scalp
hematoma is present. This study is not tailored for evaluation of
intracranial structures; however, a large right basal ganglia calcification is
noted. Please refer to dedicated head CT report performed concurrently for
details.
There is fusion of the C2-3 and C3-4 facet joints bilaterally.
IMPRESSION: No evidence of fracture. Left periorbital and frontotemporal
subcutaneous hematoma.
Radiology Report
INDICATION: ___ woman with agitation, status post fall.
COMPARISON: None.
TECHNIQUE: Non-contrast axial multidetector CT images through the cervical
spine with coronal and sagittal reformats.
DLP: 1456 mGy-cm.
CTDIvol: 17 mGy.
FINDINGS:
The examination is limited by motion artifact. Within this limitation, there
is no evidence of fracture. Cervical vertebral body heights and alignment are
maintained. There is no prevertebral soft tissue thickening.
There is bilateral fusion of the facet joints at C2-3 and C3-4 and on the
right at C5-6.
At C5-6 there is a large right-sided intervertebral osteophyte that severely
narows the right side of the spina canal and likely compresses the spinal
cord. There is severe neural foraminal narrowing at this location.
Limited view of lung apices is notable for biapical scarring. The thyroid
gland is heterogeneous and demonstrates an enlarged right lobe containing
multiple hypodense nodules. The left lobe also is enlarged and inhomogeneous.
If further evaluation is indicated, an ultrasound may be helpful.
IMPRESSION:
1. No evidence of acute fracture or subluxation within limitations of motion
artifact.
2. A large, heterogeneous thyroid gland containing multiple hypodense
nodules. This can be further evaluated with ultrasound if clinically
indicated.
NOTE ADDED AT ATTENDING REVIEW: Although I agree there is no evidence of a
fracture, there is widening of the anterior interspace at C4-5. This is
substantially different than the other levels, which demonstrate dramatic ___
if disk height and endplate sclerosis. There is relatively little degenerative
change at C4-5, and it is possible that this wide interspace reflects this
lack of degenerative disease. However, in the setting of trauma, one must
consider the possibility of anterior longitudinal ligament injury. If further
evaluation of this is indicated, then an MR examination may be helpful.
This finding was noted by Dr. ___ at 10:40 am ___ and discused by
telephone with ___ of Neurosurgery at 10:43.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall, IPH
Diagnosed with HEAD INJURY UNSPECIFIED, OTHER FALL
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 0
level of acuity: 2.0 | Ms. ___ is a ___ F with severe dementia and history of
a-fib who presents from ___ after witnessed fall,
also found to have probable UTI. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex / Morphine / bee sting
Attending: ___
Chief Complaint:
Dyspnea on exertion
Major Surgical or Invasive Procedure:
1.) cardiac catheterization
History of Present Illness:
Ms. ___ is a ___ year old woman with COPD and recent AVR/MVR
and CABG in ___ presents with dyspnea on exertion worse
than baseline over the last several days following a recent
hospitalization. She was admitted from ___ to ___ for
lightheadedness and fall though to be from overdiuresis and
orthostasis. Her home lasix dose of 40 mg BID was held on
discharge. Following discharge she developed progressively worse
DOE, leg swelling, and puffiness around her eyes. She endorses
multiple symptoms consistent with heart failure sinc her surgery
in ___, including dyspnea on minimal exertion (walking 50 steps
or climing 4 stairs), PND usualy twice nightly, she has ___
pillow orthopnea, and nocturia ___ times nightly. She also
complains of bilateral lower extremity weakness at baseline. She
reports a dry weight of 163 lbs. She called her PCP ___ ___ and
described these symptoms and her PCP restarted her home Lasix at
40 mg PO BID and she has continued to take since that time.
In the ED, initial vs were 97.4 HR 81 BP 111/74 RR 16. She was
complaining of nausea and epigastric discomfort relieved with
compazine, but no emesis. Additionally, she notes peristent left
sided sharp, intermittent, non-exertional, chest pain radiating
into her left arm, which she says has been present since her
CABG/AVR/MVR and is entirely stable. EKG was unchanged from
prior and CXR showed no acute process. Initial labs were notable
for INR of 5.9, Trop<0.01. DRE showed guiac positive brown
stool. She does note intermittent epistasix for several years
and had a nose bleed this week with large amounts of blood and 5
large clots and noted that she may have swallowed some blood at
that time. She received IV dilaudid for pain control and was
admitted to medicine for further workup.
On arrival to the floor, patient is comfortable appearing. She
has been tolerating PO. She denies diarrhea, but feels
chronically constipated. She restarted her lasix, which was held
on discharge, yesterday.
On review of systems she denies fever, chills, night sweats,
headache, vision changes, rhinorrhea, congestion, sore throat,
cough, abdominal pain, nausea, vomiting, diarrhea, BRBPR,
melena, hematochezia, dysuria, hematuria. All other 10-system
review negative in detail.
Past Medical History:
- Diabetes
- Hyperlipidemia
- Hypertension
- CAD s/p CABG ___ LIMA/OM
- Re-do sternotomy CABG x 1 (___) with saphenous vein graft
to RCA
- s/p MVR ___ On-X mechanical valve, ___
- s/p AVR (19 mm On-X mechanical valve, ___
- Non-Hodgkin's lymphoma dx ___ s/p splenectomy/partial
pancreatectomy (___), XRT/chemotherapy
- COPD/asthma/restrictive lung disease
- GERD c/b ___ esophagus
- Bipolar disorder, depression/anxiety
- Retinal artery stenoses
- Hypothyroidism
- s/p cholesystectomy ___ ago
Social History:
___
Family History:
Father died of MI at ___
Brother with PTCA at ___
Physical Exam:
#Admission Physical Exam:
VS 97.2 125/80 86 16 100%RA
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Fair air movment, no wheeze, slight crackles at bases b/l
CV RRR mechanical heart sounds with ___ SEM
ABD soft NT ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, no c/c/e
NEURO CNs2-12 intact, motor function grossly normal
SKIN no ulcers or lesions
LABS: reviewed, see below
.
#DISCHARGE PHYSICAL EXAM:
VS: T 98.3, BP 121/64, HR 83, RR 18, O2 99% 2L NC.
GENERAL: NAD, AxOx3.
HEENT: JVP unable to appreciate. Sclera anicteric. PERRL, EOMI.
MMM.
CARDIAC: RRR, normal S1, S2. No m/r/g. No S3 or S4. audible
mechanical valve click.
LUNGS: Resp were unlabored, no accessory muscle use. CTAB, no
crackles, rhonchi.
ABDOMEN: Soft, NT, mild distension. No HSM or tenderness. Abd
aorta not enlarged by palpation.
EXTREMITIES: pretibial edema 1+. No femoral bruits.
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:
___ 05:10PM BLOOD WBC-7.1 RBC-3.35* Hgb-8.8* Hct-28.4*
MCV-85 MCH-26.4* MCHC-31.1 RDW-17.5* Plt ___
___ 05:10PM BLOOD Neuts-71.5* ___ Monos-5.9 Eos-3.0
Baso-1.5
___ 05:10PM BLOOD ___ PTT-40.9* ___
___ 05:10PM BLOOD Glucose-124* UreaN-29* Creat-1.5* Na-130*
K-4.2 Cl-98 HCO3-22 AnGap-14
___ 05:10PM BLOOD CK-MB-3 cTropnT-<0.01
___ 08:15AM BLOOD Calcium-9.4 Phos-3.7 Mg-2.0
.
#PERTINENT HOSPITAL COURSE LABS:
___ 08:15AM BLOOD WBC-5.9 RBC-3.47* Hgb-8.9* Hct-29.0*
MCV-84 MCH-25.7* MCHC-30.8* RDW-17.7* Plt ___
___ 08:10AM BLOOD WBC-6.0 RBC-3.66* Hgb-9.3* Hct-31.0*
MCV-85 MCH-25.5* MCHC-30.1* RDW-17.7* Plt ___
___ 10:40AM BLOOD WBC-7.3 RBC-3.43* Hgb-8.8* Hct-28.7*
MCV-84 MCH-25.7* MCHC-30.8* RDW-17.9* Plt ___
___ 05:14PM BLOOD WBC-7.4 RBC-3.58* Hgb-9.5* Hct-30.6*
MCV-85 MCH-26.6* MCHC-31.1 RDW-17.7* Plt ___
___ 06:10AM BLOOD Hct-27.5*
___ 12:50PM BLOOD WBC-8.2 RBC-3.28* Hgb-8.4* Hct-27.8*
MCV-85 MCH-25.7* MCHC-30.4* RDW-17.8* Plt ___
___ 07:01AM BLOOD WBC-9.9 RBC-3.06* Hgb-7.8* Hct-25.5*
MCV-83 MCH-25.5* MCHC-30.6* RDW-17.6* Plt ___
___ 12:50PM BLOOD WBC-9.1 RBC-3.09* Hgb-7.9* Hct-26.0*
MCV-84 MCH-25.7* MCHC-30.5* RDW-17.8* Plt ___
___ 07:54AM BLOOD WBC-8.2 RBC-3.39* Hgb-8.5* Hct-28.2*
MCV-83 MCH-25.2* MCHC-30.3* RDW-17.7* Plt ___
___ 07:22AM BLOOD ___ PTT-68.2* ___
___ 07:01AM BLOOD ___ PTT-61.1* ___
___ 06:10AM BLOOD ___ PTT-65.5* ___
___ 04:50AM BLOOD ___ PTT-59.9* ___
___ 08:40AM BLOOD ___ PTT-59.3* ___
___ 10:40AM BLOOD ___
___ 06:45AM BLOOD ___ PTT-51.2* ___
___ 08:10AM BLOOD ___ PTT-53.3* ___
___ 07:22AM BLOOD Glucose-129* Creat-1.4* Na-131* K-4.7
Cl-96 HCO3-27 AnGap-13
___ 07:01AM BLOOD Glucose-335* UreaN-37* Creat-1.4* Na-127*
K-4.4 Cl-90* HCO3-27 AnGap-14
___ 06:10AM BLOOD Glucose-159* UreaN-38* Creat-1.4* Na-137
K-5.1 Cl-99 HCO3-27 AnGap-16
___ 04:50AM BLOOD Glucose-173* UreaN-36* Creat-1.7* Na-133
K-4.2 Cl-95* HCO3-25 AnGap-17
___ 08:40AM BLOOD Glucose-155* UreaN-31* Creat-1.3* Na-135
K-4.1 Cl-97 HCO3-27 AnGap-15
___ 10:40AM BLOOD Glucose-241* UreaN-31* Creat-1.6* Na-135
K-4.3 Cl-97 HCO3-26 AnGap-16
___ 03:55PM BLOOD Glucose-143* UreaN-29* Creat-1.4* Na-137
K-4.2 Cl-100 HCO3-26 AnGap-15
___ 08:10AM BLOOD Glucose-193* UreaN-28* Creat-1.5* Na-136
K-4.2 Cl-98 HCO3-26 AnGap-16
___ 08:15AM BLOOD cTropnT-<0.01 proBNP-6243*
___ 07:22AM BLOOD Calcium-9.1 Phos-4.3 Mg-2.2
___ 06:10AM BLOOD Calcium-9.0 Phos-4.6* Mg-2.2
___ 08:40AM BLOOD Calcium-9.0 Phos-4.1 Mg-1.9
___ 03:55PM BLOOD Calcium-9.2 Phos-4.1 Mg-2.0
___ 08:10AM BLOOD Calcium-9.4 Phos-3.8 Mg-2.0 Iron-19*
___ 08:10AM BLOOD D-Dimer-1326*
___ 08:10AM BLOOD calTIBC-407 Ferritn-34 TRF-313
___ 12:44PM BLOOD Type-ART FiO2-100 O2 Flow-15 pO2-433*
pCO2-41 pH-7.44 calTCO2-29 Base XS-4 AADO2-244 REQ O2-48
Intubat-NOT INTUBA Comment-NRB
___ 12:30PM BLOOD Type-ART Temp-37.8 pO2-390* pCO2-41
pH-7.44 calTCO2-29 Base XS-4 Intubat-NOT INTUBA
___ 12:17PM BLOOD Type-ART pO2-84* pCO2-30* pH-7.40
calTCO2-19* Base XS--4 Intubat-NOT INTUBA Comment-RM AIR
___ 12:44PM BLOOD Hgb-8.0* calcHCT-24 O2 Sat-99
___ 12:30PM BLOOD Hgb-8.6* calcHCT-26 O2 Sat-99
___ 08:25AM BLOOD WBC-8.8 RBC-3.35* Hgb-8.6* Hct-28.0*
MCV-84 MCH-25.8* MCHC-30.9* RDW-17.7* Plt ___
___ 07:40AM BLOOD WBC-8.5 RBC-3.28* Hgb-8.4* Hct-27.0*
MCV-82 MCH-25.7* MCHC-31.2 RDW-18.0* Plt ___
___ 07:54AM BLOOD WBC-8.2 RBC-3.39* Hgb-8.5* Hct-28.2*
MCV-83 MCH-25.2* MCHC-30.3* RDW-17.7* Plt ___
___ 07:01AM BLOOD WBC-9.9 RBC-3.06* Hgb-7.8* Hct-25.5*
MCV-83 MCH-25.5* MCHC-30.6* RDW-17.6* Plt ___
___ 08:25AM BLOOD ___
___ 07:40AM BLOOD ___
___ 07:22AM BLOOD ___ PTT-68.2* ___
___ 07:01AM BLOOD ___ PTT-61.1* ___
___ 08:25AM BLOOD Glucose-141* UreaN-41* Creat-1.6* Na-134
K-5.3* Cl-95* HCO3-27 AnGap-17
___ 07:40AM BLOOD Glucose-209* UreaN-39* Creat-1.5* Na-133
K-5.0 Cl-98 HCO3-26 AnGap-14
___ 01:40PM BLOOD Glucose-216* UreaN-36* Creat-1.5* Na-125*
K-5.6* Cl-91* HCO3-23 AnGap-17
___ 07:01AM BLOOD Glucose-335* UreaN-37* Creat-1.4* Na-127*
K-4.4 Cl-90* HCO3-27 AnGap-14
___ 08:25AM BLOOD Calcium-9.4 Phos-4.1 Mg-2.7*
___ 06:10AM BLOOD Calcium-9.0 Phos-4.6* Mg-2.2
___ 01:40PM BLOOD TSH-3.9
___ 01:40PM BLOOD Osmolal-281
___ 07:01AM BLOOD ___
___ 01:40PM BLOOD HIV Ab-NEGATIVE
___ 11:45AM URINE Osmolal-190
___ 11:45AM URINE Hours-RANDOM UreaN-259 Creat-28 Na-27
K-21 Cl-16
.
#STUDIES:
[]ABDOMEN (SUPINE & ERECT)Study Date of ___ 1:15 ___
FINDINGS: The bowel gas pattern is within normal limits with a
large amount
of stool throughout a non-dilated left colon and sigmoid. No
evidence of
obstruction or appreciable adynamic ileus.
[]ECGStudy Date of ___ 9:08:12 AM
Sinus rhythm. The P-R interval is prolonged. Right axis
deviation.
Non-specific intraventricular conduction delay. There is a late
transition
that is with small R waves in the anterior leads consistent with
possible
myocardial infarction. Non-specific ST-T wave changes. Compared
to the
previous tracing of ___ there is no diagnostic change.
Read ___.
___
___
[]Cardiac Catheterization Report
Study Date ___
Assessment & Recommendations
1.Vasodilatory and improved cardiac output with inhaled oxygen.
2.Smaller response to inhaled nitric oxide.
3.Hyperdynamic heart likely due to anemia.
4.Elevated right sided filling pressures due to right heart
dysfunction with preserved cardiac output.
5.Mild/moderate elevation of left sided filling pressures.
6.Suggest transfusion, home oxygen therapy, improved
bronchodilator therapy and pulmonary consultation either in
hospital or early as outpatient.
7.Current volume status adequate given right heart dysfunction.
Maintain I=O.
[]ECGStudy Date of ___ 8:30:52 ___
Sinus rhythm. Baseline artifact. Right axis deviation.
Intraventricular
conduction delay. Delayed precordial R wave transition and QS
deflections
in leads V1-V2 consistent with prior anteroseptal myocardial
infarction as
recorded on ___. The rate has increased. There is borderline
A-V conduction delay. No apparent diagnostic interim change.
Read ___
___
___
___ Radiology CHEST (PA & LAT): PA and lateral views of
the chest provided and demonstrate midline sternotomy wires and
prosthetic cardiac valve. Multiple mediastinal clips are again
noted. There is right perihilar opacity with slight distortion
of the fissural surfaces, stable, reflecting known changes from
prior radiation treatment. There is no definite sign of
pneumonia or overt CHF. Overall, cardiomediastinal silhouette is
stable. No pneumothorax. No definite signs of pleural effusion.
Bony structures are intact.
___ TTE: EF 25% (down from 55% in ___. Severe pressure
and volume overload of the right ventricle is now seen, with
resultant reduction of left ventricular function through
ventricular interaction and paradoxical interventricular septal
displacement (___ phenomenon).
___ V/Q scan: Predominant bilateral upper lobe ventilatory
abnormalities with some patchiness in perfusion; again, with
more obvious non-segmental changes in the upper lobes. Low to
intermediate likelihood ratio for acute pulmonary embolism.
Mucous plugging of the airways should be considered.
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: Multiple prior chest radiographs, most recent dating ___ as
well as a CT chest from ___.
CLINICAL HISTORY: Dyspnea on exertion, assess for pleural effusion or
pneumonia.
FINDINGS: PA and lateral views of the chest provided and demonstrate midline
sternotomy wires and prosthetic cardiac valve. Multiple mediastinal clips are
again noted. There is right perihilar opacity with slight distortion of the
fissural surfaces, stable, reflecting known changes from prior radiation
treatment. There is no definite sign of pneumonia or overt CHF. Overall,
cardiomediastinal silhouette is stable. No pneumothorax. No definite signs
of pleural effusion. Bony structures are intact.
IMPRESSION: Stable exam without acute intrathoracic process.
Radiology Report
HISTORY: Possible obstruction.
FINDINGS: The bowel gas pattern is within normal limits with a large amount
of stool throughout a non-dilated left colon and sigmoid. No evidence of
obstruction or appreciable adynamic ileus.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: DOE
Diagnosed with RESPIRATORY ABNORM NEC, DIABETES UNCOMPL ADULT, HYPERLIPIDEMIA NEC/NOS, AORTOCORONARY BYPASS, HEART VALVE REPLAC NEC
temperature: 97.4
heartrate: 81.0
resprate: 16.0
o2sat: 99.0
sbp: 111.0
dbp: 74.0
level of pain: 0
level of acuity: 2.0 | []BRIEF CLINICAL HISTORY:
Ms. ___ is a ___ year old woman with COPD and recent AVR/MVR
and CABG (___) who presented with dyspnea on minimal
exertion worsening over last several days and sharp,
non-exertional, intermittent chest pain. Notably, patient was
hospitalized ___ to ___ for lightheadedness and fall, presumed
from overdiuresis. Of note, she complains of dyspnea on
exertion since CABG/AVR/MVR in ___, but notes acute worsening
over last several days following recent discharge. She was
re-hydrated during that admission and her lasix was held on
discharge. Over the subsequent few days she developed worsening
edema and called her PCP who restarted lasix.
.
[]ACTIVE ISSUES:
# DOE: During this admission, her DOE was thought to be
multifactorial, with COPD and deconditioning also contributing
to her acutely worsening CHF, along with known restrictive lung
disease. A TTE was done which showed EF of 25% (down from 55%
in ___ and severe pressure and volume overload of right
heart consistent with symptoms of heart failure. On exam, lungs
were diffusely wheezy and rhonchorous with fair air movement,
though no rales were appreciated. Given high right heart
pressure and volume, V/Q scan was obtained to rule out PE (did
not get PE CT due to CKD) which was low to intermediate
probability for PE. Diuresis was initiated ___ with 40 mg IV
lasix and she proceeded to diurese - 2.7 liters overnight.
Ultimately, patient was transferred from medicine to ___
cardiology service for further care. Weight on ___: 156.2
lbs. Once on ___, the patient continued to complain of DOE and
SOB despite O2 sats of >95% on RA. The patient underwent a
right heart cardiac catheterization which revealed elevated
right heart filling pressures that improved significantly with
supplemental oxygen. Based on this, the patient qualified for
home O2 for symptomatic relief as an outpatient. She was seen
by the pulmonary consult service; however, as the patient has
restrictive lung disease and was already on optimal therapy,
further treatment was deferred to the outpatient setting.
.
# Chest pain: Patient reports intermittent, sharp,
non-exertional chest pain since her sternotomy. She reports it
is unchanged in character during this time. EKG unchanged, trop
negative x 2. This pain is likely musculoskeletal in origin
related to prior sternotomy. This pain is likely
musculoskeletal in origin related to prior sternotomy. She was
continued on home metoprolol, rosuvastatin, and aspirin 81 mg
daily. Given that she is likely ___ class III, she was started
on lisinopril 2.5 mg daily. Patient had been complaining of
chest pain since sternotomy in ___ (above), but this is
unlikely cardiac as it is non-exertional and ECG was stable and
troponins were flat. She was started on gabapentin for presumed
neuropathic pain with significant improvement in symptomatology.
.
# Elevated INR: INR was 5.9 on admission (goal of 3.0 to 3.5
given mechanical valves). According to patient, her coumadin
dose was increased on last hospitalization. She was previously
alternating 1 mg and 2 mg daily, and was discharged on 2 mg
daily. She has remained hemodynamically stable without evidence
of bleeding. Her coumadin was held until INR entered the
therapeutic range then restarted with lovenox bridging to be
followed up as an outpatient.
.
# Hyponatremia: Sodium 130 during this hospitalization, likely
secondary to CHF. Hyponatremic to 128 last hospitalization,
urine Na<10 and Osm 148 indicative of hypovolemia. Responded to
IV hydration, and was 136 on DC.
.
# CAD s/p CABG and AVR/MRV: She was continued on home
metoprolol, rosuvastatin, and aspirin 81 mg daily. Given that
she is likely ___ class III, she was started on lisinopril 2.5
mg daily. Patient had been complaining of chest pain since
sternotomy in ___ (above), but this is unlikely cardiac as
it is non-exertional and ECG was stable and troponis were flat.
.
# Hypothyroidism: Euthyroid on exam. Synthroid was increased
last hospitalization to 100 mcg daily due to TSH of 6 which was
continued on this hospitalization.
.
# DM: Stable. Patient was placed on humalog insulin sliding
scale during hospitalization with good blood glucose control.
.
# Hypertension: Stable in house with BPS 110s-130s/60s-80s. She
was continued on home metoprolol as above.
.
# Asthma/COPD/RLD: Likely contributing to exertional dyspnea
(above). Her exam was consistent with obstructive lung disease
with diffuse wheezing. V/Q scan also revealed evidence of
possible mucous plugging. She was continued on home regimen of
Albuterol prn, fluticasone inhaler, montelukast, and salmeterol,
salmeterol inhaler.
.
# GERD: Stable on home regimen of pantoprazole 40 mg PO Q12H and
lubiprostone 24 mcg PO BID.
.
# Depression/psych: Stable on home regimen of sertraline,
Seroquel, lamotrigine, and clonazepam.
.
# Pain: Complaints of diffuse chest and abdominal pain at
baseline. This was well controlled on home regimen of oxycodone
5 mg PO Q6H prn.
.
[] TRANSITIONAL ISSUES:
- next INR check is ___, along with routine electrolytes and
CBC which will be arranged by ___ services and sent to her PCP.
- the patient should have her TSH and FT4 checked by PCP |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Sulfa (Sulfonamide Antibiotics) / Penicillins / Topamax /
adhesive / lisinopril
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Exploratory laparotomy with lysis of adhesions
History of Present Illness:
Mrs. ___ is a ___ y/o F w h/o several abdominal surgeries
who presents to the ED with 24h of crampy abdominal pain in her
midline, that is progressively worsening. She has three loose
BMs 24h ago, no BM or flatus since. She remembers passing gas
48h ago for the last time. 12 h ago, she started having chills,
no fevers. She has had nausea and has vomited bilious fluid
three times. She denies any other symptoms including
constipation, blood in stool or emesis, burning on urination,
weakness.
Past Medical History:
COPD
HTN
Hypothyroidism
DM2
Depression
PTSD
Insomnia
PSH:
Hysterectomy
Appendectomy
Cholecystectomy
Vaginal prolapse surgery
denies midline hernia repair
tonsillectomy
___ implantation bladder?
Social History:
___
Family History:
Non-contributory
Physical Exam:
Admission PE:
VS: 97.2 97 133/71 18 100% RA
General: Non- toxic, in NAD, A&Ox3
P: CTAP, breathing comfortably on RA
CV: RRR
Abdomen: Well- healed midline incision, anterior abdominal wall
hernia palpable, reducible. Soft, distended. Pain (moderate
Midline, pain mild other quadrants)
Extremities: pulses palp, no edema
Discharge Physical Exam:
T 98.2 P 77 BP 137/61 RR 18 02 98%RA
Constitutional: NAD
Neuro: Alert and oriented x 3
Cardiac: Regular rate and rhythm, NL S1,S2
Resp: Clear to auscultation, bilaterally; breathing non-labored
Abdomen: Softly distended, appropriate ___
tenderness without rebound tenderness or guarding
Wound: abdominal midline incision with staples, CDI; no
periwound erythema or drainage
Skin: blanchable sacral erythema with areas of excoriation, no
induration or tenderness to palpation
Ext: no lower extremity edema; 2+ DP pulses, bilaterally
Pertinent Results:
Labs:
___ 04:15AM BLOOD WBC-10.9* RBC-5.07 Hgb-16.3*# Hct-46.1*
MCV-91 MCH-32.1* MCHC-35.4 RDW-13.2 RDWSD-43.7 Plt ___
___ 04:15AM BLOOD Neuts-85.2* Lymphs-10.2* Monos-3.4*
Eos-0.4* Baso-0.4 Im ___ AbsNeut-9.30*# AbsLymp-1.11*
AbsMono-0.37 AbsEos-0.04 AbsBaso-0.04 ALT-19 AST-13 AlkPhos-99
TotBili-0.8 Lipase-22 cTropnT-<0.01
Albumin-4.6 Lactate-2.1*
___ 05:26AM BLOOD WBC-5.7 RBC-3.05* Hgb-10.0* Hct-29.1*
MCV-95 MCH-32.8* MCHC-34.4 RDW-14.0 RDWSD-47.8* Plt ___
Imaging:
CT ABD & PELVIS WITH CONTRAST:
IMPRESSION:
1. Small-bowel obstruction secondary to an abnormal segment of
small bowel in the right lower quadrant spanning approximately
20 cm which demonstrates submucosal edema and stratified
enhancement with surrounding soft tissue stranding and small
amount of mesenteric fluid. Differential considerations include
ischemia, infection, or inflammatory bowel disease. There is no
pneumatosis. Follow-up imaging is recommended 4 weeks after
resolution of obstruction to assess the bowel with MR
___. 2. A 2.2 cm left adrenal nodule is increased in
size compared with the ___, and is incompletely
characterized. This can have further characterization at the
time of the MR ___.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO QMON
2. ARIPiprazole 15 mg PO QHS
3. Atorvastatin 20 mg PO QPM
4. Furosemide 20 mg PO DAILY:PRN swelling
5. LamoTRIgine 100 mg PO BID
6. Levothyroxine Sodium 137 mcg PO DAILY
7. Lisinopril 2.5 mg PO DAILY
8. LORazepam 0.5 mg PO BID
9. TraZODone 100 mg PO QHS
10. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*30 Capsule Refills:*0
3. Nicotine Patch 21 mg TD DAILY
RX *nicotine 21 mg/24 hour 1 patch daily Disp #*30 Patch
Refills:*0
4. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ capsule(s) by mouth every four (4) hours
Disp #*30 Capsule Refills:*0
5. Alendronate Sodium 70 mg PO QMON
6. ARIPiprazole 15 mg PO QHS
7. Atorvastatin 20 mg PO QPM
8. Furosemide 20 mg PO DAILY:PRN swelling
9. HumaLOG (insulin lispro) 100 unit/mL SC 20 units TID
10. insulin glargine 100 unit/mL subcutaneous 15 units BID
11. LamoTRIgine 100 mg PO BID
12. Levothyroxine Sodium 137 mcg PO DAILY
13. Lisinopril 2.5 mg PO DAILY
14. LORazepam 0.5 mg PO BID
15. TraZODone 100 mg PO QHS
16. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
Discharge Disposition:
Home With Service
Facility:
___
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
EXAMINATION: CT abdomen and pelvis with contrast
INDICATION: ___ with diffuse abdominal pain and vomiting, abdominal
tenderness, hx of hysterectomy BSO, appendectomy, cholecystecomy // Bowel
obstruction, pancreatitis, enteritis, colitis
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) = 395 mGy-cm.
COMPARISON: CT abdomen pelvis on ___
FINDINGS:
LOWER CHEST: There is mild bibasilar atelectasis. There is no evidence of
pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout. A
subcentimeter hypodensity in the left hepatic lobe is too small to
characterize, however likely represents a hepatic cyst or biliary hamartoma.
There is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is surgically absent.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right adrenal gland is normal in size and shape. A 2.2 x 1.5 cm
left adrenal nodule is increased in size from ___, at which time it
measured 1.2 x 1.0 cm, and is incompletely characterized (2:17).
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
A subcentimeter hypodensity in the right lower pole is too small to
characterize, however is similar to prior and likely represents a simple cyst.
There is no hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. There is an abnormal segment
of small bowel in the right lower quadrant with submucosal edema which spans
approximately 20 cm, with surrounding fat stranding and a small amount of
mesenteric fluid ___, 2:51). Proximal to this loop, the small bowel
loops are fluid-filled and dilated up to 3 cm. More distal to the abnormal
loop of bowel, the small bowel is collapsed. The colon and rectum are within
normal limits. The appendix is surgically absent. There is no pneumatosis or
pneumoperitoneum.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is a
small amount of free fluid in the pelvis (602b:35).
REPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal abnormality is
seen.
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. Small-bowel obstruction secondary to an abnormal segment of small bowel in
the right lower quadrant spanning approximately 20 cm which demonstrates
submucosal edema and stratified enhancement with surrounding soft tissue
stranding and small amount of mesenteric fluid. Differential considerations
include ischemia, infection, or inflammatory bowel disease. There is no
pneumatosis. Follow-up imaging is recommended 4 weeks after resolution of
obstruction to assess the bowel with MR ___.
2. A 2.2 cm left adrenal nodule is increased in size compared with the
___, and is incompletely characterized. This can have further
characterization at the time of the MR ___.
RECOMMENDATION(S): Recommend follow-up MR ___ 4 weeks after
resolution of obstruction. Attention to adrenal gland lesion as well at that
time.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, N/V
Diagnosed with Unspecified intestinal obstruction
temperature: 97.2
heartrate: 97.0
resprate: 18.0
o2sat: 100.0
sbp: 133.0
dbp: 71.0
level of pain: 9
level of acuity: 3.0 | The patient presented to the Emergency Department on ___ with progressively worsening abdominal pain and associated
nausea and vomiting. Upon arrival, she was placed on bowel rest
and given intravenous fluids and pain medication. She underwent
an abdominal/pelvic CT scan, which confirmed presence of a small
bowel obstruction prompting placement of a ___ tube for
decompression. She was subsequently admitted to the Acute Care
Surgery service and taken to the operating room where she
underwent an exploratory laparotomy with lysis of adhesions;
please see operative note for details. The patient was
extubated in the operating room and brought to the recovery room
in stable condition.
Neuro: The patient was alert and oriented throughout
hospitalization; pain was initially managed with a PCA and
intravenous acetaminophen. Once tolerating a po diet, she was
transitioned to oral oxycodone.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored. However, on
POD3, she did report chest discomfort. An EKG was obtained and
troponins were negative x 2.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored and she was
weaned from supplemental oxygen on POD4. Good pulmonary toilet,
early ambulation and incentive spirometry were encouraged
throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO with a
___ tube in place for decompression. On POD4, the
patient began passing flatus and tolerated an NGT clamping
trial, therefore, the tube was removed and her diet was advanced
to sips. Her diet was subsequently advanced as tolerated to
regular and well tolerated. She continued to pass flatus and
moved her bowels. Additionally, her abdomen be came
progressively less distended throughout her hospitalization.
Patient's intake and output were closely monitored
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
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:
Methadone
Attending: ___.
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of diabetes, ESRD on dialysis, diastolic CHF,
who presents with one-week history of worsening cough, body
aches and low grade fevers. Symptoms began a week prior to
presentation with cough. She was seen by her primary care
physician ___ ___, diagnosed with likely viral bronchitis and
discharged home with guaifenesin with codeine. She reports that
she has not had any improvement since that time and had a
low-grade fever to 99.4 at dialysis yesterday. Cough is
productive of yellow sputum. Reports nausea, post-tussive emesis
(she reports multiple episodes per day), as well as feeling of
weakness. Denies shortness of breath.
In the ED, initial vitals 98.6 59 164/51 16 98%
EKG showed SR 67, NA/NI, biphasic T wave in V3/V4 (new),
troponin 0.26 (down from previous baseline). CXR showed small r
sided effusion with pulmonary edema decreased from ___ and no
evidence of pneumonia.
Currently, she complains of diffuse body aches and fatigue, not
actively coughing.
ROS: Positive for constipation, pruritis worse for the past
motnh. per HPI, denies chills, night sweats, headache, vision
changes, rhinorrhea, sore throat, shortness of breath, chest
pain, abdominal pain, nausea, vomiting, diarrhea, BRBPR, melena,
hematochezia, dysuria, hematuria.
Past Medical History:
- Diastolic CHF
- Diabetes
- Hypertension
- Hyperlipidemia
- ESRD on HD (___)
- Hepatitis C
- Anemia
- H/o PE
- Migraines
- Depression
- Narcotic dependence
- Chronic lymphedema in right leg
- Atrial flutter s/p cardioversion ___
- Esophagitis
- MRSA bacteremia and candidemia
- Junctional bradycardia
- pituitary lesion and Rathke's cleft cyst
Social History:
___
Family History:
Mother had lupus.
Physical Exam:
Admission exam:
VS - 98.1, 196/93, 70, 20, 99/RA
GENERAL - chronically ill appearing woman in NAD, appears tired
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK - supple, no JVD
LUNGS - decreased breath sounds in all lung fields, no wheezes
or crackles appreciated, resp unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, systolic murmur
ABDOMEN - NABS, soft/NT/ND, no rebound/guarding
EXTREMITIES - WWP, legs with non-pitting edema, no joint
swelling or erythema, no muscle tenderness
SKIN - linear excoriations and small excoriated patches on
bilateral arms, chest, back
NEURO - awake, A&Ox3, CNs II-XII grossly intact, moving all 4
extremities
Discharge exam:
VS - 98.3, 150-176/60-85, 64-80, 20, 95-96/RA
GENERAL - chronically ill appearing woman in NAD
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK - supple, no JVD
LUNGS - lungs CTAB, good air entry, no crackles, wheezes,
rhonchi. no accesory muscle use. Chest wall tender to palpation
HEART - PMI non-displaced, RRR, systolic murmur
ABDOMEN - NABS, soft/NT/ND, no rebound/guarding
EXTREMITIES - WWP, legs with non-pitting edema, no joint
swelling or erythema, no muscle tenderness
SKIN - linear excoriations and small excoriated patches on
bilateral arms, chest, back
NEURO - awake, A&Ox3, CNs II-XII grossly intact, moving all 4
extremities
Pertinent Results:
Admission labs:
___ 11:35AM BLOOD WBC-5.4 RBC-3.22* Hgb-9.8* Hct-28.4*
MCV-88# MCH-30.4 MCHC-34.5# RDW-15.7* Plt ___
___ 11:35AM BLOOD Neuts-55.9 ___ Monos-5.5 Eos-3.3
Baso-0.5
___ 11:35AM BLOOD Glucose-128* UreaN-25* Creat-5.1* Na-143
K-4.4 Cl-98 HCO3-33* AnGap-16
___ 11:35AM BLOOD CK(CPK)-72
___ 11:35AM BLOOD CK-MB-2 cTropnT-0.26*
___ 12:00PM BLOOD Albumin-3.6 Calcium-10.5* Phos-5.1*
Mg-2.2
Imaging:
CXR ___
The heart remains moderately enlarged. Dense mitral annular
calcifications are re- demonstrated, and there is unchanged
enlargement of the main pulmonary artery. Mild pulmonary
vascular engorgement appears slightly improved compared to the
prior study. Aeration of the lung bases is also improved. No
large pleural effusion or pneumothorax is identified, though
there is trace blunting of the right costophrenic angle
laterally. No pneumothorax is identified. No acute osseous
abnormalities seen.
IMPRESSION:
Mild pulmonary vascular engorgement, slightly improved when
compared to the prior exam. Improved aeration of the lung bases
with resolution of the previously noted bibasilar airspace
opacities.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Milk of Magnesia 30 mL PO Q6H:PRN constipation
2. Nephrocaps 1 CAP PO DAILY
3. Omeprazole 20 mg PO BID
4. Epoetin Alfa 10,000 UNIT IV 3X/WEEK (___)
5. Gabapentin 300 mg PO Q48H
6. Aspirin 81 mg PO DAILY
7. OxycoDONE (Immediate Release) 10 mg PO Q8H:PRN pain
8. Albuterol-Ipratropium 2 PUFF IH Q6H:PRN shortness of breath
9. DiphenhydrAMINE 25 mg PO BID:PRN itch
10. Fluoxetine 10 mg PO DAILY
11. Calcium Acetate 1334 mg PO TID W/MEALS
12. Bisacodyl 10 mg PR HS:PRN constipation
13. Amlodipine 10 mg PO DAILY
Discharge Medications:
1. Amlodipine 10 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Bisacodyl 10 mg PR HS:PRN constipation
4. Calcium Acetate 1334 mg PO TID W/MEALS
5. Epoetin Alfa 10,000 UNIT IV 3X/WEEK (___)
6. Gabapentin 300 mg PO Q48H
7. Fluoxetine 10 mg PO DAILY
8. Milk of Magnesia 30 mL PO Q6H:PRN constipation
9. Nephrocaps 1 CAP PO DAILY
10. Omeprazole 20 mg PO BID
11. OxycoDONE (Immediate Release) 10 mg PO Q8H:PRN pain
12. Benzonatate 100 mg PO TID cough
RX *benzonatate 100 mg 1 capsule(s) by mouth three times a day
Disp #*21 Capsule Refills:*0
13. Guaifenesin ___ mL PO Q6H:PRN cough
14. Albuterol-Ipratropium 2 PUFF IH Q6H:PRN shortness of breath
15. Acetaminophen 325-650 mg PO Q6H:PRN pain
16. DiphenhydrAMINE 25 mg PO BID:PRN itch
Discharge Disposition:
Home
Discharge Diagnosis:
Cough
Viral bronchitis
End stage renal disease
Type 2 diabetes mellitus
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Level of Consciousness: Alert and interactive.
Followup Instructions:
___
Radiology Report
HISTORY: Cough and low-grade fever for 1 week.
TECHNIQUE: Upright AP and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
The heart remains moderately enlarged. Dense mitral annular calcifications
are re- demonstrated, and there is unchanged enlargement of the main pulmonary
artery. Mild pulmonary vascular engorgement appears slightly improved
compared to the prior study. Aeration of the lung bases is also improved. No
large pleural effusion or pneumothorax is identified, though there is trace
blunting of the right costophrenic angle laterally. No pneumothorax is
identified. No acute osseous abnormalities seen.
IMPRESSION:
Mild pulmonary vascular engorgement, slightly improved when compared to the
prior exam. Improved aeration of the lung bases with resolution of the
previously noted bibasilar airspace opacities.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: FEVER COUGH
Diagnosed with ACUTE BRONCHITIS, ABNORM ELECTROCARDIOGRAM, FAILURE TO THRIVE,ADULT
temperature: 98.6
heartrate: 59.0
resprate: 16.0
o2sat: 98.0
sbp: 164.0
dbp: 51.0
level of pain: 8
level of acuity: 2.0 | Acute issues:
# Cough and myalgias: Clinical picture consistent with viral
syndrome (including myalgias and possible costochondritis). No
signs of pneumonia on CXR, WBC not elevated, patient afebrile
throughout admission, so antibiotics were not started. Patient
treated symptomatically with guaifenansin, tessalon pearls,
tylenol and albuterol and reported symptomatic improvement.
# ESRD: Patient on MWF dialysis schedule, received dialysis on
___ as scheduled.
# Hypertension: Patient hypertensive to the 170s on admission,
likely due to the fact that she missed her morning meds on the
day of admission. She had no signs or symptoms of malignant
hypertension. She was continued on amlodipine. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Carboplatin / Ibuprofen
Attending: ___
Chief Complaint:
Bright bred blood per rectum
Acute on chronic renal failure
Metastatic Ovarian Cancer
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of recurrent metastatic ovarian cancer
currently undergoing treatment with gemcitabine overseen by
oncologist at ___ (most recent treatment this week),
history of bowel perforation c/b colectomy with ileostomy who
presents with a history of bright red blood per rectum. She has
had 4 episodes over the past day of several teaspoons each. She
has also had tenderness in the lower abdomen. Of note, she had
similar symptoms in ___, for which she was admitted to the
OMED service. Flexible sigmoidoscopy at that time was normal,
and INR was markedly elevated during that admission (now 1.1).
In the ED, initial vitals were T 98, BP 114/75, RR 18, O2 98% on
RA. Rectal exam was notable no fisures or hemmorhoids, no active
bleeding. CT abdomen pelvis was done, which showed findings
concerning for the progression of her metastatic disease but no
obvious explanation for the bleeding. Labs were notable for
acute on chronic renal failure with creatinine of 3.0 from ___
at time of last discharge, and HCO3 of 13 with AG of 16. She
received 4 mg IV Zofran and 5 mg IV morphine. She was admitted
to the medicine service for further management. Vitals on
transfer to the floor were BP 133/84, T 98.4, RR 16, O2 sat
95-96% ( check on left great toe), HR 92.
Past Medical History:
Oncologic History
- Recurrent metastatic ovarian cancer s/p TAH/BSO debulking and
chemotherapy. She was initially diagnosed with stage IIC ovarian
cancer at the time of exploratory laparotomy on ___. She
received carboplatin and Taxol therapy ___ until ___.
She was noted to have rising CA-125 up to 117 in ___. CT scan
showed no convincing areas of disease. The patient underwent
laparoscopic evaluation by Dr. ___ multiple tiny
peritoneal implants were seen and biopsy was consistent with
recurrent adenocarcinoma ovarian primary. CA-125 rose to 185
and she was initiated on carboplatin in ___. Following three
cycles, she developed carboplatin allergy and was switched to
Doxil, which she received from ___ until ___. She was then
started on Arimidex in ___. She had been stable until ___ when
she developed abominal pain, concern for acute appendicitis, and
underwent lap appy by Dr. ___ revealed several
carcinoma implants along both hemidiaphragms, the right lobe of
the liver, and the lower abdomen on the sigmoid colon and
appendix; she also had a small amount of ascites.
- s/p C6 of Gemcitabine ___ sees an Oncologist at ___
Dr. ___
- bowel perforation with ___ exlap with right colectomy and
end ileostomy
- Osteopenia, mild
- DVT left leg ___ on coumadin
- appendectomy ___
- Admitted from ___ for an abdominal wall abscess. Since
there was no evidence of communicating fistula between pouch and
abdominal wall and that the area of the abscess was close to the
staple line from the pouch, it was thought to be due to skin
flora or GI seeding from local ostomy. Surgery drained the
abscess in the ER. Her hospital course was complicated by
Enterococcal and Klebsiella bactermia treated with Zosyn for 10
days from ___
Social History:
___
Family History:
Mother and father with CAD. Mother with ovarian cancer.
Physical Exam:
Admission Physical Exam:
Vitals: 98.6 134/82 106 20 94 RA
GENERAL: Well-appearing in NAD, comfortable, appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no thyromegaly, no JVD, no carotid bruits.
HEART: RRR, no MRG, nl S1-S2.
LUNGS: Crackles bilaterally starting at the bases and present
half-way to the apex, no ronchi/rales/wheezes, good air
movement, resp unlabored.
ABDOMEN: Soft/ND, exquisitely tender to palpation in LLQ but
otherwise non-tender, ileostomy pink and productive of yellow
stool, no masses or HSM
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: Sequelae of Raynaud's phenomenon on distal finger tips
bilaterally.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, moving all
extremities well
Discharge Physical Exam:
Vitals: 98.6 94 103/63 20 100%RA
GENERAL: Well-appearing, fatigued, appropriate.
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear.
NECK: Supple, no JVD, no carotid bruits
HEART: RRR, no MRG, nl S1-S2.
LUNGS: Lungs with crackles half way up, no ronchi/rales/wheezes,
good air movement, resp unlabored.
ABDOMEN: Soft/ND, mild tenderness in LLQ>LUQ, ileostomy pink and
productive of yellow stool, no masses or HSM
EXTREMITIES: WWP, no c/c/e, 2+ peripheral pulses.
SKIN: Sequelae of Raynaud's phenomenon on distal finger tips
bilaterally.
LYMPH: No cervical LAD.
NEURO: Awake, A&Ox3, CNs II-XII grossly intact, moving all
extremities well
Pertinent Results:
Admission labs:
___ 09:50PM BLOOD WBC-10.8# RBC-2.65* Hgb-8.7* Hct-27.4*
MCV-103* MCH-32.8* MCHC-31.8 RDW-19.2* Plt ___
___ 09:50PM BLOOD ___ PTT-25.0 ___
___ 09:50PM BLOOD Glucose-95 UreaN-58* Creat-3.0* Na-136
K-4.1 Cl-107 HCO3-13* AnGap-20
___ 09:25AM BLOOD Calcium-9.0 Phos-4.1 Mg-1.4*
___ 11:01PM BLOOD Lactate-1.7 K-3.7
___ 12:05AM URINE Color-Straw Appear-Hazy Sp ___
___ 12:05AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-NEG
___ 12:05AM URINE RBC-0 WBC-0 Bacteri-NONE Yeast-NONE Epi-0
___ 12:05AM URINE CastGr-5*
___ 12:05AM URINE Uric AX-FEW
___ 12:05AM URINE Hours-RANDOM UreaN-576 Creat-63 Na-57
K-33 Cl-71 HCO3-<5
___ 12:05AM URINE Osmolal-429
CT ABD/PELVIS
IMPRESSION:
1. Interval increase in the small-to-moderate amount of
abdominopelvic
ascites, concerning for progression of metastatic disease. Known
metastatic
ovarian cancer, with multiple retroperitoneal, mesenteric, and
pelvic
metastasis and subcapsular hepatic implants.
2. No evidence of colitis, bowel obstruction or abdominal wall
abscess.
The study and the report were reviewed by the staff radiologist.
___. ___
___. ___
___ ___ 4:54 ___
Chest X-Ray
FINDINGS: There is no definite consolidation, pleural effusion,
pneumothorax
or evidence of pulmonary edema. The cardiomediastinal silhouette
is normal.
There are no acute skeletal abnormalities.
IMPRESSION: No acute cardiopulmonary process.
The study and the report were reviewed by the staff radiologist.
___. ___
___. ___
___ ___ 9:57 ___
Renal Ultrasound:
No hydronephrosis, one simple cyst in each kidney, no anatomic
abnormalities
Rheumatology Consultation:
GENERAL SUMMARY AND IMPRESSION:
___ F with history of metastatic ovarian cancer with liver and
peritoneal mets and studding of sigmoid colon undergoing chemo
with gemcitabine (last treatment this past week) who was
admitted for rectal bleeding but was noted to have ischemic
digits. Based on clinical history and presentation, the lesions
on her fingers are most consistent with gemcitabine induced
digital ischemia and necrosis which has been described in
several case reports. Another possibility would be a
paraneoplastic acral necrosis, but given the fact that her
presentation coincides with gemcitibine use, this is the most
likely etiology. The patient does not have findings by clinical
history or physical exam to suggest an underlying connective
tissue disease such as scleroderma or lupus.
RECOMMENDATIONS:
1. Evaluation by dermatology for ?biopsy to look for evidence of
underlying vasculitis lesions.
2. Would defer to oncology whether continued treatment with
gemcitibine is absolutely necessary or whether there are any
alternatives.
3. Would treat with steroids - Prednisone 30mg daily - in the
meantime. Can add Norvasc 2.5mg daily if BP tolerates (with
holding parameters). Also add daily Aspirin if GI approves
(given h/o GIB).
4. To complete her w/u, add ___ to labs as well as
antiphospholipid antibody panel (lupus anticoagulant,
anticardiolipin IgG/IgM, B2 GP).
Dermatology Consultation:
___ with met ovarian CA on gemcitabine since ___ on whom
we are c/s for digital ulcers that started after the gemcitabine
in Feburary of this year. We are c/s for cause of ulcer and
?CTD. Based on history, it seems most c/w a gemcitabine induced
raynauds/scleroderma like picture. This has been reported in the
literature ___ et al, Radiol Oncol ___ Vénat-Bouvet L et
al, Anticancer Drugs, ___, and these brief reports indicate
vascular etiologies or necrotizing vasculitides as the
underlying cause of the ulcer. Ultimately, the purple
discoloration, scleroderma like changes, would lead us to
consider treatment of vasospasm in the usual manner as the first
line of therapy (eg: nifedipine/amlodipine over other CCB). Most
studies indicate nifedipine as the CCB of choice (___ et
al. Am Heart J ___ 111: 7425; ___ et al. Br Med J
___ 298: 5614). A w/u of primary rheumatologic disorders is
reasonable, and if concerned about a focal sclerosing condition,
we would favor sending anti-centromere for a CREST syndrome.
RECOMMENDATIONS:
- Agree with current w/u. Would also consider sending
anti-centromere for CREST, and less helpful would be anti-Scl70
for systemic sclerosis.
- ___ defer titration of CCB to rheumatology. If possible,
would consider switching to nifedipine as most studies report
efficacy with this drug.
- Can bx, however hesitant to do so at this time given pt's
desire and desire to avoid poor wound healing.
Discharge Labs:
___ 07:45AM BLOOD WBC-13.1* RBC-2.94* Hgb-9.3* Hct-29.4*
MCV-100* MCH-31.8 MCHC-31.8 RDW-19.5* Plt ___
___ 07:45AM BLOOD Plt ___
___ 07:30AM BLOOD ACA IgG-PND ACA IgM-PND
___ 07:30AM BLOOD Lupus-PND
___ 07:45AM BLOOD Glucose-95 UreaN-48* Creat-3.1* Na-133
K-3.4 Cl-106 HCO3-13* AnGap-17
___ 07:45AM BLOOD Calcium-8.7 Phos-3.4 Mg-1.7
___ 07:30AM BLOOD SCLERODERMA ANTIBODY-PND
___ 07:30AM BLOOD BETA-2-GLYCOPROTEIN 1 ANTIBODIES (IGA,
IGM, IGG)-PND
Medications on Admission:
Omeprazole 20 mg PO daily
Discharge Medications:
1. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
2. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
Disp:*30 Tablet, Chewable(s)* Refills:*0*
3. vancomycin 125 mg Capsule Sig: One (1) Capsule PO Q6H (every
6 hours) for 12 days.
Disp:*48 Capsule(s)* Refills:*0*
4. nifedipine 10 mg Capsule Sig: One (1) Capsule PO Q8H (every 8
hours).
Disp:*90 Capsule(s)* Refills:*0*
5. ondansetron HCl 4 mg Tablet Sig: One (1) Tablet PO three
times a day as needed for nausea.
Disp:*10 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Clostridium difficile colitis
Rectal bleeding
Hemorrhoids
Acute on chronic renal failure
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with abdominal pain and rectal bleeding. The
patient's past history is significant for right colectomy , ileostomy for
colonic perforation and metastatic ovarian cancer.
TECHNIQUE: Multidetector CT imaging of the abdomen and pelvis was obtained
without intravenous contrast. Intravenous contrast was deferred due to the
patient's elevated creatinine of 3.2. Sagittal and coronal reformations were
performed.
FINDINGS: The imaged lung bases demonstrate mild dependent atelectasis, no
pleural or pericardial effusion is seen.
Hypodense serosal implant along the segment IV of the liver (2:16) now
measures 2.2 x 1.7 cm, and is not significantly changed since the earlier
study of ___. Additional smaller serosal hepatic implants are not well
evaluated in this non-contrast study. The gallbladder is mildly distended.
There is no intrahepatic biliary dilatation. There is diffuse thickening of
both adrenal glands, consistent with adrenal hyperplasia. No hydronephrosis
or renal stones are seen. A 12 mm exophytic lesion in the right kidney (2:39)
and 16 mm exophytic lesion in the lower pole of the left kidney (2:43) are
consistent with hyperdense cysts and are unchanged since the prior study. The
patient is status post right hemicolectomy and right lower quadrant ileostomy.
There is no evidence of bowel obstruction. There is moderate amount of
abdominal and pelvic ascites, which has increased in size since earlier study
of ___. Known infiltrative masses in the region of the porta
hepatis/mesenteric root , abdominal adenopathy and peritoneal deposits, are
not well evaluated in this non-contrast study, but grossly appear similar to
the recent prior study. There is no intra-abdominal free air. A small
fat-containing epigastric hernia is noted.
CT OF THE PELVIS WITHOUT INTRAVENOUS CONTRAST: The urinary bladder is normal.
Again seen is an enlarged right perirectal lymph node measuring 12 mm, stable
since the prior study. Previously, noted heterogeneous wall thickening along
the base of the bladder, is redemonstrated. The patient is status post
hysterectomy and salpingo-oophorectomy for ovarian cancer.
BONES AND SOFT TISSUES: No lytic or sclerotic bone lesion is detected.
IMPRESSION:
1. Interval increase in the small-to-moderate amount of abdominopelvic
ascites, concerning for progression of metastatic disease. Known metastatic
ovarian cancer, with multiple retroperitoneal, mesenteric, and pelvic
metastasis and subcapsular hepatic implants.
2. No evidence of colitis, bowel obstruction or abdominal wall abscess.
Radiology Report
INDICATION: ___ woman with metastatic ovarian cancer and bilateral
crackles. Assess for pulmonary edema, pneumonia, infiltrate, or effusion.
COMPARISONS: PA and lateral chest radiograph from ___.
FINDINGS: There is no definite consolidation, pleural effusion, pneumothorax
or evidence of pulmonary edema. The cardiomediastinal silhouette is normal.
There are no acute skeletal abnormalities.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
ABDOMINAL RADIOGRAPH OF ___
COMPARISON: CT of ___.
FINDINGS: The patient is status post right colectomy and ileostomy. A
non-obstructive bowel gas pattern is visualized. Questionable focal
thickening of small bowel folds is noted in the right mid abdomen, difficult
to assess on this single portable radiographic exam. Given clinical suspicion
for bowel disease and history of metastatic ovarian cancer, a CT would be more
sensitive for evaluating the abdominal structures and may be considered if
warranted clinically. Within the imaged portion of the lung bases, there is
apparent increasing small left pleural effusion as well as adjacent
consolidation or atelectasis at the left base, incompletely evaluated on this
radiograph.
Radiology Report
REASON FOR EXAMINATION: Metastatic ovarian cancer with crackles suspected
volume overload.
PA and lateral upright chest radiographs were reviewed in comparison to ___.
There is interval progression of left lower lobe opacity, highly concerning
for infectious process. Bilateral pleural effusions are present, small.
Right lower lobe linear atelectasis is new as well. There is no pneumothorax.
Heart size and mediastinum are stable.
IMPRESSION:
Interval increase in left pleural effusion as well as left basal opacities
that might reflect interval development of infectious process. No evidence of
pulmonary edema. Small right pleural effusion is unchanged. New right basal
atelectasis is small.
Radiology Report
HISTORY: ___ woman with metastatic ovarian cancer, acute on chronic
renal failure.
COMPARISON: Liver ultrasound ___.
FINDINGS:
The right kidney measures 10.2 cm and the left kidney measures 9.6 cm. There
is no hydronephrosis. A simple cyst is seen in the posterior margin of the
right kidney measuring 1.5 x 0.9 x 1.6 cm. A simple cyst is seen in the lower
pole of the left kidney measuring 1.7 x 1.3 x 1.3 cm. There is no stone or
suspicious solid mass seen in either kidney. No perinephric fluid collection
is identified. The urinary bladder is minimally distended and is
unremarkable. There is a trace of ascites is again seen in the pelvis.
IMPRESSION:
No hydronephrosis. A small simple cyst is seen bilaterally in the kidneys.
Trace ascites.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABD PAIN, RECTAL BLEEDING
Diagnosed with ABDOMINAL PAIN UNSPEC SITE, ACUTE KIDNEY FAILURE, UNSPECIFIED, CHRONIC KIDNEY DISEASE, UNSPECIFIED, RECTAL & ANAL HEMORRHAGE, SECOND MALIG NEO LIVER, SEC MAL NEO PERITONEUM, HX OF OVARIAN MALIGNANCY, HX OF COLONIC MALIGNANCY
temperature: nan
heartrate: 98.0
resprate: 18.0
o2sat: 98.0
sbp: 114.0
dbp: 75.0
level of pain: 0
level of acuity: 2.0 | FAX DISCHARGE SUMMARY TO PCP'S OFFICE
#Bright Red Blood Per Rectum (BRBPR)--The patient initially
noted the bleeding, a few tablespoons over three different
instances, the day prior to admission. Throughout the remainder
of her hospital course, she noticed passing a couple of small
clots. Her hematocrits were trended throughout and slowly
declined (possibly related to multiple lab draws), and she
received 1U PRBC. The GI team was consulted, and they felt the
most likely cause of the bleeding was from hermorrhoids. They
felt there was no need for a sigmoidoscopy at this time given
her recent scope which showed no correctable anatomic lesions.
They recommended steroid suppositories which the patient was
started on. Given C.diff infection, they recommended stopping
the suppositories especially as her bleeding had improved.
#C. diff colitis--the patient showed a marked leukocytosis from
admission (WBC on admission 10, peaked at 17), and a C diff PCR
assay showed a positive C diff infection. She was initially
treated with IV flagyl, but ultimately developed
nausea/vomiting. The IV flagyl was discontinued and she was
transitioned to PO vancomycin. The GI team was consulted to
ensure that the PO vancomycin would provide adequate intestinal
coverage given that the patient was in discontinuity, and they
commented that the infection was likely in the small bowel
(given that the sample was sent from the ostomy) and that PO
vancomycin would provide adequate treatment. She was continued
on PO vancomycin and ___ need continued therapy through
___.
#Abdominal pain/nausea/vomiting--The patient was initially noted
to have exquisite tenderness in her LLQ upon admission. This
pain ultimately shifted to the LUQ, and the LLQ was no longer
painful. Her CT scan showed no acute intraabdominal process such
as diverticulitis or obstruction. Notably, the pain was only
present upon palpation of the abdomen and not present at rest.
On hospital day 3, after starting on IV flagyl, she developed
nausea and vomiting. She received a KUB, which showed a normal
bowel gas pattern. She was started on an anti-emetic regimen
including ondansetron and prochlorperazine, with good effect.
Her ostomy output during this time was entirely normal. Upon
discharge, she was no longer nauseous or vomiting and was taking
a regular diet.
#Acute on Chronic Renal Failure--Creatinine upon admission was
3.0, up from a baseline of 2.5 on ___. Urine studies were
sent and her FENa was 2.0%, indicating an intrinsic renal cause.
She received a renal ultrasound, which was negative. Her renal
function ___ need continued follow-up upon discharge, as it
appears to be continuing to decline. She was set up with a
nephrology follow-up here at the ___.
#Skin Ulcers--The patient was suffering from severe skin damage
and pain on her distal finger tips with ulcerations on many of
her fingers. It was further noted that the patient's hands may
also have sclerodactyly. Accordingly, a rheumatology consult was
order, and they felt the lesion was more consistent with
gemcitabine induced digital ischemia and necrosis. A dermatology
consultation was ordered and concurred that the most likely
etiology was gemcitabine induced condition as reported in the
literature ___ et al, Radiol Oncol ___ ___ et
al, Anticancer Drugs, ___. An extensive rheumatologic
serological work-up was ordered to rule out any alternative
rheumatologic causes, the results were pending up until right
before the patient was discharged and ___ was found to be very
positive with high titer. Rheumatology recommended the patient
follow up as an outpatient with the first available appointment.
She was started on nifidipine TID and aspirin 81 mg to relieve
the vasospastic component of the skin necrosis. The patient
reports significantly improved feeling in her fingers upon
discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Bactrim / Percodan / Shellfish / Aspirin / NSAIDS / erythromycin
base / Zithromax / Zosyn / tetracycline / Sulfa (Sulfonamide
Antibiotics)
Attending: ___
Chief Complaint:
Weakness, Diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ ___ F ___ ___
Note History
Note Date: ___ Time: 0006
Note Type: Initial note
Note Title: Resident Admission Note
Signed by ___, MD on ___ at 12:06 am Affiliation:
___
==============================================================
___ ADMISSION NOTE
Date of Admission: ___
==============================================================
PCP: ___.
Outpatient Nephrologist: Dr. ___
CHIEF COMPLAINT: weakness
HISTORY OF PRESENTING ILLNESS:
This is an ___ woman with Gaucher's disease on cerezyme
infusions, ESRD s/p living donor renal transplant (___), CKD
II,
recurrent C. diff infections, rectal prolapse, recent admission
___ for abdominal pain attributed to complicated UTI who
presents with weakness and one bloody bowel movement.
She had a recent admission ___ for abdominal pain that was
attributed to a complicated UTI. She was treated with 1 week of
cipro for UTI and given PO vancomycin given h/o C. diff for
prophylaxis. Urine culture on review was notable for mixed
bacterial flora, no culprit organism identifed and worry was for
contamination covering up a true UTI. However, when she was
discharged home, her symptoms of intermittent abdominal pain
largely persisted. She also developed some loose stools over the
last couple days, that were soft rather than watery. She
finished
taking cipro and the PO vancomycin yesterday.
This morning, she had some blood with her bowel movement, bright
red but unable to quantify (seemed to be a relatively small
amount). This has happened once before and she is nor confident
that this was worked up. does have known rectal prolapse and
has
been having rectal irritation worse than baseline recently. She
has not had further BRBPR. Prior to and following this bloody
BM,
she felt lousy and weak today and was having trouble getting up
and moving about. Her son who takes care of her at home was
concerned and reached out to her ___, but accidentally called
her
PCP. He spoke to her PCP who offered to have her come in to be
seen, but pt's son was concerned and discussed bringing her in
to
be seen in the ER.
In the ED initial vitals were T98.6, HR 80, BP 190/60, RR 16,
98% on RA.
- Exam notable for: bibasilar crackles, rectal exam with GUAIAC
negative brown stool
- Labs notable for: baseline anemia H/H 8.4/25.8, Cr 2.0 near
baseline, no leukocytosis, UA with large leuks, negative nitrite
>82 WBC, mod bacteria
- Imaging notable for: renal transplant within normal
- Consults: transplant nephrology
- Patient was given: 2g cefepime, PO vanc 125mg
On the floor, she noted that she had not eaten anything prior to
arrival in the ED. She began to feel more herself this evening.
She denied fevers, chills, worsening abdominal pain, dysuria,
N/V, or liquid stools. He has stooled twice today, but thought
it
was more frequently yesterday.
REVIEW OF SYSTEMS: Positive per HPI, remaining 10 point ROS
reviewed and negative.
Past Medical History:
-- ___ disease diagnosed in ___. On Cerezyme infusions.
-- Osteoporosis
-- Stage III CKD; s/p renal transplant from related donor (son)
for renal failure d/t pamidronate-induced segmental
glomerulosclerosis with collapsing features in ___. Course
complicated by acute graft rejection TX with Thymoglobulin, high
dose corticosteroids and plasmapheresis with preservation of
transplanted kidney and normalization of renal function; on
chronic immunosuppression with prednisone, CellCept and
tacrolimus.
-- Asthma
-- HTN
-- Hyperlipidemia
-- Trigeminal neuralgia
-- Bladder cystocele managed with pessary placement,
Premarin-followed by GYN, Dr. ___
-- ___
-- Osteoarthritis
-- s/p abscess/cellulitis L breast
-- Hard of hearing
Social History:
___
Family History:
Mother died of cardiac issues and PE. Father had bladder cancer
and DM
Parents were first cousins and both carried ___ trait.
5 siblings-2 brothers and 3 sisters. ___ brother died of
cardiac issues. 1 sister died of complications of Gaucher. Twin
sister (___) also with ___ in a milder form. Other sister
w/o ___.
Physical Exam:
================================
ADMISSION PHYSICAL EXAMINATION:
================================
VS: T98.6, HR 80, BP 190/60, RR 16, 98% on RA.
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, ___ SEM. NO gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles . Bibasilar crackles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly. Tenderness to deep
palpation on LLQ
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
=========================
DISCHARGE PHYSICAL EXAM:
=========================
GENERAL: NAD, elderly appearing female, interactive. alert and
oriented.
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, ___ SEM. NO gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles . Bibasilar crackles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly. Tenderness to deep
palpation on LLQ
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 12:09PM BLOOD WBC-8.2 RBC-2.69* Hgb-8.4* Hct-25.8*
MCV-96 MCH-31.2 MCHC-32.6 RDW-13.1 RDWSD-45.1 Plt ___
___ 12:09PM BLOOD Neuts-80.2* Lymphs-10.0* Monos-8.2
Eos-0.0* Baso-0.4 Im ___ AbsNeut-6.54* AbsLymp-0.82*
AbsMono-0.67 AbsEos-0.00* AbsBaso-0.03
___ 11:18AM BLOOD ___ PTT-29.0 ___
___ 11:18AM BLOOD Glucose-103* UreaN-51* Creat-2.0* Na-143
K-4.4 Cl-108 HCO3-20* AnGap-15
___ 06:05AM BLOOD ALT-9 AST-14 LD(LDH)-225 AlkPhos-54
TotBili-0.4
___ 11:18AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.0
___ 04:10PM BLOOD TSH-2.0
___ 06:05AM BLOOD tacroFK-3.1*
PERTINENT INTERVAL LABS:
___ 08:42AM STOOL NoroGI-NEGATIVE NoroGII-NEGATIVE
MICROBIOLOGY:
___ URINE URINE CULTURE-FINAL NEGATIVE.
___ STOOL C. difficile PCR-FINAL NEGATIVE
DISCHARGE LABS:
___ 04:35AM BLOOD WBC-7.4 RBC-2.66* Hgb-8.4* Hct-25.2*
MCV-95 MCH-31.6 MCHC-33.3 RDW-13.1 RDWSD-45.0 Plt ___
___ 04:35AM BLOOD Plt ___
___ 04:35AM BLOOD UreaN-52* Creat-1.9* Na-143 K-4.6 Cl-108
HCO3-21* AnGap-14
___ 04:35AM BLOOD ALT-8 AST-14 AlkPhos-54 TotBili-0.3
___ 04:35AM BLOOD Calcium-8.7 Phos-3.5 Mg-2.2
___ 04:35AM BLOOD tacroFK-3.7*
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB/Wheeze
3. amLODIPine 10 mg PO DAILY
4. Calcitriol 0.25 mcg PO 3X/WEEK (___)
5. Calcium Carbonate 750 mg PO TID
6. Furosemide 20 mg PO EVERY OTHER DAY
7. Labetalol 200 mg PO TID
8. Losartan Potassium 100 mg PO DAILY
9. Mycophenolate Mofetil 250 mg PO BID
10. PredniSONE 5 mg PO DAILY
11. Sertraline 125 mg PO DAILY
12. Simvastatin 40 mg PO QPM
13. Sodium Bicarbonate 650 mg PO BID
14. Tacrolimus 1 mg PO Q12H
15. Vitamin D 1000 UNIT PO 4X/WEEK (___)
16. Zolpidem Tartrate 5 mg PO QHS
17. Vancomycin Oral Liquid ___ mg PO/NG Q6H
18. imiglucerase 3200 units injection EVERY 2 WEEKS
19. raloxifene 60 mg oral DAILY
Discharge Medications:
1. Acetaminophen 500 mg PO Q8H:PRN Pain - Mild
2. Albuterol Inhaler ___ PUFF IH Q6H:PRN SOB/Wheeze
3. amLODIPine 10 mg PO DAILY
4. Calcitriol 0.25 mcg PO 3X/WEEK (___)
5. Calcium Carbonate 750 mg PO TID
6. Furosemide 20 mg PO EVERY OTHER DAY
7. imiglucerase 3200 units injection EVERY 2 WEEKS
8. Labetalol 200 mg PO TID
9. Losartan Potassium 100 mg PO DAILY
10. Mycophenolate Mofetil 250 mg PO BID
11. PredniSONE 5 mg PO DAILY
12. raloxifene 60 mg oral DAILY
13. Sertraline 125 mg PO DAILY
14. Simvastatin 40 mg PO QPM
15. Sodium Bicarbonate 650 mg PO BID
16. Tacrolimus 1 mg PO Q12H
17. Vancomycin Oral Liquid ___ mg PO Q6H
RX *vancomycin 125 mg 1 capsule(s) by mouth four times a day
Disp #*12 Capsule Refills:*0
18. Vitamin D 1000 UNIT PO 4X/WEEK (___)
19. Zolpidem Tartrate 5 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Acute Issues:
#Diarrhea
Chronic Issues:
#History of recurrent C. diff
#Hypertension
#Normocytic anemia
#S/P LLRT ___
#Depression
#Insomnia
#Mineral metabolism
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: RENAL TRANSPLANT U.S.
INDICATION: ___ female with end-stage renal disease status post renal
transplant in ___ presenting with generalized weakness and urinary tract
infection. Evaluate allograft function.
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: Renal transplant ___
FINDINGS:
There is a right iliac fossa transplant renal morphology. Fullness of the
renal collecting system in the upper and interpolar regions of the transplant
kidney are grossly unchanged as compared to renal transplant ___. There is no perinephric fluid collection.
The resistive index of intrarenal arteries ranges from 0.69 to 0.80, within
the normal range, and improved as compared to ___. The
intrarenal arterial waveforms of are normal and there is evidence of diastolic
flow in the intrarenal arteries, improved from ___. The main
renal artery shows a normal waveform, with prompt systolic upstroke and
continuous antegrade diastolic flow, with peak systolic velocity ranging from
111 to 117 centimeters/second, previously ranging from 76 to 142
centimeters/second on ___. Vascularity is symmetric throughout
transplant. The transplant renal vein is patent and shows normal waveform.
IMPRESSION:
1. Fullness of the renal collecting system in the upper pole and interpolar
region of the transplant kidney is grossly unchanged as compared to renal
transplant ultrasound ___.
2. Interval improvement in arterial flow in the intrarenal arteries of the
transplant kidney. Specifically, the intrarenal arteries demonstrate normal
waveforms and demonstrate normal diastolic flow, improved from ___, when there was no diastolic flow demonstrated.
3. No perinephric fluid collection.
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with weakness// pna?
TECHNIQUE: AP upright and lateral chest
COMPARISON: ___.
FINDINGS:
AP upright and lateral views the chest provided. Midline sternotomy wires are
again seen with underlying mediastinal clips. The heart remains mildly
enlarged. Lungs are clear without focal consolidation, pneumothorax or signs
of edema. Subtle blunting at the right costophrenic recess on the lateral
view may reflect a tiny pleural effusion. Aortic calcifications are similar
to prior. A vascular stent is again seen projecting over the superior
mediastinum. Imaged bony structures are intact.
IMPRESSION:
Probable tiny left pleural effusion. Stable mild cardiac enlargement. No
signs of pneumonia.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness
Diagnosed with Urinary tract infection, site not specified
temperature: 98.6
heartrate: 80.0
resprate: 16.0
o2sat: 98.0
sbp: 190.0
dbp: 60.0
level of pain: 0
level of acuity: 3.0 | ASSESSMENT & PLAN:
___ woman with ESRD s/p living donor renal transplant
(___), CKD II, recurrent C. difficile, and history of Ga___'s
disease on cerezyme infusion, presenting with one bloody bowel
movement, loose BMs, and weakness. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
s/p fall, failure to thrive, confusion
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ y/o male with a past medical history of dementia, ADHD,
depression and anxiety who presented from his ALF with FTT and
s/p fall. History is extremely limited as patient is unable to
provide a detailed history and ALF was unable to provide a
history overnight (called, however person covering did not know
the patient and did not provide collateral history). Per the ED,
patient has had a rapid decline over the past several months. He
currently lives at an assisted living facility ___
___) and he has been difficult to care for. There
is concern that his decompensation could be psychiatric related
and in the past he has had issues with polypharmacy. Patient
reportedly has had multiple falls and recently had a fall today.
In the ED, initial VS were T 97.8, HR 94, BP 154/82, RR 18, 92%
RA. Labs were notable for a normal WBC, normal Hb, PLT 134,
normal electrolytes and renal function. Lactate 1.2. UA was
negative for UTI. BCx obtained. CT C-spine with no fracture but
degenerative changes. CT head w/o acute process. CXR showed no
acute process.
On arrival to the floor, T 97.7, BP 135/94, HR 95, RR 20, 95%
RA, weight 67.1 kg. Patient was resting in bed and in no acute
distress, but withdrawn and slow to respond. Patient stated he
was brought to the hospital but does not know why. Complained of
feeling confused for quite some time now. Denied hallucinations.
Denied HI. Stated that he "would like to go to sleep and never
wake up" and would like to die in a "passive way". Reports that
years ago he overdosed on aspirin.
Past Medical History:
PAST PSYCHIATRIC HISTORY:
Hospitalizations: Pt reports several past hospitalizations but
was unable to provide definitive details
Current treaters and treatment: Dr. ___, psychiatrist,
and
___, therapist, at ___
(___)
Medication and ECT trials: Currently takes fluoxetine 40mg PO
daily, seroquel 25mg PO BID prn, and bupropion 300mg PO
Self-injury: pt vaguely mentioned a past aspirin overdose
Harm to others: unknown
Access to weapons: unknown
PAST MEDICAL HISTORY, per ___ note written by PCP, ___, on ___, confirmed with pt and updated today:
HTN
HLD
DM
CAD
AF
Paroxysmal SVT
Low-tension glaucoma
___: Admitted for confusion and gait disturbance. Was
discharged on same day to ___.
Social History:
___
Family History:
FAMILY PSYCHIATRIC HISTORY:
Father had dementia and depression
Mother had depression
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS - T 97.7, BP 135/94, HR 95, RR 20, 95% RA, weight 67.1 kg
GENERAL: alert, withdrawn, oriented to self, place (hospital).
Patient did not know the year initially but when provided
multiple choice options he said "it may be ___, but I don't
know"
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM, good dentition
NECK: nontender supple neck, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing or edema, moving all 4
extremities with purpose
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact, ___ ___ strength, sensation intact to
soft touch, normal FNF, no pronator drift, no asterixis, +
essential tremor, toes down b/l, impaired proprioception
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vital Signs: 98.1, 156/84, 95, 20, 95% on RA
General: Oriented to person, knows he is in hospital, but not
sure which
HEENT: sclera anicteric, MMM
Lungs: clear to auscultation b/l, no wheezes/rales/rhonchi
CV: RRR, nl S1, S2, no murmurs, rubs, gallops
Abdomen: soft, NT, ND, NABS, no HSM
Ext: WWP, no ___ edema
Skin: no rash
Neuro: CN ___ intact, normal strength and sensation in upper
and lower extremities, (+) intention tremor, (+) pronator drift
R > L, no dysdiadochokinesis, gait deferred
Pertinent Results:
ADMISSION LABS:
___ 08:50PM BLOOD WBC-8.1 RBC-4.93 Hgb-14.7 Hct-43.1 MCV-87
MCH-29.8 MCHC-34.1 RDW-12.5 RDWSD-39.7 Plt ___
___ 08:50PM BLOOD Neuts-62.6 ___ Monos-7.7 Eos-1.1
Baso-0.7 Im ___ AbsNeut-5.09 AbsLymp-2.24 AbsMono-0.63
AbsEos-0.09 AbsBaso-0.06
___ 08:50PM BLOOD Plt ___
___ 08:50PM BLOOD Glucose-159* UreaN-13 Creat-0.6 Na-138
K-3.8 Cl-99 HCO3-26 AnGap-17
___ 08:55PM BLOOD Lactate-1.2
DISCHARGE LABS:
___ 07:30AM BLOOD WBC-6.8 RBC-4.77 Hgb-14.3 Hct-41.8 MCV-88
MCH-30.0 MCHC-34.2 RDW-12.6 RDWSD-39.8 Plt ___
___ 07:30AM BLOOD Glucose-132* UreaN-10 Creat-0.5 Na-134
K-3.1* Cl-97 HCO3-25 AnGap-15
___ 07:30AM BLOOD ALT-20 AST-24 AlkPhos-49 TotBili-1.1
___ 07:30AM BLOOD Calcium-9.5 Phos-2.7 Mg-1.6
___ 07:30AM BLOOD ASA-NEG Acetmnp-NEG Bnzodzp-NEG
Barbitr-NEG
___ 12:55PM BLOOD Ethanol-NEG
___ 07:30AM BLOOD ___ PTT-27.7 ___
IMAGING/STUDIES:
___ CT HEAD W/O CONTRAST
No intra-axial or extra-axial hemorrhage, edema, shift of
normally midline
structures, or evidence of acute major vascular territorial
infarction. There is mild periventricular white matter
hypodensity which is consistent with chronic microvascular
ischemic disease. There is global involution likely age
related. Basilar cisterns are widely patent. The paranasal
sinuses appear well aerated as do the mastoid air cells and
middle ear cavities. The bony calvarium is intact. Carotid
siphon calcification is notable.
IMPRESSION:
No acute intracranial process.
___ CT C-SPINE
No fracture or malalignment. Extensive multilevel degenerative
disease
appears unchanged.
___ CXR
PA and lateral views of the chest provided. 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. Partially
imaged fusion hardware at the thoracolumbar junction noted.
IMPRESSION:
No acute intrathoracic process.
MICROBIOLOGY:
___ URINE CULTURE Pending
___ BLOOD CULTURE Pending
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. RISperidone 1 mg PO QHS
2. Simvastatin 40 mg PO QPM
3. Thiamine 100 mg PO DAILY
4. Cyanocobalamin 50 mcg PO DAILY
5. Vitamin D 1000 UNIT PO DAILY
6. Lorazepam 0.5 mg PO BID:PRN anxiety
7. Mirtazapine 7.5-15 mg PO DAILY:PRN acute anxiety or agitation
8. Aspirin 81 mg PO DAILY
9. BusPIRone 10 mg PO TID
10. Duloxetine 90 mg PO DAILY
11. FoLIC Acid 1 mg PO DAILY
12. GlipiZIDE XL 2.5 mg PO DAILY
13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
14. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
15. Metoprolol Succinate XL 25 mg PO DAILY
16. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Cyanocobalamin 50 mcg PO DAILY
3. Duloxetine 60 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
6. Metoprolol Succinate XL 25 mg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. RISperidone 1 mg PO QHS
9. Simvastatin 40 mg PO QPM
10. Thiamine 100 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
13. Lorazepam 0.5 mg PO BID:PRN anxiety
14. GlipiZIDE XL 2.5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Depression, Confusion/Altered Mental Status, s/p
mechanical fall
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: ___ with s/p fall // fracture?
COMPARISON: ___
FINDINGS:
PA and lateral views of the chest provided. 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. Partially imaged fusion hardware at the thoracolumbar junction noted.
IMPRESSION:
No acute intrathoracic process.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ with s/p fall, assess intracranial hemorrhage.
TECHNIQUE: Routine unenhanced head CT was performed and viewed in brain,
intermediate and bone windows. Coronal and sagittal reformats were also
performed.
DOSE: Total DLP (Head) = 803 mGy-cm.
COMPARISON: Prior exam from ___.
FINDINGS:
No intra-axial or extra-axial hemorrhage, edema, shift of normally midline
structures, or evidence of acute major vascular territorial infarction. There
is mild periventricular white matter hypodensity which is consistent with
chronic microvascular ischemic disease. There is global involution likely age
related. Basilar cisterns are widely patent. The paranasal sinuses appear
well aerated as do the mastoid air cells and middle ear cavities. The bony
calvarium is intact. Carotid siphon calcification is notable.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST
INDICATION: ___ with s/p fall, neck pain
TECHNIQUE: Noncontrast CT cervical spine with axial, coronal, sagittal
reformations. Dose: Total DLP (Body) = 792 mGy-cm.
COMPARISON: Prior exam dated ___.
FINDINGS:
There is no acute fracture or traumatic change in alignment. Extensive
multilevel degenerative disease is essentially unchanged from the prior exam.
There is no prevertebral edema. Lung apices appear clear. The imaged thyroid
gland is unremarkable.
IMPRESSION:
No fracture or malalignment. Extensive multilevel degenerative disease
appears unchanged.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: s/p Fall
Diagnosed with Altered mental status, unspecified
temperature: 97.8
heartrate: 94.0
resprate: 18.0
o2sat: 92.0
sbp: 154.0
dbp: 82.0
level of pain: 0
level of acuity: 3.0 | ___ y/o male with a past medical history of dementia, ADHD,
depression and anxiety who presented from his ALF with
confusion, failure to thrive, and s/p fall.
# Depression with SI: The patient has a long standing history of
depression, requiring inpatient hospitalization and ECT. On
presentation, the patient reported sadness and desire to go to
sleep and not wake up. The patient was found to have flat affect
with psychomotor slowing. The patient was evaluated by
psychiatry who recommended 1:1 sitter and placed patient under
___. It was thought that the patient's depression may be
contributing to his worsening confusion. The patient's
psychiatric medication regimen was adjusted as below. The
patient was discharged to an inpatient psychiatric facility and
should follow up with these psychiatric providers for further
titration of medication regimen and further management.
# Confusion: The patient reported progressively worsening
confusion, which was corroborated by his sister whom he speaks
to on the phone nearly daily. The patient was evaluated with a
CT head which showed no acute changes. Similarly, electrolytes,
UA, Utox and serum tox were found to be within normal limits.
TSH, B12 and urine culture remained pending at the time of
discharge. The patient's confusion was thought to be due to his
worsening neurocognitive condition (Alzheimer's disease versus
vascular dementia versus mixed) vs. worsening depression vs.
polypharmacy. The patient was evaluated by psychiatry who
recommended discontinuation of buspar, and mirtazapine as well
as reduction in duloxetine dosing. They recommended discharge to
inpatient psychiatric facility at ___. The patient
should f/u with psychiatric providers for further evaluation and
management.
# s/p fall: The patient reportedly had a fall prior to
admission, in which he fell onto his lower back. Though the
patient did not recall the exact circumstances of his fall, it
was suspected to be mechanical in origin given his history of
unsteady gait and possible peripheral neuropathy. The patient's
ECG showed sinus arrhythmia and the patient reported no history
of chest pain, lightheadedness or dizziness. The patient was
evaluated as above and his medications were adjusted as above.
CT Head, CT C-Spine and CXR did not show any acute changes or
injury. The patient was evaluated by physical therapy who felt
that intermittent gait disturbance was likely secondary to his
underlying medical and psychiatric conditions.
# DM: the patient was restarted on his home metformin and
glipizide at discharge (he was managed on ISS while in the
hospital)
# HLD: continued home statin
# CAD: continued aspirin, metoprolol
# h/o EtOH use: The patient reported his last drink was years
prior. He was continued on thiamine, folate, MVI |
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:
___ Therapaeutic Paracentesis
History of Present Illness:
___ PMH of metastatic mixed carcinosarcoma/serous endometrial
cancer (on supportive care, awaiting hospice initiation), PE
(Xarelto), Depression, presented with abdominal pain/distension
As per review of notes, patient met with Dr ___ in ___ and
imaging reviewed which showed rapidly progressive disease, so
hospice was discussed but patient wished to continue with best
supportive care instead. In the weeks since, outpatient CM
called
patient to see if her thinking had evolved and she noted that
she
was not yet ready to enroll in hospice. Accordingly, she
presented today with abdominal pain/distension.
Patient reported that she has weeks of gradually increasing
abdominal distention that is associated with b/l lower quadrant
abdominal pain when she eats. She noted that she has had
decreased stooling in that time period, but is also passing less
flatus, last yesterday morning. She noted that she occasionally
vomits nonbloody emesis every day. Noted that p.o. intake has
decreased significantly as a result. Denied any fever or
chills.
Noted that she is urinating normally. She noted that her
decision-making regarding hospice is involving and she feels
ready to consider it, but did not want to talk about it in depth
overnight. She noted that she also did not want to discuss any
procedures tonight or her CODE STATUS.
In the ED, initial vitals: Afebrile, 96 124/88 18 99% RA.
CBC/CHEM/LFTs/Lactate wnl. UA 5WBC, 10 RBC, + ketones/protein/tr
bld.
CXR:
Enteric tube terminates in the left upper abdomen, presumably
within the stomach. Apparent elevation of the right
hemidiaphragm
may be due to pleural effusion and atelectasis.
CT A/P:
1. Several loops of proximal bowel are minimally dilated and
there are
distally decompressed small bowel loops without a discrete
transition point, suggestive of partial small bowel obstruction.
Given the additional findings of peritoneal thickening and large
volume ascites, is concerning for a malignant etiology.
2. Interval increase in large loculated intraperitoneal ascites,
large right pleural effusion, and interval development of small
left pleural effusion, likely malignant in etiology.
3. Right external iliac lymphadenopathy, new from prior exam.
4. Redemonstration of a prominent pancreatic duct and common
bile
ducts.
Given apparent SBO seen on imaging, which corresponded to
patient's symptoms, GYN/ONC consulted noted that she is not a
surgical candidate and therefore rec'd admission to OMED. NGT
placed without incident. Patient given Zofran/morphine, LR and
admitted. Outpatient oncology team was contacted and agreed.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
- Heart murmur
- Asthma
- Denies history of heart disease, bleeding or clotting
disorders
Social History:
___
Family History:
FHx: patient is adopted and family history is unknown
Physical Exam:
Admission:
GENERAL: sitting in bed, appears fatigued, easily irritated
EYES: PERRLA, anicteric sclera
HEENT: Oropharynx clear, no thrush, no mucosal lesions, NGT in
right nare
NECK: Supple, normal range of motion
LUNGS: Clear to auscultation bilaterally without any wheezes
rales or rhonchi
CV: Regular rate and rhythm, no murmurs, normal distal perfusion
without edema
ABD: distended/nearly tense abdomen, but not rigid, no rebound
or
guarding, no tenderness, dull to percussion
GENITOURINARY: no foley or suprapubic tenderness
EXT: Warm, no deformity, normal muscle bulk
SKIN: Warm dry, no rash
NEURO: Alert and oriented x3, fluent speech
ACCESS: Peripheral IV right arm
Patient was examined on day of discharge .
Pertinent Results:
Admission:
___ 03:05PM URINE HOURS-RANDOM
___ 03:05PM URINE UHOLD-HOLD
___ 03:05PM URINE COLOR-Yellow APPEAR-Hazy* SP ___
___ 03:05PM URINE BLOOD-TR* NITRITE-NEG PROTEIN-100*
GLUCOSE-NEG KETONE-40* BILIRUBIN-SM* UROBILNGN-4* PH-6.0
LEUK-NEG
___ 03:05PM URINE RBC-10* WBC-5 BACTERIA-FEW* YEAST-NONE
EPI-1
___ 03:05PM URINE MUCOUS-MANY*
___ 02:34PM LACTATE-1.5
___ 02:29PM estGFR-Using this
___ 02:29PM GLUCOSE-92 UREA N-17 CREAT-0.9 SODIUM-145
POTASSIUM-4.9 CHLORIDE-108 TOTAL CO2-25 ANION GAP-12
___ 02:29PM ALT(SGPT)-24 AST(SGOT)-40 ALK PHOS-89 TOT
BILI-0.4
___ 02:29PM ALBUMIN-3.8 CALCIUM-9.8 PHOSPHATE-3.5
MAGNESIUM-2.2
___ 02:29PM WBC-5.4 RBC-4.22 HGB-12.3 HCT-40.5 MCV-96
MCH-29.1 MCHC-30.4* RDW-11.9 RDWSD-41.5
___ 02:29PM NEUTS-68.4 ___ MONOS-9.4 EOS-0.9*
BASOS-0.4 IM ___ AbsNeut-3.71 AbsLymp-1.11* AbsMono-0.51
AbsEos-0.05 AbsBaso-0.02
___ 02:29PM PLT COUNT-281
___ 02:29PM ___ PTT-30.6 ___
MICROBIOLOGY:
Urine culture pending
STUDIES:
CXR:
Enteric tube terminates in the left upper abdomen, presumably
within the stomach. Apparent elevation of the right
hemidiaphragm
may be due to pleural effusion and atelectasis.
CT A/P:
1. Several loops of proximal bowel are minimally dilated and
there are
distally decompressed small bowel loops without a discrete
transition point, suggestive of partial small bowel obstruction.
Given the additional findings of peritoneal thickening and large
volume ascites, is concerning for a malignant etiology.
2. Interval increase in large loculated intraperitoneal ascites,
large right pleural effusion, and interval development of small
left pleural effusion, likely malignant in etiology.
3. Right external iliac lymphadenopathy, new from prior exam.
4. Redemonstration of a prominent pancreatic duct and common
bile
ducts.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
2. Escitalopram Oxalate 20 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. LORazepam 0.5 mg PO QHS:PRN insomnia
5. MethylPHENIDATE (Ritalin) 5 mg PO BID
6. Montelukast 10 mg PO DAILY
7. Nystatin Oral Suspension 5 mL PO QID
8. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First Line
9. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
10. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
11. Rivaroxaban 20 mg PO DAILY
12. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
13. Vitamin D Dose is Unknown PO DAILY
14. Famotidine 20 mg PO BID
15. Fluticasone Propionate NASAL 1 SPRY NU DAILY
16. ketotifen fumarate 0.025 % (0.035 %) ophthalmic (eye)
Q12H:PRN itchy eyes
17. Loratadine 10 mg PO DAILY
18. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
Discharge Medications:
1. Simethicone 40-80 mg PO QID:PRN gas pan
2. Vitamin D 1000 UNIT PO DAILY
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
4. Albuterol Inhaler 2 PUFF IH Q6H:PRN SOB
5. Escitalopram Oxalate 20 mg PO DAILY
6. Famotidine 20 mg PO BID
7. Fluticasone Propionate NASAL 1 SPRY NU DAILY
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
9. ketotifen fumarate 0.025 % (0.035 %) ophthalmic (eye)
Q12H:PRN itchy eyes
10. Loratadine 10 mg PO DAILY
11. LORazepam 0.5 mg PO QHS:PRN insomnia
12. MethylPHENIDATE (Ritalin) 5 mg PO BID
13. Montelukast 10 mg PO DAILY
14. Ondansetron ODT 8 mg PO Q8H:PRN Nausea/Vomiting - First
Line
15. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Moderate
16. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
17. Prochlorperazine 10 mg PO Q6H:PRN Nausea/Vomiting - Second
Line
18. Rivaroxaban 20 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary: Partial SBO, loculated ascites
Secondary: Metastatic mixed carcinosarcoma/serous endometrial
cancer
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 Stage IV Mixed Carcinosarcoma/Serous
Endometrial CA with abdominal pain, nausea, vomiting. Please evaluate for
small bowel obstruction.
TECHNIQUE: Supine abdominal radiograph was obtained.
COMPARISON: CT abdomen and pelvis dated ___
FINDINGS:
There is air distending the rectum and sigmoid. There is a large fecal load.
No dilated small bowel loops are identified.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
There are no unexplained soft tissue calcifications.
Surgical clips are seen projecting over the left mid abdomen.
Lower lumbar and femoroacetabular degenerative changes are noted.
IMPRESSION:
Nonobstructive bowel gas pattern.
Radiology Report
EXAMINATION: Ultrasound-guided paracentesis
INDICATION: ___ year old woman with met uterine ca with ascites// discomfort
from ascites
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated moderate
ascites. A suitable target in the deepest pocket in the right lower quadrant
was selected for paracentesis.
PROCEDURE: Ultrasound guided diagnostic and therapeutic paracentesis
Location: right lower quadrant
Fluid: 2.1 L of serosanguinous fluid
Samples: None
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.
Ascites fluid was aspirated via a 5 ___ catheter advanced into the largest
fluid pocket.
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. 2.1 L of fluid were removed and sent for requested analysis.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ with abdominal pain, cancer, obstipation. / eval for bowel
obstruction
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered. Coronal and sagittal reformations were
performed and reviewed on PACS.
DOSE: Total DLP (Body) = 739 mGy-cm.
COMPARISON: CT abdomen pelvis ___
FINDINGS:
LOWER CHEST: Increased right pleural effusion with associated compressive
lower lobe atelectasis. There is new small left pleural effusion. The imaged
portion of the heart is unremarkable.
ABDOMEN: There is interval increase in size of loculated abdominal ascites,
now large in overall volume. There is associated peritoneal thickening with
findings concerning for peritoneal carcinomatosis. There is no free air.
HEPATOBILIARY: A large loculated intraperitoneal fluid collection abuts the
right hepatic lobe with resultant mass effect. Several small hepatic
hypodensities are again seen and likely represent simple cysts. There is
unchanged mild intrahepatic and extrahepatic biliary ductal dilation.
The gallbladder contains gallstones without wall thickening or surrounding
inflammation.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions. The pancreatic duct to 7 mm in diameter, similar in size to
prior. On the anterior body of the pancreas, there is a ovoid 1.3 cm
hypodense fat density lesion (series 2, image 33), unchanged in size from
prior exam, which may represent a lipoma. 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 omentectomy. There is a similar
pattern of left upper quadrant omental nodularity. There is dilation of
proximal to mid jejunum with gradual caliber transition to decompressed bowel
in the right lower quadrant. Findings likely reflect partial malignant
small-bowel obstruction. The colon is unremarkable. The appendix is not
clearly visualized. There is mass effect on the colon from loculated large
volume ascites. Patient is undergone prior low anterior resection with
unremarkable appearance of the anastomosis.
PELVIS: The urinary bladder is decompressed. Presacral fluid is similar to
prior.
REPRODUCTIVE ORGANS: Patient is status post hysterectomy bilateral
salpingo-oophorectomy.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy,
although there are several measurable, non pathologically enlarged lymph nodes
within the perineum. Compared to ___ exam, there is a new, enlarged
lymph node along the right external iliac chain, measuring up to 1.6 cm in the
short axis (series 2, image 74), previously 1.0 cm.
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. Findings concerning for partial malignant small-bowel obstruction in the
setting of peritoneal carcinomatosis and large volume loculated ascites which
is increased from prior.
2. Significant mass effect on the liver from loculated peritoneal fluid.
3. Right external iliac lymphadenopathy, new from prior exam.
4. Prominent pancreatic duct and biliary tree unchanged.
5. Similar appearance of omental nodularity in the left upper quadrant.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with NGT// eval NGT
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___ chest radiograph from chest CT from ___
FINDINGS:
Enteric tube courses below the diaphragm, terminating expected location of the
stomach, with side port the proximal stomach. There is apparent elevation of
the right hemidiaphragm which may be due to underlying right pleural effusion,
with overlying atelectasis. The left aspect of the heart and mediastinum is
similar compared to the prior study. No large pneumothorax is seen..
IMPRESSION:
Enteric tube terminates in the left upper abdomen, presumably within the
stomach.
Apparent elevation of the right hemidiaphragm may be due to pleural effusion
and atelectasis.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Other intestnl obst unsp as to partial versus complete obst, Other ascites, Lower abdominal pain, unspecified, Personal history of pulmonary embolism, Long term (current) use of anticoagulants
temperature: 96.7
heartrate: 96.0
resprate: 18.0
o2sat: 99.0
sbp: 124.0
dbp: 88.0
level of pain: 6
level of acuity: 3.0 | ___ PMH of metastatic mixed carcinosarcoma/serous endometrial
cancer (on supportive care, awaiting hospice initiation), PE
(Xarelto), Depression, presented with abdominal pain/distension,
found to have partial SBO and ascites.
#Abdominal Pain:
#Partial SBO:
#Ascites
Presented with abdominal pain, nausea, and abdominal distension
noted to have partial SBO and worsening ascites on CT abdomen.
Initially requiring NGT for decompression but removed shortly
after admission. Patient also underwent LVP with improvement of
her pain/distension. Per Gyn-onc, not a surgical candidate. Diet
was slowly advanced and she was tolerating multiple small meals
and having regular BMs prior to discharge. Discussed with
patient, the possibility of recurrence and whether a venting
g-tube should be placed. The patient elected to defer this
palliative intervention on this visit but will consider it again
if her symptoms recur. On this admission, patient confirmed her
preference for DNR/DNI and MOLST was completed. She is being
discharged with home hospice.
#PE:
On Xarelto at home transitioned to heparin gtt in anticipation
of LVP. Given her toleration of diet on discharge, she was
resumed on her home Xarelto.
#Metastatic mixed carcinosarcoma/serous endometrial cancer:
As above, not a surgical candidate. Patient now being discharged
on home hospice but will see her oncologist, Dr. ___, in follow
up after discharge.
#Depression -Continued lexapro.
TRANSITIONAL ISSUES:
==================
[] If patient develops recurrent obstructive symptoms, would
again recommend venting g-tube for palliation.
> 30 mins spent on discharge coordination |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lithium / Wellbutrin / Seroquel
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ year old lady with history of HFpEF, mild to
moderate pulmonary artery systolic hypertension, chronic hypoxic
respiratory failure (multifactorial- COPD, ?old interstitial
pneumonitis and WHO Group 2 pulmonary hypertension) on 3L NC at
home, DVT on warfarin, who presents for evaluation of dyspnea.
At baseline she uses 3L NC oxygen and occasionally walks with a
walker at her assisted living facility. She says that she
generally does not walk very much and is not very active,
preferring to use her computer all day, but is able to perform
all ADL's independently. She is unable to estimate how far she
is able to walk on a good day; prior cardiology notes document
___ class III symptoms.
Around three weeks ago she developed a cough productive of
sputum and worsening shortness of breath associated with low
grade temperatures ~ ___. No chills, no sick contacts, no other
URI symptoms. Her dyspnea is worse when she is sitting up and
also when she lies down- she is unable to lie flat but is unable
to say if this has really changed. She has not noticed increased
lower extremity edema or weight gain. She currently denies any
new chest pain. Her other complaint is that when she nods her
head or extends it backwards she develops dizziness which is
described as a room spinning sensation. No tinnitus, ear
fullness, vision changes, focal weakness. Not triggered when she
moves her head side to side; not particularly worse when getting
up from bed. This has never happened in the past. She says that
she has not been eating or drinking much recently due to
dysphagia and heartburn; this has been evaluated by GI and
thought ___ ___ dysmotility.
Regarding her cardiac and pulmonary history (extracted from
OMR)- she was admitted to ___ in ___ for elective
laparoscopic sigmoid colectomy, complicated by ___
blood loss and hemodynamic instability. During workup for
elevated cardiac markers, echocardiogram demonstrated
hyperdynamic left ventricle (EF >75%) and dilated, hypokinetic
RV with abnormal septal motion consistent with RV
pressure/volume overload, as well as moderately elevated
pulmonary artery systolic pressure (TR gradient ___ mm Hg). Of
note, a prior
echo showed similar findings, and there was concern for acute or
acute on chronic pulmonary embolism. Right heart catheterization
was
performed in ___, which demonstrated only mild pulmonary
hypertension with PA ___ (23), normal filling pressures and
cardiac output. In ___, she presented to ___ ED with
chest pain and had a negative PMIBI examination. Her most recent
TTE from ___ actually demonstrated normal global and regional
biventricular systolic function w/ moderate pulmonary
hypertension (PASP 42 mmHg), improved RV function compared to
___.
Her most recent set of PFTs are from ___, with FEV1/FVC 86%,
FEV1 107% (1.58). Previously in ___ FEV1/FVC 84%, FEV1 99%,
DLCO 45%.
It is thought that the etiology of her chronic hypoxemic
respiratory failure and right ventricular dysfunction is
multifactorial, related to COPD, pulmonary hypertension, and
HFpEF.
In ED initial VS: HR 98 BP 103/49 RR 24 85% 4L NC
Exam: Diffuse wheezing
Labs:
(1) WBC 7.3 Hgb 12.1 Plt 298, 62% neutrophils, 1% bands
(2) INR 3.9, PTT 38.7
(3) Troponin 0.05, ___ 5, BNP 14014
(4) vBG ___
Patient was given:
- Albuterol neb x 1, ipratropium neb x 1, methylprednisolone 125
mg
- Pip/tazo 4.5 g
- Vancomycin 1 mg
- Magnesium sulfate 2gm
Imaging notable for:
CXR- Patchy left basilar opacity, concerning for pneumonia in
the correct clinical setting.
VS prior to transfer: 97.3 HR 80 BP 96/55 94% on BiPAP ___
On arrival to the MICU, she confirms the history as above.
REVIEW OF SYSTEMS:
(+) Per HPI
Past Medical History:
1. Mild to moderate pulmonary hypertension with an estimated TR
gradient of ___ mmHg on echocardiograms done ___ and
___. Right heart catheterization ___ with PASP 42
mmHg.
2. Right ventricular dilation, hypertrophy and basal hypokinesis
of free wall (TTE ___. Improved RV function on TTE ___.
3. Chronic diastolic heart failure/HFpEF (EF >55% on TTE
___.
4. Chronic atypical chest pain. Negative PMIBI ___.
5. Chronic hypoxic respiratory failure on 3L O2
(multifactorial).
6. Esophageal dysmotility
Social History:
___
Family History:
- Mother: emphysema
- Sister: O2 dependent
- No relevant cardiac history including premature coronary
artery
disease, cardiomyopathies, arrhythmias or sudden cardiac death
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
97.6, 85, 113/60, 19, 93%/6L NC
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Crackles at bilateral bases L>R, expiratory wheezing
anteriorly
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
ABD: soft, ___, bowel sounds present, no
rebound tenderness or guarding, no organomegaly
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
DISCHARGE PHYSICAL EXAM
=======================
Afebrile, SBPs ___, P ___, RR 18, 92 on 4L
Alert oriented NAD
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
Lungs clear to auscultation bilaterally with no wheezing or
crackles
No JVD
No ___
___
Pertinent Results:
ADMISSION LABS
==============
___ 11:37PM BLOOD ___
___ Plt ___
___ 11:37PM BLOOD ___
___
___
___ 11:37PM BLOOD ___
___
___ Tear
___
___ 11:37PM BLOOD ___ ___
___ 11:37PM BLOOD Plt ___ Plt ___
___ 11:37PM BLOOD ___
___
___ 11:37PM BLOOD CK(CPK)-451*
___ 11:37PM BLOOD ___
___ 11:37PM BLOOD ___
___ 11:37PM BLOOD ___
___ 11:44PM BLOOD ___
___ Base XS--3
MICRO
=====
Urine Culture (___): negative
MRSA Screen (___): negative
Sputum Culture (___): cancelled
IMAGES
======
CXR (___):
Patchy left basilar opacity, concerning for pneumonia in the
correct clinical setting.
TTE (___): IMPRESSION: Dilated right ventricle with moderate
global hypokinesis and pressure/volume overload. Normal left
ventricular systolic function. Mild mitral regurgitation. Mild
pulmonary hypertension. Compared with the prior study (images
reviewed) of ___, the right ventricle is dilated and
hypokinetic with signs of pressure/volume overload.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Nitroglycerin Patch 0.1 mg/hr TD Q24H
2. Warfarin 3 mg PO DAILY16
3. ClonazePAM 1 mg PO QHS
4. Benztropine Mesylate 0.5 mg PO DAILY
5. Levothyroxine Sodium 50 mcg PO DAILY 8pm
6. TraMADol 50 mg PO TID
7. Loxapine Succinate 30 mg PO DAILY
8. Oxybutynin 5 mg PO BID
9. Symbicort ___ mcg/actuation
inhalation BID
10. Furosemide 40 mg PO BID
11. Omeprazole 20 mg PO BID WIHT LUNCH AND DINNER
12. Fluticasone Propionate NASAL 1 SPRY NU DAILY
13. Sertraline 150 mg PO DAILY
14. Linzess (linaclotide) 290 mcg oral daily
15. Aspirin 81 mg PO DAILY
16. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN CP for up to 3 doses
17. Senna 8.6 mg PO QHS:PRN constipation
18. ClonazePAM 0.25 mg PO DAILY 2PM
19. ClonazePAM 0.5 mg PO DAILY
20. Docusate Sodium 100 mg PO DAILY
21. Simvastatin 20 mg PO QPM
22. RisperiDONE 1 mg PO DAILY
23. Systane Gel (artificial tears(hypromellose);<br>peg
___ glycol) ___ % ophthalmic TID
Discharge Medications:
1. Azithromycin 250 mg PO Q24H
continue until you ___ with your pulmonologist
2. GuaiFENesin ER 600 mg PO Q12H
3. ___ Neb 1 NEB NEB Q6H:PRN wheezing
take PRN for wheezing or shortness of breath
4. Nicotine Patch 14 mg TD DAILY
5. PNEUMOcoccal ___ polysaccharide vaccine 0.5 ml IM NOW
X1
6. PredniSONE 10 mg PO DAILY Duration: 3 Days
7. Torsemide 10 mg PO DAILY
8. Aspirin 81 mg PO DAILY
9. Benztropine Mesylate 0.5 mg PO DAILY
10. ClonazePAM 1 mg PO QHS
11. ClonazePAM 0.25 mg PO DAILY 2PM
12. ClonazePAM 0.5 mg PO DAILY
13. Docusate Sodium 100 mg PO DAILY
14. Fluticasone Propionate NASAL 1 SPRY NU DAILY
15. Levothyroxine Sodium 50 mcg PO DAILY 8pm
16. Linzess (linaclotide) 290 mcg oral daily
17. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN CP for up to 3 doses
18. Omeprazole 20 mg PO BID WIHT LUNCH AND DINNER
19. Oxybutynin 5 mg PO BID
20. RisperiDONE 1 mg PO DAILY
21. Senna 8.6 mg PO QHS:PRN constipation
22. Sertraline 150 mg PO DAILY
23. Simvastatin 20 mg PO QPM
24. Symbicort ___ mcg/actuation
inhalation BID
25. Systane Gel (artificial tears(hypromellose);<br>peg
___ glycol) ___ % ophthalmic TID
26. TraMADol 50 mg PO TID
27. Warfarin 3 mg PO DAILY16
28. HELD- Loxapine Succinate 30 mg PO DAILY This medication was
held. Do not restart Loxapine Succinate until you discuss with
PCP
29. HELD- Nitroglycerin Patch 0.1 mg/hr TD Q24H This medication
was held. Do not restart Nitroglycerin Patch until discuss with
PCP - soft BPs on discharge
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Pneumonia
COPD exacerbation
Right heart failure, RV Strain
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 COPD, pneumonia, hypoxia// Interval change
Interval change
IMPRESSION:
Comparison to ___. New ill-defined parenchymal opacities at the left
lung bases, with air bronchograms, could potentially reflect pneumonia in the
appropriate clinical setting. Mild cardiomegaly persists. The patient is
rotated to the right. No larger pleural effusions. No pulmonary edema.
Radiology Report
EXAMINATION: Chest radiographs
INDICATION: ___ year old woman with COPD, pneumonia, hypoxia// Interval change
TECHNIQUE: AP portable upright view of the chest
COMPARISON: Radiographs dated ___
FINDINGS:
Lung volumes are low leading to crowding of the bronchovascular structures.
Previously noted left basilar airspace opacities have modestly improved. The
remainder of the lungs are grossly clear. There is no large pleural effusion,
pneumothorax, or pulmonary edema. The cardiomediastinal contours are
unchanged. Scoliosis is noted centered in the lower thoracolumbar spine.
IMPRESSION:
Low lung volumes and modest interval improvement in the previously noted left
lower lobe airspace opacities.
Radiology Report
INDICATION: ___ year old woman with history of heart failure, pulmonary
hypertension here with pneumonia now with worsening oxygen requirement// ?
worsening volume overload
TECHNIQUE: Single portable view of the chest. Chest x-ray from ___.
COMPARISON: Multiple prior exams over the past few days with most recent from
___. chest CT from ___.
FINDINGS:
There is no focal consolidation. Prominent interstitial markings particularly
at the lung bases are chronic. There is no superimposed edema nor effusion.
The cardiomediastinal silhouette is within normal limits. No acute osseous
abnormalities.
IMPRESSION:
No focal consolidation or pulmonary edema.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hypoxia
Diagnosed with Pneumonia, unspecified organism, Chronic obstructive pulmonary disease w (acute) exacerbation, Acute respiratory failure, unsp w hypoxia or hypercapnia
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: denies
level of acuity: 1.0 | Ms. ___ is a ___ year old lady with history of HFpEF, mild to
moderate pulmonary artery systolic hypertension, chronic hypoxic
respiratory failure (multifactorial- COPD, possible interstitial
pneumonitis and WHO Group 2 pulmonary hypertension) on 3L NC at
home, DVT on warfarin, who is admitted to the ICU for hypoxemic
respiratory failure found to have pneumonia and right heart
failure.
=================
ACTIVE ISSUES
=================
# Hypoxemic respiratory failure/Pneumonia: Pt p/w patchy left
basilar opacity in setting of cough and low grade temperatures,
concerning for pneumonia. She has resided in nursing home for
greater than ___ years, which places her at risk for resistant
organisms. She has not improved with levofloxacin in outpatient
setting. Antibiotics were broadened to
vancomycin/ceftazidime/azithromycin (___), vancomycin was
discontinued when MRSA swab returned negative. Likely
respiratory distress worsened by baseline pulmonary
hypertension, COPD and HFpEF. Pt was gently diuresed out of c/f
pulmonary edema and also received a prednisone 40 mg burst (___) out of concern for COPD exacerbation given wheezes on exam.
She will require slow prednisone taper 10mg daily to start in AM
___ to complete her taper in addition to indefinite
azithromycin. TTE showed RV volume overload, discussed below.
# Right Heart Strain. Pt p/w new TWI in inferior leads as well
as ___, rightward axis in addition to an elevated BNP, all c/f
TV strain iso known pulmonary HTN. TTE showed e/o right heart
volume overload, no sign of new ischemic changes and mild
admission troponin of 0.05 ___. Etiology of right heart
strain is unclear as it is out of proportion for underlying
pulmonary hypertension. As discussed, ischemia is unlikely and
PE is unlikely given that pt presented supratherapeutic on
warfarin. Cardiology was consulted and recommneded starting 10
mg torsemide. The patient has follow up scheduled with
cardiology.
# ___: Pt presented with ___ likely ___ given sodium avid
urine lytes. Improved with IVF.
# Supratherapeutic INR: In setting of decreased PO intake d/t
esophageal dysmotility, also possible drug interaction as she
was recently on levofloxacin. Warfarin was held while patient
was supra therapeutic and resumed while hospitalized. INR was
2.1 on discharge. Coumadin will be resumed at 3mg daily.
===============
CHRONIC ISSUES
===============
# Esophageal dysmotility: Per GI, nonspecific dysmotility and
would attempt treatment for spasm, with suggestion for SL nitro
prior to meals. After TTE could consider this w/ close
monitoring of BP as well as swallow evaluation.
# Hypothyroidism: Continue home levothyroxine.
# Depression/anxiety: Continue home sertraline and clonazepam
# Constipation: Continue home linzess 290 mcg daily, senna 2
tabs every 3 days.
====================
TRANSITIONAL ISSUES
====================
CODE: DNR/DNI
HCP: ___ (son) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Concerta
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a previously healthy ___ presenting with
abdominal pain, nausea, and anorexia since ___. He reports
that the pain is in his right lower quadrant and suprapubic
area. Otherwise, he denies fevers but does report chills.
Reports one episode of nonbloody emesis. Denies diarrhea, bloody
bowel movements, or urinary symptoms. He is accompanied in the
ED today by his father.
Past Medical History:
Past Medical History: denies
Past Surgical History:
right shoulder repair, wisdom teeth
extracted
Social History:
___
Family History:
non-contributory
Physical Exam:
At admission:
Vitals: 98.5 64 126/57 18 99% RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: soft, TTP RLQ, suprapubic
Ext: No ___ edema, ___ warm and well perfused
At discharge:
Vitals: 99.6 68 123/70 18 98% RA
GEN: NAD
HEENT: EOMI, MMM
CV: RRR
PULM: nonlabored breathing
ABD: soft, mild TTP RLQ, non-distended, no rebound, no guarding
Ext: no edema
PSYCH: appropriate mood, appropriate affect
NEURO: A&Ox3
Pertinent Results:
CT A/P (___):
IMPRESSION:
Acute appendicitis with contained perforation. No drainable
abscess.
WBC: 16 ___ 18 ___ 12 (___) ->8
(___)
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
Do not exceed 4000 mg daily.
2. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*20 Tablet Refills:*0
3. MetroNIDAZOLE 500 mg PO Q8H
Do not drink alcohol while taking this medication.
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
acute appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen pelvis
INDICATION: ___ with lower abdominal pain// periumbilical pain
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) = 342 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: The imaged lung bases are clear. No pleural or pericardial
effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of concerning renal lesions or hydronephrosis. There is
no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is considerably enlarged
hyperemic, and there is nonenhancement of the posterior wall with
heterogeneous fluid and air along the lumen where it measures 19 mm (02:56).
There is moderate stranding of the adjacent fat. No mesenteric or
retroperitoneal adenopathy.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is a
small amount of reactive fluid in the pelvis. The prostate and seminal
vesicles are normal. No pelvic sidewall or inguinal adenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
Acute appendicitis with contained perforation. No drainable abscess.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 5:33 pm, 3 minutes after
discovery of the findings.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Appendicitis, Transfer
Diagnosed with Acute appendicitis with generalized peritonitis
temperature: 99.5
heartrate: 60.0
resprate: 20.0
o2sat: 100.0
sbp: 130.0
dbp: 70.0
level of pain: 5
level of acuity: 2.0 | Mr. ___ presented to the ___ ED on ___. CT imaging and
physical exam were consistent with acute appendicitis and he was
admitted for non-operative management with IV antibiotics
(Cipro/Flagyl) and bowel rest. He continued to spike
intermittent fevers and white count continued to increase (max
18k) until ___ when WBC decreased, pain improved, and he
remained afebrile.
Diet was advanced to regular on ___ and he was transitioned
to PO medications once tolerating oral intake. IV fluids were
discontinued once oral intake was adequate.
He was discharged home on ___. At the time of discharge, WBC
was normalized, he was ambulating independently, voiding
spontaneously, tolerating a regular diet, and abdominal pain had
resolved. He was instructed to follow up in ___ clinic on
___ to discuss interval appendectomy in 6 weeks. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Imipramine
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
percutaneous cholecystostomy tube placement
History of Present Illness:
___ s/p lap hiatal hernia repair with Hill gastropexy on
___ which was complicated by peritonitis for which she
underwent a negative ex-lap on ___. She was noted to have
cholangitis and then underwent ERCP with stone extraction and
placement of a stent in the left hepatic duct. Her course was
complicated by Ecoli bacteremia for which she was discharged on
___ with a course of linezolid and ultimately changed to CTX
which she has since completed. She presents to the ED today with
a one day history of sudden onset diffuse abdominal pain as well
as nausea and multiple episodes of NBNB emesis. She denies
fevers
or chills. She is having bowel movements and has diarrhea at her
baseline in the setting of lymphocytic colitis for which she was
recently started on a steroid taper by her GI doctor. Her
nursing
home reportedly checked a c.diff 3 days ago which was negative.
Past Medical History:
___ esophagus
Paraesophageal hernia with ___ erosions
lymphocytic colitis- 6+ years
Anemia
depression
hypertension,
history of spinal stenosis- s/p 8 surgeries
hypothyroidism
osteopenia
ETOH use
Tobacco abuse ___ x ___ years
lumbar and cervical stenosis
breast carcinoma s/p right mastectomy ___
s/p EUA, D&C and hysteroscopy ___
s/p multiple surgeries for chronic back pain, (fusion L1-3,
___
s/p kissing iliac stents, ___
s/p ERCP sphincterotomy
s/p Achilles tendon lengthening,
s/p appendectomy
s/p D&C
Social History:
___
Family History:
Mother: CVA
Father: CAD
Siblings: sister died CVA, sister breast cancer, sister
Physical Exam:
General-AAOX3
HEENT-AT, NC, PERRLA
Heart-RRR, normal s1, s2
Lungs-CTA B/L
abd-PTC tube in place, drain sponge clean and dry, soft, NT, ND
extr-no edema
Pertinent Results:
___ 05:51AM BLOOD WBC-14.6* RBC-2.54* Hgb-8.6* Hct-28.1*
MCV-111* MCH-34.0* MCHC-30.8* RDW-17.0* Plt ___
___ 02:01AM BLOOD WBC-21.0* RBC-2.36* Hgb-8.3* Hct-26.4*
MCV-112* MCH-35.0* MCHC-31.3 RDW-17.0* Plt ___
___ 01:56AM BLOOD WBC-27.7* RBC-2.41* Hgb-8.5* Hct-27.2*
MCV-113* MCH-35.4* MCHC-31.3 RDW-16.5* Plt ___
___ 02:10PM BLOOD WBC-42.6* RBC-2.66* Hgb-9.4* Hct-29.8*
MCV-112* MCH-35.4* MCHC-31.6 RDW-17.6* Plt ___
___ 04:04PM BLOOD WBC-30.0*# RBC-3.22*# Hgb-11.0*#
Hct-35.6*# MCV-111*# MCH-34.3* MCHC-31.0 RDW-17.2* Plt ___
___ 05:51AM BLOOD Plt ___
___ 02:01AM BLOOD Plt ___
___ 01:56AM BLOOD Plt ___
___ 02:10PM BLOOD Plt ___
___ 04:04PM BLOOD Plt ___
___ 04:04PM BLOOD ___ PTT-27.1 ___
___ 05:51AM BLOOD Glucose-88 UreaN-2* Creat-0.3* Na-138
K-3.1* Cl-103 HCO3-27 AnGap-11
___ 05:09AM BLOOD Glucose-64* UreaN-4* Creat-0.3* Na-133
K-3.4 Cl-101 HCO3-24 AnGap-11
___ 02:30PM BLOOD Glucose-102* UreaN-5* Creat-0.4 Na-133
K-3.1* Cl-102 HCO3-27 AnGap-7*
___ 01:56AM BLOOD Glucose-126* UreaN-6 Creat-0.4 Na-134
K-2.8* Cl-102 HCO3-23 AnGap-12
___ 02:10PM BLOOD Glucose-86 UreaN-6 Creat-0.4 Na-136
K-3.2* Cl-103 HCO3-22 AnGap-14
___ 04:04PM BLOOD Glucose-114* UreaN-7 Creat-0.4 Na-135
K-4.5 Cl-97 HCO3-24 AnGap-19
___ 02:10PM BLOOD ALT-18 AST-16 AlkPhos-67 TotBili-0.5
___ 04:04PM BLOOD ALT-29 AST-52* AlkPhos-87 TotBili-0.5
___ 05:51AM BLOOD Calcium-7.8* Phos-4.5# Mg-1.7
___ 05:09AM BLOOD Calcium-7.6* Phos-2.4* Mg-1.6
___ 02:01AM BLOOD Calcium-8.0* Phos-2.9 Mg-2.2
___ 04:04PM BLOOD Albumin-3.4*
___ 05:52AM BLOOD Vanco-15.3
___ 05:28AM BLOOD Vanco-18.8
___ 04:22AM BLOOD Lactate-1.6
___ 02:39PM BLOOD freeCa-1.05*
___ 02:22PM BLOOD VoidSpe-WRONG SAMP
US liver
IMPRESSION:
1. Distended gallbladder with wall edema, though no definite
stones.
Findings are equivocal for acute cholecystitis but raise concern
for such.
Consider HIDA for further assessment if clinically indicated.
2. Prominent common bile duct measuring 7 mm. Known CBD stent
not well
visualized. Central intrahepatic ducts remain prominent.
3. Splenomegaly.
CT abd/pel
IMPRESSION:
1. Dilated gallbladder with wall edema and surrounding
stranding concerning
for acute cholecystitis in the appropriate clinical setting.
Consider
followup ultrasound for further assessment.
2. Biliary stent in unchanged position with unchanged
prominence of the
central intrahepatic ducts.
3. Stable diffuse prominence of the pancreatic duct of
uncertain etiology.
MRCP could be performed for further assessment.
4. Severe atherosclerotic disease of the aorta with bi-iliac
stents in
unchanged position.
5. Post-surgical changes from recent ___ fundoplication. No
evidence of
recurrent hiatal hernia.
CHEST ON ___
HISTORY: Rapid AFib, question pneumonia or CHF.
FINDINGS: Compared to the study from the prior day, the heart
is slightly
larger and there is a small left pleural effusion. There is
pulmonary
vascular re-distribution and some patchy areas of volume loss in
the lower
lobe. Compared to the prior study, the lungs appear slightly
worse.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325 mg PO Q8H:PRN pain
2. Mesalamine (Rectal) ___ID
3. Gabapentin 600 mg PO HS
4. acidophilus-B.bifidum-B.longum (L.acidoph &
___ acidophilus) 150 mg (3
billion cell) oral BID
5. LOPERamide 2 mg PO QID:PRN diarrhea
6. Tolterodine 4 mg PO DAILY
7. Guaifenesin-CODEINE Phosphate 5 mL PO HS:PRN cough
8. Metoprolol Succinate XL 50 mg PO DAILY
9. Amlodipine 2.5 mg PO DAILY
10. Guaifenesin ER 600 mg PO Q12H
11. Enoxaparin Sodium 40 mg SC DAILY
Start: Today - ___, First Dose: Next Routine Administration
Time
12. Multivitamins 1 TAB PO DAILY
13. saccharomyces boulardii 250 mg oral BID
14. Omeprazole 20 mg PO BID
15. Calcium Carbonate 500 mg PO DAILY
16. Aspirin 81 mg PO DAILY
17. Levothyroxine Sodium 150 mcg PO DAILY
18. FoLIC Acid 1 mg PO DAILY
19. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Amlodipine 2.5 mg PO DAILY
2. FoLIC Acid 1 mg PO DAILY
3. Gabapentin 600 mg PO HS
4. Levothyroxine Sodium 150 mcg PO DAILY
5. Amiodarone 200 mg PO BID
6. Digoxin 0.125 mg PO DAILY
7. Metoprolol Tartrate 12.5 mg PO TID
8. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*40 Tablet Refills:*0
9. Acetaminophen 325 mg PO Q8H:PRN pain
10. acidophilus-B.bifidum-B.longum (L.acidoph &
___ acidophilus) 150 mg (3
billion cell) oral BID
11. Aspirin 81 mg PO DAILY
12. Calcium Carbonate 500 mg PO DAILY
13. Enoxaparin Sodium 40 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
14. Guaifenesin ER 600 mg PO Q12H
15. Guaifenesin-CODEINE Phosphate 5 mL PO HS:PRN cough
16. LOPERamide 2 mg PO QID:PRN diarrhea
17. Mesalamine (Rectal) ___ID
18. Multivitamins 1 TAB PO DAILY
19. Omeprazole 20 mg PO BID
20. saccharomyces boulardii 250 mg oral BID
21. Tolterodine 4 mg PO DAILY
22. Vitamin D 1000 UNIT PO DAILY
23. Amoxicillin-Clavulanic Acid ___ mg PO Q8H Duration: 5 Days
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Cholecystitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
ULTRASOUND-GUIDED PERCUTANEOUS CHOLECYSTOTOMY
CLINICAL INDICATION: ___ female status post laparoscopic hiatal
hernia repair with subsequent cholangitis status post ERCP with fever and
leukocytosis.
COMPARISON: Ultrasonography of the liver and gallbladder dated ___.
TECHNIQUE: After the risks, benefits, and alternatives were explained to the
patient, written informed consent was obtained. Prior to the procedure, a
timeout was performed with three patient identifiers. The patient was placed
supine on the ultrasound bed. The right upper quadrant was scanned with
realtime and color Doppler ultrasound. A suitable approach to the right upper
quadrant was identified with mark placed on the skin for approach. The skin
above this region was prepped and draped in the usual sterile fashion. 1%
lidocaine was administered locally to the skin for anesthesia. Under
ultrasound guidance, an ___ pigtail catheter was inserted in
what appeared to be the gallbladder lumen. Subsequently, 5 to 7 mL of bilious
material was aspirated. Then, the catheter was secured with a StatLock and
the catheter was connected to a bag to drain. After the procedure, hemostasis
was achieved. There were no immediate complications. The patient tolerated
the procedure well.
Moderate sedation was provided by administrating divided doses of Versed and
fentanyl intravenously for total doses of 1 mg of Versed and 125 mcg of
fentanyl throughout the total intraservice time of approximately 25 minutes,
during which the patient's hemodynamic parameters were continuously monitored
by nursing staff here at the ___.
FINDINGS: Grayscale and color Doppler images of the right upper quadrant
demonstrated a distended gallbladder with gallbladder wall thickening and
pericholecystic edema consistent with acute cholecystitis.
IMPRESSION:
1. Technically successful ultrasound-guided percutaneous cholecystostomy with
tube and pigtail catheter likely within the gallbladder lumen. However, as
this was a portable technique, we recommend CT examination to definitively
visualize the pigtail catheter tip within the lumen of the gallbladder.
2. Pericholecystic edema with distention of the gallbladder consistent with
acute cholecystitis.
The attending radiologist, Dr. ___, was present for the entire
procedure and provided direct supervision.
Radiology Report
CHEST ON ___
HISTORY: Rapid AFib, question pneumonia or CHF.
FINDINGS: Compared to the study from the prior day, the heart is slightly
larger and there is a small left pleural effusion. There is pulmonary
vascular re-distribution and some patchy areas of volume loss in the lower
lobe. Compared to the prior study, the lungs appear slightly worse.
Radiology Report
CT-GUIDED PERCUTANEOUS CHOLECYSTOSTOMY DRAIN
CLINICAL INDICATION: ___ female status post hiatal hernia repair with
cholangitis status post ERCP with abdominal pain and leukocytosis and concern
for acute cholecystitis.
COMPARISON: Ultrasound-guided percutaneous cholecystostomy dated earlier the
same day on ___.
TECHNIQUE: After the risks, benefits and alternatives were explained to the
patient, written informed consent was obtained. Prior to the procedure, a
timeout was performed with three patient identifiers. The patient was placed
supine on the CT table. Images were taken of the right upper quadrant of the
abdomen.
An appropriate approach was found and a mark was placed on the skin. The skin
overlying the region of interest was prepped and draped in the usual sterile
fashion. 1% lidocaine was administered locally to the skin for anesthesia.
Using a Seldinger technique and an 18-gauge ___ needle, an 8 ___
___ pigtail catheter was secured within the gallbladder lumen over a wire
after sequential dilation. After CT examination confirmed the pigtail to be
within the lumen of the gallbladder, 5 cc of bilious fluid was aspirated.
Subsequently, the catheter was attached to a drainage bag and secured with a
StatLock device. Pressure was applied and hemostasis was achieved. There
were no immediate complications. The patient tolerated the procedure well.
Moderate sedation was provided by administering divided doses of Versed and
fentanyl for total doses of 1.0 mg of Versed and 50 mcg of fentanyl throughout
the total intra-service time of approximately 15 minutes, during which the
patient's hemodynamic parameters were continuously monitored by nursing staff
here at the ___.
FINDINGS: Pre-biopsy CT images demonstrate a percutaneous catheter not
optimaly positioned within the gallbladder. This prompted re-positioning of a
new catheter in the Gallbladder. The gallbladder was slightly distended with
pericholecystic edema. There is edema within the mesentery as well as small
amount of fluid within the right paracolic gutter. Extensive atherosclerotic
vascular calcifications were seen within the abdominal aorta and common iliac
arteries.
Post-catheter placement demonstrated a pigtail catheter within the lumen of
the gallbladder. Subsequently, the catheter within the second/third portion
of the duodenum was removed.
IMPRESSION:
1. Successful CT-guided percutaneous cholecystostomy with repositioning of
catheter and new one placed. Pigtail tip within the lumen of the gallbladder.
2. Distended gallbladder with pericholecystic edema consistent with acute
cholecystitis. The original suboptimaly positioned pigtail catheter was
removed.
Dr. ___ attending radiologist, was present and supervised the
entire procedure.
Radiology Report
HISTORY: New PICC line.
___.
FINDINGS:
A left-sided PICC line is malpositioned coursing up the left IJ with the tip
off the film. There is a moderate left pleural effusion has increased
compared to prior. There is pulmonary vascular redistribution and ___ B
lines compatible with CHF. There is increased right lower lobe infiltrate
with air bronchograms.
IMPRESSION:
1. Malpositioned PICC line. This finding was discussed over the phone with
Peg of IV access at 925 on ___ by Dr. ___.
2. Worsened CHF.
3. Right lower lobe infiltrate.
Radiology Report
HISTORY: PICC line pulled back.
___.
FINDINGS:
The PICC line has been pulled back and the tip is now just past the axilla
probably in the brachiocephalic vein. The appearance of the lungs is
unchanged.
Radiology Report
INDICATION: History of cholecystitis, PICC line is currently in midline
position. Please advance.
OPERATORS: Dr. ___.
ANESTHESIA: 1% lidocaine.
PROCEDURE:
1. Repositioning of a left-sided PICC line.
PROCEDURE DETAILS: Using sterile technique and local anesthesia, the existing
PICC line was aspirated and flushed. A nitinol Glidewire was introduced and
advanced under fluoroscopic guidance into the superior vena cava. A peel-away
sheath was then placed over the guide wire. A double-lumen PICC measuring 42
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 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 was applied.
The patient tolerated the procedure well. There were no immediate
complications.
FINDINGS:
1. The accessed vein was patent and compressible.
2. The existing left basilic approach PICC with tip in the brachiocephalic
vein was replaced with a new double-lumen PICC with the tip in the
mid-to-distal SVC.
IMPRESSION: Successful placement of a 42 cm left basilic approach
double-lumen PICC line with the tip in the distal SVC. The line is ready to
use.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ABD PAIN,BACTEREMIA
Diagnosed with ABDOMINAL PAIN GENERALIZED
temperature: 98.1
heartrate: 65.0
resprate: 16.0
o2sat: 98.0
sbp: 110.0
dbp: 84.0
level of pain: 5
level of acuity: 1.0 | Ms. ___ presented to the emergency department on
___ with abdominal pain. Right upper quadrant ultrasound
as well as Ct abdomen/pelvis were obtained showing acute
cholecystitis. Acute Care Surgery service was consulted for
further work up and treatment. Given her extensive medical
history she was deemed not to be a surgical candidate therefore
percutaneous cholecystostomy was planned. She was admitted to
the hospital on ___ under Acute Care Surgery Service.
Intervantional radiology was consulted for percutaneous
cholecystomtomy placement. She was made NPO and prepared for the
procedure. On hospital day 1 she developed atrial fibrillation
with rapid ventricular response requiring ICU transfer and
treatment with amiodarone drip and digoxin. Once she was
stabilized she underwent perc chole tube placement on
___. She tolerated the procedure well without
complications. Her diet was advanced to sips to clear liquids on
___. She tolerated it well. On ___ the the foley came out,
she voided without issues. Intravenous antiarrhythmics were
switched to oral, her heart rate was well controlled. Her diet
was advanced to regular. She tolerated it well. The patient
received intravenous vancomycin and ceftriaxone. IV Vanc was
discontinued on ___, IV ceftriaxone was doscontinued on ___
___. The patinet was dischagrged with 5 day course of Augmentin.
On ___ she reported increased episodes of loose bowel
movements, c.diff was sent which came back negative. Her Ins
and Outs have been recorded throughout the hospital day which
remained adequate. She received subcutaneous heparin three times
a day.
On ___ she was discharged to a rehab clinic to continue her
treatment. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ presenting with 2 days of RLQ abdominal
pain. He was in his normal state of health until two days ago
when he woke-up with mild RLQ pain. He describes the pain as
dull
and intermittent. No associated fevers, nausea, vomiting or
diarrhea. No loss of appetite. He notes a similar pain 3 months
ago that resolved within a few hours. During his overnight shift
as a ___ at ___, he had moderately worsening RLQ
pain so he presented to the ED for further evaluation. No family
or personal history of inflammatory bowel disease. Never had a
colonoscopy before.
Past Medical History:
PMH: obesity, OSA
PSH: left ankle ORIF (___)
Social History:
___
Family History:
DM, HTN
No family hx of inflammatory bowel disease
Physical Exam:
Vitals: 97.1 90 145/86 16 96%RA
GEN: AOx3, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, mild RLQ tenderness to deep palpation,
no rebound or guarding, negative psoas or rovsing sign
DRE: normal tone, no gross or occult blood
Ext: No ___ edema, ___ warm and well perfused
Exam on discharge
GEN: AOx3, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
Abd: Soft, NT/ND no R/G
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
INDICATION: ___ with ___ days of RLQ abd pain radiating to
back, evaluate for
appendicitis or other right lower quadrant to pathology.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images
were acquired
through the abdomen and pelvis following intravenous contrast
administration
with split bolus technique.
Oral contrast was 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 5.0 s, 54.0 cm; CTDIvol = 16.9 mGy
(Body) DLP = 910.1
mGy-cm.
Total DLP (Body) = 922 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits.
There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation
throughout.
There is no evidence of focal lesions. There is no evidence of
intrahepatic
or extrahepatic biliary dilatation. The gallbladder is
relatively
decompressed likely containing small gallstones or sludge
(02:30). There is
no pericholecystic stranding or fluid.
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 a small hiatal hernia in the
partially visualized
distal esophagus is fluid-filled, which may predispose
aspiration. The
stomach is otherwise unremarkable. Small bowel loops
demonstrate normal
caliber, wall thickness, and enhancement throughout. The colon
and rectum are
within normal limits. The appendix is normal in caliber with
intraluminal air
and minimal associated stranding.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric
lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild
atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture.
Bone fragments adjacent to the left pubic symphysis likely
represent the
sequelae of prior trauma (2:90).
SOFT TISSUES: The abdominal and pelvic wall is within normal
limits.
IMPRESSION:
No acute intra-abdominal process.
RECOMMENDATION(S): The findings were discussed with ___
___, M.D. by
___, M.D. on the telephone on ___ at 9:52 AM,
2 minutes
after discovery of the findings.
Medications on Admission:
None
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Appendicitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with ___ days of RLQ abd pain radiating to back, evaluate for
appendicitis or other right lower quadrant to pathology.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was 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 5.0 s, 54.0 cm; CTDIvol = 16.9 mGy (Body) DLP = 910.1
mGy-cm.
Total DLP (Body) = 922 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is relatively
decompressed likely containing small gallstones or sludge (02:30). There is
no pericholecystic stranding or fluid.
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 a small hiatal hernia in the partially visualized
distal esophagus is fluid-filled, which may predispose aspiration. The
stomach is otherwise unremarkable. Small bowel loops demonstrate normal
caliber, wall thickness, and enhancement throughout. The colon and rectum are
within normal limits. The appendix is normal in caliber with intraluminal air
and minimal associated stranding.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Bone fragments adjacent to the left pubic symphysis likely represent the
sequelae of prior trauma (2:90).
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
No acute intra-abdominal process.
RECOMMENDATION(S): The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 9:52 AM, 2 minutes
after discovery of the findings.
The updated impression above was discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 1:59 ___, 10 minutes
after discovery of the findings.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: RLQ abdominal pain
Diagnosed with Unspecified appendicitis
temperature: 97.1
heartrate: 90.0
resprate: 16.0
o2sat: 96.0
sbp: 145.0
dbp: 86.0
level of pain: 2
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the Acute Care Surgery Team. The patient was found
to have possible appendicitis and was admitted to the Acute Care
Surgery Service. The patient was given IV cipro/flagyl.On
re-read of the CT scan, the patient was deemed to not have an
evidence of appendicitis and would not need antibiotics on
discharge.
The patient will follow up in Acute Care Surgery Clinic in 2
weeks. 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:
bloody diarrhea
Major Surgical or Invasive Procedure:
Flexible signoidoscopy ___
History of Present Illness:
___ year old female with history of UC presenting and followed by
Dr. ___ in GI clinic presenting with abdominal pain, bloody
diarrhea, and nausea for 2 weeks that has progressively
worsened.
She was in her usual state of health until 2 weeks prior to
admission when she developed lower band-like abdominal pain and
frequent stools that were often liquid and bloody. She has had
decreased PO intake but has intermittently been able to eat
meals
and still feels hungry from time to time. She initially though
she would get better on her own but the pain worsened over time
and her bowel though decreasing in volume did not decrease in
frequency. She called her GI physician and attempted to get labs
and C. diff given her history of C. diff however only completed
bloodwork. She was then told to present to ___ to be
admitted for possible UC flare and C. diff r/o by on call GI
team
on the day prior to admission to the ward. GI team recommended
preliminarily recommendations to obtain "CRP (124), C. diff
(pending), CMV, hepatitis B panel, quant gold, Magnesium and
cholesterol levels-for possible need of emergent biologic
therapy
per outpatient provider (Dr. ___. If C. Diff negative, may
need high dose IV steroid therapy. Avoid NSAIDs and treat pain
with IV Tylenol. Keep NPO for possible flex sig in AM."
On arrival to the floor she is feeling a bit better after
receiving IV Tylenol, Ativan, Zofran, and IVF in the ED. She
tells me that this does not feel exactly like prior UC flares as
she does not have joint pains and does not have profound fatigue
as normal. She denies fevers, chills, shortness of breath, rash,
joint pain, sick contacts. She can recall eating a hamburger 4
days prior to admission. She has had significant nausea with dry
heaving. CT from OSH revealed "diffuse bowel wall thickening
involving the colon from the mid right colon distally through
the
transverse, left colon and proximal sigmoid colon. Cecum as well
as the distal sigmoid colon and rectum are spared. Findings
consistent with nonspecific colitis. Differential diagnosis
includes infectious colitis and inflammatory bowel disease. No
abscess or free intraperitoneal air. No bowel obstruction. No
bowel wall gas. No ascites in the pelvis. Unopacified urinary
bladder grossly unremarkable."
Past Medical History:
ULCERATIVE COLITIS
INFLAMMATORY BOWEL DISEASE
C. diff ___
Social History:
___
Family History:
Father with lung cancer died at ___. Sister with
hypothyroidism. Aunt with UC on mother's side.
Physical Exam:
VS: Afebrile and vital signs stable (reviewed in bedside
record)
General Appearance: pleasant, mildly uncomfortable appearing, no
acute distress
Eyes: PERLL, EOMI, no conjuctival injection, anicteric
ENT: no sinus tenderness, MMM, oropharynx without exudate or
lesions,
Respiratory: CTA b/l with good air movement throughout
Cardiovascular: RR, S1 and S2 wnl, no murmurs, rubs or gallops
Gastrointestinal: nd, +b/s, soft, tender to deep palpation in
LLQ> RLQ. No tap tenderness or guarding.
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. fluent speech.
Psychiatric: pleasant, appropriate affect
GU: no catheter in place
discharge
avss
well appearing non toxic
soft abdomen without tenderness
no rashes
Pertinent Results:
___ 12:27AM BLOOD WBC-18.0* RBC-4.50 Hgb-13.3 Hct-39.7
MCV-88 MCH-29.6 MCHC-33.5 RDW-13.4 RDWSD-43.3 Plt ___
___ 07:45AM BLOOD Neuts-66.7 Lymphs-13.0* Monos-16.4*
Eos-2.9 Baso-0.6 Im ___ AbsNeut-11.32* AbsLymp-2.20
AbsMono-2.79* AbsEos-0.49 AbsBaso-0.10*
___ 12:27AM BLOOD Glucose-82 UreaN-4* Creat-0.9 Na-132*
K-7.1* Cl-96 HCO3-19* AnGap-17
___ 07:45AM BLOOD Glucose-101* UreaN-4* Creat-0.8 Na-137
K-3.9 Cl-103 HCO3-23 AnGap-11
___ 07:45AM BLOOD ALT-7 AST-11 AlkPhos-70 TotBili-0.3
___ 12:27AM BLOOD Calcium-8.8 Phos-4.9* Mg-1.9 Cholest-156
___ 07:45AM BLOOD Mg-1.7
___ 12:27AM BLOOD Triglyc-73 HDL-52 CHOL/HD-3.0 LDLcalc-89
___ 12:27AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG HAV Ab-NEG
___ 12:27AM BLOOD CRP-124.6*
___ 12:27AM BLOOD HCV Ab-NEG
___ 07:53AM BLOOD WBC-19.6* RBC-4.69 Hgb-13.7 Hct-41.7
MCV-89 MCH-29.2 MCHC-32.9 RDW-13.4 RDWSD-43.1 Plt ___
___ 12:27AM BLOOD HBsAg-NEG HBsAb-POS HBcAb-NEG HAV Ab-NEG
___ 07:53AM BLOOD CRP-9.5*
___ 12:27AM BLOOD HCV Ab-NEG
___ 12:27AM BLOOD CMV VL-NOT DETECT
___ 07:18AM BLOOD THIOPURINE METHYLTRANSFERASE (TPMT),
ERYTHROCYTES-PND
___ 07:25AM BLOOD QUANTIFERON-TB GOLD-Test
sigmoidoscopy
dec vascularity, erythema, exudate and erosions in sigmoid colon
c/w ulcerative colitis (biopsied)
active colitis on path, no granulomas or dysplasia
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Mesalamine 1.2 grams PO QID
2. Hydrocortisone Acetate 10% Foam 1 Appl PR TID
3. MedroxyPROGESTERone Acetate 2.5 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Acute Ulcerative Colitis
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 ulcerative colitis and abdominal pain//
baseline film per GI
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: None
FINDINGS:
There is an overall paucity of gas-filled bowel loops within the abdomen.
Several loops of bowel project over the pelvis. There is apparent wall
thickening and an ahaustral appearance of the descending colon as well as the
visualized ascending colon.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Overall paucity of gas-filled bowel loops within the abdomen as well wall
thickening with an ahaustral appearance of the colon compatible with the
provided history of ulcerative colitis.
Radiology Report
INDICATION: ___ year old woman with ulcerative colitis, pending quant gold, no
known TB risk factors, GI considering biologic therapy for UC// assess for any
pulmonary opacities
TECHNIQUE: Chest PA and lateral
COMPARISON: None
IMPRESSION:
There are no parenchymal lung opacities. Cardiomediastinal and hilar
silhouettes are normal. There is no pleural effusion or pneumothorax.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Ulcerative (chronic) pancolitis without complications, Unspecified abdominal pain
temperature: 98.2
heartrate: 82.0
resprate: 16.0
o2sat: 100.0
sbp: 107.0
dbp: 64.0
level of pain: 2
level of acuity: 3.0 | ___ y/o F h/o of UC and C. Diff presenting with blood diarrhea
from UC flare.
#Colitis
#UC Flare
#Leukocytosis
Started Solumedrol 20mg IV q8 on ___. She received her first
dose of infliximab 10mg/kg (700mg) on ___ and received a second
dose indicated for signs of inflammation w initial elevation in
CRP on ___ with another 10mg/kg. She was didscharged with a
steroid taper starting with prednisone 40mg daily to be reduced
by 10mg every three days. By the time of discharge her stools
were less frequent, not bloody and more formed than on admission
(described as many pea sized particles)
She had no known Tb risk factors though her quant gold was
indertimanante and her CXR was clear. Hep serologies show
immunity to HBV. TPMT activity is pending at discharge. She
did have leukocytosis at time of discharge so repeat CBC as
outpatient is indicated.
Hyperkalemia likely relates to elevated platelet count. whole
blood K 4.5 WHole blood potassium can be checked to monitor
actual K level if elev plts persist.
-
#Positive blood culture ___ - micrococcus, repeat cultures
negative. contaminant suspected. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
___
Attending: ___.
Chief Complaint:
Diplopia, ataxia, sensory changes
Major Surgical or Invasive Procedure:
Lumbar puncture
History of Present Illness:
___ is a ___ year-old left-handed female with h/o RRMS
currently on Tecfidera who presents with 2 weeks of worsening
sensory changes, dizziness, and vision changes with MRI
suggestive of MS flare vs early PML iso persistently elevated
JCV
titers.
Per patient and Dr. ___ who is her outpatient MS Dr. ___
was doing quite well until about 2 weeks ago when she started to
have L'hermittes. Then a week later she started to notice new
vertigo she denied any falls but states that the sensation of
"getting a push from behind" when she walks. Few days prior to
contacting her outpatient doctor she also started noticing new
left arm and leg paresthesias. She also endorses double vision
worse on the right side of her vision when looking to the right
she describes it as horizontal and goes away when she closes 1
of
her eyes. She denies any changes in color vision or blurry
vision. She also denies any cuts in her vision. Over the last
few days she is also started to notice some urinary retention
and
says it is harder for her to initiate her urine and feels like
she has not completely voided.
Due to the above symptoms and concern for new MS flare versus
iritis after coming off Tysabri versus PML in the setting of
positive ___ virus titers patient had an outpatient MRI brain
with
and without contrast. She was also scheduled to get MRI C and
T-spine as well but these were not able to be scheduled the same
day. MRI brain was notable for new enhancing lesions and
increase in flair burden of plaques. She came to outpatient
providers office on ___ for urgent LP. Unfortunately Dr. ___
was unable to successfully complete the LP so she was referred
to
the emergency room for emergent ___ guided LP and admission to
neurology for inpatient IVMP and consideration of additional
therapy if LP and imaging is more suggestive of PML then MS
flare.
In regards to her MS she has had MS for 10+ years. She was
recently on Tysabri but had to come off in the setting of a
persistently positive ___ virus titer. At this time she was
switched to Tecfidera. She has continued to have positive ___
virus titers.
Past Medical History:
Relapsing remitting multiple sclerosis
HISTORY OF NEUROLOGICAL SYMPTOMS:
Onset: ___
Diagnosis: ___
Flare History:
1. ___- numbness and tingling in lower extremities up to torso
2. ___- diplopia x 3 weeks
3. ___- diplopia
4. ___- Right leg numbness/tingling and weakness, diplopia
At some point, developed sensory deficits in left leg and
right>left upper extremities but timeline unclear. No
hospitalizations since ___
TREATMENT HISTORY:
1. Interferon (?Betaseron) ___ (stopped
due to liver abnormalities)
2. Gilenya ___- developed heart block on
first dose monitoring
3. Tysabri ___ (JCV negative as of ___, negative titer 0.10 on ___, POSITIVE titer 3.39 on
___, positive titer 3.4 on ___
4. Tecfidera ___- present
Social History:
___
Family History:
Unsigned notes are not final until signed by the author.
Note Date: ___ Time: 1803
Note Type: Initial note
Note Title: Neurology Consult Note
Electronically signed by ___, MD on ___ at
1:37 am Affiliation: ___
NEEDS COSIGN
=====================
Neurology Consult Note
======================
___
___ (BID #: ___
Reason for Consult: MS flare vs PML
HPI:
___ is a ___ year-old left-handed female with h/o RRMS
currently on Tecfidera who presents with 2 weeks of worsening
sensory changes, dizziness, and vision changes with MRI
suggestive of MS flare vs early PML iso persistently elevated
JCV
titers.
Per patient and Dr. ___ who is her outpatient MS Dr. ___
was doing quite well until about 2 weeks ago when she started to
have L'hermittes. Then a week later she started to notice new
vertigo she denied any falls but states that the sensation of
"getting a push from behind" when she walks. Few days prior to
contacting her outpatient doctor she also started noticing new
left arm and leg paresthesias. She also endorses double vision
worse on the right side of her vision when looking to the right
she describes it as horizontal and goes away when she closes 1
of
her eyes. She denies any changes in color vision or blurry
vision. She also denies any cuts in her vision. Over the last
few days she is also started to notice some urinary retention
and
says it is harder for her to initiate her urine and feels like
she has not completely voided.
Due to the above symptoms and concern for new MS flare versus
iritis after coming off Tysabri versus PML in the setting of
positive ___ virus titers patient had an outpatient MRI brain
with
and without contrast. She was also scheduled to get MRI C and
T-spine as well but these were not able to be scheduled the same
day. MRI brain was notable for new enhancing lesions and
increase in flair burden of plaques. She came to outpatient
providers office on ___ for urgent LP. Unfortunately Dr. ___
was unable to successfully complete the LP so she was referred
to
the emergency room for emergent ___ guided LP and admission to
neurology for inpatient IVMP and consideration of additional
therapy if LP and imaging is more suggestive of PML then MS
flare.
In regards to her MS she has had MS for 10+ years. She was
recently on Tysabri but had to come off in the setting of a
persistently positive ___ virus titer. At this time she was
switched to Tecfidera. She has continued to have positive ___
virus titers.
On neuro ROS, the pt endorses symptoms noted in HPI
Patient denies headache, loss of vision, blurred vision,
dysarthria, dysphagia, tinnitus or hearing difficulty. Denies
difficulties producing or comprehending speech. Denies focal
weakness. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or
abdominal pain. No recent change in bowel or bladder habits.
No
dysuria. Denies arthralgias or myalgias. Denies rash.
PMH:
RRMS
HISTORY OF NEUROLOGICAL SYMPTOMS:
Onset: ___
Diagnosis: ___
Flare History:
1. ___- numbness and tingling in lower extremities up to torso
2. ___- diplopia x 3 weeks
3. ___- diplopia
4. ___- Right leg numbness/tingling and weakness, diplopia
At some point, developed sensory deficits in left leg and
right>left upper extremities but timeline unclear. No
hospitalizations since ___
TREATMENT HISTORY:
1. Interferon (?Betaseron) ___ (stopped
due to liver abnormalities)
2. Gilenya ___- developed heart block on
first dose monitoring
3. Tysabri ___ (JCV negative as of ___, negative titer 0.10 on ___, POSITIVE titer 3.39 on
___, positive titer 3.4 on ___
4. Tecfidera ___- present
Medications:
--------------- --------------- --------------- ---------------
Active Medication list as of ___:
Medications - Prescription
ALPRAZOLAM - alprazolam 0.25 mg tablet. 1 tablet(s) by mouth as
needed
DIMETHYL FUMARATE [TECFIDERA] - Tecfidera 120 mg (14)-240 mg
(46)
capsule,delayed release. 1 capsule(s) by mouth Twice a day
KETOCONAZOLE - ketoconazole 2 % shampoo. Rinse the body ___
times
a week. ___ times a week
METOCLOPRAMIDE HCL - metoclopramide 5 mg tablet. 1 tablet(s) by
mouth Twice a day as needed As needed to take with Tecfidera
NORGESTIMATE-ETHINYL ESTRADIOL [TRI-LO-MARZIA] - Dosage
uncertain
- (Prescribed by Other Provider)
Medications - OTC
CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3)
5,000
unit tablet. 1 tablet(s) by mouth daily - (OTC)
IRON - Dosage uncertain - (Prescribed by Other Provider)
--------------- --------------- --------------- ---------------
Allergies
Gilenya
Social Hx:
___
Family Hx: From Dr. ___ recent clinic note
No MS in family.
Father- HTN, heart attack
Maternal GM- PD diagnosed in her ___
Maternal GF- Kidney disease
Maternal Aunt- ___ cancer diagnosed age ___
Physical Exam:
Vitals:Temp 98.7, HR 82, BP 115/72, RR 18, 100% RA
General: Awake, cooperative, NAD.
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx
Neck: Supple, no nuchal rigidity
Pulmonary: breathing non labored on room air
Cardiac: warm and well perfused
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities: No cyanosis, clubbing or edema bilaterally
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Awake, alert, oriented to self, place, time and
situation. Able to relate history without difficulty. Attentive,
able to name ___ backward without difficulty. Language is fluent
with intact repetition and comprehension. Normal prosody. There
were no paraphasic errors. Pt was able to name both high and low
frequency objects. Able to read without difficulty. Speech was
not dysarthric. Able to follow both midline and appendicular
commands. The pt had good knowledge of current events. There was
no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. No RAPD, VFF to confrontation.
Fundoscopic exam performed, revealed crisp disc margins with no
papilledema, exudates, or hemorrhages.
III, IV, VI: Unable to fully bury sclera on right eye with right
gaze, no nystagmus, diplopia horizontal on right gaze, outer
image goes away when she closes her right eye, normal saccades.
V: Facial sensation intact to light touch.
VII: No facial droop, facial musculature symmetric.
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 5 5 4+ 5 5 4+ 4+ 4+ 5 5 5
R 5 ___ 5 5 5 5 5 5 5
-Sensory: No deficits to light touch, pinprick testing she has
increased paresthesias in her left hand, also has hyperesthesia
to pinprick in the left foot. Sensation intact to cold
proprioception and vibration throughout in upper and lower
extremities. No extinction to DSS.
-DTRs: ___ are brisk throughout 3+ in the bilateral upper
extremities, with a negative ___ and ___
bilaterally,
lower extremities are 3+ in the patella with cross adductors and
suprapatellar as Achilles are 2+ toes are downgoing bilaterally
without any clonus.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Deferred
DISCHARGE
General: Awake, cooperative, NAD. Closing right eye when
speaking
to examiner.
Pulmonary: Non-labored breathing
Extremities: No ___ edema.
Skin: warm, well perfused
NEUROLOGIC:
-Mental Status:
Awake, alert. Able to relate history without difficulty.
Language
is fluent. Normal prosody.
-Cranial Nerves: pupils equal and briskly reactive to light.
Normal color desaturation. On left gaze, can bury sclera and no
double vision. On right gaze, right eye does not bury completely
and there is horizontal double vision which resolves with
covering the right eye (lateral image disappears).
-Motor:
Normal bulk and tone. No pronator drift b/l.
No adventitious movements, such as tremor, noted. No asterixis
noted.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 5 ___ 5 5 5 5 5 5 5
R 5 ___ 5 5 5 5 5 5 5
*limited by pain
-Sensory:
No deficits to light touch, pinprick testing she has
increased paresthesias in her left hand
-DTRs: ___ are brisk throughout 3+ in the bilateral upper
extremities, lower extremities are 3+ in the patella with
suprapatellar
-Coordination:
No intention tremor, no dysmetria on FNF
-Gait:
Deferred
Pertinent Results:
___ 05:39PM BLOOD WBC-11.2* RBC-4.92 Hgb-12.5 Hct-41.5
MCV-84 MCH-25.4* MCHC-30.1* RDW-12.1 RDWSD-36.6 Plt ___
___ 05:39PM BLOOD Neuts-76.3* Lymphs-16.5* Monos-6.1
Eos-0.4* Baso-0.3 Im ___ AbsNeut-8.53* AbsLymp-1.85
AbsMono-0.68 AbsEos-0.05 AbsBaso-0.03
___ 07:00PM BLOOD ___ PTT-25.6 ___
___ 05:39PM BLOOD Glucose-161* UreaN-10 Creat-0.6 Na-143
K-3.7 Cl-103 HCO3-27 AnGap-13
___ 12:38PM BLOOD ALT-24 AST-20 LD(LDH)-137 AlkPhos-46
TotBili-0.5
___ 05:39PM BLOOD Albumin-4.5 Calcium-9.1 Phos-3.3 Mg-1.8
MRI C/T ___
WET READ
CERVICAL:
Alignment is normal. Vertebral body and intervertebral disc
signal intensity
appear normal. The spinal cord appears normal in caliber and
configuration.
There is no evidence of spinal canal or neural foraminal
narrowing. There are
multiple nonenhancing T2/STIR hyperintense lesions again seen
within the
spinal cord at level C2-C7. Compared to prior exam, the extent
of these
lesions has increased. There is no abnormal enhancement after
contrast
administration.
THORACIC:
Alignment is normal. Vertebral body and intervertebral disc
signal intensity
appear normal. The spinal cord appears normal in caliber and
configuration.
There is no evidence of spinal canal or neural foraminal
narrowing. There are
multiple nonenhancing T2/FLAIR hyperintense lesions again seen
within the
spinal cord at levels C7-T1, T1-T2, T6, T7-T8. Compared to prior
exam, the
extent of these lesions is similar to slightly increased. There
is no evidence
of infection or neoplasm. There is no abnormal enhancement after
contrast
administration.
___ HEAD W & W/O CONTRAS
1. Multiple new and more confluent foci of abnormal FLAIR
signal, with areas
of enhancement and restriction. This pattern is more suggestive
of
progression of multiple sclerosis with active disease compared
to early PML,
however this is difficult to completely exclude.
RECOMMENDATION(S): Findings are more suggestive of progression
of multiple
sclerosis compared to early PML, however recommend close
follow-up and
correlation with ___ virus titers.
NOTIFICATION: The findings were discussed with ___,
M.D. by
___, M.D. on the telephone on ___ at
15:03 pm, 15
minutes after discovery of the findings.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. dimethyl fumarate 120 mg (14)- 240 mg (46) oral BID
2. ALPRAZolam 0.25 mg PO TID:PRN anxiety
3. Ketoconazole 2% 1 Appl TP BID
4. Metoclopramide 5 mg PO BID:PRN with tecfidara
5. norgestimate-ethinyl estradiol 0.18/0.215/0.25 mg-25 mcg oral
DAILY
6. Vitamin D 5000 UNIT PO DAILY
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth once a day Disp #*7
Capsule Refills:*0
2. ALPRAZolam 0.25 mg PO TID:PRN anxiety
3. dimethyl fumarate 120 mg (14)- 240 mg (46) oral BID
4. Ketoconazole 2% 1 Appl TP BID
5. Metoclopramide 5 mg PO BID:PRN with tecfidara
6. norgestimate-ethinyl estradiol 0.18/0.215/0.25 mg-25 mcg
oral DAILY
7. Vitamin D 5000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Relapsing Remitting Multiple sclerosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRI CERVICAL AND THORACIC PT21 MR SPINE
INDICATION: ___ year old woman with RRMS, new lesions in brain MRI, need
spine, weakness and sensory changes// interval change, active lesions
interval change, active lesions
interval change, new active lesions
TECHNIQUE: Sagittal imaging was performed with T2, T1, and STIR technique.
Axial T2 imaging was performed. Axial GRE images of the cervical spine were
performed. After the uneventful administration of ___ contrast agent,
additional axial and sagittal T1 images were obtained.
COMPARISON: MRI cervical and thoracic spine with and without contrast stated
___.
FINDINGS:
CERVICAL:
Multiple T2/STIR intramedullary hyperintense lesions are visualized
predominantly within the periphery of the cervical cord spanning all cervical
spine levels; which shows interval increase in size and extent when compared
to previous study dated ___. There is no abnormal enhancement after
contrast administration.
There is no evidence of cord expansion. The cervical spine alignment, and
intervertebral disc spaces are maintained, with no evidence of neural
foraminal narrowing or spinal canal stenosis. The visualized paravertebral
structures throughout the cervical region are unremarkable.
THORACIC:
Multiple T2/STIR intramedullary hyperintense lesions throughout the thoracic
spinal cord, at
C7-T1, T2, T6, T7-T8, T11-T12 levels, which also shows minimal interval
increase in size and extent when compared to previous study dated ___. There is no evidence of cord expansion or evidence of
abnormal intramedullary enhancement after contrast administration.
Vertebral bodies and intervertebral disc signal intensity appear normal.
There is no evidence of spinal canal or neural foraminal narrowing.
There is no evidence of infection or neoplasm. There is no abnormal
enhancement after contrast administration.
IMPRESSION:
1. Interval increase in size of intramedullary lesions in the cervical and
thoracic spinal cord.
2. There is no i abnormal enhancement after contrast administration.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: Abnormal MRI, Dizziness, L Numbness
Diagnosed with Multiple sclerosis, Dizziness and giddiness, Paresthesia of skin, Diplopia
temperature: 98.7
heartrate: 82.0
resprate: 18.0
o2sat: 100.0
sbp: 115.0
dbp: 72.0
level of pain: 6
level of acuity: 3.0 | ___ is a ___ woman with a history of relapsing
remitting multiple sclerosis currently on Tecfidera who
presented with 2 weeks of sensory changes, vertigo, and
diplopia.
Her exam was notable for a partial right ___ nerve palsy and
left hand dysesthesia. Her MRI revealed multiple new and more
confluent abnormal flair hyperintensities suggestive of
progression of her underlying multiple sclerosis. There were
some new ring-enhancing lesions. She had a lumbar puncture that
was mostly bland (6 nucleated cells and 44 protein with 77
glucose).
Given her history of treatment with natalizumab there was some
concern initially that she may have progressive multifocal
leukoencephalopathy with immune reconstitution. However, after
reviewing these images at neuroradiology conference, these were
felt to be more consistent with progression of her underlying
multiple sclerosis. Toxo PCR and ___ virus PCR were sent from the
CSF (results pending at discharge). She was treated with 2 doses
of 1 g IV methylprednisolone.
Transitional issues
===================
-Patient will complete outpatient course of prednisone as
dictated by her multiple sclerosis doctor.
-___ virus and toxoplasma gondii PCR pending at discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
cardiac cath ___
History of Present Illness:
This is a ___ with history of CAD s/p NSTEMI (___) -
medically managed, HTN, diastolic CHF, hypothyroidism, anemia,
and neuropathy who presents from assisted living with dyspnea.
Of note patient was recently admitted from ___ with new
onset afib and dypspnea and was started on amiodarone and lasix.
Anticoagulation was deferred given repeated falls. On day of
presentation she was found by her ___ to be dyspneic/wheezy. Her
daughter came to evaluate her who felt that her breathing was
more labored. Patient reports at that time not feeling SOB or
having CP or palpitations. She reports increasing DOE however
per daughters she was able to walk outside without any
difficulty. She denies fevers, ST or cough but endorsed chills
and sore throat. Denies orthopnea and PND however states that
she slept in a recliner yesterday night because of urinary
frequency and urgency. Denied dysuria, nausea or diarrhea. Given
her symptoms she represented to the ED for evaluation.
In the ED, initial vitals were 97.5 54 176/70 18 100% 4L.
Evaluation was significant for bilateral crackles to mid lung
fields. Labs revealed Hct 29 (baseline low to mid ___, Na 131
(normal baseline), TropT 0.09, proBNP 5613 (prior values were
lower), and UA positive for nitrite with 10 WBC and no epi.
Patient underwent a chest XR which showed interstitial edema.
She received lasix 40mg IV, aspirin 325mg and macrobid. SHe was
then admitted to cardiology for further management of acute on
chronic diastolic CHF. VS prior to transfer were 97.9 54 129/69
25 96%.
On arrival to the floor, patient reports feeling better however
is concerned about her condition. Reported urinary frequency.
Of note patient was seen by Dr. ___ on ___ during which time
electrolytes were checked and revealed elevated to Cr 1.5. Lasix
was then discontinued. It appeared that during this visit, Dr.
___ the etiology of her dyspnea to be related
angina as lasix had not improved symptoms. She was started on
imdur and invasive measures were not pursued given goals of
care.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, myalgias, joint pains, cough, hemoptysis, black
stools or red stools. She denies recent fevers, chills or
rigors. She denies exertional buttock or calf pain. All of the
other review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
dyspnea on exertion, paroxysmal nocturnal dyspnea, orthopnea,
ankle edema, palpitations, syncope or presyncope.
Past Medical History:
1. Coronary artery disease, status post NSTEMI in ___ as
described.
2. Atrial fibrillation with rapid ventricular response, now on
amiodarone, not on systemic anticoagulation.
3. Hypertension.
4. Diastolic heart failure.
5. Anemia.
6. Hypothyroidism.
7. Cervical spondylosis.
8. Status post hip replacement.
Social History:
___
Family History:
Father had MI at ___, mother had colon cancer. Daughters are both
healthy.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 51.3kg 97.6 164/79 51 16 100% 2LNC
General: well appearing, NAD, comfortable
HEENT: EOMI, PERRL, MMM, clear OP
Neck: supple, JVP elevated to mandible of jaw, no cervical LAD
CV: nls1s2 rrr no mrg
Lungs: crackles b/l to mid lung fields; markedly kyphotic
Abdomen: soft, NT, ND +BS
GU: no foley
Ext: wwp, +2DP, ___ and radial pulses, no edema
Neuro: AAOx3, CN II-XII grossly intact, ___ strength throughout
Skin: intact
.
.
DISCHARGE PHYSICAL EXAM:
VS: 97.6 116-143/57-60 51-52 18 92%RA-96%2LNC
General: well appearing, NAD, comfortable
HEENT: EOMI, PERRL, MMM, clear OP
Neck: supple, JVP at 7cm, no cervical LAD
CV: nls1s2 rrr no mrg
Lungs: dry velcro crackles up to apices; markedly kyphotic
Abdomen: soft, NT, ND +BS
GU: no foley
Ext: wwp, +2DP, ___ and radial pulses, no edema
Neuro: AAOx3, CN II-XII grossly intact, ___ strength throughout
Skin: intact
Pertinent Results:
Admission Labs:
___ 09:20AM BLOOD WBC-8.8 RBC-2.90* Hgb-9.4* Hct-29.2*
MCV-101* MCH-32.5* MCHC-32.2 RDW-13.6 Plt ___
___ 09:20AM BLOOD Neuts-73.5* Lymphs-13.7* Monos-5.4
Eos-6.7* Baso-0.6
___ 09:20AM BLOOD ___ PTT-36.5 ___
___ 09:20AM BLOOD Glucose-71 UreaN-24* Creat-0.9 Na-131*
K-4.6 Cl-95* HCO3-29 AnGap-12
___ 09:20AM BLOOD CK(CPK)-87
___ 09:20AM BLOOD CK-MB-10 MB Indx-11.5* proBNP-5613*
___ 09:20AM BLOOD Calcium-9.3 Phos-3.3 Mg-2.2
___ 07:00AM BLOOD TSH-6.5*
___ 09:20AM BLOOD VitB12-796
.
Trop trend:
___ 09:20AM BLOOD cTropnT-0.09*
___ 05:40PM BLOOD CK-MB-7 cTropnT-0.10*
___ 07:20AM BLOOD CK-MB-6 cTropnT-0.12*
___ 07:17AM BLOOD CK-MB-4 cTropnT-0.11*
___ 07:00AM BLOOD cTropnT-0.10*
Urine:
URINE CULTURE (Final ___:
CITROBACTER FREUNDII COMPLEX. >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
_________________________________________________________
CITROBACTER FREUNDII COMPLEX
|
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
.
.
Imaging:
___ CXR: IMPRESSION: Mild pulmonary edema.
.
___ Cardiac Cath: COMMENTS:
1. Selective coronary angiography in this right-dominant system
demonstrated severe, single-vessel coronary artery disease. The
___
had no angiographically significant coronary artery disease.
The LAD
had 99% proximal stenosis. The LCX and RCA had mild disease.
2. Left heart catheterization revealed normal left ventricular
end-diastolic pressure (101/10 mmHg) with no significant aortic
valve
gradient and central aortic pressure of 103/46/57 mmHg.
3. Successful PTCA and stenting of the proximal LAD with a 2.5 x
15 mm
Minivision BMS postdilated to 3.0 mm (see PTCA comments).
4. Successful RFA AngioSeal (see ___ comments).
.
FINAL DIAGNOSIS:
1. Severe, single-vessel coronary artery disease of the proximal
LAD.
2. Successful placement of 2.5x15 mm Mini Vision stent to
proximal LAD.
.
___ ECHO: The left atrium is elongated. 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. Right ventricular chamber size and
free wall motion are normal. The ascending aorta is mildly
dilated. The aortic valve leaflets (3) are mildly thickened but
aortic stenosis is not present. Mild (1+) aortic regurgitation
is seen. The mitral valve leaflets are mildly thickened. There
is no mitral valve prolapse. Trivial mitral regurgitation is
seen. The tricuspid valve leaflets are mildly thickened. There
is moderate pulmonary artery systolic hypertension. The
end-diastolic pulmonic regurgitation velocity is increased
suggesting pulmonary artery diastolic hypertension. There is no
pericardial effusion.
.
___ CXR: FINDINGS: Cardiomediastinal contours are stable in
appearance. Persistent calcifications in right superior
mediastinum correlate with vascular calcifications on recent
chest CTA. Worsening opacity in left retrocardiac area could
reflect either atelectasis or developing infectious pneumonia.
Minor atelectasis is present in the right upper lobe with
associated slight elevation of the minor fissure. Small
bilateral pleural effusions are present, left greater than
right.
.
___ CT HEAD: There is no evidence of hemorrhage, edema,
large masses, mass effect or acute infarct. A tiny linear
hypodensity in the left thalamus (2:15) likely reflects chronic
infarct. The absence of this finding on prior CT can be
attributed to small size of lesion and slice selection.
Confluent periventricular and subcortical white matter
hypodensities are most consistent with small vessel ischemic
disease.
The ventricles and sulci are prominent consistent with age
related parenchymal involution. The mastoid air cells, middle
ear cavities and visualized paranasal sinuses are clear. Dense
atherosclerotic calcifications are noted in the bilateral
carotid siphons. No soft tissue swelling identified.
IMPRESSION: No acute intracranial process.
.
Discharge Labs:
___ 06:10AM BLOOD WBC-8.9 RBC-3.00* Hgb-9.8* Hct-30.0*
MCV-100* MCH-32.8* MCHC-32.8 RDW-14.0 Plt ___
.
Radiology Report
HISTORY: History of CHF and shortness of breath, evaluate for edema.
COMPARISON: ___
FINDINGS: AP upright and lateral chest radiographs demonstrate low lung
volumes. Cardiomegaly is unchanged. Cardiomediastinal contours are otherwise
unremarkable. Increased interstitial markings with cephalization of the
vessels suggest mild pulmonary edema. No consolidations or large effusions.
Marked thoracic kyphosis is noted.
IMPRESSION: Mild pulmonary edema.
Radiology Report
PORTABLE CHEST ___
COMPARISON: ___ radiograph.
FINDINGS: Cardiomediastinal contours are stable in appearance. Persistent
calcifications in right superior mediastinum correlate with vascular
calcifications on recent chest CTA. Worsening opacity in left retrocardiac
area could reflect either atelectasis or developing infectious pneumonia.
Minor atelectasis is present in the right upper lobe with associated slight
elevation of the minor fissure. Small bilateral pleural effusions are
present, left greater than right.
Radiology Report
HISTORY: Confusion, difficulty swallowing. Evaluate for intracranial
hemorrhage or other pathology.
TECHNIQUE: Noncontrast axial images obtained through the brain.
COMPARISON: Comparison is made to head CT performed ___.
FINDINGS:
There is no evidence of hemorrhage, edema, large masses, mass effect or acute
infarct. A tiny linear hypodensity in the left thalamus (2:15) likely reflects
chronic infarct. The absence of this finding on prior CT can be attributed to
small size of lesion and slice selection. Confluent periventricular and
subcortical white matter hypodensities are most consistent with small vessel
ischemic disease.
The ventricles and sulci are prominent consistent with age related parenchymal
involution.
The mastoid air cells, middle ear cavities and visualized paranasal sinuses
are clear. Dense atherosclerotic calcifications are noted in the bilateral
carotid siphons. No soft tissue swelling identified.
IMPRESSION:
No acute intracranial process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: DYSPNEA
Diagnosed with SHORTNESS OF BREATH, URIN TRACT INFECTION NOS, HYPERTENSION NOS
temperature: 97.5
heartrate: 54.0
resprate: 18.0
o2sat: 100.0
sbp: 176.0
dbp: 70.0
level of pain: 0
level of acuity: 3.0 | ___ with history of CAD s/p NSTEMI (___) - medically
managed, HTN, diastolic CHF, hypothyroidism, anemia, and
neuropathy who presents from assisted living with dyspnea and
URI, had episode of hypotension and episode of delirium, both
resolved.
.
# NSTEMI/Dyspnea: Given findings on cardiac cath with 90%
lesions, acute symptoms can likely be explained by ischemic
cardiac disease. Lung exam on full review of chart and
discussion with outpatient provider has been abnormal prior to
initiation of amiodarone, and ___ evals have also shown
desaturation with ambulation in the past. She was weaned off of
O2 without any recurrence of her shortness of breath. She should
follow up with pulmonology and further imaging as outpatient.
She was started on Plavix after placement of BMS to LAD. She was
continued on lisinopril, metoprolol, aspirin was increased to
325mg. Atorvastatin 80mg was initiated but switched to 40mg
given interaction with amiodarone. She was started on Imdur as
well.
- follow up with Dr. ___ in ___ weeks
.
# Atrial fibrillation: She completed amiodarone load while in
the hospital and switched to 200mg daily dose. She is also rate
controlled on metoprolol. Per previous discussions with
outpatient cardiologist, no acticoagulation will be pursued due
to history of falls. She was switched to aspirin 325mg daily.
- follow up with Dr. ___ in ___ weeks
.
# Diastolic CHF: Presented in decompensated heart failure in the
setting of ischemia. Initially not on home lasix. She was
diuresed and shortness of breath improved, after cath and BMS to
LAD it had completely resolved. She was started on lasix PO
prior to discharge.
.
# Delirium: Resolved. Episode of decreased level of arousal
though remained AxOx3. Infectious workup negative, CT head
unremarkable and within a few hours patient was at baseline.
Neurology consult also in agreement that this was likely
hospital-induced delirium. Seizure was considered but no
evidence of ictal event or post-ictal state, only possible
contributing medication was cipro which can cause delirium in
the elderly. This was switched to bactrim to complete course of
treatment for her UTI.
.
# UTI: Last UTI was citrobacter sensitive. No recent organisms
in the past. This would be ___ UTI in one month, found to be
ceftriaxone resistant, so patient was switched to cipro
(sensitive), however in the setting of deliriuos episode she was
switched to Bactrim to complete full course of treatment.
- continue bactrim until ___ (treated ___
.
# Hypotension: Resolved. She had episode of hypotension after
aggressive diuresis on admission. Resolved with IVF. Lisinopril
was initially decreased and returned to home dose prior to
discharge.
.
# Hyponatremia: Resolved. Patient admitted with hyponatremia.
Improved with diuresis and euvolemia.
.
# Anemia: Macrocytic. Baseline Hct mid ___. Hemodynamically
stable, no acute issues during this hospitalization.
.
# HTN: Antihypertensive medications were adjusted: metoprolol,
lisinopril were continued. Imdur and lasix were added to her
medication regimen.
.
# HLD: Atorvastatin dose was increased to 40mg PO daily.
.
# Neuropathy: Continued home gabapentin.
.
Transitional Issues:
- CODE: DNR/DNI
- CONTACT: Patient and daughter, ___ (HCP) ___
- patient will require further workup with pulmonology and
further imaging as outpatient.
- follow up with Dr. ___ in ___ weeks
- follow up with PCP |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
MVC with L rib fx ___, sternal fx, T8 vertebral body fracture, R
lateral malleolus fracture
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ was a restrained passenger in 30mph MVC w/ airbag deployment
however negative for loss of consciousness. Initially evaluated
at outside hospital with CT showing left rib ___ fractures,
sternal fractures, T8 vertebral body fracture, and R lateral
malleolus fracture.
Past Medical History:
DM II
HTN
Hyperlipidemia
PSH: Left adrenalectomy ___, ___, Lap CCY ___, ___
Social History:
___
Family History:
Mother and father both died of heart failure. One brother who is
healthy in his ___, and a second brother developed CAD in his
___.
Physical Exam:
PHYSICAL EXAMINATION on admission
Temp: 97.1 HR: 70 BP: 123/73 Resp: 18 O(2)Sat: 97 Normal
Constitutional: Comfortable
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light
Oropharynx within normal limits
Chest: Bilateral breath sounds mild sternal tenderness
Abdominal: Soft, Nontender
Extr/Back: Right pinky finger splinted, right ankle with air
cast, mild right proximal fibular tenderness
Skin: No rash
Neuro: Speech fluent, 5 out of 5 strength
Physical exam on discharge:
Gen: A&O x3
VS: T; 98.6, HR: 69, BP: 125/61, RR: 18, O2: 96%ra
HEENT: Normocephalic, atraumatic, Pupils equal, round and
reactive to light
Chest: Bilateral breath sounds mild sternal tenderness. In TLSO
brace
Abdominal: Soft, Nontender
Extr/Back: Right pinky finger splinted, right ankle with air
cast, mild right proximal fibular tenderness. R-foot with
bruising, swelling
Skin: No rash
Neuro: Speech fluent, 5 out of 5 strength
Pertinent Results:
___ 09:18AM ___ PTT-27.5 ___
___ 07:05AM GLUCOSE-171* UREA N-20 CREAT-0.9 SODIUM-136
POTASSIUM-4.7 CHLORIDE-102 TOTAL CO2-21* ANION GAP-18
___ 07:05AM estGFR-Using this
___ 07:05AM WBC-11.7*# RBC-4.20 HGB-12.8 HCT-38.1 MCV-91
MCH-30.5 MCHC-33.6 RDW-13.2 RDWSD-43.5
___ 07:05AM NEUTS-73.3* LYMPHS-16.0* MONOS-9.0 EOS-0.3*
BASOS-0.7 IM ___ AbsNeut-8.55* AbsLymp-1.87 AbsMono-1.05*
AbsEos-0.03* AbsBaso-0.08
___ 07:05AM PLT SMR-NORMAL PLT COUNT-232
___ CT Abdomen Pelvis:
1. Partially visualized T8 vertebral body fracture, better
assessed on chest CT. No additional sequelae of trauma in the
abdomen pelvis.
2. Mild hypodense thickening of the endometrium measure up to 4
mm, correlate clinically and with ultrasound warranted.
___ MR ___ Spine w/ w/o contrast
1. Nondisplaced fracture through the ossified anterior
longitudinal ligament at T8 and through the anterior superior
corner of T8, without loss of height. The posterior longitudinal
ligament and the posterior ligamentous complex are intact.
2. While linear fluid signal intensity through the left lamina
of T7 and
subtle linear lucency through the left transverse process of T7
on the
preceding CT raise a question of an nondisplaced fracture, there
is no edema in the adjacent soft tissues or left T7-T8 facet
joint capsule. The posterior ligamentous complex is intact.
3. No epidural hematoma.
___ Right ankle
Possible fracture the tip of the lateral malleolus.
___ Right hand
No acute bony injury seen. There are moderate degenerative
changes in the distal interphalangeal joints of all digits and
interphalangeal joint of the thumb. No fracture or dislocation
seen. No soft tissue calcification. An IV cannula is noted at
the wrist.
Medications on Admission:
1. Atorvastatin 80 mg PO QPM
2. GlipiZIDE XL 5 mg PO QAM
3. GlipiZIDE XL 10 mg PO QHS
4. MetFORMIN (Glucophage) 1000 mg PO BID
5. Metoprolol Tartrate 50 mg PO BID
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
2. GlipiZIDE XL 5 mg PO QAM
3. GlipiZIDE XL 10 mg PO QHS
4. Metoprolol Tartrate 50 mg PO BID
5. Acetaminophen 1000 mg PO Q8H
6. Docusate Sodium 100 mg PO BID
please hold for loose stool
7. Glucagon 1 mg IM Q15MIN:PRN hypoglycemia protocol
8. Glucose Gel 15 g PO PRN hypoglycemia protocol
9. Heparin 5000 UNIT SC BID
10. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
do NOT drink alcohol or drive while taking this medication
RX *hydromorphone 2 mg ___ tablet(s) by mouth Q3H Disp #*30
Tablet Refills:*0
11. Insulin SC
Sliding Scale
Fingerstick Q6H
Insulin SC Sliding Scale using HUM Insulin
12. MetFORMIN XR (Glucophage XR) 1000 mg PO BID
13. Senna 8.6 mg PO BID
please hold for loose stool
14. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
15. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
L rib fx ___, sternal fx, T8 vertebral body fracture, R lateral
malleolus fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
Followup Instructions:
___
Radiology Report
EXAMINATION: DX KNEE AND TIB/FIB
INDICATION: ___ with right knee TTP with ankle fracture after MVC// eval for
fracture/dislocation
TECHNIQUE: AP, lateral, obliques views of the right knee and AP and lateral
views of the right tibia and fibula provided.
COMPARISON: None.
FINDINGS:
Right knee: No acute fracture or dislocation. No joint effusion. Small
enthesophytes is seen along the superior patellar pole. Bone mineralization
is normal. No significant DJD.
Right tibia fibula: Right tibia and fibula appear intact. The right ankle
joint appears to align normally. A prominent retro calcaneal enthesophytes is
noted.
IMPRESSION:
No fracture or dislocation.
Radiology Report
EXAMINATION: CT abdomen and pelvis
INDICATION: ___ with MVC // eval for acute intraabdominal 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. Oral contrast was not administered.Coronal and
sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 858 mGy-cm.
COMPARISON: CTA abdomen with and without contrast from ___.
Reference CT Chest from ___
FINDINGS:
LOWER CHEST: Left basal atelectasis is noted. The imaged portion of the heart
is unremarkable.
ABDOMEN:
HEPATOBILIARY: The liver enhances normally without focal lesion or signs of
injury. Minimal prominence of the intrahepatic biliary tree is likely due to
prior cholecystectomy. The main portal vein is patent. The gallbladder is
surgically absent.
PANCREAS: The pancreas enhances normally without abnormality.
SPLEEN: Spleen is intact and normal in appearance.
ADRENALS: Right adrenal is normal. The left adrenal gland is surgically
absent.
URINARY: The kidneys appear intact with symmetric enhancement and prompt
excretion of contrast. No signs of renal injury. A tiny hyperdensity in the
lower pole right kidney is too small to characterize.
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. No signs of bowel
or mesenteric injury. No free air or free fluid.
PELVIS: Urinary bladder is only partially distended and contains dense
excreted contrast. Equivocal mild thickening of the endometrium up to 4 mm
may be further assessed by pelvic ultrasound. Ovaries are grossly
unremarkable. No pelvic sidewall or inguinal adenopathy. There is no free
fluid in the pelvis.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: Partially visualized is a linear fracture lucency traversing the T8
vertebra better visualized on outside hospital CT chest. Moderate
degenerative changes are seen in the lumbosacral spine.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Partially visualized T8 vertebral body fracture, better assessed on chest
CT. No additional sequelae of trauma in the abdomen pelvis.
2. Mild hypodense thickening of the endometrium measure up to 4 mm, correlate
clinically and with ultrasound warranted.
RECOMMENDATION(S): Recommend clinical correlation for increased hypodensity
in the uterine cavity.
Radiology Report
EXAMINATION: MR ___ ANDW/O CONTRAST ___ MR SPINE
INDICATION: ___ year old woman s/p MVC with T8 fracture seen on CT. Evaluate
T8 fracture, epidural hematoma.
TECHNIQUE: Sagittal imaging was performed with T2, T1, and IDEAL technique,
followed by axial T2 imaging. This was followed by sagittal and axial T1
images obtained after the uneventful intravenous administration of 8 mL of
Gadavist contrast agent.
COMPARISON: CT abdomen ___. CT chest ___ at 03:21.
FINDINGS:
There are 12 rib-bearing vertebrae. The anterior longitudinal ligament is
ossified. There is a nondisplaced fracture through the ossified anterior
longitudinal ligament at the mid T8 level, extending through the anterior
superior corner of T8 into the T8 superior endplate. There is no significant
loss of vertebral body height. There is fluid signal intensity within the
fracture line, but no significant edema in the adjacent bone marrow. There is
no edema within the adjacent intervertebral discs. There is no edema or
disruption of the posterior longitudinal ligament. There is linear fluid
signal intensity through the left laminae of T7, series 5, images 7 and 8.
The preceding CT demonstrates a subtle linear lucency through the left
transverse process of C7 heading towards the lamina. This raises the question
of a subtle nondisplaced fracture. However, there is no soft tissue edema
surrounding the left C7 posterior elements, and no fluid signal intensity in
the left T7-T8 facet joint. The facet joint capsule and the posterior
ligamentous complex are intact.
Other thoracic vertebral bodies maintain normal heights. Alignment is normal.
There is no epidural collection. There is no significant spinal canal
narrowing or neural foraminal narrowing. There is no abnormal contrast
enhancement.
There is mild atelectasis in the partially visualized basal lower lobes,
similar to the preceding chest CT on the left, but new on the right.
IMPRESSION:
1. Nondisplaced fracture through the ossified anterior longitudinal ligament
at T8 and through the anterior superior corner of T8, without loss of height.
The posterior longitudinal ligament and the posterior ligamentous complex are
intact.
2. While linear fluid signal intensity through the left lamina of T7 and
subtle linear lucency through the left transverse process of T7 on the
preceding CT raise a question of an nondisplaced fracture, there is no edema
in the adjacent soft tissues or left T7-T8 facet joint capsule. The posterior
ligamentous complex is intact.
3. No epidural hematoma.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) RIGHT
INDICATION: ___ year old woman s/p MVC concern for fx // ankle fx
TECHNIQUE: Three views right ankle.
COMPARISON: Right ankle radiographs 22 fibular ___
FINDINGS:
There is a linear lucency evident at the tip of the lateral malleolus which
may reflect a minimally displaced fracture. This is not well visualized on
the lateral projection. This is distal to the level of syndesmosis. The
ankle mortise is congruent on these nonstress views. There is a prominent
bony spur arising from the medial malleolus, unchanged compared to the prior
study and likely reflecting a remote injury. Prominent Achilles enthesophyte
and calcaneal spur. Dystrophic calcifications of the plantar fascia likely
reflect chronic injury.
IMPRESSION:
Possible fracture the tip of the lateral malleolus.
Radiology Report
EXAMINATION: HAND (PA,LAT AND OBLIQUE) RIGHT
INDICATION: ___ year old woman s/p MVC concern for finger fx // fracture
TECHNIQUE: Three views right hand
COMPARISON: Right hand radiographs ___
FINDINGS:
There are moderate degenerative changes in the distal interphalangeal joints
of all digits and interphalangeal joint of the thumb. No fracture or
dislocation seen. No soft tissue calcification. An IV cannula is noted at
the wrist.
IMPRESSION:
No acute bony injury seen. Degenerative changes as described.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: MVC, Transfer
Diagnosed with Unsp fracture of T7-T8 vertebra, init for clos fx, Multiple fractures of ribs, left side, init for clos fx, Unsp fracture of sternum, init encntr for closed fracture, Passenger injured in collision w unsp mv in traf, init
temperature: 97.1
heartrate: 70.0
resprate: 18.0
o2sat: 97.0
sbp: 123.0
dbp: 73.0
level of pain: 4
level of acuity: 2.0 | Mrs. ___ was admitted to the ___ for monitoring for her
traumatic injuries after an MVC. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Aricept / Bees / codeine / rivastigamine / Cipro / Exelon
Attending: ___.
Chief Complaint:
Lethargy
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is an ___ year old woman a history of Alzheimers and
prior concern for NPH based on ___ head CT who presented to
the ED s/p fall with lethargy. Per report, the patient suffered
a fall on ___ but HCP (son) refused work up at that time. ___
NP at ___ noted pt to be more lethargic
over the past few days. She was found on the ground sleeping
today. ___ concentration and gait have been worsening. Per NP,
no F/C, CP, dyspnea, abdominal pain, N/V, diarrhea, or dysuria.
In the past the patient's son has not wanted further work up for
___ symptoms. The patient was sent to the ED where staff members
spoke with HCP who agreed with work up.
Per referral note, pt has had mental status changes, states that
___ head hurts, and c/o L back/hip pain. The patient has end
stage dementia, is non verbal but but ambulatory. She is
dependent for all ___ ADLs. Per NP referral note, pt is DNR/DNI.
In the ED, initial vitals were: T 98.1 P 76 BP 120/83 R 20 O2Sat
96% RA.
- Labs were significant for normal CBC, normal chem 10, lactate
of 1.4, UA with lrg leuks, many bacteria, neg nitrites.
- CT head revealed persistent dilation of ventricles, concerning
for NPH. CXR showed Mild increase in interstitial markings
bilaterally, similar to the prior study, may be due to chronic
lung disease or mild interstitial edema.
- The patient was given ceftriaxone and admitted to the floor.
Upon arrival to the floor, pt is speaking non-sensical words.
Does not answer questions. His son was called for further
information but was unreachable. Unable to elicit any tenderness
to palpation of abdomen, hips, or extremities.
Past Medical History:
1. Docusate Sodium 100 mg PO DAILY
2. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral
DAILY
3. QUEtiapine Fumarate 12.5 mg PO TID
4. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
5. Acetaminophen 1000 mg PO Q8H:PRN pain
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600-800
mg-IU oral DAILY
Social History:
___
Family History:
Non-contributory
Physical Exam:
ADMISSION EXAM:
Vitals: T 97.3 BP 142/69 P 61 R 18 O2 Sat 99% RA
General: Alert, NAD, speaking non-sensical words
HEENT: Sclera anicteric, MMM, EOMI
Neck: Supple, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally anteriorly
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused
Neuro: MAE
DISCHARGE EXAM:
Pertinent Results:
LAB RESULTS:
___ 06:16AM BLOOD WBC-9.1 RBC-3.91* Hgb-12.9 Hct-35.7*
MCV-91 MCH-33.1* MCHC-36.2* RDW-12.6 Plt ___
___ 05:00PM BLOOD Neuts-67.6 ___ Monos-7.2 Eos-3.1
Baso-0.4
___ 06:16AM BLOOD Glucose-101* UreaN-11 Creat-0.6 Na-136
K-4.1 Cl-104 HCO3-24 AnGap-12
___ 06:16AM BLOOD Calcium-10.2 Phos-2.9 Mg-2.1
___ 06:45AM BLOOD VitB12-___ Folate-12.9
___ 06:45AM BLOOD TSH-1.3
___ 06:52AM BLOOD HIV Ab-NEGATIVE
___ 05:19PM BLOOD Lactate-1.4
___ 04:45PM CEREBROSPINAL FLUID (CSF) WBC-3 RBC-165*
Polys-5 ___ ___ 04:45PM CEREBROSPINAL FLUID (CSF) WBC-6 RBC-775*
Polys-5 ___ ___ 04:45PM CEREBROSPINAL FLUID (CSF) TotProt-98*
Glucose-52
MICROBIOLOGY:
Urine Culture ___: >100,000 colonies viridans group strep
Urine Culture ___: MIXED BACTERIAL FLORA ( >= 3 COLONY
TYPES), CONSISTENT WITH SKIN AND/OR GENITAL CONTAMINATION.
Urine Culture ___: GRAM POSITIVE COCCUS(COCCI). ~1000/ML.
IMAGING:
CXR (frontal) ___:
Mild increase in interstitial markings bilaterally, similar to
the prior study, may be due to chronic lung disease or mild
interstitial edema.
CT Head w/o contrast ___:
1. Extremely motion limited study, within these limitations, no
acute process identified.
2. Persistent dilation of the ventricles out of proportion to
the sulci, again raises possibility of normal pressure
hydrocephalus.
CT Head w/o contrast: ___:
1. No significant change in dilated lateral and third
ventricles out of proportion to sulci raise the possibility of
parenchymal volume loss with or without normal pressure
hydrocephalus. Clinical correlation is recommended. Asymmetric
enlargement of the right temporal is more in favor of medial
temporal atrophy.
2. No intracranial hemorrhage.
MR ___ contrast: ___:
1. There is ventriculomegaly, which may be disproportionate to
the degree of superimposed global cerebral volume loss. In
addition, there is
periventricular FLAIR hyperintensity, which may represent
transependymal CSF flow and underlying changes due to small
vessel disease. Clinical correlation with normal-pressure
hydrocephalus is recommended.
2. The pattern of global cerebral volume loss is nonspecific.
3. No acute intracranial hemorrhage or infarct.
4. Likely subarachnoid cyst in the right posterior fossa.
Otherwise no other intracranial mass.
EEG ___:
This is an abnormal recording due to the presence of generalized
and multifocal interictal discharges that were seen without
rhythmicity to suggest ongoing or potential seizures. Rather,
the presence of a slow and disorganized background with
generalized suppressive bursts is consistent with a moderate
encephalopathy with multifocal cortical irritability.
EEG ___:
This continuous EEG recording is notable for isolated multifocal
and generalized discharges superimposed upon a slow and
disorganized
background. This pattern is consistent with multiple areas of
cortical
irritability along with a mild to moderate encephalopathy of
toxic, metabolic, or anoxic etiology.
EEG ___:
This continuous tracing captured one clinical event captured
during physical examination; no EEG changes separate from
baseline were seen. Multifocal areas of potential
epileptogenesis were seen involving the right hemisphere, as
were generalized discharges. No ongoing seizures were seen, and
a poorly organized background is consistent with a mild
encephalopathy or with widespread regions of subcortical
dysfunction. These findings were communicated to the treating
team intermittently during this recording period to assist with
medical decision-making.
Left Shoulder Xray ___:
Glenohumeral joint space and alignment appear normal. No acute
fracture is seen. Soft tissues appear normal. No evidence of
calcific tendinitis. The acromioclavicular joint demonstrates
mild degenerative change.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO DAILY
2. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral
DAILY
3. QUEtiapine Fumarate 12.5 mg PO TID
4. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
5. Acetaminophen 1000 mg PO Q8H:PRN pain
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600-800
mg-IU oral DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Docusate Sodium 100 mg PO DAILY
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
4. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
5. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600-800
mg-IU oral DAILY
6. Vitamin D3 (cholecalciferol (vitamin D3)) 2,000 unit oral
DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
- Alzheimer's dementia
- Delirium and lethargy due to acute UTI
- Urinary tract infection
Secondary:
- Carotid artery stenosis NOS
- Vertebral compression Fractures
- Glaucoma
- Vaginal Prolapse
Discharge Condition:
Somnolent, minimally responsive. Withdraws and says 'ouch' to
pain.
Mental Status: Confused - always.
Level of Consciousness: Lethargic and not arousable.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST
INDICATION: ___ year old woman with history of dementia attributed to
Alzheimer's and acute cognitive decline/delirium. ? of NPH on CT. EEG
consistent with a moderateencephalopathy with multifocal cortical irritability
// Any evidence of inflammatory, infectious or other acute intracranial
process or potential seizure focus? Any evidence of Alzheimer's or NPH?
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 6cc 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 of ___.
FINDINGS:
The examination is motion degraded. Within these confines:
There is global cerebral volume loss and ventriculomegaly. The degree of
ventriculomegaly may be disproportionate to the degree of volume loss. There
is periventricular white matter FLAIR hyperintensities, which may represent
transependymal CSF flow and underlying changes due to small vessel disease.
There is no acute infarct or intracranial hemorrhage. There is an apparent
nonenhancing 1.8 x 0.9 cm (AP, TRV) CSF intensity lesion adjacent to the
sigmoid sinus and the right posterior fossa (series 108, image 40) compatible
with arachnoid cyst.
The intracranial flow voids are preserved. The dural venous sinuses are
patent. The patient is status post left lens replacements otherwise the
orbits are unremarkable. The paranasal sinuses are clear. Mastoid air cells
are clear.
IMPRESSION:
1. There is ventriculomegaly, which may be disproportionate to the degree of
superimposed global cerebral volume loss. In addition, there is
periventricular FLAIR hyperintensity, which may represent transependymal CSF
flow and underlying changes due to small vessel disease. Clinical correlation
with normal-pressure hydrocephalus is recommended.
2. The pattern of global cerebral volume loss is nonspecific.
3. No acute intracranial hemorrhage or infarct.
4. Likely subarachnoid cyst in the right posterior fossa. Otherwise no other
intracranial mass.
Radiology Report
EXAMINATION: PRE-MRI ABDOMEN, SINGLE VIEW ONLY
INDICATION: ___ year old woman who need mri. ? metal pessary. // r/o foreign
body for MRI.
TECHNIQUE: Supine abdominal radiograph.
FINDINGS:
No metallic objects are seen in the abdomen or pelvis. Gallbladder stones are
noted in the right upper quadrant. Chain suture and surgical material are
noted in the right lower quadrant. Circular dense lower pelvic object is
compatible with clinical history of pessary. Nonspecific bowel gas pattern is
noted. Compression deformities of at least L4 and L5 are noted.
IMPRESSION:
No metallic objects in the abdomen or pelvis.
Radiology Report
EXAMINATION: ABDOMEN (SUPINE ONLY)
INDICATION: ___ year old woman who needs mri. evaluate for metal pessary w/
kub // evaluate for metal pessary.
TECHNIQUE: Supine abdominal radiograph.
COMPARISON: Abdominal radiograph dated ___ at 06:50.
FINDINGS:
No metallic object is seen in the abdomen or pelvis. Compression deformities
of the lower lumbar spine are again the identified. Chain sutures are seen in
the right lower quadrant. Gallstones are seen in the right upper quadrant.
Circular opacity in the lower pelvis likely corresponds to pessary.
IMPRESSION:
No metallic objects are seen in the abdomen or pelvis.
Radiology Report
EXAMINATION: SHOULDER (AP, NEUTRAL AND AXILLARY) TRAUMA LEFT
INDICATION: ___ year old woman with fall, pain on passive movement at L
glenohumeral joint // eval for fracture
TECHNIQUE: Three views left shoulder.
COMPARISON: None available.
FINDINGS:
Glenohumeral joint space and alignment appear normal. No acute fracture is
seen. Soft tissues appear normal. No evidence of calcific tendinitis. The
acromioclavicular joint demonstrates mild degenerative change.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ year old woman with altered mental status and worsening
lethargy. Assess for any evidence of bleed or cause of increased lethargy
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
Coronal and sagittal as well as thin bone-algorithm reconstructed images were
obtained.
DOSE: DLP: 1121.4 mGy-cm
CTDI: 56.07 mGy
COMPARISON: Noncontrast head CT ___.
FINDINGS:
There is no evidence of infarction, hemorrhage, or mass. The ventricles are
similar in size in appearance to previous examination. The ventricles appear
persistently enlarged out of proportion to sulci. Periventricular and
subcortical white matter hypodensities are likely sequelae of chronic small
vessel ischemic disease however transependymal flow is on the differential.
The basal cisterns are patent.
No osseous abnormalities seen. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The orbits are unremarkable.
IMPRESSION:
1. No significant change in dilated lateral and third ventricles out of
proportion to sulci raise the possibility of parenchymal volume loss with or
without normal pressure hydrocephalus. Clinical correlation is recommended.
Asymmetric enlargement of the right temporal is more in favor of medial
temporal atrophy.
2. No intracranial hemorrhage.
Radiology Report
EXAMINATION: DX ANKLE AND FOOT
INDICATION: ___ year old woman with dementia (non-verbal at baseline)
presenting with AMS, UTI, and inability to put weight on R foot/ankle. // R/u
fracture vs infection R/u fracture vs infection
COMPARISON: None available
FINDINGS:
No fracture, dislocation, or foreign body is detected. The mortise is
congruent on this non stress view. The tibial talar joint space is preserved
and no talar dome osteochondral lesion is identified. No suspicious lytic or
sclerotic lesion is identified. Within the foot, note is made of Hale except
bowel gas and degenerative changes at the first metatarsal phalangeal joint
along with curvilinear periarticular calcifications. Increased bone formation
is noted at the insertion of the Achilles tendon. Vascular calcifications are
present in the soft tissues.
IMPRESSION:
No evidence of acute fracture of the right ankle or fluid. Osseous
demineralization reduces sensitivity for detecting subtle fractures and
followup radiographs may be helpful if symptoms persist. .
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with AMS and UTI, with poor clinical
improvement on appropriate antibiotics. // R/u aspiration event R/u
aspiration event
IMPRESSION:
In comparison with the study of ___, there is an area of increased
opacification at the right base. This most likely represents atelectasis,
though in the appropriate clinical setting aspiration would have to be
seriously considered.
Otherwise little change.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Lethargy
Diagnosed with ALTERED MENTAL STATUS
temperature: 98.1
heartrate: 76.0
resprate: 20.0
o2sat: 96.0
sbp: 120.0
dbp: 83.0
level of pain: 13
level of acuity: 2.0 | Ms. ___ is an ___ year old woman with a history of advanced
Alzheimer's Dementia and carotid artery occlusion (unknown side)
who initially presented to ___ on ___ with two days of
lethargy and a change in mental status. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Aldactazide
Attending: ___
Chief Complaint:
Fever, tachycardia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ with a PMHx of metastatic bladder ca,
HTN, HLD, Afib and OSA, who presents with fever and tachycardia.
For the past 3d, pt has been feeling unwell. He experienced
geeralized weakness, non-productive cough, nausea, and chills.
Measured temp at home on day of admission was 104. Pt called his
Oncologist who advised that pt present to ED.
In the ED, initial vitals: T 98.8 Tm 102.4, P ___, BP
159/112 R 18, O2 Sat 98% on RA. Labs were remarkable for lactate
3, K 3.2, Cr 1.4, HCT 36.1. EKG showed Afib with RVR to 152bpm.
UA was weakly positive. CXR was unremarkable. Pt received
cefepime 2g IV x 1, azithromycin 500mg IV x 1, KCl 40mEq, Zofran
4mg IV x 1, MgSO4 2g IV x 1, tylenol 1g IV x 1, phos 250mg po x
1, 3L NS.
On arrival to the MICU, pt reports feeling well.
Past Medical History:
Bladder Cancer Depression, hypertension, eczema, history
of SVT, GERD, hyperlipidemia, OSA, BPH, gout
Social History:
___
Family History:
No GU Cancers. Son with thyroid ca, brother died suddenly of
unclear cause at ___ yrs of age.
Physical Exam:
ADMISSION PHYSICAL EXAM:
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear; ?R eye ptosis
NECK: supple, JVP not elevated, no LAD
LUNGS: Rhonchi at L base; no wheeze
CV: Irregularly irregular, tachycardic, normal S1 S2, no
murmurs, rubs, gallops
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding, no organomegaly; +urostomy in
RLQ
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema; no CVAT
NEURO: CNII-XII intact; strength ___ in UE and ___ bl
DISCHARGE:
Vitals: Temp 99.0 150/100(124-150) p87-91 rr16 97%RA blood
sugars: 132, 175, 144, 177
GENERAL: Alert and oriented x 3. NAD. speech coherent. speaking
in full sentences.
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: ___, S1/S2, no mrg
LUNG: CTAB, no w/r/r
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly . Urostomy site looks
clean without erthema, swelling or drainage.
PULSES: 2+ DP pulses bilaterally
NEURO: CN ___ intact
Pertinent Results:
ADMISSION LABS:
___ 07:50PM BLOOD WBC-6.4 RBC-3.96* Hgb-11.7* Hct-36.1*
MCV-91 MCH-29.6 MCHC-32.5 RDW-14.0 Plt ___
___ 07:50PM BLOOD Neuts-87.4* Lymphs-5.1* Monos-6.1 Eos-0.9
Baso-0.3
___ 02:11AM BLOOD ___ PTT-27.5 ___
___ 07:55PM BLOOD Glucose-220* UreaN-17 Creat-1.4* Na-134
K-3.2* Cl-100 HCO3-22 AnGap-15
___ 07:55PM BLOOD ALT-18 AST-18 AlkPhos-79 Amylase-33
TotBili-0.8
___ 07:55PM BLOOD CK-MB-1 cTropnT-<0.01
___ 02:11AM BLOOD CK-MB-2 cTropnT-<0.01
___ 07:55PM BLOOD Calcium-8.5 Phos-1.8* Mg-1.3*
___ 07:55PM BLOOD TSH-2.1
___ 07:55PM BLOOD Free T4-1.1
___ 07:59PM BLOOD Lactate-3.0*
___ 02:56AM BLOOD Lactate-1.8
MICRO:
___ 8:15 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- <=1 S
VANCOMYCIN------------ 1 S
___
FINDINGS: The known paramediastinal parenchymal opacities are
better
characterized by recent chest CT. There is no evidence of new
parenchymal
opacity. The cardiomediastinal silhouette is within normal
limits. No acute osseous abnormalities.
IMPRESSION: No acute cardiopulmonary process.
CXR ___:
IMPRESSION:
Right upper paramediastinal pulmonary consolidation is grown
more cough lung, probably acute pneumonia. Pulmonary
vasculature is engorged and mediastinal veins are dilated,
probably a function of hyper circulation in a febrile patient.
There are no other regions upper pneumonia is suspected and no
pleural effusion is present.
DISCHARGE LABS:
___ 07:15AM BLOOD WBC-4.1 RBC-3.93* Hgb-11.8* Hct-35.9*
MCV-91 MCH-30.1 MCHC-32.9 RDW-14.3 Plt ___
___ 07:15AM BLOOD Neuts-66.7 Lymphs-17.7* Monos-7.6
Eos-7.4* Baso-0.6
___ 07:15AM BLOOD Glucose-124* UreaN-18 Creat-1.0 Na-139
K-3.9 Cl-104 HCO3-24 AnGap-15
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Simvastatin 20 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Citalopram 20 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Lisinopril 20 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Simvastatin 20 mg PO DAILY
5. Amlodipine 5 mg PO DAILY
6. Lisinopril 20 mg PO DAILY
7. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate [Toprol XL] 100 mg 1 tablet(s) by mouth
daily Disp #*30 Tablet Refills:*0
8. Amoxicillin 500 mg PO Q8H Duration: 10 Days
RX *amoxicillin 500 mg 1 tablet(s) by mouth three times daily
Disp #*29 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
- Acute complicated cystitis
- Sepsis
Secondary diagnoses:
- Atrial fibrillation with rapid ventricular response
- Metastatic bladder carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
PORTABLE CHEST: ___.
HISTORY: ___ male with fever.
COMPARISON: Chest CT from ___.
FINDINGS: The known paramediastinal parenchymal opacities are better
characterized by recent chest CT. There is no evidence of new parenchymal
opacity. The cardiomediastinal silhouette is within normal limits. No acute
osseous abnormalities.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)CHEST (PORTABLE AP)i
INDICATION: ___ year old man with severe sepsis // PNA?
COMPARISON: Chest radiographs since ___ most recently ___
IMPRESSION:
Right upper paramediastinal pulmonary consolidation is grown more cough lung,
probably acute pneumonia. Pulmonary vasculature is engorged and mediastinal
veins are dilated, probably a function of hyper circulation in a febrile
patient. There are no other regions upper pneumonia is suspected and no
pleural effusion is present.
NOTIFICATION: Dr. ___ reported the findings to Dr. ___ by telephone on
___ at 12:10 ___, 2 minutes after discovery of the findings.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with URIN TRACT INFECTION NOS, ATRIAL FIBRILLATION, MALIG NEO BLADDER NOS
temperature: 98.8
heartrate: 144.0
resprate: 18.0
o2sat: 98.0
sbp: 159.0
dbp: 112.0
level of pain: nan
level of acuity: 1.0 | Mr. ___ is a ___ with a PMHx of metastatic bladder ca,
HTN, HLD, Afib and OSA, who presented with fever and
tachycardia.
# Severe Sepsis/Acute complicated cystitis/HCAP: Pt presented
with fever, tachycardia and elevated lactate. Source was not
clear but thought possibly UTI given +UA (though from urostomy)
vs PNA given rhonchi on left. Initially no evidence of pneumonia
on CXR, but on morning of HD one a second x-ray was read as a
right paramediastinal consolidation. He had no clinical s/sxs of
pneumonia and there was previous note of paramediastinal
opacities on CT chest. He was treated empirically with
vancomycin/cefepime. His lactate normalized within 24 hours, and
his tachycardia improved to 90-100s with IVF and beta blockade.
Blood, and urine cultures had not grown by hospital day one, and
he was transferred to the oncology medicine floor with continued
fevers but in stable condition. His urine cultures grew
Vancomycin-sensitive enterococcus. Cefepime was discontinued.
His blood cultures were negative. His fever curve down-trended.
Vancomycin was eventually changed to Amoxicillin x 10days. He
was afebrile at discharge.
# AFib. Pt with known history of afib, not anticoagulated.
Presented with RVR, likely ___ fever/infection. CHADS2 = 1,
though stroke risk potentially higher given severe sepsis. Pt
was fluid resuscitated and given metoprolol 25mg po q6h with
good response in his heart rate. He was switched to home
Metoprolol succinate 100mg daily at discharge. Atenolol was
discontinued.
# Bladder Ca. no active tx while in-house
# CKD: Cr at baseline. Lisinopril initially held in setting of
sepsis. Restarted at discharge.
# Anemia. Chronic, likely ___ malignancy. At baseline, no
evidence of bleeding.
# HTN: Held lisinopril and amlodipine in setting of sepsis.
Resumed upon discharge. SBP running in the 120's to 150's.
# Hyperglycemia. Hyperglycemic during ICU admission. On no orals
or insulin at home. Maintained on insulin sliding scale. BS
better controlled with infection source control.
.
# GERD. Continued omeprazole at home dose.
# HLD: Held simvastatin during ICU admission. Resumed
# Depression. Held citalopram in setting of Afib with rvr and
concomitant zofran use, given potential for long QT. Resumed
upon discharge |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / lamotrigine / aripiprazole
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
Cholecystectomy
History of Present Illness:
___ y/o F with PMHx of DM1, bipolar d/o, presented initially to
___ on ___ with abrupt onset of severe RUQ pain
associated with nausea and vomiting.
Per patient, her symptoms started on ___ at 1AM with RUQ pain,
nausea and non-bilious, non-bloody emesis. No chest pain,
dyspnea, fevers, chills, diarrhea, constipation. At ___,
she was found to have WBC 15.4, normal chemistries (except
glucose 270), and normal LFTs except alk phos 142. RUQ u/s
showed large gall stones w/o cholecystitis, but did show
multiple liver lesions, largest measuring 7cm, which were
concerning for metastatic lesions. CT abdomen w/ contrast showed
multiple early-enhancing liver lesions, again no evidence of
cholecystitis. She received 2L normal saline, cipro, flagyl, and
morphine, and transferred here for furthur management.
In the ___ ED intial vitals were: pain 5, T 98.7, HR 106, BP
168/82, RR 20, O2 98%
- Exam notable for well appearing but dry MM. Moderate RUQ TTP
without rebound, guarding, or ___
- Labs were significant for WBC 23.0 (89.3%PMN). LFT's were
unremarkable except ALP 139. Normal Chem7 aside from
hyperglycemia to 280.
- Patient was given 2g IV Mg, 1g ceftriaxone, 500mg IV
metronidazole, IV morphine x3, and 19 units lantus.
On the floor, patient reports pain is much improved, now ___.
No nausea, last vomited in the ED.
Past Medical History:
DM1
bipolar
Social History:
___
Family History:
cousin with lymphoma, another cousin with leukemia
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals - 98.5; 162-82; 105; 100RA
GENERAL: NAD
HEENT: EMOI, dry MM, pink conjunctiva
CARDIAC: tachycardic, regular rhythm, S1/S2, II/VI holosystolic
murmur at RUSB
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, +BS, RUQ tenderness on palpation.
hepatomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS
___ 05:37PM LACTATE-2.0
___ 05:10PM GLUCOSE-280* UREA N-10 CREAT-0.5 SODIUM-134
POTASSIUM-4.1 CHLORIDE-97 TOTAL CO2-22 ANION GAP-19
___ 05:10PM estGFR-Using this
___ 05:10PM ALT(SGPT)-17 AST(SGOT)-22 ALK PHOS-139* TOT
BILI-0.8
___ 05:10PM LIPASE-24
___ 05:10PM ALBUMIN-4.0 CALCIUM-8.8 PHOSPHATE-3.8
MAGNESIUM-1.5*
___ 05:10PM WBC-23.0* RBC-4.68 HGB-13.5 HCT-39.7 MCV-85
MCH-28.9 MCHC-34.1 RDW-12.7
___ 05:10PM NEUTS-89.3* LYMPHS-6.1* MONOS-4.2 EOS-0.1
BASOS-0.3
___ 05:10PM PLT COUNT-405
IMAGING
MRI ABDOMEN ___
IMPRESSION:
1. Moderate distended gallbladder with wall edema and trace
perihepatic fluid, and likely an impacted stone in the neck,
worrisome for acute cholecystitis.
2.. Three liver lesions in segments VI/ VII, V and VI, largest
measuring 8.4 cm, with imaging features of adenoma. The MR
imaging characteristics for ___ of adenomas are
not classic, but these are thought to represent inflammatory
adenomas.
3. Two liver lesions in the segment VI, ___ are consistent
with focal
nodular hyperplasia.
GALLBLADDER SCAN ___
IMPRESSION: Findings compatible with acute cholecystitis.
Although lack of gallbladder filling may be due to the extended
NPO state, this is felt to be less likely.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LaMOTrigine 300 mg PO DAILY
2. Aripiprazole 30 mg PO HS
3. Glargine 46 Units Breakfast
Glargine 6 Units Bedtime
Humalog 12 Units Breakfast
Humalog 10 Units Lunch
Humalog 15 Units Dinner
4. Zovia ___ (28) (ethynodiol diac-eth estradiol) ___ mg-mcg
oral daily
5. Multivitamins 1 TAB PO DAILY
6. Vitamin D 800 UNIT PO DAILY
7. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Aripiprazole (ARIPiprazole) 30 mg ORAL QHS
2. Aspirin 81 mg PO DAILY
3. Glargine 46 Units Breakfast
Glargine 6 Units Bedtime
Humalog 12 Units Breakfast
Humalog 10 Units Lunch
Humalog 15 Units Dinner
4. LaMOTrigine (lamoTRIgine) 300 mg ORAL DAILY
5. Multivitamins 1 TAB PO DAILY
6. Vitamin D 800 UNIT PO DAILY
7. Acetaminophen 1000 mg PO Q8H
Maximum 6 of the 500 mg tablets daily
RX *acetaminophen 500 mg 2 tablet(s) by mouth every 8 hours Disp
#*24 Tablet Refills:*0
8. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
daily Disp #*40 Capsule Refills:*0
9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
No driving if taking this medication. Taper as tolerated
RX *oxycodone 5 mg 1 capsule(s) by mouth every ___ hours Disp
#*35 Tablet Refills:*0
10. Senna 8.6 mg PO DAILY
RX *sennosides [___] 8.6 mg 1 tablet by mouth daily Disp
#*40 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Acute cholecystitis
8 cm hepatic adenoma in the right lobe
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with acute onset nausea, vomiting and abdominal
pain, is here for evaluation of liver lesions seen on recent CT.
TECHNIQUE: Multi planar T1 and T2 weighted MR images of the abdomen were
performed in a 1.5 Tesla magnet, prior to, during and after uneventful
intravenous administration 9 mL of Eovist.
COMPARISON: Reference CT abdomen and ultrasound abdomen performed ___.
FINDINGS:
A 7.3 (cc) x 8.4 (TR) x 7.0 (AP) cm lesion spanning segments VI/VII of the
liver (13:21), is slightly iso to hyperintense to the liver on T2 weighted
images, isointense to the liver on T1 weighted images, and shows mild drop in
signal in the out of phase images, compared to the inphase images indicating
small amount of intra voxel fat. A rim of T2 hyperintensity surrounding this
lesion, represents bulk fat, and not the typical 'Atoll sign' seen in
inflammatory adenomas (8a:19). This lesion demonstrates homogeneous mild
hyperenhancement in the arterial phase images, which fades out in the delayed
phases. No significant retention of Eovist is seen in the delayed 20 min
images. The imaging findings are consistent with an adenoma, likely of the
inflammatory subtype
A 1.5 x 1.4 x 1.3 cm lesion in segment V (13:27), is hyperintense on T2
weighted images, hypointense on T1 weighted images, and contains modest amount
of intra-voxel fat. This lesion demonstrates mild heterogeneous enhancement in
the post-contrast images, and appears hypointense on 20 min delayed images,
without significant Eovist retention, imaging findings suggestive of an
adenoma.
A 1.7 x 1.0 cm lesion in segment VI (17:88), with minimal intra-voxel fat,
shows arterial hyperenhancement, without retention of hepatobiliary contrast
in the 20 min delayed images, consistent with an adenoma.
A 1.5 x 1.4 cm lesion at the junction of segments V/IV a (17:77), a 1.7 x 1.5
cm lesion in segment ___ (16:21), appear inconspicuous on pre-contrast images
and show arterial hyperenhancement with retention of hepato-biliary contrast
agent in the 20 min delayed images, consistent with focal nodular hyperplasia.
The gallbladder is moderately distended and contains a single large gallstone
in the neck. There is moderate gallbladder wall edema, mild hyperemia along
the gallbladder fossa and trace perihepatic fluid, raising concern for acute
cholecystitis. There is no intrahepatic or extrahepatic bile duct dilation.
The adrenal glands, spleen, kidneys and pancreas are normal. The imaged bowel
loops are unremarkable. The abdominal aorta is normal in caliber. No
pathologic retroperitoneal or mesenteric lymphadenopathy is seen.
IMPRESSION:
1. Moderate distended gallbladder with wall edema and trace perihepatic fluid,
and likely an impacted stone in the neck, worrisome for acute cholecystitis.
2.. Three liver lesions in segments VI/ VII, V and VI, largest measuring 8.4
cm, with imaging features of adenoma. The MR imaging characteristics for
___ of adenomas are not classic, but these are thought to
represent inflammatory adenomas.
3. Two liver lesions in the segment VI, ___ are consistent with focal
nodular hyperplasia.
NOTIFICATION: The critical findings for discussed with ___ on ___ at 10:00 A.M, 5 min after discovery.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Fever, atelectasis, evaluation.
COMPARISON: No comparison available at the time of dictation.
FINDINGS: The lung volumes are very low. Moderate cardiomegaly is present.
There are bilateral diffuse and subtle increases in radiodensity seen over the
entire lung parenchyma. These changes might be the result of layering pleural
effusions, low lung volumes, compounded by the body habitus of the patient.
Both lateral and frontal views as well as a repeat radiograph with a stronger
inspiratory effort would be helpful in determining the nature of the
opacities.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: N/V, Abd pain
Diagnosed with CHOLELITHIASIS NOS, LIVER DISORDERS NEC, DIABETES UNCOMPL JUVEN, LONG-TERM (CURRENT) USE OF INSULIN
temperature: 98.7
heartrate: 106.0
resprate: 20.0
o2sat: 98.0
sbp: 168.0
dbp: 82.0
level of pain: 5
level of acuity: 2.0 | ___ woman with DMI and bipolar disorder admitted for abdominal
pain, found to have cholecystitis and multiple hepatic adenomas
and FNH.
1) Cholecystitis: noted on MRI abdomen. Initially started on
ceftriaxone and flagyl. Surgery consulted. HIDA scan was also
positive.
2) Hepatic adenomas: OCP stopped.
On ___ the patient was taken to the OR for cholecystectomy
by Dr ___. At the time of surgery the gallbladder was
noted to be very distended and inflamed. There was also a very
large gallstone impacted in the infundibulum. Due to the degree
of inflammation and the difficulty in locating the cystic duct,
the decision was made to convert to an open procedure. Intra-op
cholangiogram was performed assuring no bile duct injury. A
subtotal cholecystectomy was then completed, and the gallstone
had also been removed.
The patient was extubated and transferred to the PACU in stable
condition. Please see the operative note for surgical details.
Post operatively the patient initially did have pain management
issues and was using a dilaudid PCA with only moderate success.
Adjustments were made and tylenol scheduled which seemed to
improve her pain management. She did have a fever to 102. Blood
cultures were sent which have been no growth to date. A chest
xray was done showing very low lung volumes. Spirometry was
encouraged. She did have a desaturation into the 80's on POD 1
evening. She was encouraged to increase the use of her
spirometer and this did not occur again.
The JP drain was sero-sanguinous, with no evidence of a bile
leak. Her diet was advanced from clears to a regular diet with
good tolerance. No nausea or vomiting. And once on a regular
diet she was tolerating PO oxycodone with improved pain
management such that she was ambulating. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
egg
Attending: ___.
Chief Complaint:
Motor vehicle Collision
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ unrestrained driver, MVC vs pole. Pt said he hit black ice
then slammed on brakes, swerved right to avoid people on left
and in doing so hit a pole. There was intrusion on driver side,
no air bag, likely +LOC. Denied EtOH. Taken to OSH where CT scan
head was suspicious for a SAH so after initial stabilization he
was transferred to ___ for further management.
Past Medical History:
PMH: bipolar disorder
PSH: tonsillectomy, tympanostomy tubes
Social History:
___
Family History:
Non-contributory
Physical Exam:
PHYSICAL EXAM ON DISCHARGE
VITALS: Temp 98.4 HR 57 BP 112/62 RR 18 Sa02 98% (RA)
GEN: A/O x 3
___: RRR
RRR: CTA b/l
ABD: soft, non-tender, non-distended, BS active
EXT: peripheral pulses palpable b/l
Pertinent Results:
___ 07:15AM BLOOD WBC-9.5 RBC-4.50* Hgb-13.5* Hct-40.6
MCV-90 MCH-30.0 MCHC-33.2 RDW-12.7 Plt ___
___ 03:47AM BLOOD Glucose-106* UreaN-7 Creat-1.0 Na-140
K-3.9 Cl-104 HCO3-27 AnGap-13
___ 03:47AM BLOOD Calcium-9.2 Phos-4.2 Mg-2.0
___ 11:38PM BLOOD Glucose-93 Lactate-1.8 Na-141 K-3.9
Cl-101 calHCO3-28
Medications on Admission:
None
Discharge Medications:
1. HYDROmorphone (Dilaudid) ___ mg PO Q3H:PRN pain
2. Docusate Sodium 100 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Motor Vehicle Collision
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH
INDICATION: Left pneumothorax, evaluation.
COMPARISON: No chest radiographic comparison available at the time of
dictation. CT torso from ___.
FINDINGS: On the previous CT examination, a minimal right apical pneumothorax
was visible. This pneumothorax is not visible on the current chest
radiographic examination. Normal size of the cardiac silhouette. Normal
appearance of the lung parenchyma. No pleural effusions. No pulmonary edema.
No pneumonia.
Radiology Report
INDICATION: Patient is status post motor vehicle accident. Assess for
fracture.
COMPARISONS: none.
FINDINGS:
Four views of the right wrist are provided, which demonstrate no evidence of a
fracture. No dislocation. The joint spaces are well preserved. No
significant degenerative joint changes are seen. Bone mineralization is
normal. No suspicious lytic or sclerotic bony lesion is seen.
IMPRESSION:
No fracture.
Radiology Report
INDICATION: Status post motor vehicle accident. Assess for fracture.
COMPARISONS: None available.
FINDINGS:
Three views of the left shoulder demonstrate no evidence of acute fracture or
dislocation. Glenohumeral articulation appears preserved. Bone
mineralization is normal. Partially imaged left lung is clear. Soft tissues
are unremarkable.
IMPRESSION:
No fracture or dislocation.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: MVC
Diagnosed with SPLEEN PARENCHYMA LACER, MV COLLISION NOS-DRIVER, TETANUS TOXOID INOCULAT
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | The patient presented as above to the ED at ___ ON ___.
On arrival the patient's vitals were within normal limits. His
OSH imaging (CT head/neck/Chest/Abdomen) was reviewed and it was
decided that a SAH was unlikely. CT neck was negative. CT chest
revealed a small left apical pneumothorax while the CT abdomen
demonstrated a Grade 2 splenic laceration, L lobe liver
laceration without any ___ fluid and a R adrenal
hemorrhage. Subsequently, the patient was admitted to the ICU
under the Acute Care Surgery Service.
Neuro: The patient was alert and oriented throughout
hospitalization. He was kept on Q4H neuro-checks in the ICU
which were negative so they were discontinued when the patient
was transferred to the floor in the evening of HD1. His pain was
initially managed with IV narcotics and then transitioned to
oral medication when his diet was resumed. His C-collar was
cleared after the CT neck was confirmed to be negative and the
patient was transferred to the floor on HD1 when he was deemed
to be stable.
CV: The patient remained stable from a cardiovascular
standpoint; he was kept on telemetry in the ICU which was
discontinued when he came to the floor.
Pulmonary: The patient remained stable from a pulmonary
standpoint; he had a small L apical pneumothorax on admission
which remained stable on repeat am CXR. Good pulmonary toilet,
early ambulation and incentive spirometry were encouraged
throughout hospitalization.
GI/GU/FEN: The patient was initially kept NPO. On HD1 his diet
was advanced sequentially to a regular diet, which was well
tolerated. Patient's intake and output were closely monitored.
The patient refused a Foley on admission so his urine output was
closely monitored and was adequate.
ID: The patient's fever curves were closely watched for signs of
infection, of which there were none.
HEME: The patient's blood counts were closely watched for signs
of bleeding, of which there were none.
Prophylaxis: We held SQH until intracranial bleeding was
definitively ruled out and the patient was encouraged to get up
and ambulate as early as possible.
MSK: The patient had complained of L shoulder and wrist pain on
admission so we obtained X rays which were negative for any
fractures or dislocation.
At the time of discharge on HD2, 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 cautioned against
partaking in any activity that involved contact with his abdomen
or heavy weights for at least ___ weeks and was advised bed rest
until clinic follow-up in 2 weeks. The patient received
discharge teaching and follow-up instructions and verbalized
understanding of and agreement with the discharge plan. However
he left without his paperwork so efforts were made to fax the
paperwork to him. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
erythromycin base / ___
Attending: ___.
Chief Complaint:
Rectal bleeding
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ y/o male w/hx CAD, AAA repair, diverticulitis s/p open
sigmoidectomy presents w/ acute onset of bright red bleeding
from the rectum. Patient report that he started having dull
onset of RLQ and mid lower abdominal pain starting about 1 week
ago with no other associated symptoms. Then this morning he
started to have some dizziness and headache and at 10am, he had
a BM and
noticed a large amount of bright red clots which has not stopped
since. He presented to ___ where he was noted to
be tachycardic and pale with large amount active bright red
bleeding through his rectum. He was given 5U RBCs, ___ and
1Plt. underwent a CTA a/p which showed many diverticuli with
enhancement in the diverticular lumen which are likey calcified
inspissated stool with some regions with questionable contrast
blush.. Upon transfer to ___, he continued to large clots of
blood from the rectum with associated tachycardia and SBP 90's.
Massive transfusion protocol was activated and he got additional
4U RBC, ___ 1Plt. Patient currently reports pain in his RLQ. He
denies other symptoms. He reports he had a bright GIB almost ___
years ago and was hospitalized however does not remember the
diagnosis or intervention. He had his last colonoscopy ___
at ___ which he reports was normal. He also
underwent an EGD a few months ago for reflux symptoms which
showed mild gastritis. He has been on Omeprazole. He denies any
hx of fevers, chills, weight loss, chest pain, SOB, nausea or
emesis.
Past Medical History:
Past Medical History:
CAD (s/p CABG)
COPD
Asthma
HTN
DM2
Diverticulitis
RA
BCC (face)
GI bleed
Constipation
Pneumonia
Past Surgical History:
CABG 4v
Open AAA repair
Open cholecystectomy (remote)
Open sigmoidectomy
Social History:
___
Family History:
Family History:
No PVD in family
Physical Exam:
Physical Exam on Admission:
98.8 101 112/60 19 100% 2L MC
GEN: NAD
PULM: nonlabored, 2L NC
CV: regular
ABD: soft, nondistended, focally tender in RLQ with voluntary
guarding, no rebound tenderness
RECTAL: large amount of clot on the sheets and actively draining
from the rectum, tender to rectal exam, blood in rectal vault,
no masses palpable.
EXT: WWP, palpable DPs bilaterally
Physical Exam on Discharge:
VS: Temp 98.4F, BP 163/65, HR 93, RR 18, O2 Sat 94% on RA
GEN: NAD, afebrile
PULM: Nonlabored, CATB, on RA
CV: RRR
ABD: Soft, nondistended, non-tender.
EXT: No edema
Last BM in AM of d/c hemocult negative.
Pertinent Results:
MESENTERIC ARTERIOGRAM Study Date of ___
No active extravasation, pseudoaneurysm, angiodysplasia, or
source of
gastrointestinal bleeding was identified despite thorough
angiography.
GI BLEEDING STUDY Study Date of ___
No evidence of active GI bleeding during the 90 minutes of
study.
Small Bowel Enteroscopy: ___
-Linear erosions in distal esophagus and prixumal gastric body
consistent with NG tube trauma.
- Normal mucosa in the whole stomach, examined duodenum and
proximal jejunum.
Sigmoidoscopy: ___
- high residue maternal noted throughout. multiple attempts were
made to irrigate the oclon but the mucosa could not be
visualized. internal hemorrhoids, old, non-adherent clot at
32cm. Clot was suctioned away with non-bleeding diverticulum
underneath and no stigmata of recent bleeding.
CHEST (PORTABLE AP) Study Date of ___
Comparison to ___. The patient has been extubated and
all other
monitoring and support devices were removed, with the exception
of the right internal jugular vein introduction sheet.
Pre-existing signs of mild pulmonary edema have resolved.
Today's radiograph shows minimal pleural effusions bilaterally
with areas of retrocardiac and right basilar atelectasis but no
evidence of pneumonia or pneumothorax.
CHEST (PORTABLE AP) Study Date of ___
In comparison with the study of ___, the right IJ catheter
is been
removed. Cardiomediastinal silhouette is stable and there is no
evidence
vascular congestion. Again there are bilateral pleural
effusions with
atelectatic changes at the bases. No evidence of acute focal
consolidation.
___ 05:24PM BLOOD WBC-13.3* RBC-3.60* Hgb-11.0* Hct-33.4*
MCV-93 MCH-30.6 MCHC-32.9 RDW-14.3 RDWSD-48.5* Plt ___
___ 08:44PM BLOOD WBC-13.2* RBC-2.87* Hgb-8.6* Hct-25.9*
MCV-90 MCH-30.0 MCHC-33.2 RDW-14.7 RDWSD-48.1* Plt Ct-80*
___ 10:05PM BLOOD WBC-10.7* RBC-2.83* Hgb-8.5* Hct-25.5*
MCV-90 MCH-30.0 MCHC-33.3 RDW-14.6 RDWSD-48.1* Plt Ct-85*
___ 11:48PM BLOOD WBC-17.2* RBC-3.15* Hgb-9.5* Hct-28.1*
MCV-89 MCH-30.2 MCHC-33.8 RDW-14.9 RDWSD-48.7* Plt Ct-98*
___ 03:49AM BLOOD Hct-21.8*
___ 04:44AM BLOOD WBC-11.8* RBC-2.56* Hgb-7.4* Hct-22.8*
MCV-89 MCH-28.9 MCHC-32.5 RDW-15.3 RDWSD-49.9* Plt ___
___ 08:12AM BLOOD WBC-9.6 RBC-2.85* Hgb-8.5* Hct-25.1*
MCV-88 MCH-29.8 MCHC-33.9 RDW-15.4 RDWSD-48.9* Plt ___
___ 01:57PM BLOOD WBC-10.1* RBC-2.81* Hgb-8.4* Hct-24.6*
MCV-88 MCH-29.9 MCHC-34.1 RDW-15.8* RDWSD-49.7* Plt ___
___ 08:29PM BLOOD WBC-9.4 RBC-2.84* Hgb-8.4* Hct-24.5*
MCV-86 MCH-29.6 MCHC-34.3 RDW-15.8* RDWSD-49.6* Plt Ct-46*
___ 01:34AM BLOOD WBC-9.3 RBC-2.65* Hgb-8.0* Hct-23.2*
MCV-88 MCH-30.2 MCHC-34.5 RDW-15.9* RDWSD-50.6* Plt Ct-93*
___ 06:50PM BLOOD WBC-10.6* RBC-2.71* Hgb-8.1* Hct-24.4*
MCV-90 MCH-29.9 MCHC-33.2 RDW-15.6* RDWSD-51.3* Plt Ct-97*
___ 02:30AM BLOOD WBC-10.0 RBC-2.80* Hgb-8.3* Hct-25.0*
MCV-89 MCH-29.6 MCHC-33.2 RDW-15.2 RDWSD-49.6* Plt Ct-94*
___ 06:00AM BLOOD WBC-10.1* RBC-2.79* Hgb-8.3* Hct-25.1*
MCV-90 MCH-29.7 MCHC-33.1 RDW-15.2 RDWSD-50.5* Plt Ct-66*
___ 03:48PM BLOOD WBC-10.2* RBC-2.96* Hgb-8.9* Hct-26.6*
MCV-90 MCH-30.1 MCHC-33.5 RDW-15.1 RDWSD-49.3* Plt ___
___ 06:24AM BLOOD WBC-9.0 RBC-2.87* Hgb-8.6* Hct-25.9*
MCV-90 MCH-30.0 MCHC-33.2 RDW-14.8 RDWSD-48.2* Plt ___
___ 05:24PM BLOOD Neuts-80.0* Lymphs-8.9* Monos-8.9 Eos-1.2
Baso-0.4 Im ___ AbsNeut-10.62* AbsLymp-1.18* AbsMono-1.18*
AbsEos-0.16 AbsBaso-0.05
___ 05:24PM BLOOD ___ PTT-22.4* ___
___ 05:24PM BLOOD Plt ___
___ 08:44PM BLOOD ___ PTT-38.3* ___
___ 08:44PM BLOOD Plt Smr-LOW* Plt Ct-80*
___ 10:05PM BLOOD ___ PTT-33.0 ___
___ 10:05PM BLOOD Plt Ct-85*
___ 11:48PM BLOOD Plt Ct-98*
___ 04:44AM BLOOD ___ PTT-25.7 ___
___ 04:44AM BLOOD Plt ___
___ 08:12AM BLOOD Plt ___
___ 01:57PM BLOOD ___ PTT-27.3 ___
___ 01:57PM BLOOD Plt ___
___ 08:29PM BLOOD ___ TO PTT-UNABLE TO
___ TO
___ 08:29PM BLOOD Plt Ct-46*
___ 01:34AM BLOOD ___ PTT-21.5* ___
___ 01:34AM BLOOD Plt Ct-93*
___ 06:50PM BLOOD Plt Ct-97*
___ 02:30AM BLOOD Plt Ct-94*
___ 06:00AM BLOOD Plt Ct-66*
___ 03:48PM BLOOD Plt ___
___ 06:24AM BLOOD Plt ___
___ 05:24PM BLOOD ___ 08:44PM BLOOD ___
___ 10:05PM BLOOD ___
___ 04:44AM BLOOD ___ 08:12AM BLOOD ___ 01:57PM BLOOD ___ 01:34AM BLOOD ___ 05:24PM BLOOD Glucose-174* UreaN-12 Creat-1.0 Na-142
K-4.5 Cl-106 HCO3-23 AnGap-13
___ 11:48PM BLOOD Glucose-200* UreaN-11 Creat-1.0 Na-142
K-4.1 Cl-115* HCO3-20* AnGap-7*
___ 04:28AM BLOOD Glucose-190* UreaN-12 Creat-1.0 Na-145
K-4.1 Cl-114* HCO3-21* AnGap-10
___ 01:34AM BLOOD Glucose-118* UreaN-10 Creat-1.1 Na-143
K-3.5 Cl-110* HCO3-23 AnGap-10
___ 06:00AM BLOOD Glucose-121* UreaN-8 Creat-1.1 Na-142
K-3.9 Cl-108 HCO3-20* AnGap-14
___ 06:24AM BLOOD Glucose-136* UreaN-8 Creat-1.1 Na-138
K-3.7 Cl-105 HCO3-21* AnGap-12
___ 05:24PM BLOOD ALT-11 AST-17 AlkPhos-61 TotBili-2.3*
___ 01:34AM BLOOD ALT-10 AST-16 AlkPhos-44 TotBili-1.3
___ 05:24PM BLOOD Lipase-50
___ 05:24PM BLOOD cTropnT-<0.01
___ 05:24PM BLOOD Albumin-3.3* Calcium-8.0* Phos-3.2 Mg-1.6
___ 11:48PM BLOOD Calcium-7.1* Phos-5.0* Mg-1.2*
___ 04:28AM BLOOD Calcium-7.6* Phos-5.3* Mg-2.5
___ 01:34AM BLOOD Calcium-7.6* Phos-3.0 Mg-1.8
___ 06:00AM BLOOD Calcium-7.9* Phos-2.2* Mg-1.7
___ 06:24AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.9
___ 05:24PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Tricycl-NEG
___ 08:34PM BLOOD Type-CENTRAL VE pO2-30* pCO2-47* pH-7.26*
calTCO2-22 Base XS--6 Intubat-NOT INTUBA
___ 10:07PM BLOOD Type-CENTRAL VE pO2-38* pCO2-47* pH-7.26*
calTCO2-22 Base XS--6 Intubat-NOT INTUBA
___ 02:07AM BLOOD ___ pO2-34* pCO2-47* pH-7.27*
calTCO2-23 Base XS--6
___ 05:31PM BLOOD Lactate-1.5
___ 08:34PM BLOOD Glucose-175* Lactate-1.1 Na-141 K-3.4*
Cl-116* calHCO3-21
___ 10:07PM BLOOD Glucose-181* Lactate-0.9 Na-138 K-3.7
Cl-113* calHCO3-20*
___ 02:07AM BLOOD Lactate-1.0
___ 08:34PM BLOOD Hgb-9.0* calcHCT-27
___ 10:07PM BLOOD Hgb-8.9* calcHCT-27
___ 08:34PM BLOOD freeCa-0.89*
___ 10:07PM BLOOD freeCa-1.15
___ 02:07AM BLOOD freeCa-1.07*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 100 mg PO BID
2. Lisinopril 10 mg PO BID
3. Omeprazole 20 mg PO DAILY
4. Tiotropium Bromide 1 CAP IH 2 INHALATIONS DAILY
5. ProAir HFA (albuterol sulfate) 108 mcg inhalation X2 PRN
6. Levothyroxine Sodium 25 mcg PO DAILY
7. Atorvastatin 10 mg PO QPM
8. Dulera (mometasone-formoterol) 200-5 mcg/actuation inhalation
X2 PRN
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 10 mg PO QPM
3. Dulera (mometasone-formoterol) 200-5 mcg/actuation
inhalation X2 PRN
4. Levothyroxine Sodium 25 mcg PO DAILY
5. Lisinopril 10 mg PO BID
6. Metoprolol Tartrate 100 mg PO BID
7. Omeprazole 20 mg PO DAILY
8. ProAir HFA (albuterol sulfate) 108 mcg inhalation X2 PRN
9. Tiotropium Bromide 1 CAP IH 2 INHALATIONS DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Gastrointestinal Bleed
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 lower gastrointestinal bleeding, for
angiography and/or embolization// ___ year old man with lower gastrointestinal
bleeding, for angiography and/or embolization. Multiple episodes of bright
red blood per rectum.
COMPARISON: CTA from outside hospital on ___
TECHNIQUE: OPERATORS: Dr. ___ Interventional ___ and Dr.
___ resident 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: The procedure was performed with anesthesia.
MEDICATIONS: See anesthesiology notes.
CONTRAST: 175 ml of Optiray contrast
FLUOROSCOPY TIME AND DOSE: 78 minutes, 2250 mGy
PROCEDURE:
1. Ultrasound-guided right internal jugular vein temporary triple-lumen
catheter placement
2. Right common femoral artery access.
3. Superior mesenteric arteriogram.
4. Selective left colic arteriogram
5. Selective middle colic arteriogram
6. Selective ileocolic arteriogram
7. Selective right colic arteriogram
8. Celiac arteriogram
9. Abdominal aortogram
10. Pelvic aortogram
11. Right common iliac arteriogram
12. Selective internal pudendal arteriogram
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.
General anesthesia was administered. A pre-procedure time-out was performed
per ___ protocol. Both groins and the right neck were prepped and draped in
the usual sterile fashion.
First, using real-time ultrasound guidance, micropuncture needle access was
obtained to the right internal jugular vein. Ultrasound demonstrated a patent
vein before and after access. Permanent ultrasound images were obtained.
Through the needle, a micropuncture wire was advanced into the SVC, and a
micropuncture sheath was placed. Through this, a J tip wire was placed within
the SVC, and following sequential fascial dilation, a 12 ___ MAC central
line was placed over the wire. Fluoroscopic spot image confirmed tip in good
position within the distal SVC. All ports aspirated and flushed successfully.
Catheter was secured with suture and dressed.
Next, using ultrasound and fluoroscopic guidance, the right common femoral
artery was punctured using a micropuncture set at the level of the mid-femoral
head. A 0.018 wire was passed easily into the vessel lumen. A small skin
incision was made over the needle. Then the inner dilator and wire were
removed and ___ wire was advanced under fluoroscopy into the aorta. The
micropuncture sheath was exchanged for a 5 ___ sheath which was attached to
a continuous heparinized saline side arm flush.
A ___ 1 glide catheter was advanced over ___ wire into the aorta and
formed within the aortic arch. This was used to selectively catheterize the
superior mesenteric artery. A diagnostic arteriogram was performed. Next,
given profuse bleeding, a decision was made to selectively sequentially
catheterize several branches of the SMA. First, a Prowler microcatheter and
0.018 headliner wire were used to selectively catheterize the left colic
artery via the middle colic to marginal artery. A diagnostic angiogram was
performed. Next, the microcatheter and wire were withdrawn and used to
selectively cannulate the right branch of the middle colic artery and a
diagnostic angiograms performed. Next, the microcatheter and wire were
withdrawn and used to selectively cannulate the ileocolic artery and a
diagnostic angiogram was performed. Next, the microcatheter and wire were
withdrawn and used to selectively cannulate the right colic artery and a
diagnostic angiogram was performed. As all of these angiograms did not
identify active extravasation or a source of bleeding, and a decision was made
to perform a celiac arteriogram.
The microcatheter and wire were removed and the ___ 1 catheter was used to
select the celiac artery and a diagnostic arteriogram was performed. No
active extravasation or source of bleeding was identified, decision was made
to perform an abdominal aortogram given prior history of aortic surgery. The
C1 catheter was removed over ___ wire, and a pigtail flush catheter was
placed in the upper abdomen at the level of the diaphragm and an abdominal
aortogram performed. No extravasation was identified. Therefore, a decision
was made to perform a pelvic aortogram to look for collateral supply to the
rectum and anal canal. The pigtail catheter was withdrawn and positioned at
the level of the aortic bifurcation, and a pelvic aortogram was performed.
This demonstrated a potential irregular vessel within the pelvis overlying the
area of the rectum. Therefore, a decision was made to perform a right common
iliac arteriogram. A straight flush catheter was placed in a right common
iliac arteriogram was performed. This demonstrated a persistent potential
area of abnormality within the pelvis overlying the rectum, therefore a
decision was made to selectively catheterize and evaluate the right internal
pudendal artery. Using a rim catheter positioned within the ostium of the
right internal iliac artery, a Prowler microcatheter and microwire were used
to selectively catheterize the right internal pudendal artery. A diagnostic
arteriogram was performed. No extravasation was identified.
As no source of bleeding or active extravasation was identified in all of the
interrogated vessels, a decision was made to complete the procedure. The
catheters were removed and the sheath was removed and manual pressure applied
to hemostasis. The patient tolerated the procedure well and was transferred
to the ICU following completion
All diagnostic arteriography described above was medically necessary to
specifically evaluate for source of active extravasation, vessel irregularity,
and/or pseudoaneurysm.
FINDINGS:
1. Successful placement of right internal jugular vein central venous line,
with the tip in the distal SVC. The line is ready to use.
2. SMA arteriogram was performed demonstrating no source of active
extravasation. Collateral flow to the distribution of the ___ was noted
through the marginal artery to the left colic artery. Given that there was no
active extravasation on this angiogram, decision was made to selectively and
sequentially evaluate additional first order branches.
3. Left colic arteriogram demonstrated no active extravasation,
pseudoaneurysm, or angiodysplasia.
4. Middle colic arteriogram demonstrated no active extravasation,
pseudoaneurysm, or angiodysplasia.
5. Ileocolic arteriogram demonstrated no active extravasation,
pseudoaneurysm, or angiodysplasia.
6. Right colic arteriogram demonstrated no active extravasation,
pseudoaneurysm, or angiodysplasia.
7. Celiac arteriogram demonstrated no active extravasation or pseudoaneurysm.
8. Abdominal aortogram demonstrated no active extravasation, or presence of
underlying aortoenteric connection.
9. Pelvic a radiogram demonstrated faint irregularity overlying the rectum
requiring further selective angiography.
10. Right common iliac arteriogram demonstrated vessel irregularity overlying
the region of the rectum requiring further selective angiography. No discrete
active extravasation or pseudoaneurysm.
11. Right internal pudendal arteriogram demonstrated flow to the area of the
rectum and distal sigmoid colon, without active extravasation. On late venous
phase images, filling of hemorrhoids noted.
IMPRESSION:
No active extravasation, pseudoaneurysm, angiodysplasia, or source of
gastrointestinal bleeding was identified despite thorough angiography.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 3 EXAMS
INDICATION: ___ year old man with h/o cabg, aaa repair, open sigmoidectomy. w/
bleeding per rectum. new central line and NGT// new NGT and central line
Contact name: ___: ___
TECHNIQUE: 3 frontal chest radiographs
COMPARISON: Comparisons made to chest radiograph obtained ___ as
well as ___.
FINDINGS:
New right IJ central venous catheter, whose tip terminates in the proximal SVC
without signs of pneumothorax.. The lung volumes are persistently low. The
cardiac silhouette is within normal limits, as well as the mediastinal
contours and hila. There is pulmonary vascular indistinctness, consistent
with mild pulmonary edema or worsening chronic lung disease. The right
hemidiaphragm is somewhat obscured by right basal consolidation, consistent
with likely atelectasis and pleural fluid. Less prominent changes at the left
base.. Subsequent images of the chest show the NG tube following the normal
course of the esophagus with both the tip and the side hole terminating in the
level of the stomach. Median sternotomy wire and appliances in place. The
superior most sternotomy wire is fractured.
IMPRESSION:
Mild pulmonary edema with likely small right-sided pleural effusion and
bibasilar atelectasis. Interval placement of right IJ venous catheter, which
terminates in the proximal SVC and placement of NG tube, which terminates in
the stomach.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with gi bleeding. s/p intubation. Evaluate for
changes
TECHNIQUE: Portable chest radiograph
COMPARISON: Comparisons made to chest radiograph obtained 2 hours prior and
___.
FINDINGS:
Persistently low lung volumes. The patient has been intubated and the ET tube
terminates approximately 5 cm from the carina. The endotracheal tube balloon
appears over-distended. Cardiac silhouette is within normal limits, as well
as the mediastinal contours and hila, there is pulmonary vascular
indistinctness, consistent with mild pulmonary edema or worsening chronic lung
disease. This is stable compared to previous and there are no other
significant changes compared to chest radiograph from 2 hours prior.
IMPRESSION:
Interval intubation with ET tube terminating 5 cm from the carina. Consider
desufflating endotracheal balloon. Mild interval worsening of pulmonary
edema, otherwise unchanged.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 1:41 pm, 5 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ y/o male w/hx CAD s/p CABG, AAA repair, diverticulitis s/p
open sigmoidectomy presents w/acute onset of large amount of bright red
bleeding from the rectum. Imaging reviewed with radiology. He has many
diverticuli with enhancement in the diverticular lumen which are likey
calcified inspissated stool with some regions with questionable contrast
blush. He has a segment of right colon that with severe stranding with an
associated focal tenderness/guarding on exam. NGT lavage at bedside was
negative. His differential for bleeding at this point remains broad including
diverticularIncreased work of breathing
IMPRESSION:
Comparison to ___. The patient has been extubated and all other
monitoring and support devices were removed, with the exception of the right
internal jugular vein introduction sheet. Pre-existing signs of mild
pulmonary edema have resolved. Today's radiograph shows minimal pleural
effusions bilaterally with areas of retrocardiac and right basilar atelectasis
but no evidence of pneumonia or pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ hx AAA repair, diverticulitis s/p open sigmoidectomy
w/massive LGIB// fluid overload?
IMPRESSION:
In comparison with the study of ___, the right IJ catheter is been
removed. Cardiomediastinal silhouette is stable and there is no evidence
vascular congestion. Again there are bilateral pleural effusions with
atelectatic changes at the bases. No evidence of acute focal consolidation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ hx AAA repair, diverticulitis s/p open sigmoidectomy
w/massive LGIB with tachypnea, given IV lasix.// eval for effusion
TECHNIQUE: Frontal chest radiograph.
COMPARISON: Multiple chest radiographs, most recent dated ___ at
02:08.
FINDINGS:
Compared to prior radiograph dated ___, there are mildly reduced
lung volumes. The extent of the bilateral pleural effusions and atelectasis
is grossly unchanged. There are no focal consolidations or pneumothorax.
There is unchanged appearance of sternal wires, the top sternal wire was
previously seen to be fractured on the prior radiograph.
RECOMMENDATION(S): No interval change in extent of bilateral effusions.
Radiology Report
INDICATION: ___ hx AAA repair, diverticulitis s/p open sigmoidectomy
w/massive LGIB with worsening abd distention.// eval ? obstruction
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: CT abdomen and pelvis from ___.
FINDINGS:
There is air seen throughout the extent of the colon. There are no
pathologically dilated loops of colon or small bowel, however the colon is
prominent. There is air extending to the region of the rectum.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are degenerative changes within the lumbar spine. There
are radiodense sternal wires in situ.
Contrast is seen within the bladder. There are tram track calcifications in
the pelvis consistent with atherosclerosis of the iliac vessels. EKG leads
project over the upper abdomen. There are no unexplained soft tissue
calcifications or radiopaque foreign bodies.
There is bibasilar atelectasis with blunting of the costophrenic sulci
consistent with bilateral pleural effusions. These are better seen on
portable chest radiograph from ___.
IMPRESSION:
1. There is gaseous distension without pathologic dilation of the colon. No
evidence of small or large bowel obstruction.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: GI bleed, Transfer
Diagnosed with Gastrointestinal hemorrhage, unspecified
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 2.0 | Patient is a ___ year old male with pmh significant for CAD, AAA
repair, and diverticulitis s/p open sigmoidectomy that presented
to OSH ER with complaints of acute onset of bright red bleeding
from the rectum. At the OSH, he was given 5U RBCs, ___ and
1Plt. Imaging was completed and CTA demonstrated many
diverticuli with
enhancement in the diverticular lumen. Therefore he was
transferred to ___ for definitive care. Once at ___, massive
transfusion protocol was activated and he received additional 4U
RBC, ___ 1Plt. He was then admitted to ___ for further
evaluation and management.
Interventional Radiology was consulted for mesenteric
angiography, but on ___, ___ could not find active extravasation,
therefore, no embolization/intervention completed. The patient
continued to bleed via his rectum and his Hct dropped from 28 to
21 which brought total transfusion numbers to 12PRBC, ___,
4plt, 2cryo. EGD was then completed on ___ with no clear source
of an upper GI bleed. The surgical team requested for a tagged
RBC scan which also came back negative and partially low yield
because the patient was not actively bleeding. He was then
transferred to the inpatient unit when his hct was noted to be
stable. Once on the inpt unit, he developed increased work of
breathing for which he received tiotropium and albuterol
nebulizer with good effect and one time dose of 10mg labetalol
for HTN.
Once stable, his diet was advanced as tolerated to regular.
During this hospitalization, the patient voided without
difficulty, was adherent with respiratory toilet and incentive
spirometry and actively participated in the plan of care.
Venodyne boots were used during this stay.
At the time of discharge, the patient was doing well. He was
afebrile and his vital signs were stable. The patient was
tolerating a regular diet, ambulating, voiding without
assistance, and his pain was well controlled. The patient was
discharged home without services. Discharge teaching was
completed and follow-up instructions were reviewed with reported
understanding and agreement. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right femur fracture
Major Surgical or Invasive Procedure:
Right femoral osteotomy and ORIF
History of Present Illness:
___ with history of OI, prior L femur periprosthetic
fracture s/p ORIF ___, ___ and remote R femur
fracture treated with ex-fix, now s/p fall with R midshaft femur
fracture.
Patient reports that she was rehearsing at safety demonstration
at a musical at the elementary school she works, when she fell
down hard onto her right knee from standing and had immediate
right leg pain. She suspected fracture, and subsequently was
brought in by EMS for evaluation. She denies head strike, loss
of consciousness, or pain in other joints. She denies other
sites of pain.
On interview, patient denies numbness or tingling in her lower
extremity. She denies antecedent hip or thigh pain on the right
side, and prodromal symptoms prior to her fall. Since her
fixation with Dr. ___ in ___ on her left side, she
endorses continued weakness in her left lower extremity but no
ongoing pain. She currently is not using assistive devices.
Review of systems is otherwise negative.
Past Medical History:
Osteogenesis imperfecta
Depression/Anxiety
Social History:
___
Family History:
nc
Physical Exam:
Temp: 98.3 PO BP: 106/73 HR: 96 RR: 17 O2 sat: 98%
O2 delivery: ra
Gen: Lying comfortably in bed
RLE: Dressing removed, incision c/d/i w/ staples in place
SILT in dp/sp/s/s/t
Fires ___
2+ ___ pulse
Pertinent Results:
See OMR for pertinent lab and imaging results
Medications on Admission:
BUSPIRONE - buspirone 5 mg tablet. 1 tablet(s) by mouth in the
morning and take 10mg at bedtime.
OXYCODONE - oxycodone 5 mg tablet. ___ tablet(s) by mouth
Q4-6hrs
as needed for severe pain
VENLAFAXINE [EFFEXOR XR] - Effexor XR 150 mg capsule,extended
release. 2 capsule by mouth once a day
CALCIUM CARBONATE [CALCIUM 600] - Calcium 600 600 mg calcium
(1,500 mg) tablet. tablet(s) by mouth - (Prescribed by Other
Provider)
FERROUS SULFATE - ferrous sulfate 325 mg (65 mg iron) tablet. 1
tablet(s) by mouth once a day - (Prescribed by Other Provider)
MULTIVITAMIN - multivitamin tablet. 1 tablet by mouth once a day
- (Prescribed by Other Provider)
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin Sodium 40 mg SC QPM
RX *enoxaparin 40 mg/0.4 mL 1 syringe subcutaneous once a day
Disp #*30 Syringe Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
6. Senna 8.6 mg PO QHS
7. Vitamin D 1000 UNIT PO DAILY
8. BusPIRone 5 mg PO DAILY
9. BusPIRone 10 mg PO QHS
10. Calcium Carbonate 500 mg PO TID
11. Ferrous Sulfate 325 mg PO DAILY
12. Venlafaxine XR 300 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right femoral fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid
(crutches).
Followup Instructions:
___
Radiology Report
INDICATION: ORIF right femur.
COMPARISON: ___
IMPRESSION:
Intraoperative images demonstrate placement of an intramedullary rod with
proximal and distal interlocking screws fixating a fracture involving the
midshaft of the right femur. There is good anatomic alignment. There are no
signs for hardware related complications. Total intra service fluoroscopic
time is 253.9 seconds. Please refer to the operative note for additional
details.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Leg injury
Diagnosed with Oth fracture of shaft of right femur, init for clos fx, Fall on same level, unspecified, initial encounter, Osteogenesis imperfecta
temperature: 98.4
heartrate: 98.0
resprate: 15.0
o2sat: 98.0
sbp: 131.0
dbp: 87.0
level of pain: 5
level of acuity: 2.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a right midshaft femur fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for right femur osteotomy and ORIF,
which the patient tolerated well. For full details of the
procedure please see the separately dictated operative report.
The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to home was appropriate. During hospitalization the
patient was intermittently tachycardic. This was consistent
with prior hospital admissions. The patient remained
asymptomatic. EKG showed sinus tachycardia. She was treated
with IV fluids. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
___ weightbearing in the right lower extremity, and will be
discharged on Lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
Percutaneous cholecystostomy tube placement
History of Present Illness:
___ h/o bladder and prostate CA s/p cystectomy/prostatectomy
presents from ___ w N/V and abdominal pain x 5d. Work-up
was notable for acute cholecystitis and choledocholithiasis on
CTAP in setting of WBC 24 and normal LFTs. He notes that on
___, he felt very gassy, nauseous, and had three episodes of
nonbloody, nonbilious emesis. On ___, he had two more episodes
of nonbloody, nonbilious emesis, noticed
epigastric and RUQ pain. He has been having trouble drinking and
eating due to early satiety and feeling full. His last bowel
movement was on ___, which he describes as very small in
quantity and "tannish" in color. He denies fever, chills,
radiation of pain to the arms, back, or jaw, and changes in pain
with eating or position.
At time of consultation, pt AVSS without scleral icterus and
focal RUQ tenderness with palpable gallbladder and RUQ u/s with
gallstones, wall thickening, pericholecystic fluid, no
intrahepatic biliary dilation.
Past Medical History:
PMH
- bladder cancer
- prostate cancer
- Afib: discovered incidentally in ___
- GERD
- hypothyroidism
- UTI: due to self-catheterization necessitated by his bladder
resection
PSH:
- cystectomy: ___
- prostatectomy: ___
Social History:
___
Family History:
Family Hx:
- mother: ovarian cancer
- brother: bladder, prostate cancer
Physical Exam:
VITAL SIGNS: 98.5 81 140/73 18 95RA
GENERAL: AAOx3 NAD
HEENT: NCAT, EOMI, PERRLA, No scleral icterus, mucosa moist, no
LAD
CARDIOVASCULAR: R/R/R, S1/S2, NO M/R/G
PULMONARY: CTA ___, No crackles or rhonchi
GASTROINTESTINAL: S/NT/ND. No guarding, rebound, or frank
peritonitis. +BSx4
INCISION/WOUNDS: C/D/I. Soft, no ecchymosis or signs of
infection
EXT/MS/SKIN: No C/C/E; Feet warm. Good perfusion
NEUROLOGICAL: Reflexes, strength, and sensation grossly intact
CNII-XII: WNL
Pertinent Results:
___ 10:15AM PLT COUNT-210
___ 10:15AM WBC-20.3* RBC-4.15* HGB-12.7* HCT-37.9*
MCV-91 MCH-30.6 MCHC-33.5 RDW-14.6 RDWSD-49.3*
___ 10:15AM CALCIUM-8.6 PHOSPHATE-3.5 MAGNESIUM-1.7
___ 10:15AM ALT(SGPT)-8 AST(SGOT)-17 ALK PHOS-78 TOT
BILI-0.7
___ 10:15AM estGFR-Using this
___ 10:15AM GLUCOSE-85 UREA N-47* CREAT-1.5* SODIUM-144
POTASSIUM-3.5 CHLORIDE-116* TOTAL CO2-17* ANION GAP-15
___ 01:00PM ___ PTT-37.1* ___
___ 01:00PM PLT COUNT-207
___ 01:00PM WBC-19.4* RBC-4.06* HGB-12.4* HCT-37.0*
MCV-91 MCH-30.5 MCHC-33.5 RDW-14.6 RDWSD-48.3*
___ 01:00PM CALCIUM-8.1* PHOSPHATE-3.2 MAGNESIUM-1.7
___ 01:00PM LIPASE-25
___ 01:00PM ALT(SGPT)-8 AST(SGOT)-13 ALK PHOS-78 TOT
BILI-0.6
___ 01:00PM estGFR-Using this
___ 01:00PM GLUCOSE-85 UREA N-46* CREAT-1.4* SODIUM-143
POTASSIUM-3.3 CHLORIDE-113* TOTAL CO2-17* ANION GAP-16
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with RUQ abd pain // cholecystitis?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen pelvis: ___ at 22:27.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. A hyperechoic 0.8 x 1.2 x 0.7 cm focus in the right hepatic
lobe is avascular, compatible with a hemangioma. The main portal vein is
patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 7 mm.
The distal common bile duct and previously described distal CBD stones are not
imaged.
GALLBLADDER: The gallbladder is distended, with multiple gallstones and
significant gallbladder wall thickening and pericholecystic fluid.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Acute cholecystitis.
2. Right hepatic lobe hemangioma.
Radiology Report
EXAMINATION: Cholecystostomy.
INDICATION: ___ year old man with chole cystitis. S/p ercp with
sphincterotomy. // Percutaneous cholecystostomy tube placement
COMPARISON: Ultrasound ___
PROCEDURE: Ultrasound-guided percutaneous cholecystostomy.
OPERATORS: Dr. ___ radiology fellow and Dr. ___
radiologist, who personally supervised the trainee during the key components
of the procedure and reviewed and agrees with the trainee's findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the ultrasound table. Limited
preprocedure imaging was performed to localize the gallbladder. An
appropriate skin entry site was chosen and the site marked. Local anesthesia
was administered with 1% Lidocaine solution.
Using continuous sonographic guidance, an ___ ___ drainage catheter
was advanced via trocar technique into the gallbladder. A sample of fluid was
aspirated, confirming catheter position within the collection. The stiffener
was removed. The pigtail was deployed. The position of the pigtail was
confirmed within the collection via ultrasound. Ultrasound images were stored
on PACS.
Approximately 120 cc of turbid brownish foul smelling fluid was drained with a
sample sent for microbiology evaluation. The catheter was secured by a
StatLock. The catheter was attached to bag. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
SEDATION: Moderate sedation was provided by administering divided doses of 1
mg Versed and 50 mcg fentanyl throughout the total intra-service time of 5
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Distended gallbladder with cholelithiasis and gallbladder wall thickening
consistent with cholecystitis.
Completely decompressed gallbladder post cholecystostomy...
120 cc of turbid brownish foul smelling fluid was drained, specimen sent for
C&S.
IMPRESSION:
8 ___ cholecystostomy with removal of 120 cc turbid brownish foul-smelling
fluid.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: N/V, Transfer
Diagnosed with Nausea with vomiting, unspecified
temperature: 97.5
heartrate: 87.0
resprate: 18.0
o2sat: 97.0
sbp: 116.0
dbp: 64.0
level of pain: 1
level of acuity: 3.0 | Mr. ___, an ___ w h/o bladder and prostate CA s/p
cystectomy/prostatectomy, presented from ___ several
days of N/V and nonbloody emesis, with abdominal pain on
___. His labs notable were for 24 WBC, LFT and lipase wnl,
and imaging demonstrating acute cholecystitis. He underwent EUS
to evaluate CBD stones, of which there were. Therefore, he
proceeded with ERCP for sphincterotomy and stone extraction on
___. Subsequently, in order to manage his cholecystitis,
patient underwent percutaneous cholecystostomy drain placement.
A ___ ___ was placed with 120cc of turbid brown purulent
material drained. This was sent for microbiology eval
(preliminarily GNR and GPC). After normalizing him to his normal
regimen, diet, home medication, and pain control, Mr. ___
was discharged with a course of augmentin for 8 days. He had a
foley catheter up until discharge due to his bladder history. He
reports self-catheterization at home and we felt comfortable for
him to continue to do so. His foley was therefore removed upon
discharge.
Upon d/c, pt was doing well, afebrile, and hemodynamically
stable wnl. pt received discharge instructions and teaching,
along with follow up instructions. pt verbalizes agreement and
understanding of discharge plans. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
right hip lump
Major Surgical or Invasive Procedure:
___: I+D of right flank abscess
History of Present Illness:
HPI:
___ yo with PMH of IDDM who initially presented to ___
on ___ for acutely developed right hip lump she had also
subjective fevers. At that time u/s showed 2x2 cm fluid
accumulation s/p needle aspiration and was started on bactrim
and
keflex; culture resutls heavy growth + strep. Today she presents
to the ED with fluid reaccumulation. Denies fever, nausea,
vomiting or any other symptoms. Minimally tender at this point.
Past Medical History:
IDDM
HLP
HTN
Hypothyroidism
Social History:
___
Family History:
nc
Physical Exam:
Physical Exam: upon admission ___
No acute distress, comfortable in bed
Vitals: 97.2 66v132/50 18 100%RA
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR, No M/G/R
PULM: Clear to auscultation b/l, No W/R/R
ABD: Soft, nondistended, nontender, no rebound or guarding,
normoactive bowel sounds, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
Right hip: 8 cm diameter rubbery mass, mobile, minimal erythema,
no discharge, no tenderness on palpation, no fluctuating area
palpated
Pertinent Results:
___ 05:27AM BLOOD WBC-4.8 RBC-3.55* Hgb-11.1* Hct-34.5*
MCV-97 MCH-31.2 MCHC-32.1 RDW-12.9 Plt ___
___ 03:10PM BLOOD WBC-5.7 RBC-3.74* Hgb-11.8* Hct-36.1
MCV-97 MCH-31.4 MCHC-32.5 RDW-12.9 Plt ___
___ 03:10PM BLOOD Neuts-72.1* ___ Monos-4.8 Eos-1.1
Baso-0.3
___ 05:27AM BLOOD Plt ___
___ 03:10PM BLOOD ___
___ 03:10PM BLOOD Glucose-234* UreaN-11 Creat-1.0 Na-137
K-3.6 Cl-101 HCO3-27 AnGap-13
___ 03:21PM BLOOD Lactate-0.7
___: cat scan of the pelvis:
1. 3.2 x 2.7 cm superficial organized phlegmon in the
subcutaneous fat of the right lateral hip is not yet
encapsulated.
Medications on Admission:
Medications:
Levothyroxine 125'
Simvastatin 40'
Humalog ___ U am
4U lunch
___ U dinner
ASA 81'
NPH10 U Am
Discharge Medications:
1. Augmentin 500-125 mg Tablet Sig: One (1) Tablet PO three
times a day for 7 days.
Disp:*21 Tablet(s)* Refills:*0*
2. levothyroxine 125 mcg Tablet Sig: One (1) Tablet PO once a
day.
3. NPH insulin sc 10 units daily
4. humalog sliding scale: ___ units morning, 4 units sc at
lunch, ___ units at dinner
5. oxycodone 5 mg Tablet Sig: ___ Tablets PO every ___ hours as
needed for pain for 5 days: please do not drive while taking
this medication.
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
right flank abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with right hip abscess, here to evaluate
extent of abscess.
COMPARISON: No prior studies available.
TECHNIQUE: MDCT-acquired axial images of the pelvis were obtained after the
uneventful administration of 130 cc Omnipaque intravenous contrast. Coronally
and sagittally reformatted images were generated and reviewed.
FINDINGS:
CT OF THE PELVIS WITH INTRAVENOUS CONTRAST: The rectum, sigmoid colon and
intrapelvic loops of bowel are unremarkable without evidence of wall
thickening or obstruction. The urinary bladder appears unremarkable. The
uterus is anteverted and contains a 2.8 x 2.2 cm rounded hyperdensity in the
left uterine fundus consistent with a uterine fibroid. No free pelvic fluid
is present. Multiple phleboliths are noted within the pelvis. There is no
pelvic lymphadenopathy. Enlarged, fatty replaced lymph nodes are noted in the
right inguinal region measuring up to 1.1 cm in short axis (2:39).
An uncomplicated, fat-containing ventral hernia is noted in the lower abdomen
(2:6) with the abdominal defect measuring 1.1 x 1.0 cm.
OSSEOUS STRUCTURES AND SOFT TISSUES: No suspicious lytic or sclerotic lesions
are identified in the bone.
There is a superficial fluid collection within the subcutaneous fat lateral to
the right anterior superior iliac spine measuring 3.2 x 2.7 cm (2:18) with
associated subcutaneous fat stranding and thickening of the adjacent skin but
no rim enhancement or encapsulation.
IMPRESSION:
1. 3.2 x 2.7 cm superficial organized phlegmon in the subcutaneous fat of the
right lateral hip is not yet encapsulated.
2. Fibroid uterus.
3. Uncomplicated, fat-containing ventral hernia with abdominal defect
measuring 1 cm.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABSCESS
Diagnosed with CELLULITIS/ABSCESS OF TRUNK, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERCHOLESTEROLEMIA
temperature: 97.2
heartrate: 66.0
resprate: 18.0
o2sat: 100.0
sbp: 132.0
dbp: 50.0
level of pain: 4
level of acuity: 3.0 | ___ year old female admitted to the acute care service with right
hip lump. Initial aspiration was done at an OSH, but reported
recurrence of mass size. Incision and drainage done at OSH
which grew strept. Upon admission, she was made NPO, given
intravenous fluids and started on pippercillin and vancomycin.
During her hospital course, she remained afebrile with a white
blood cell count of 5. She underwent a cat scan of the pelvis on
HD #2 to assess progression of the fluid collection. It was
determined that the fluid collection was superficial and and
incision and drainage was done. wound was packed with nugauze
and she was sent with ___ services for packing wound and will be
continued on 7 day course of Augmentin.
She was discharged on a 2 week course of augmentin with
follow-up appointment in ___ clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Demerol / Zosyn / Vancomycin / adhesive
Attending: ___.
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx OLT ___ for ___ c/b recurrent HepC cirrhosis s/p
Harvoni, recurrent cholangitis requiring multiple drain
placements, p/w fevers.
History obtained from patient on the floor. He took his
temperature on ___ and found it to be 102.1 at 8p. He normally
get chills and shakes, but did not with this particular fever.
He took 1g of Tylenol and called the ___
instructions; he was directed to the ED. He had no other
accompanying symptoms, no sick contacts.
In the ED, initial vitals were: 101.0 85 130/69 16 97% RA.
Labs were notable for: WBC 12.6, PLT 130, Bicarb 21, BUN 21.
Other labs were normal.
Imaging was ordered, not yet read.
Blood cultures were sent.
Liver was consulted, recs as below.
Vanc/Cef were given.
VS on transfer were: 99 71 112/66 16 97% RA.
On the floor, the patient is alert, comfortable, able to
contribute to the history above and below. He denies HA, n/v,
cp/pressure, cough, congestion, rhinitis, SOB, abdominal pain
including RUQ pain, change in bowel habits, urinary frequency or
pain with urination, rashes, muscle aches. He has chronic joint
pains, unchanged.
ROS: See HPI.
Past Medical History:
- Hepatitis C cirrhosis (genotype 1a) with HCC: s/p OLT in ___,
complicated by recurrent Hep C cirrhosis (nonresponder to
multiple courses of interferon/ribavirin, as well as
telapravir). Currently on Harvoni.
- S/p orthotopic liver transplant (___) for ___
- Cholangitis secondary to infected bilomas, s/p numerous
external biliary PTC drain placements and successful
internalization of the drain into biliary system on ___.
Patient underwent removal of internal biliary drain ___ with
MR abdomen ___ with resolution of previously seen biloma.
- Hospitalization requiring intubation for either an infectious
pneumonia vs possible hypersensitivity reaction to the study
drug ___
- Pulmonary emboli, post-operatively (___)
- Anemia, medication-related
- Anxiety/Depression
- Osteopenia
PAST SURGICAL HISTORY
- Tonsillectomy and adenoidectomy
- Liver transplant
- Hernia repair with mesh
Social History:
___
Family History:
Father: just turned ___ yo, still working for ___
Mother: had one lung, died following surgery with inappropriate
general anesthsia according to pt
Siblings: one sister with HTN
Physical Exam:
ADMISSION PHYSICAL EXAM
VS: 100.1 104/57 75 18 99%RA
General: Well-appearing male, reclined in bed, AAOx3, NAD
HEENT: NCAT, EOMI, PERRLA, anicteric sclera, clear OP, MMM
Neck: no JVD
CV: RRR, no r/g/m
Lungs: CTAB
Abdomen: Soft NT ND +BS, well-healed old surgical scars
Ext: WWP, no edema
Neuro: Face symmetric, moving all four limbs normally
DISCHARGE PHYSICAL EXAM
Vitals: T: 97.9 BP:117/76 P:61 R:16 O2:98%RA
General: Alert, oriented, no acute distress. No asterixis.
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Strong inspiratory effort, 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, large
ventral hernia, surgical scars appear well healed, no
appreciable ascites
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Not jaundiced
Neuro: CN ___ in tact, strength and sensation grossly in tact,
gait deferred.
Pertinent Results:
ADMISSION LABS
___ 12:00AM WBC-12.6*# RBC-4.81 HGB-14.3 HCT-43.6 MCV-91
MCH-29.7 MCHC-32.8 RDW-13.2 RDWSD-43.6
___ 12:00AM NEUTS-76.2* LYMPHS-13.4* MONOS-9.3 EOS-0.2*
BASOS-0.5 IM ___ AbsNeut-9.61*# AbsLymp-1.69 AbsMono-1.17*
AbsEos-0.03* AbsBaso-0.06
___ 12:00AM PLT COUNT-130*
___ 12:00AM LIPASE-42
___ 12:00AM ALT(SGPT)-26 AST(SGOT)-27 ALK PHOS-123 TOT
BILI-0.5
___ 12:00AM GLUCOSE-131* UREA N-21* CREAT-1.0 SODIUM-137
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-21* ANION GAP-16
___ 12:16AM LACTATE-1.4
___ 08:09AM ___ PTT-30.8 ___
DISCHARGE LABS
___ 06:47AM BLOOD WBC-5.7 RBC-4.69 Hgb-14.0 Hct-42.0 MCV-90
MCH-29.9 MCHC-33.3 RDW-13.3 RDWSD-43.5 Plt ___
___ 06:47AM BLOOD Plt ___
___ 06:47AM BLOOD Glucose-113* UreaN-15 Creat-0.8 Na-142
K-3.9 Cl-105 HCO3-25 AnGap-16
___ 06:47AM BLOOD ALT-31 AST-24 AlkPhos-126 TotBili-0.4
PERTINENT LABS DURING ADMISSION
___ 08:09AM BLOOD tacroFK-4.2*
MICRO
URINE CX: NG FINAL
BLOOD CX: NGTD
STUDIES
Liver/Gallbladder ultrasound
1. Patent hepatic vasculature with appropriate waveforms.
2. Stable intrahepatic biliary ductal dilatation status post
hepaticojejunostomy.
CXR: No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: Chest radiograph.
INDICATION: History: ___ with fever // ?pna
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
The cardiomediastinal and hilar contours are within normal limits. The lung
fields are clear. There is no pneumothorax, fracture or dislocation. Limited
assessment of the abdomen is unremarkable.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: History: ___ with liver transplant // ?interval change
TECHNIQUE: Grey scale, color and spectral Doppler ultrasound images of the
abdomen were obtained.
COMPARISON: Ultrasound ___
FINDINGS:
Liver echotexture is normal. There is no evidence of focal liver lesions. The
patient status post hepaticojejunostomy with stable intrahepatic biliary
ductal dilatation. There is no ascites, right pleural effusion or sub- or
___ fluid collections/hematomas.
The spleen measures 12.8 cm and has normal echotexture.
DOPPLER: The main hepatic arterial waveform is within normal limits, with
prompt systolic upstrokes and continuous antegrade diastolic flow. Peak
systolic velocity in the main hepatic artery is 84cm/s. Appropriate arterial
waveforms are seen in the right hepatic artery and the left hepatic artery
with resistive indices of 0.60, and 0.66, respectively. The main portal vein,
right and left portal veins are patent with hepatopetal flow with normal
waveform. Appropriate flow is seen in the hepatic veins and the IVC.
IMPRESSION:
1. Patent hepatic vasculature with appropriate waveforms.
2. Stable intrahepatic biliary ductal dilatation status post
hepaticojejunostomy.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with Fever, unspecified
temperature: 101.0
heartrate: 85.0
resprate: 16.0
o2sat: 97.0
sbp: 130.0
dbp: 69.0
level of pain: 0
level of acuity: 3.0 | ___ hx OLT ___ for ___ c/b recurrent HepC cirrhosis s/p
Harvoni, recurrent cholangitis requiring multiple drain
placements, p/w fevers without other infectious symptoms
concerning for possible biliary source.
# Fevers. He was afebrile the entirety of his admission (Tmax
100.1). Given his history of recurrent cholangitis from infected
bilomas, the initial concern was for repeat cholangitis. RUQ
ultrasound on admission showed stable ductal dilation without
evidence of focal liver or splenic lesions. He was started on
Cefepime and Daptomycin for empiric GN and Enterococci
treatment. Daptomycin was selected given his history of "Red
Mans Syndrome" with Vancomycin. Abx were discontinued after 48
hours of no growth on cultures. He was monitored for 24 hours
off antibiotics and discharged to home in stable clinical
condition. His WBC trended down and he did not endorse any
infectious symptoms on discharge. CXR was clear, urine cx was
negative and blood cultures were NGTD at the time of discharge.
# HCV cirrhosis with h/o OLT in ___: He remained
well-compensated without ascites or hepatic encephalopathy. His
LFTs, Tbilli, and Albumin were trended and remained within
normal limits. Tacrolimus level was 4.2 and he was continued on
home tacrolimus dosing without adjustment. Home ursodiol and
bactrium were continued.
Chronic
# Osteopenia: Continued alendronate
# Anxiety and depression: Continued citalopram, lorazepam, and
zolpidem
# Cardiac: Continued ASA
Transitional Issues
- Tacrolimus level: 4.2 on ___. Continued on home dosing
without changes.
- Patient will continue with monthly lab draws with results
faxed to Dr. ___ office as previously arranged.
# CODE: Full
# CONTACT: Wife, ___, ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ceclor / Grass ___ Blue, Standard / Ragweed /
lisinopril / Tegaderm / paper tape
Attending: ___.
Chief Complaint:
dyspnea, increased o2 requirement
Major Surgical or Invasive Procedure:
PICC placement.
History of Present Illness:
___ year old lady with PMH asthma (one 1.5 L at home), afib, PEs
on xarelto, CHF w/ pacemaker p/w dyspnea and hypoxia. Pt was
found to be 82% on her usual home O2 and ntoed to have increased
O2 requirement.
In the ED, initial vitals: ___ 76 148/86 16 95% 2L
Admitted to medicine for HCAP. ___ has known PE and switched
anticoagulation recently so obtained CTA to ensure no
progression of PEs. clinically does not look like CHF.
In ED switched from vanc/ceft/azithro to vanc/zosyn given
concern for UTI as well e.coli in past.
In ED pt had potential reaction to 2nd dose of IV Vanco, proph
treated with 25mg of IV benadryl. Vanc rate cut down by ___.
Prior to that pt had complaints of sob with exertion and scant
scattered wheezing, received one duoneb with good effect. SOB
complaint preceeded complaints with IV.
In ED she received Vancomycin 1g, Ceftriaxone, Azithromycin
500mg, Piperacillin-Tazobactam 4.5 g, Vancomycin 1g Frozen Bag,
Albuterol 0.083% Neb Soln , Ipratropium Bromide Neb,
DiphenhydrAMINE 25mg, Piperacillin-Tazobactam 4.5 g.
Vitals prior to transfer: Today 17:15 0 97.9 58 113/57 18 99%
Nasal Cannula
Currently, she reports feeling OK but increased dyspnea overall
starting on ___. The girls that help her at home came as
usual but commetned that she looked kind of bad. Eventually the
poliec rang her doorbell and told her they were called bc she
wasn't picking up her phone and her neighbors were concerned.
Given her increased O2 requirement and inability to get
up/ambulate as normal they told her they would bring her to
___. Diet has not changed. Some weight gain overall. Reports
compliant with furosemide though she hates it because of
increased urinary frequency (unclear compliance). Prescribed a
new med by PCP for urinary frequency but this seems to be
related to furosemide, no dysuria, no diarrhea (has had c diff
and this is not like that). Mild cough since ___. Also when
coughing on ___ had hemoptysis, which has never happened
before.
ROS: No fevers, chills, night sweats, or weight changes. No
chest pain or palpitations. No nausea or vomiting. No diarrhea
or constipation. No dysuria. No hematochezia, no melena.
Genrealized weakness+
Past Medical History:
- OSA on 1.5L home O2, typically at night (baseline O2 sat
92-97%)
- tracheobronchomalacia
- Atrial fibrillation on warfarin, but changed in ___ to
rivaxoban
- tachybrady syndrome - s/p dual chamber PPM
- CKD, stage 3, GFR 54
- History of pulmonary embolus- b/l PEs, dx in ___ on therapy X
6
months---> warfarin was d/c'ed due to recurrent falls; recurrent
PE in ___ w/ saddle embolus thus restarted warfarin
- DVT--unsure date
- CHF, EF 55% ___ with mild LVH
- hypothyroidism
- hypertension
- polyneuropathy
- bilateral knee replacements
- left shoulder replacement
- hiatal hernia
- bladder repair
- depression
- c diff at ___ ___
Social History:
___
Family History:
(Per OMR, verified with patient) Mother: HTN, CVA, lived to ___
yo . Father: deceased ___ yo
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- 97.5 - 142/___ - 20 99 on 4L
General- Alert, speaks in 5 word sentences, mild distress on NC
HEENT- Sclerae anicteric, MMM
Neck- supple, JVP not elevated, no LAD
Lungs- bilateral crackles and mild wheeze at bases, poor effort
CV- irregularly irregular, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU- no foley
Ext- no pitting pedal edema
Neuro- face symmetric, moving all extremities
DISCHARGE PHYSICAL EXAM:
PHYSICAL EXAM:
Vitals: 97.9 - 128/___
weights: no weight today <-- 98.2 kg <-- 98 <-- 97.6
General- obese fatigued lady appearing her stated age, speaks in
full sentences, no distress
HEENT- Sclerae anicteric, MM dry w/o lesions
Neck- supple, JVP not elevated, no LAD +HJR
Lungs- poor effort, crackles in bases
CV- irregularly irregular, Nl S1, S2, No MRG
Abdomen- soft, NT/ND bowel sounds present, no rebound tenderness
or guarding, no organomegaly
GU- no foley
Ext- no pitting pedal edema. skin: redness in blateral ACs,
stable from yesterday, erythema around and inside tegaderm
Neuro- face symmetric, moving all extremities
Pertinent Results:
ADMISSION LABS
===========
___ 05:45PM BLOOD WBC-9.4 RBC-3.60* Hgb-11.2* Hct-34.4*
MCV-95 MCH-31.0 MCHC-32.5 RDW-15.3 Plt ___
___ 05:45PM BLOOD Neuts-78.2* Lymphs-12.7* Monos-6.9
Eos-2.0 Baso-0.2
___ 06:01PM BLOOD ___ PTT-36.7* ___
___ 05:45PM BLOOD Glucose-102* UreaN-23* Creat-1.0 Na-139
K-4.2 Cl-101 HCO3-30 AnGap-12
___ 10:55AM BLOOD Calcium-9.9 Phos-3.6 Mg-2.5
___ 11:11AM BLOOD ___ pO2-32* pCO2-44 pH-7.37
calTCO2-26 Base XS--1
OTHER PERTINENT LABS
================
___ 05:51PM BLOOD Lactate-1.1
___ 11:11AM BLOOD Lactate-1.2
___ 05:45PM BLOOD proBNP-4063*
___ 10:55AM BLOOD cTropnT-<0.01
___ 07:00AM BLOOD cTropnT-<0.01
___ 04:05PM BLOOD cTropnT-<0.01
DISCHARGE LABS
============
___ 08:40AM BLOOD WBC-5.9 RBC-3.51* Hgb-10.8* Hct-33.8*
MCV-96 MCH-30.7 MCHC-31.8 RDW-14.8 Plt ___
___ 10:55AM BLOOD ___ PTT-29.1 ___
___ 06:02AM BLOOD Glucose-102* UreaN-18 Creat-0.9 Na-140
K-4.0 Cl-100 HCO3-33* AnGap-11
___ 06:02AM BLOOD Mg-2.2
___ 01:45AM URINE Color-Yellow Appear-Clear Sp ___
___ 01:45AM URINE Blood-NEG Nitrite-POS Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 01:45AM URINE RBC-4* WBC-25* Bacteri-FEW Yeast-NONE
Epi-2
MICROBIOLOGY
===========
___ STAIN-FINAL; RESPIRATORY
CULTURE-FINALINPATIENT
___ SCREENMRSA SCREEN-FINAL {POSITIVE FOR
METHICILLIN RESISTANT STAPH AUREUS}INPATIENT
___ VANCOMYCIN RESISTANT
ENTEROCOCCUS-FINAL {ENTEROCOCCUS SP.}INPATIENT
___ Urinary Antigen
-FINALINPATIENT
___ CULTURE-FINALINPATIENT
___ CULTUREBlood Culture,
Routine-FINALEMERGENCY WARD
___ CULTUREBlood Culture,
Routine-FINALEMERGENCY WARD
STUDIES
EKG ___
Atrial fibrillation with intermittent ventricular pacing.
Delayed anterior R wave progression. Cannot exclude prior
anterior wall myocardial infarction. Compared to the previous
tracing of ___ the ventricular response rate is slower. No
other diagnostic interim change.
___
___
CXR ___
IMPRESSION:
Patchy right upper lung opacity worrisome for pneumonia.
Recommend followup to
resolution. Additional ground-glass opacities seen on chest CT
from ___ are better appreciated on CT. Findings should be followed
up with CT.
CTA CHEST ___
FINDINGS:
CTA THORAX: The aorta and main thoracic vessels are well
opacified. The aorta
demonstrates normal caliber throughout the thorax without
intramural hematoma
or dissection. The pulmonary arteries are opacified to the
subsegmental level.
There is no filling defect in the main, right, left, lobar or
subsegmental
pulmonary arteries. No arteriovenous malformation is seen.
CT OF THE THORAX: Extensive streak artifact from a left shoulder
arthroplasty
somewhat limits evaluation of the thyroid gland and upper
portions of the
chest. There are scattered mediastinal and hilar lymph nodes,
not
significantly changed since prior examination from ___, the largest
measuring up to 11 mm (series 2, image 45). The airways are
patent to the
subsegmental level. There is a dual lead left-sided pacer which
is in stable
position. There is significant reflux of administered
intravenous contrast
into the hepatic veins, suggestive of right heart dysfunction.
The heart,
pericardium, and great vessels are otherwise within normal
limits.
There are multifocal ground-glass opacities involving the
bilateral lungs
diffusely, most prominent in the upper lobes, right worse than
left and
worsened since prior examination from ___. The previously
seen opacity
at the right lung apex now measures approximately 3 x 2.5 cm,
previously
measuring 2.4 x 2.4 cm (series 2: Image 20). Again seen is a
mosaic
attenuation with bronchiectasis most notable in the lower lobes.
No pleural
effusion or pneumothorax is present. There is no significant
septal thickening
to suggest pulmonary edema.
Although this study is not designed for assessment of
intra-abdominal
structures, note is made of a small hiatal hernia. Otherwise,
the visualized
solid organs and the stomach are unremarkable.
OSSEOUS STRUCTURES: There is significant degenerative changes
involving the
lower thoracic spine with anterior osteophytosis and multilevel
vacuum disc
phenomenon. Left shoulder arthroplasty is noted. No focal
osseous lesion
concerning for malignancy.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Interval worsening of diffuse multifocal ground-glass
opacities in the
upper lobes predominantly, right worse than left. Findings could
reflect
cryptogenic organizing pneumonia. Bronchoalveolar carcinoma is
felt less
likely given the rapid progression as compared to prior
examination from ___, however it is possible that the opacity in the right upper
lobe could
reflect BAC. Bronchial biopsy of the posterior segment of the
right upper lobe
is recommended as well as continued surveillance with short term
follow up in
3 months.
3. Mosaic pattern of attenuation with bronchiectasis could
reflect chronic
small airway disease and could also relate to recurrent
aspirations.
4. Reflux of administered intravenous contrast intrahepatic
veins, suggestive
of right heart dysfunction. There is no significant septal
defect to suggest
pulmonary edema.
___ IMPRESSION:
In comparison with the study of ___, there has been
placement of right
subclavian PICC line that extends to the mid portion of the SVC.
This was
conveyed to the venous access nurse.
The area of increased opacification in the right mid zone has
decreased.
Otherwise, there is little overall change.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Docusate Sodium 100 mg PO DAILY:PRN constipation
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Fluticasone Propionate NASAL 2 SPRY NU BID
6. Rivaroxaban 20 mg PO DAILY
7. Simvastatin 20 mg PO DAILY
8. Ferrous Sulfate 325 mg PO DAILY
9. Montelukast 10 mg PO DAILY
10. Furosemide 60 mg PO BID
11. TraMADOL (Ultram) ___ mg PO Q4H:PRN pain
12. Ibuprofen 600 mg PO Q12H:PRN pain
13. Calcium Carbonate 1250 mg PO BID
14. Potassium Chloride 20 mEq PO DAILY
15. Aspirin 81 mg PO DAILY
16. Myrbetriq (mirabegron) 25 mg oral daily
17. Sertraline 100 mg PO DAILY
18. Cyanocobalamin 1000 mcg IM/SC MONTHLY
19. Levothyroxine Sodium 175 mcg PO DAILY
20. Vitamin D 1000 UNIT PO DAILY
21. Sarna Lotion 1 Appl TP QID:PRN itchy skin
22. Lidocaine 5% Patch 1 PTCH TD QAM
23. Estrogens Conjugated 0.625 gm VG DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 1250 mg PO BID
4. Ferrous Sulfate 325 mg PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU BID
6. Furosemide 80 mg PO DAILY
RX *furosemide 80 mg 1 tablet(s) by mouth every morning Disp
#*30 Tablet Refills:*0
7. Metoprolol Succinate XL 25 mg PO DAILY
8. Montelukast 10 mg PO DAILY
9. Senna 8.6 mg PO BID:PRN constipation
10. Sertraline 100 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. TraMADOL (Ultram) ___ mg PO Q4H:PRN pain
13. Simvastatin 20 mg PO DAILY
14. Cyanocobalamin 1000 mcg IM/SC MONTHLY
15. Myrbetriq (mirabegron) 25 mg oral daily
16. Polyethylene Glycol 17 g PO DAILY:PRN constipation
17. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP TID:PRN arm
rash
RX *triamcinolone acetonide 0.1 % apply 4 times per day
Refills:*0
18. Morphine Sulfate (Oral Soln.) 5 mg PO Q4H:PRN dyspnea
RX *morphine 10 mg/5 mL 0.5 (One half) teaspoon by mouth every 4
hours Refills:*0
19. Levothyroxine Sodium 175 mcg PO DAILY
20. Rivaroxaban 20 mg PO DAILY
21. Docusate Sodium 100 mg PO DAILY:PRN constipation
22. Sarna Lotion 1 Appl TP QID:PRN itchy skin
23. Estrogens Conjugated 0.625 gm VG DAILY
24. Lidocaine 5% Patch 1 PTCH TD QAM
Discharge Disposition:
Home with Service
Facility:
___
Discharge Diagnosis:
Atypical healthcare associated pneumonia
Hypoxia
acute diastolic CHF exacerbation
Contact dermatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with 45cm right PICC. ___ ___ // 45cm right
PICC. ___ ___ Contact name: ___: ___ right PICC. ___
___
IMPRESSION:
In comparison with the study of ___, there has been placement of right
subclavian PICC line that extends to the mid portion of the SVC. This was
conveyed to the venous access nurse.
The area of increased opacification in the right mid zone has decreased.
Otherwise, there is little overall change.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Productive cough
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 98.1
heartrate: 76.0
resprate: 16.0
o2sat: 95.0
sbp: 148.0
dbp: 86.0
level of pain: 8
level of acuity: 2.0 | ___ year old lady with PMH asthma (one 1.5 L at home), afib, PEs
on xarelto, CHF w/ pacemaker p/w dyspnea and hypoxia ___ CHF
exacerbation and atypical pneumonia. We treated with an 8 day
course of vancomycin and cefepime, augmented by azithromycin. We
placed a PICC, and treated with IV diuretics which were
bothersome. She explained to us that she would not want to be
rehospitalized under any circumstance, be treated with
antibiotics, diuretics, get a PICC line, or receive aggressive
care. After discussion with her PACT team, palliative care she
was sent home with ___, with plan to transition to hospice care
as an outpatient.
ACTIVE MEDICAL ISSUES
================
# Healthcare associated pneumonia and mild diastolic CHF
exacerbation. She presented with dyspnea and hypoxia. HCAP was
likely primary cause of hypoxia and dyspnea (dced from rehab ~6
weeks PTA), with some contribution from CHF exacerbation. By
imaging pneumonia appears atypical (legionella negative),
repeated pneumonias likely related to tracheobronchomalacia.
Less likely bronchoalveolar carcinoma given only one episode
hemoptysis. PE ruled out by CT-A but hepatic reflux suggestive
of R heart dysfunction w/ a primary lung process.
- Consider 3 month short term follow for posterior RUL lesion vs
biopsy if admitted.
She appeared euvolemic with 80 mg PO furosemide daily (avoided
BID dosing as patient not compliant with it). She received
vancomycin/cefepime/azithromycin x8 days via ___, which was
dc'ed. Course ended ___. Per IP, there are no further
management strategies for her TBM.
Asymptomatic. Bacteriuria: Had this in the past. Notable history
of ESBL EColi UCxn included meropenem. Asymptomatic, so did not
treat with broader spectrum antibiotics.
# Arm rash/ contact dermatitis from ___ site tegaderm. Consider
alternative bandage for ___ site in future. Attempted to
control discomfort with fluocinolone and low dose
diphenhydramine.
# DIASTOLIC CHF: TTE ___, LVEF >55%, moderate MR. ___
home beta blockade, initially diuresed with IV furosemide, then
switched to PO furosemide as above. She is incontinent, would
monitor daily weights and exam.
# Goals of care: She repeatedly expressed that she wanted to go
home, not a rehab or long term care facility. She has had
discussions about hospice in the past, but has been ambivalent
about it. She intermittently endorsed wanting to go home with
hospice and asking "what is hospice?" after long discussion
(patient not confused), re-demonstrating this ambivalence. She
initially agreed to go to rehab but then did not want anybody to
enter her home to retrieve her checkbook, as such she remained
at ___ throughout her antibiotics course. The ___ care
team, PACT, and her ___ case manager were all closely involved
and after several discussions, she noted that she would consider
transitioning to home hospice in the future, would probably want
hospital re-admission if dyspneic, but would not want to go to a
facility.
CHRONIC ISSUES
===========
# ATRIAL FIBRILLATION WITH CONTROLLED VENTRICULAR RESPONSE:
Stable during admission. She is s/p pacer which intermittently V
paces. Anticoagulated with rivaroxaban. CHADS2 score is 3
(CHF,HTN, age). Continued home rivaroxaban 20mg and metoprolol
succinate 25mg XL.
# Tachy-___ syndrome: s/p pacer which intermittently V paces,
monitor on telemetry.
# OSA. On 1.5L O2 at night at baseline. Not on CPAP.
# Depression: Continued home sertraline.
# Hypothyroidism: Continued home levothyroxine.
# Chronic hip pain: Continued home tramadol. Consider restarting
NSAIDs if patient prefers comfort.
# CKD, stage 3: No longer trending as kidney function had been
stable.
# History of pulmonary embolus- b/l PEs, dx in ___ on therapy
for 6 months---> warfarin was d/c'ed due to recurrent falls;
recurrent PE in ___ w/ saddle embolus thus restarted warfarin,
now on rivaroxaban. Continued rivaroxaban.
# Hypertension: Normotensive.
TRANSITIONAL ISSUES
===================
- Code status: DNR/DNI, do not rehospitalize. Confirmed with
patient.
- Emergency contact:
- Studies pending on discharge: None.
- Please consider checking chem-7 at f/u.
- Please discuss transition to hospice w/ patient and care team. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
cefepime
Attending: ___.
Chief Complaint:
Hypotension
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with metastatic RCC on votrient, presenting with 2 weeks of
worsening weakness and fatigue, with hypotension in clinic
prompting ED referral. In clinic SBP was initially 89, attempted
direct admit but could not obtain IV access. Patient also have
increasing lower extremity edema L > R and decreasing ability to
ambulate over the last 2 weeks. She denies any fevers, shortness
of breath, nausea, diarrhea, or dysuria. She did fall recently.
Of note she was diagnosed with a DVT ___ years ago and was on
Coumadin until this was stopped prior to her cyberknife
treatment
in ___.
Past Medical History:
PAST ONCOLOGIC HISTORY
In terms of her oncological history, Ms. ___ was incidentally
found to have a right renal mass when she was admitted to an
outside hospital on ___ with altered mental status and acute
renal failure with a creatinine of 3.7. Renal US demonstrated a
new right exophytic renal mass in the setting of an atrophic
left kidney. Mental status changes were felt to be related to
cefepime in the setting ___ and UTI. Renal failure was
attributed to volume depletion. Confusion and renal failure
resolved. She underwent an MRI of her right kidney on ___ without evidence of lymphadenopathy or renal vein
involvement. She was planned for a partial nephrectomy; however,
preop chest CT showed three subcentimeter solid lung nodules new
since ___ felt likely to represent metastasis.
She was referred for medical oncology evaluation at ___ on
___ and close observation, CT guided biopsy, or open surgical
biopsy were discussed. Per ___, CT guided biopsy was not an
option due to the small size of the lung nodules and she
declined surgical biopsy. Close observation was planned. Scans
on ___ showed growth in the lung nodules and CT guided biopsy
was felt possible, but patient opted to hold off and continue
close observation. Scans on ___ revealed progression of
mediastinal and hilar lymphadenopathy, as well as increase in
size and number of pulmonary metastases. The right renal mass
was stable. Biopsy was again discussed, but deferred since she
was asymptomatic and wanted to go to ___.
PAST MEDICAL HISTORY:
CAD s/p CABG and sternal wound infection
HTN
DM2
Urinary incontinence
Depression
Melanoma on shin that was excised
H/O breast cancer s/p lumpectomy, node dissection, and XRT
Renal mass
h/o DVT after CABG
Past Surgical History: appendectomy, hernia repair, C-section x
2, CABG x 3 in ___, right knee TKR in the late ___.
Social History:
___
Family History:
Premature coronary artery disease- Father had heart disease &
CVA, Mother had CABG in her ___ & heart failure
Physical Exam:
DISCHARGE PHYSICAL EXAM:
VITAL SIGNS: T 97.9 BP 92/64 RR 20 HR 110 O2 96%RA
General: NAD
HEENT: MMM, no OP lesions
CV: RR, NL S1S2
PULM: CTAB
GI: Soft, NTND, no masses or hepatosplenomegaly
LIMBS: Bilateral lower extremity edema L > R.
NEURO: Alert and oriented, no focal deficits.
Discharge Physical Exam:
VS: 98.5 105-119/49-61 ___
General: NAD
HEENT: MMM, no OP lesions
CV: RR, NL S1S2
PULM: CTAB no w/r/r
GI: Soft, NTND, no masses or hepatosplenomegaly, no rebound or
guarding
LIMBS: Bilateral lower extremity edema L > R. no c/c
NEURO: Alert and oriented, no focal deficits.
Pertinent Results:
ADMISSION LABS
___ 12:45PM BLOOD WBC-8.3 RBC-3.79* Hgb-9.9* Hct-32.9*
MCV-87 MCH-26.1 MCHC-30.1* RDW-22.6* RDWSD-71.0* Plt ___
___ 12:45PM BLOOD Plt ___
___ 12:45PM BLOOD UreaN-42* Creat-1.5* Na-132* K-4.9 Cl-96
HCO3-22 AnGap-19
___ 12:45PM BLOOD ALT-10 AST-12 LD(LDH)-304* AlkPhos-111*
TotBili-0.4
___ 12:45PM BLOOD Albumin-3.1* Calcium-9.0 Phos-3.2 Mg-1.9
___ 12:52PM BLOOD %HbA1c-6.6* eAG-143*
___ 12:45PM BLOOD Cortsol-33.4*
DISCHARGE LABS
___ 11:50AM BLOOD WBC-5.2 RBC-2.96* Hgb-7.8* Hct-25.7*
MCV-87 MCH-26.4 MCHC-30.4* RDW-22.2* RDWSD-69.1* Plt ___
___ 11:50AM BLOOD Plt ___
___ 11:50AM BLOOD Glucose-82 UreaN-32* Creat-1.1 Na-135
K-4.3 Cl-100 HCO3-22 AnGap-17
MR HEAD W & W/O CONTRAST Study Date of ___
1. Numerous enhancing supratentorial enhancing metastatic
lesions
in the bilateral frontal, right parietal, and left occipital
lobes which are grossly unchanged as compared MRI ___.
2. No evidence of new or worsening enhancing lesions or
worsening
edema.
CXR: New left IJ line ends in the mid superior vena cava. No
pneumothorax.
___ Doppler:
1. Extensive deep venous thrombosis in all imaged lower
extremity
veins bilaterally. A CTV of the abdomen/pelvis would be more
sensitive in evaluating proximal extent of clot burden.
2. 2.1 x 0.9 cm hemorrhagic left ___ cyst.
CTA CHEST Study Date of ___
1. There is a small pulmonary embolus in the mediobasal segment
of the left pulmonary artery. There may also be a tiny
pulmonary
embolus in a subsegmental pulmonary artery branch of the right
lower lobe.
2. Mild interval decrease in size of extensive pulmonary
nodules,
mediastinal, and hilar lymphadenopathy compared to exam from
___. No new pulmonary nodules are seen.
CT HEAD W/O CONTRAST Study Date of ___
1. Within the limits of this noncontrast study, there is no
definite CT
evidence of acute intracranial hemorrhage.
2. Known brain metastasis previously seen on MRI are not well
demonstrated on
the CT exam. Please note that some of the masses were
hemorrhagic on prior
MRI. If clinically indicated, consider contrast enhanced brain
MRI for
further evaluation.
3. Paranasal sinus disease as described.
CHEST (PORTABLE AP) Study Date of ___
Allowing for differences in technique, there has not been a
relevant change in the appearance of the chest since recent
study of 1 day earlier.
MR HEAD W & W/O CONTRAST Study Date of ___
1. Numerous enhancing supratentorial enhancing metastatic
lesions in the
bilateral frontal, right parietal, and left occipital lobes
which are grossly unchanged as compared MRI ___.
2. No evidence of new or worsening enhancing lesions or
worsening edema.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ciprofloxacin HCl 250 mg PO Q12H
2. Docusate Sodium 100 mg PO BID:PRN Constipation
3. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
4. Tolterodine 4 mg PO BID
5. Dexamethasone 0.5 mg PO EVERY OTHER DAY
6. Clotrimazole 1 TROC PO QID:PRN Thrush
7. Glargine 20 Units Bedtime
8. Votrient (pazopanib) 600 mg PO DAILY
9. Metoprolol Succinate XL 100 mg PO DAILY
10. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
11. LevETIRAcetam 250 mg PO BID
Discharge Medications:
1. Ciprofloxacin HCl 250 mg PO Q12H
2. Clotrimazole 1 TROC PO QID:PRN Thrush
3. Dexamethasone 0.5 mg PO EVERY OTHER DAY
4. Docusate Sodium 100 mg PO BID:PRN Constipation
5. Glargine 20 Units Bedtime
6. LevETIRAcetam 250 mg PO BID
7. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
9. Tolterodine 4 mg PO BID
10. Enoxaparin Sodium 100 mg SC Q12H
Start: Today - ___, First Dose: Next Routine Administration
Time
11. Metoprolol Succinate XL 50 mg PO DAILY
12. Mirtazapine 15 mg PO QHS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Bilateral ___ DVTs, Bilateral PE's
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS LEFT
INDICATION: History: ___ with 2 days LLE swelling, history of DVT // Eval
for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None available.
FINDINGS:
There is deep venous thrombosis within all imaged lower extremity veins
bilaterally. Minimal flow is detected in the right popliteal vein, but there
is still nearly occlusive thrombus. The popliteal and peroneal veins could
not be visualized bilateral.
There is a ___ cyst in the left popliteal fossa that measures
approximately 2.1 x 0.9 cm. Echogenic material within the ___ the cyst
may represent hemorrhage/clot.
There is subcutaneous edema about the left popliteal fossa.
IMPRESSION:
1. Extensive deep venous thrombosis in all imaged lower extremity veins
bilaterally. Proximal extent of thrombus is not seen on this study. A CTV of
the abdomen/pelvis would be more sensitive in evaluating proximal extent of
clot burden.
2. 2.1 x 0.9 cm complex left ___ cyst.
Radiology Report
INDICATION: ___ s/p L IJ CVL. Evaluate left internal jugular line placement.
TECHNIQUE: Portable frontal view of the chest.
COMPARISON: Chest radiograph ___.
FINDINGS:
A new left internal jugular line ends in the mid superior vena cava. Multiple
masses and nodules in both lungs are consistent with known pulmonary
metastases. There is no focal consolidation, pleural effusion or
pneumothorax. The cardiac and mediastinal contours are stable. Postoperative
changes are similar.
IMPRESSION:
New left IJ line ends in the mid superior vena cava. No pneumothorax.
Radiology Report
EXAMINATION: CTA chest.
INDICATION: ___ year old woman with metastatic RCC and extensive ___ DVT. //
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) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.2 mGy (Body) DLP = 1.4
mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.2 mGy (Body) DLP = 1.4
mGy-cm.
3) Spiral Acquisition 4.8 s, 30.9 cm; CTDIvol = 7.3 mGy (Body) DLP = 219.7
mGy-cm.
Total DLP (Body) = 223 mGy-cm.
COMPARISON: CT chest with contrast from ___.
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no
evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present.
Atherosclerotic coronary calcifications are identified.
There is a filling defect in the mediobasal segment of the left pulmonary
artery (5:161-5 and 7:94), compatible with pulmonary embolus. As well, there
may be a possible filling defect in a subsegmental pulmonary arterial branch
of the right lower lobe (5:157-9). The main and right pulmonary arteries are
normal in caliber, and there is no evidence of right heart strain.
There is interval decrease in size of extensive mediastinal and hilar
lymphadenopathy compared to prior exam from ___. For example, the
right or paratracheal lymph node now measures 1.2 x 2.0 cm, previously 1.9 x
2.8 cm (5:63). A right lower paratracheal lymph node now measures 1.1 x 1.4
cm, previously 1.4 x 2.0 cm (5:83). A subcarinal conglomerate of lymph nodes
measures 2.3 x 3.8 cm, previously 3.0 x 4.9 cm (5:127). A right hilar nodal
conglomerate measures 2.0 x 2.6 cm, previously 2.5 x 2.9 cm (5:119), and a
left hilar lymph node measures 1.0 x 1.5 cm, previously 1.8 x 1.8 cm (5:137).
There is no supraclavicular or axillary lymphadenopathy. The previously
described hypodense nodule in the left thyroid lobe is not as clearly
visualized on current exam.
Numerous pulmonary nodules of varying sizes are again seen. A 4 mm right
upper lobe pulmonary nodule (05:34) and a 6 mm left upper lobe nodule (05:44)
are grossly stable. There is mild interval decrease in the size of some
nodules including a left lower lobe nodule measuring 1.7 x 1.7 cm, previously
2.4 x 2.6 cm (5:182), a right middle lobe nodule measuring 2.0 x 2.7 cm,
previously 2.1 x 3.4 cm (5:134), and a right lower lobe nodule measuring 1.8 x
2.1 cm, previously 2.6 x 2.7 cm (5:117). There are no new nodules identified.
The airways are patent to the subsegmental level. There is mild dependent
atelectasis bilaterally.
There is no evidence of pericardial effusion. There is no pleural effusion.
Limited images of the upper abdomen are unremarkable. No lytic or blastic
osseous lesion suspicious for malignancy is identified. Patient has had prior
median sternotomy.
IMPRESSION:
1. There is a small pulmonary embolus in the mediobasal segment of the left
pulmonary artery. There may also be a tiny pulmonary embolus in a
subsegmental pulmonary artery branch of the right lower lobe.
2. Mild interval decrease in size of extensive pulmonary nodules, mediastinal,
and hilar lymphadenopathy compared to exam from ___. No new pulmonary
nodules are seen.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 12:09 ___, 5 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old woman with renal cell carcinoma and brain metastasis,
now with need for anticoagulation. Evaluate for acute intracranial hemorrhage
and extent of intracranial masses.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.0 s, 18.8 cm; CTDIvol = 45.5 mGy (Head) DLP =
855.5 mGy-cm.
Total DLP (Head) = 856 mGy-cm.
COMPARISON: ___ contrast brain MRI.
FINDINGS:
Known brain metastasis and surrounding vasogenic edema seen on prior MRI are
not well demonstrated on this noncontrast CT exam. The subtle effacement of
left lateral ventricle posterior horn which is suggestive of underlying mass
which likely corresponds to the largest mass seen on prior MRI.
There is no evidence of large territorial infarction or acute intracranial
hemorrhage. Ventricles and sulci are stable in size and configuration.
There is no evidence of fracture. Small mucous retention cysts are noted in
the sphenoid sinus. The visualized portion of the orbits are unremarkable.
IMPRESSION:
1. Within the limits of this noncontrast study, there is no definite CT
evidence of acute intracranial hemorrhage.
2. Known brain metastasis previously seen on MRI are not well demonstrated on
the CT exam. Please note that some of the masses were hemorrhagic on prior
MRI. If clinically indicated, consider contrast enhanced brain MRI for
further evaluation.
3. Paranasal sinus disease as described.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old female with a history of metastatic RCC with brain
metastasis r/o edema // ___ year old female with a history of metastatic RCC
with brain metastasis r/o edema
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 10 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: MRI head ___
MRI head ___
FINDINGS:
There is no new or worsening metastatic lesion as compared to MRI head ___.
The 6 mm enhancing lesion along the right parasagittal frontal lobe (1000:117)
is unchanged from MRA brain ___. The 5 mm enhancing lesion in the
right frontal lobe (1000:105) is stable. The 2 mm enhancing lesion along the
right coronal radiata (1000:99) is stable. The 3 mm enhancing lesion in the
left temporal lobe (1000:72) is stable. The 5 mm enhancing lesion (1000:66)
and the 1 mm enhancing lesion (1000:60) in the right temporal lobe are stable.
The 1.0 x 1.0 rim enhancing lesion in the right superior frontal lobe
(1000:115) is grossly unchanged, previously 1.1 x 1.1 cm on comparison study.
The 1.0 x 1.0 cm rim enhancing lesion (1000:100) in the left frontal
operculum is grossly unchanged, previously 1.1 x 1.0 cm.
The 1.6 x 1.5 cm rim enhancing lesion in the right parietal lobe (1000:95) is
grossly unchanged, previously 1.7 x 1.5 cm.
The 1.9 x 1.5 cm rim enhancing lesion in the left occipital lobe (1000:73) is
grossly unchanged, previously 1.8 x 1.7 cm.
The confluent T2 and FLAIR hyperintense signal surrounding the rim enhancing
lesions in the right parietal lobe, bilateral frontal lobes, and left
occipital lobe appear grossly unchanged from ___. All of these lesions
are associated with susceptibility, unchanged from comparison study. There is
no evidence of acute intracranial hemorrhage, acute infarction, midline shift.
There is mild mucosal thickening in the bilateral ethmoid air cells. Patient
is status post bilateral cataract surgery.
There is a focus of hyperintense signal on diffusion images without
corresponding ADC abnormality (5 02:22). This lesion also has corresponding
FLAIR abnormality in the right frontal lobe (07:17). This appears to be an
abnormality better visualized on the current study but was present on the
previous MRI examination when accounting for differences in angulation.
IMPRESSION:
1. Numerous enhancing supratentorial enhancing metastatic lesions in the
bilateral frontal, right parietal, and left occipital lobes which are grossly
unchanged as compared MRI ___.
2. No evidence of new or worsening enhancing lesions or worsening edema.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
___ on the telephone on ___ at 9:13 AM, 5 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with hypotension, tachycardia // ___ year old
woman with hypotension, tachycardia
IMPRESSION:
Allowing for technical differences between the exams, there has not been a
substantial change in the appearance of the chest since recent study of 2 days
earlier.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with tachycardia and crackles at bases //
Effusion? Edema?
IMPRESSION:
Allowing for differences in technique, there has not been a relevant change in
the appearance of the chest since recent study of 1 day earlier.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Weakness
Diagnosed with Acute embolism and thombos of deep vein of low extrm, bi
temperature: 97.9
heartrate: 85.0
resprate: 18.0
o2sat: 99.0
sbp: 110.0
dbp: 61.0
level of pain: 0
level of acuity: 3.0 | ___ year old female with a history of metastatic RCC with brain
metastasis who is admitted with hypotension and extensive DVTs
found to have bilateral PEs started on lovenox.
Bilateral PE's, Bilateral DVTs: etiology of hypercoagulability
likely malignancy
- Discussed with neuro oncology - given brain metastasis,
patient is at risk for hemorrhagic masses intracranially. CT
head showed no active bleed.
- patient was started on hep gtt no bolus; transitioned to
lovenox BID. will continue this medication at discharge
- considered starting apixaban, but this medication was not
fully covered by insurance. Patient will continue lovenox
instead. Some consideration of restarting patient on Coumadin,
but deferred, chose to continue lovenox instead in setting of
___ brain mets with bleeding risk and Coumadin being higher risk
for intracranial bleeding
Hypotension
- Likely secondary to ___ PE's and poor PO intake.
- IV fluids given as needed.
- CTA Chest as above; treat PE's as above on lovenox
- IJ placed in the ED as no other IV access options were
available. Will obtain PICC if needed
___: Cr 1.2 today. continue to monitor with daily lytes.
encourage PO intake, IVF PRN. renally dosed medications.
#Metastatic RCC
- previously on pazopanib; patient was not tolerating it well.
consider restarting as appropriate
- ___ consult given decreased mobility.
TRANSITIONAL ISSUES
#started on lovenox BID for PE, DVT treatment
#Anticoagulation plan: patient discharged on lovenox BID.
considered starting apixaban, but this medication was not fully
covered by insurance. Some consideration of restarting patient
on Coumadin, but deferred, chose to continue lovenox instead in
setting of ___ brain mets with bleeding risk and Coumadin being
higher risk for intracranial bleeding
#consider restarting on Coumadin with close follow up if patient
is not tolerating SQ lovenox
#Patient had complaints of dizziness with the sensation of room
spinning, which started several days prior to admission. She is
unable to say what triggers the dizziness, no focal neurological
signs or symptoms. should follow up with PCP for further ___ if
necessary
#Metoprolol XL decreased from 100mg to 50mg; should be increased
back to home dose by PCP as appropriate
#EMERGENCY CONTACT HCP:
Husband ___ ___
___ ___
#CODE STATUS: DNR/DNI |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PLASTIC
Allergies:
Penicillins / adhesives / latex / metformin / Motrin
Attending: ___
Chief Complaint:
sepsis secondary to right breast cellulitis and abscess
Major Surgical or Invasive Procedure:
US-guided drainage of right breast x2
I&D right breast
History of Present Illness:
Pt s/p b/l mastectomy and ___ months ago, with recent fat
grafting to right breast and lat flap to left. C/o f/c right
breast cellulitis and found to have abscess of right breast.
Past Medical History:
breast cancer
Social History:
___
Family History:
Denies breast or ovarian cancer. Reports negative genetic
testing.
Physical Exam:
Physical Exam: Per PRS consult note ___
alert, oriented, non-toxic, nauseous
On exam, fever 102.6, tachy 109, normotensive. Right breast
erythema within marked borders drawn by ___, although patient
notes erythema has intensified and increasing fullness. There is
no overt fluctuance. WBC 14, normal renal function, lactate 2,
glucose 258.
Pertinent Results:
___ 08:45PM WBC-14.2* RBC-4.00 HGB-11.0* HCT-34.4 MCV-86
MCH-27.5 MCHC-32.0 RDW-14.6 RDWSD-45.5
___ 02:09AM LACTATE-1.8
___ 01:46AM URINE COLOR-Straw APPEAR-Clear SP ___
Medications on Admission:
1. zolpidem 5 mg tablet, 1 (One) tablet(s) by mouth at bedtime
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
2. Clindamycin 300 mg PO Q6H Duration: 10 Days
RX *clindamycin HCl 300 mg 1 capsule(s) by mouth every six (6)
hours Disp #*40 Capsule Refills:*0
3. Glargine 10 Units Breakfast
Insulin SC Sliding Scale using NOVOLOG Insulin
RX *blood sugar diagnostic [FreeStyle Lite Strips] check blood
glucose four times a day Disp #*100 Strip Refills:*2
RX *insulin glargine [Basaglar KwikPen U-100 Insulin] 100
unit/mL (3 mL) AS DIR 10 Units before BKFT; Disp #*1 Syringe
Refills:*2
RX *lancets [FreeStyle Lancets] 28 gauge check blood glucose
four times a day Disp #*100 Each Refills:*2
RX *insulin lispro [Admelog SoloStar U-100 Insulin] 100 unit/mL
AS DIR Up to 10 Units QID per sliding scale Disp #*1 Syringe
Refills:*2
4. Linezolid ___ mg PO Q12H Duration: 10 Days
RX *linezolid ___ mg 1 tablet(s) by mouth twice a day Disp #*20
Tablet Refills:*0
5. Zolpidem Tartrate 5 mg PO QHS insomnia
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1) Right breast cellulitis and abscess
2) Type II diabetes (initiated on insulin this admission)
Discharge Condition:
x
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with ___ flap to b/l breast now sepsis// US
guided drainage of right breast collection
COMPARISON: Breast ultrasound performed earlier on same day on ___
TECHNIQUE: Right breast aspiration
OPERATORS: Dr. ___, radiology trainee and Dr. ___
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agree with the trainee's
findings.
FINDINGS:
Limited scanning of the reconstructed right breast was performed. There is
diffuse edema. The largest pocket of fluid spanning approximately 3.3 cm was
targeted for aspiration.
PROCEDURE: The risks and benefits of the procedure were explained to the
patient, and written informed consent was obtained. The preprocedure time out
was performed per ___ protocol. An entrance site for the aspiration was
determined. The patient was prepped and draped in usual sterile fashion. 1%
lidocaine was injected subcutaneously for local anesthesia.
Using ultrasound guidance, the right breast collection was aspirated until it
was collapsed. 4 cc of thick yellowish/brown fluid was aspirated. Samples
were submitted for microbiology. There is persistent scattered fluid
throughout upper outer quadrant of the reconstructed right breast.
No periprocedural complications were encountered. The patient tolerated the
procedure well and was discharged in stable condition.
IMPRESSION:
Technically successful aspiration of a right breast fluid collection. The
sample was sent for microbiology.
Radiology Report
EXAMINATION: US BREAST UNILATERAL LIMITED RIGHT
INDICATION: ___ female with right breast abscess. Assess for
drainable fluid collection.
TECHNIQUE: Grayscale ultrasound images were obtained of the -.
COMPARISON: ___
FINDINGS:
There is diffuse edema in the reconstructed right breast. The largest pocket
of fluid in the right breast at 12 o'clock spans approximately 3.6 cm.
IMPRESSION:
Diffuse edema in the reconstructed right breast, with the largest pocket of
fluid spanning approximately 3.6 cm, which would be amenable to aspiration.
Radiology Report
INDICATION: ___ h/o NIDDM s/p ___ c/b loss of left inferior pole s/p left
lats and bilateral fat graft (___) p/w R breast abscess s/p US-guided
aspiration ___// continued fevers on triple antibiotics and worsening redness
at abscess site concerning for residual infection
COMPARISON: ___
TECHNIQUE: Right breast aspiration.
OPERATORS: Dr. ___, radiology fellow and Dr. ___
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agree with the trainee's
findings.
FINDINGS:
Limited scanning of the reconstructed right breast was performed. There is
diffuse edema. The largest pocket of fluid in the right breast just deep to
the surgical scar was targeted for drainage.
PROCEDURE: The risks and benefits of the procedure were explained to the
patient, and written informed consent was obtained. The preprocedure time out
was performed per ___ protocol. An entrance site for aspiration was
determined. The patient was prepped and draped in usual sterile fashion. 1%
lidocaine was injected subcutaneously for local anesthesia.
Using ultrasound guidance, the largest pocket of fluid underlying the surgical
scar was aspirated, producing approximately 7 cc of thick yellowish fluid.
The sample was sent to microbiology. No periprocedural complications were
encountered. The patient tolerated the procedure well.
IMPRESSION:
Technically successful aspiration of a right breast fluid collection. The
sample was sent to microbiology.
The findings paged to Dr. ___ by Dr. ___ on ___ at 13:27.
Radiology Report
EXAMINATION: RIGHT BREAST ULTRASOUND
INDICATION: ___ woman status post ___ with induration over right
breast. Evaluate for abscess.
COMPARISON: None.
TECHNIQUE: Targeted breast ultrasound was performed. Selected images were
obtained.
FINDINGS:
In the lateral aspect of the reconstructed right breast, there is a 4.2 x 2.5
x 1.2 cm simple appearing fluid collection. There is surrounding subcutaneous
edema. There is no evidence of hyperemia with color Doppler evaluation.
IMPRESSION:
4.2 cm simple appearing fluid collection in the lateral aspect of the
reconstructed right breast. This would be amenable to aspiration.
4.2 cm right breast fluid collection is amenable to
aspiration.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever, Wound eval
Diagnosed with Infection following a procedure, other surgical site, init, Mastitis without abscess, Oth surgical procedures cause abn react/compl, w/o misadvnt, Oth places as the place of occurrence of the external cause
temperature: 102.6
heartrate: 109.0
resprate: 16.0
o2sat: 100.0
sbp: 105.0
dbp: 70.0
level of pain: 3
level of acuity: 3.0 | Pt presented w/ fevers and WBC 14, found to have advancing
breast cellulitis and abscess s/p US-guided drainages on ___ and
___. Continued to have fevers with drainage from breast and so
on ___ the patient had bedside I&D with copious purulent
malodorous fluid drained (about 400cc). Cx have grown staph
epidermidis and gram pos rods sent out and awaiting speciation.
ID consult recommended broadening abx to linezolid and clinda
from initial abx of vanc, cipro, flagyl. Patient will be
discharged on PO linezolid and clinda to continue until ___ per
ID recommendations. ___ was consulted for
hyperglycemia and noncompliance with metformin due to metallic
taste. Recommended patient be started on Lantus 10U QAM and
insulin sliding scale QID while admitted and sent home with
Basaglar Kwikpen 10U QAM and Novolog Kwikpen sliding scale with
follow-up at ___ on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
fevers, chills, left flank pain
Major Surgical or Invasive Procedure:
Upper endoscopy
History of Present Illness:
Briefly this is a ___ yo female presenting with fevers/chills for
6 days with Tmax 102. She has been feeling unwell for the last
___ days with body aches, fevers. She tried managing it at home
with tylenol and ibuprofen. The symptoms started with dysuria,
and progressed to include left-sided flank pain
over the past 2 days, however she also has a cough. Her cough is
nonproductive and she denies any chest pain, dyspnea, diarrhea,
sore throat, confusion, neck pain. She does endorse fatigue,
headache which has improved with fluid, and diffuse muscle
soreness. She also endorses a change in stool coloration notng
that they are slightly more black than ususal. She has had poor
by mouth intake and feels exhausted. Of note she reports mild
epigastric tenderness in the setting of taking Tylenol and
Ibuprofen for the last ___ days.
In the ED, initial VS: 100.2 80 118/64 16 95%. She recieved
Ibuprofen, Tylenol and 1 gram of Ceftriaxone.Given 3LNS.
Prior to transfer from the ED her vitals were: 102.8 129/65 118
24 98%6LNC
Currently, she feels a little "better." She has less muscle
aches, but she still has a persisting headache. She continues to
have persisting dysuria with foul smelling urine and persisting
left side back pain.
REVIEW OF SYSTEMS:
Denies vision changes, rhinorrhea, congestion, sore throat,
cough, shortness of breath, chest pain, abdominal pain, nausea,
vomiting, diarrhea, constipation, hematochezia, and hematuria.
Past Medical History:
HTN
Remote history of depression
Sickle trait
Social History:
___
Family History:
No family history of cancer
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
VS - Temp 97.2 118/78 93 18 100RA
GENERAL - Alert & oriented X 3, interactive, uncomfortable
looking
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear . No
tonsillar erythema. Neck tenderness with no nuchal rigidity,
full range of motion intact.
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
HEART - PMI non-displaced, tachycardic, regular, nl S1-S2, no
MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/suprapubic tenderness, no rebound
tenderness and no guarding/ND, no masses or HSM, tender to
palpation on both left and right flanks (L>>R), RUQ tender on
palpation.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses.Left CVAT ,
none on the right
SKIN - no rashes or lesions
LYMPH - no cervical, axillary, or inguinal LAD
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
Pertinent Results:
LABS ON ADMISSION:
___ 08:51PM BLOOD WBC-13.4*# RBC-4.19* Hgb-11.7* Hct-34.3*
MCV-82 MCH-27.9 MCHC-34.1 RDW-13.4 Plt ___
___ 08:51PM BLOOD Neuts-86.2* Lymphs-9.6* Monos-3.6 Eos-0.2
Baso-0.4
___ 08:51PM BLOOD Plt ___
___ 08:51PM BLOOD Glucose-122* UreaN-10 Creat-1.1 Na-135
K-3.5 Cl-97 HCO3-28 AnGap-14
___ 08:51PM BLOOD ALT-138* AST-64* LD(LDH)-243 CK(CPK)-166
AlkPhos-151* TotBili-0.4
___ 08:51PM BLOOD Albumin-4.3 Calcium-9.1 Phos-2.9 Mg-2.4
___ 08:56PM BLOOD Lactate-1.0
MICRO:
___:
Positive Hepatitis B core antibody and surface antibody,
negative surface antigen
Hepatitis C Ab negative
___ URINE CULTURE (Final ___: ESCHERICHIA COLI.
>100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in MCG/ML
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
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING:
___ EGD:
Normal esophagus, normal stomach, normal duodenum.
___ COMPLETE ABDOMEN U/S: The gallbladder appears normal
without stones. There is no biliary dilatation. The flow in the
main portal vein is hepatopetal. The liver parenchyma is
unremarkable. The pancreas is not entirely visualized due to
overlying bowel gas. The spleen is normal in size and
appearance, measuring 9.1 cm in length. The right kidney
measures 11.6 cm in length and appears within normal limits. The
left kidney measures 12.0 cm in length. A simple cyst in the
interpolar region measures 17 x 19 x 20 mm and is of doubtful
clinical significance. There is a trace right-sided pleural
effusion.
IMPRESSION: Unremarkable study aside from trace right pleural
effusion.
___ Chest X-ray: IMPRESSION: No acute cardiopulmonary
process.
Medications on Admission:
Triamterene/HCTZ - 3.75mg/25mg
Ibuprofen
Calcium 500mg QD
Vitamin D
Discharge Medications:
1. ciprofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q12H
(every 12 hours) for 10 days: To be taken for 10 additional days
until ___.
Disp:*20 Tablet(s)* Refills:*0*
2. triamterene-hydrochlorothiazid 37.5-25 mg Capsule Sig: One
(1) Cap PO DAILY (Daily).
3. Calcium-Vitamin D 600 mg calcium- 400 unit Tablet Sig: One
(1) Tablet PO twice a day.
4. omega-3 fatty acids-vitamin E Oral
5. albuterol sulfate 90 mcg/actuation HFA Aerosol Inhaler Sig:
___ puff Inhalation every six (6) hours as needed for shortness
of breath or wheezing.
Discharge Disposition:
Home
Discharge Diagnosis:
Pyelonephritis
Elevated liver function tests
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
PORTABLE CHEST, ___.
HISTORY: ___ female with desaturation, question pneumonia.
FINDINGS: Single portable view of the chest is compared to previous exam from
___. Lungs are notable for bibasilar atelectasis, but are
otherwise clear. Cardiomediastinal silhouette is stable. Osseous and soft
tissue structures are unremarkable.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
RIGHT UPPER QUADRANT AND RENAL ULTRASOUND STUDIES
HISTORY: Left flank and right upper quadrant pain with elevated liver
function tests. The patient also has fever, chills and slight hypotension.
COMPARISONS: CT is available from ___.
TECHNIQUE: Right upper quadrant and renal ultrasound examinations.
FINDINGS: The gallbladder appears normal without stones. There is no biliary
dilatation. The flow in the main portal vein is hepatopetal. The liver
parenchyma is unremarkable. The pancreas is not entirely visualized due to
overlying bowel gas. The spleen is normal in size and appearance, measuring
9.1 cm in length. The right kidney measures 11.6 cm in length and appears
within normal limits. The left kidney measures 12.0 cm in length. A simple
cyst in the interpolar region measures 17 x 19 x 20 mm and is of doubtful
clinical significance. There is a trace right-sided pleural effusion.
IMPRESSION: Unremarkable study aside from trace right pleural effusion.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: FEVER, BODY ACHES
Diagnosed with PYELONEPHRITIS NOS, HYPERTENSION NOS
temperature: 100.2
heartrate: 80.0
resprate: 16.0
o2sat: 95.0
sbp: 118.0
dbp: 64.0
level of pain: 7
level of acuity: 3.0 | ___ presenting with fevers/chills for 6 days with Tmax 102
concerning for pyleonephritis.
#. Pyelonephritis: The patient presented with dysuria,
fevers/chills, and suprapubic pain. She was found to have left
greater than right CVA tenderness and positive UA which grew
pan-sensitive E.Coli, and was started on Zosyn for
pyelonephritis. Given her fever, white count, and tachycardia
an abdominal ultrasound was obtained to rule out complicated
pyelonephritis, which was negative. She was switched to IV
Ciprofloxacin following the return of the E. coli sensitivity
panel with continued improvement of her signs and symptoms. She
was discharged on PO Ciprofloxacin for a 14 day course of
antibiotics.
#Anemia/Black Stools: The patient was noted to have a hct of
32.5 from a prior baseline of 40. She reports black stool
within the last ___ days in the setting of significant NSAID use
for the pain secondary to pyelonephritis, raising the concern
for NSAID-induced gastritis. She had guiac positive brown
stool, and was started on a PPI and underwent an EGD in-house
which was negative. The PPI was discontinued. T.bili and LDH
were normal on initial presentation, ruling out hemolysis. She
will need outpatient follow-up to work up her anemia with a
colonoscopy and further blood tests when her acute infection has
resolved. H. pylori antigen was negative and EGD was normal
without any abnormalities. Her PPI was discontinued and she was
discharged with instructions to have an outpatient colonoscopy.
#. RUQ Tenderness/Elevated LFTs: The patient does not complain
of RUQ tenderness but on exam, exhibited RUQ tenderness to
palpation. She was also found to have elevated LFT's on initial
presentation with ALT > AST and elevated Alk Phos. She denies
nausea/vomitting and denies alcohol use. Abdominal ultrasound
was negative for cholelithiasis or cholecystitis or fatty liver,
and viral hepatitis studies were sent, which showed positive
Hepatitis B core antibody and surface antibody, negative surface
antigen consistent with prior exposure. Hepatitis C Ab was
negative. LFT's down-trended during her hospital stay. She
will follow-up as an outpatient with her PCP for monitoring of
LFT's and further workup, if necessary.
#. Hypertension: The patient's anti-hypertensives were
initially held in the setting of her acute illness. Her blood
pressures have been elevated in-house and her home
anti-hypertensives were restarted prior to discharge
(Triamterene/HCTZ 37.5/25 mg daily).
#Neck Pain: The patient has chronic neck pain, unchanged from
prior symptoms. No confusion, signs of meningismus, and
headache improved. Her neck pain improved in-house.
# CONTACT: Daughter ___ ___. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Penicillins / Protonix / adhesive tape / Metallic Poisoning,
Agents To Treat / Effexor / PROTONIX / PAPER TAPE / METALS /
Bactrim / diazepam / Pravastatin / clonidine / metoprolol /
hydrochlorothiazide / PLASTICS / red dye / WELLBURTIN /
amlodipine / lorazepam
Attending: ___.
Chief Complaint:
Abdominal pain, back pain
Major Surgical or Invasive Procedure:
___ Surgery #1
1. Ultrasound-guided access to bilateral common femoral
arteries.
2. Abdominal aortogram.
4. Coil embolization of the right internal iliac artery.
3. Bilateral extension of previously placed EVAR iliac
limbs with 2 additional limbs into the iliac arteries on
both sides.
___ Surgery #2
1. Right groin exploration.
2. Right femoral patch angioplasty with Dacron graft.
3. Right femoral endarterectomy.
4. Selective catheterization of right external iliac
artery, ___ order vessel.
5. Angiogram of right lower extremity.
History of Present Illness:
___ PMH DMII, COPD, ruptured AAA s/p EVAR c/b failure L fem
perclose req patch angioplasty, ex-lap for evac RP
___, PAD s/p L fem-peroneal bypass, presenting now
___/ ___ abdominal and back pain which started overnight. She
became concerned given her previous history of ruptured
aneurysm,
and decided to come to the ___ ED. She was initially found to
be hypertensive to a SBP of 220s, and an esmolol gtt was
started.
A CTA was performed, which showed what appears to be contained
rupture without active extravasation of contrast. Vascular
surgery was consulted for assessment of surgical repair of
ruptured AAA.
Upon initial assessment by vascular surgery, Ms. ___ reports
continued abdominal pain that has improved mildly with dilaudid.
She denies chest fevers, chills, nausea, vomiting, chest pain,
shortness of breath, dysuria, or pain or weakness in her legs.
She expresses intense anxiety and concern over her condition.
ROS:
(+) per HPI
(-)
Past Medical History:
Past Medical History:
-DMII
-COPD
-L adrenal adenoma
-primary hyperparathyroidism
-HTN
-fibromyalgia
-Hx TIAs
-Hx CVA
-osteopenia
-neuropathy,
-spinal stenosis
-PVD w/claudication
-vitD deficiency
-diverticulosis
-hemorrhoids
-hx GI bleed
Past Surgical History:
-tonsillectomy
-rectal prolapse reconstruction (___),
-oophorectomy
-CCY
-R CEA (___)
-parathyroidectomy w re-implantation of one parathyroid gland
(___) -L thyroid lobectomy (___)
-EVAR for ruptured infrarenal AAA w L groin exploration for
repair aortotomy w thrombectomy and patch angioplasty
(___), -exlap for decompression RP hematoma
(___)
-takeback for abdominal closure (___)
-R short trochanteric femoral ___
-L groin exploration
-redo L femoral to peroneal artery bypass graft w composite
reverse and non-reverse saphenous vein (___)
Social History:
___
Family History:
Her father died of lung cancer. Her mother died of tuberculosis.
Her fraternal twin sister died of lung cancer. Her paternal
grandfather died of cancer.
Physical Exam:
DISCHARGE PHYSICAL EXAM:
==========================
Vitals: T 98.7, BP 143/72, HR 81, RR 20, O2 94% 2L NC
GEN: A&O x3, NAD, tearful when speaks about all that she has
been through
HEENT: No scleral icterus, EOMI, mucus membranes moist
CV: RRR
PULM: No respiratory distress, on 2L NC
ABD: Non-tender. Non-distended.
GROIN: Staples to right groin, incision site clean/dry/intact
with mild surrounding erythema, no drainage. Dermabond to left
groin.
Ext: warm, dry, no lesions or erythema, no edema.
Pertinent Results:
ADMISSION LABS:
================
___ 08:23AM NEUTS-84.5* LYMPHS-11.1* MONOS-3.3* EOS-0.2*
BASOS-0.4 IM ___ AbsNeut-10.41*# AbsLymp-1.37 AbsMono-0.41
AbsEos-0.02* AbsBaso-0.05
___ 08:23AM WBC-12.3*# RBC-5.12 HGB-15.5 HCT-49.3* MCV-96
MCH-30.3 MCHC-31.4* RDW-14.3 RDWSD-51.0*
___ 08:23AM CALCIUM-9.4 MAGNESIUM-2.3
___ 08:23AM GLUCOSE-157* UREA N-31* CREAT-1.0 SODIUM-141
POTASSIUM-4.4 CHLORIDE-101 TOTAL CO2-24 ANION GAP-20
___ 08:45AM LACTATE-2.2*
___ 09:40AM ___ PTT-29.4 ___
___ 10:12AM URINE MUCOUS-RARE
___ 10:12AM URINE RBC-1 WBC-<1 BACTERIA-NONE YEAST-NONE
EPI-0
___ 10:12AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 10:12AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 11:07AM ___
___ 11:07AM ___ PTT-30.2 ___
___ 11:07AM NEUTS-88.8* LYMPHS-7.1* MONOS-3.2* EOS-0.1*
BASOS-0.3 IM ___ AbsNeut-12.07* AbsLymp-0.96* AbsMono-0.44
AbsEos-0.01* AbsBaso-0.04
___ 11:07AM WBC-13.6* RBC-4.41 HGB-13.4 HCT-42.0 MCV-95
MCH-30.4 MCHC-31.9* RDW-14.2 RDWSD-49.2*
___ 11:09AM freeCa-1.09*
___ 11:09AM HGB-13.2 calcHCT-40
___ 11:09AM GLUCOSE-124* LACTATE-1.4 NA+-141 K+-4.1
CL--106
___ 11:09AM TYPE-ART PO2-227* PCO2-49* PH-7.31* TOTAL
CO2-26 BASE XS--2 INTUBATED-INTUBATED VENT-CONTROLLED
___ 12:41PM freeCa-1.01*
___ 12:41PM HGB-12.1 calcHCT-36
___ 12:41PM GLUCOSE-127* LACTATE-1.2 NA+-139 K+-3.9
CL--109*
___ 12:41PM TYPE-ART PO2-228* PCO2-48* PH-7.26* TOTAL
CO2-23 BASE XS--5
___ 01:18PM freeCa-0.97*
___ 01:18PM HGB-11.5* calcHCT-35
___ 01:18PM GLUCOSE-122* LACTATE-1.2 NA+-139 K+-3.9
CL--111*
___ 01:18PM TYPE-ART PO2-224* PCO2-40 PH-7.30* TOTAL
CO2-20* BASE XS--5
___ 10:11PM ___ PTT-29.1 ___
___ 10:11PM WBC-11.9* RBC-3.39* HGB-10.4* HCT-32.6*
MCV-96 MCH-30.7 MCHC-31.9* RDW-14.8 RDWSD-52.2*
___ 10:11PM CALCIUM-7.3* PHOSPHATE-4.0 MAGNESIUM-1.8
___ 10:11PM GLUCOSE-134* UREA N-23* CREAT-0.9 SODIUM-138
POTASSIUM-4.2 CHLORIDE-106 TOTAL CO2-21* ANION GAP-15
___ 10:24PM TYPE-ART PO2-73* PCO2-37 PH-7.39 TOTAL CO2-23
BASE XS--1
DISCHARGE LABS:
===============
___ 07:45AM BLOOD WBC-10.4* RBC-3.30* Hgb-10.0* Hct-31.9*
MCV-97 MCH-30.3 MCHC-31.3* RDW-14.6 RDWSD-51.4* Plt ___
___ 07:45AM BLOOD ___ PTT-24.9* ___
___ 07:45AM BLOOD Glucose-115* UreaN-24* Creat-0.7 Na-139
K-4.1 Cl-102 HCO3-27 AnGap-14
___ 07:45AM BLOOD Calcium-8.1* Phos-3.4 Mg-2.1
PERTINENT RESULTS:
===================
___ CHEST (PORTABLE AP):
FINDINGS:
Interval increase in heart size, dilatation of the azygos vein,
widened
vascular pedicle and cephalization of upper lobe pulmonary blood
vessels.
Mild indistinctness of the blood vessels. No large effusion. No
airspace
consolidation. Subsegmental atelectasis in the left lung base.
IMPRESSION:
Findings in keeping with pulmonary edema.
___ ___ DUP EXTEXT BIL (MAP
FINDINGS:
RIGHT:
The great saphenous vein is patent and ranges in diameter from
0.31 to 0.70 cm. The small saphenous vein is patent and ranges
in diameter from 0.22 to 0.36 cm.
LEFT:
The great saphenous vein has been surgically removed. The left
small
saphenous vein is patent and ranges in diameter from 0.24 to
0.30 cm.
IMPRESSION:
The right great saphenous and small saphenous veins are patent
with diameters above.
The left great saphenous vein has been surgically removed. The
small
saphenous vein is patent with diameters above.
___ VENOUS DUP UPPER EXT UN
FINDINGS:
RIGHT:
Examination was not performed as the patient had multiple IVs in
the right arm veins.
LEFT:
The cephalic vein is not visualized in the upper arm. In the
forearm, the
cephalic vein is patent and measures 0.18 cm. The basilic vein
is patent and ranges in diameter from 0.13 to 0.33 cm.
IMPRESSION:
The cephalic vein is not visualized in the left upper arm. In
the left
forearm, the cephalic vein is patent with diameters above. The
left basilic vein is patent with diameters above.
Examination of the right arm was not performed as the patient
had multiple IVs in the right arm veins.
___ ART DUP EXT LO UNI;F/U
FINDINGS:
The right common femoral artery is patent with a peak systolic
velocity of 120 cm/sec. The deep femoral artery is patent with
a peak systolic velocity 104 cm/sec. There is occlusive
thrombus within the right proximal SFA. Flow is reconstituted
in the distal SFA however there are very low velocities of 24
cm/sec. The right popliteal artery is patent with a low peak
systolic velocity of 12 cm/sec. There is no flow seen in the
right posterior tibial or dorsalis pedis arteries. The peroneal
artery is not visualized.
IMPRESSION:
Occlusive thrombus within the right proximal SFA.
Flow reconstitutes in the distal SFA however there are very low
velocities in the distal SFA and popliteal artery.
No flow seen in the right posterior tibial or dorsalis pedis
arteries. The
peroneal artery is not visualized.
___ CTA ABD & PELVIS
FINDINGS:
VASCULAR:
As before, the patient is status post endovascular repair of an
abdominal
aortic aneurysm with a suprarenal aortobi-iliac stent. There is
high density fluid draping outside the confines of the partially
calcified aneurysm, consistent with aneurysmal rupture. There
is high density fluid within the excluded aneurysmal sac (for
example, ___ and ___). Notably, the iliac portions of the stent
are above the bifurcation, concerning for type 1B endoleak. The
excluded aneurysmal sac measures 6.8 x 7.1 cm (___), minimally
decreased compared to ___, when it measured 8.4 x 6.7
cm. No significant change in near complete occlusion of the
left common iliac artery (___), with distal reconstitution.
There is a 1.4 cm left common femoral artery aneurysm, new
compared to ___. (___).
There is a very focal high density along the small bowel, just
anterior to
infrarenal aorta, which is not well seen on pre-contrast images
(___).
Fistulous connection cannot be excluded. No additional evidence
to suggest an aorto-enteric fistula.
LOWER CHEST: Again seen is scarring and atelectasis in the lung
bases. There is no pleural or pericardial effusion. There are
coronary artery
calcifications.
ABDOMEN:
HEPATOBILIARY: There is focal fatty infiltration near the
falciform ligament. There is a punctate calcification in the
right hepatic lobe, likely a calcified granuloma. The liver
otherwise demonstrates homogenous attenuation throughout. There
is no evidence of focal lesions. There is no evidence of
intrahepatic biliary dilatation. There is mild dilatation of
the central intrahepatic bilary tree and common bile duct,
measuring up to 0.8 cm, likely secondary to cholecystectomy.
PANCREAS: The pancreas has normal attenuation throughout,
without evidence of focal lesions. The pancreatic duct is
prominent, though unchanged and
non-enlarged. 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 an unchanged heterogeneous left adrenal gland nodule,
consistent with an adrenal adenoma as characterized on MRI from
___.
URINARY: There multiple unchanged hypodense lesions throughout
the kidneys, some are simple cysts and others are too small to
characterize. There is a right lower pole hypodense lesion,
which measures slightly above expected for a simple cyst and may
represent a hemorrhagic cyst. It is minimally increased in size
compared to ___. There is bilateral cortical thinning,
consistent with remote scarring. The kidneys are of normal and
symmetric size with normal nephrogram. There is no evidence of
stones or hydronephrosis. There are no urothelial lesions in the
kidneys or ureters. There is no perinephric abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber,
wall thickness and enhancement throughout. Diverticulosis
without evidence diverticulitis. Colon and rectum are otherwise
within normal limits. Appendix contains air, has normal caliber
without evidence of fat stranding. There is no evidence of
mesenteric lymphadenopathy.
RETROPERITONEUM: There is no evidence of retroperitoneal
lymphadenopathy.
PELVIS: The urinary bladder and distal ureters are unremarkable.
There is no evidence of pelvic or inguinal lymphadenopathy.
There is high density fluid in the pelvis, likely representing
blood from AAA rupture.
REPRODUCTIVE ORGANS: The reproductive organs are atrophic.
BONES: There is no evidence of worrisome osseous lesions or
acute fracture. As before the patient is status post ORIF of
the right femur. There are moderate degenerative changes with
facet arthropathy, disc space narrowing and osteophytosis.
SOFT TISSUES: There is a small fat containing umbilical hernia
and two small fat containing ventral hernias (___, 106). The
abdominal and pelvic wall is otherwise within normal limits.
IMPRESSION:
1. Acute rupture of an infrarenal abdominal aneurysm. The
patient is status post suprarenal aorto bi-iliac stent with the
iliac portions of the stent located superiorly to the aortic
bifurcation, concerning for endoleak type 1B. High-density
material is visualized in the excluded aneurysm sac.
2. There is a very focal high density along the small bowel,
just anterior to infrarenal aorta, which is not well seen on
pre-contrast images (___). Fistulous connection cannot be
excluded. No additional evidence to suggest an aorto-enteric
fistula.
3. 1.4 cm left common femoral artery aneurysm, new compared to
___.
___ Cardiovascular ECHO
Conclusions
Exam done during vascular procedure;
LVEF >55% no wall motion abnormalities. Grade I diastolic
dysfunction with lateral mitral e' < 5cm/sec. The left atrium is
normal in size. There is moderate symmetric left ventricular
hypertrophy. Right ventricular chamber size and free wall motion
are normal. There are complex (>4mm) atheroma in the descending
thoracic aorta. There are three aortic valve leaflets. The
aortic valve leaflets are moderately thickened. There is no
aortic valve stenosis. No aortic regurgitation is seen. The
mitral valve appears structurally normal with trivial mitral
regurgitation. There is no pericardial effusion. Normal coronary
sinus. Possible PFO.
OPERATIVE REPORTS:
====================
___ Operation #1
--------------------
Surgeon: ___, ___
FIRST ASSISTANT: Dr. ___.
SECOND ASSISTANT: ___.
PREOPERATIVE DIAGNOSIS: Ruptured abdominal aortic aneurysm.
POSTOPERATIVE DIAGNOSIS: Ruptured abdominal aortic aneurysm.
PROCEDURES PERFORMED:
1. Ultrasound-guided access to bilateral common femoral
arteries.
2. Abdominal aortogram.
4. Coil embolization of the right internal iliac artery.
3. Bilateral extension of previously placed EVAR iliac
limbs with 2 additional limbs into the iliac arteries on
both sides.
CONTRAST USED: 60 mL Visipaque.
FLUORO DOSE: 337 mGy.
FLUORO TIME: 30.3 minutes.
INDICATIONS FOR PROCEDURE: An ___ woman who
previously underwent an EVAR for ruptured abdominal aortic
aneurysm ___ years ago presents with new rupture, which appears
to have been contained. The imaging was suggestive of loss
of distal seal of the iliac limbs, therefore, she presents
for angiogram and repair of ruptured aneurysm.
DESCRIPTION OF PROCEDURE: The patient was brought to the
operating room and placed in the supine position. Both
groins were prepped and draped in the standard fashion and a
time-out was performed. The patient was kept awake at this
time as we used ultrasound to interrogate both common femoral
arteries. These were both found to be patent and free of
significant calcification. Therefore, under direct
ultrasound visualization, the right common femoral artery was
accessed with a micropuncture needle and the left proximal
bypass graft was accessed with a micropuncture needle. Two
Perclose devices were placed in each groin in the pre-close
technique and ___ sheaths were placed. We then used a
wire to cannulate the iliac limbs from their respective
sides. We then turned our attention to coil embolization of
the right hypogastric artery from the right groin. We were
able to advance a wire into the right hypogastric artery and
then an 0.035 catheter tracked easily into it. We placed a
number of Tornado embolization coils and an Interlock coil
into the hypogastric artery. When this was completely
coiled, we removed the catheter from the hypogastric and shot
an aortogram. This revealed good type 1A seal and good flow
through the graft. There was no obvious evidence of any leak
into the aneurysm sac, although the limbs were clearly not
sealed in the iliac arteries. At this point, we decided to
proceed with treating the left limb. Therefore, we performed
a retrograde left groin hand injection and sized our pieces.
We placed first a 16 mm to 16 mm Endurant limb, which
extended the limb into the proximal left common iliac. We
then placed an additional 16 mm to 8 mm Gore limb, which
brought the seal down even further to the very distal common
iliac just above the hypogastric artery. These 2 limbs were
then ballooned with a Reliant balloon. We then turned our
attention to the right groin. We performed a retrograde
right sheath injection and similarly extended the graft with
a 16 mm to 16 mm right iliac Endurant limb, and then extended
further with a 16 mm to 10 mm Endurant limb into the external
iliac on the right. After deployment, it was determined that
the limb on the right was not fully expanded, so we performed
a balloon angioplasty with a 10 x 40 balloon with a good
result. We then used a Reliant balloon to mold all the areas
of overlap on the right. A catheter was advanced up the
aorta and an angiogram was performed. This showed good flow
through both limbs and no evidence of any 1B leak on either
side. The left hypogastric filled and the right was occluded
by the embolization coils. We then decided to complete the
procedure, so the wires and catheters were removed, the
sheaths were removed, and the arteriotomies were closed with
Perclose devices Protamine 30 mg was given and 5 minutes of
manual groin pressure was held. At the completion of this,
the patient had soft groins without any evidence of hematoma
and was transferred to the PACU for recovery. There was some
concern initially for right leg ischemia, but the ultrasound
showed that there was some flow in the superficial femoral
artery distal to the puncture site, so we transferred her to
the ICU for recovery.
Dr. ___ was present for the entire duration of the
operation.
___, MD ___
I was physically present during all critical and key portions of
the procedure and immediately available to furnish services
during
the entire procedure, in compliance with CMS regulations.
Dictated By: ___, Fellow
Edited By: ___ MD
___ Operation #2
Surgeon: ___, MD ___
ASSISTANTS: Dr. ___, vascular fellow, and Dr. ___, PGY-5.
PREOPERATIVE DIAGNOSIS: Right lower leg critical limb
ischemia status post ruptured abdominal aortic aneurysm.
POSTOPERATIVE DIAGNOSIS: Right lower leg critical limb
ischemia status post ruptured abdominal aortic aneurysm.
PROCEDURES PERFORMED:
1. Right groin exploration.
2. Right femoral patch angioplasty with Dacron graft.
3. Right femoral endarterectomy.
4. Selective catheterization of right external iliac
artery, ___ order vessel.
5. Angiogram of right lower extremity.
ANESTHESIA: General endotracheal anesthesia.
INDICATIONS: Briefly, this is an ___ woman with a
history of a ruptured AAA status post EVAR, who presented
this morning with acute abdominal pain and back pain. She
was found to have extravasation concerning for repeat
ruptured AAA. As such, earlier in the day she had undergone
emergent endovascular assessment with bilateral common iliac
artery stent placement for presumed type 1B bar graft leak.
Postoperatively, she had initially been doing well, but was
noted to have a cooler right foot over the course of the
subsequent hours and loss of her posterior tibial Doppler
signal. Arterial duplex confirmed occlusion of the right
lower extremity lower leg arteries, prompting concern for
proximal occlusion. As such, the patient was prepped for
immediate right groin exploration.
OPERATIVE DESCRIPTION: After informed consent was obtained,
the patient was brought to the operating room and placed
supine on the operating table. The patient's right lower
extremity and right groin were prepped and draped in the
usual sterile fashion. General endotracheal anesthesia was
induced, which the patient tolerated well. A time-out was
performed confirming the patient's identity and planned
operation. 5000 units of IV heparin was given prior to our
arteriotomy. A vertical incision was made overlying the
right femoral artery including the percutaneous site where
the EVAR had been performed earlier in the day. The soft
tissue was divided down to the level of the femoral artery
using a combination of sharp dissection and ___
electrocautery. The proximal common femoral artery was
identified, and we identified the location of the arteriotomy
from the EVAR with Perclose sutures attached. We carefully
dissected out the common femoral artery and worked our way
down towards this takeoff of the superficial femoral artery
and the profunda femoris artery. We obtained control of
these vessels using silastic vessel loops. On examination,
it was clear that there was a palpable pulse proximal to the
Perclose closure, but that this was absent distal to the site
of the Perclose closure. Also of note, the common femoral
artery was noted to be significantly atherosclerotic and
hardened, though the SFA and profunda femoris as well as the
proximal common femoral artery did have some healthy and soft
and less diseased portions. We thus decided to enter the
artery. We used 15 blade to create an arteriotomy
longitudinally on the anterior aspect of the common femoral
artery just proximal to the continuation of the profunda
femoris artery. We extended this proximally using Potts
scissors. We identified some atherosclerotic plaque, and an
endarterectomy was performed. Working our way more
proximally towards the side of the Perclose closure, we noted
that the Perclose closure appeared to have raised a flap of
plaque from the posterior aspect of the common femoral
artery. This appeared to be the cause of the occlusion. We
did not identify significant amounts of thrombus further
corroborating this diagnosis. Once we freed up and excised
the plaque that had been raised by the Perclose device, we
noted very strong inflow from the common femoral artery.
At this point, we turned our attention towards performing our
patch angioplasty. We decided to use a Dacron patch to
perform the angioplasty. We noted good backbleeding from the
profunda femoris artery and some slow backbleeding from a
superficial femoral artery. The Dacron patch was sized to
our arteriotomy and sutured in place circumferentially with 5-
0 Prolene suture. After allowing for back-bleeding and
forward-bleeding, we completed our angioplasty. We then
performed an angiogram to further assess the outflow to the
right lower extremity. We used a micropuncture needle and
passed a wire retrograde up into the aorta through the
endovascular stent. Fluoroscopy was utilized to perform an
aortogram, and subsequently the catheter was moved down to
the right common iliac artery, and the right lower extremity
angiogram was performed. We noted good flow into the
superficial femoral artery. The profunda femoris appeared
occluded at the level of the mid femur. Below the knee,
there was 2-vessel runoff into a diffusely diseased posterior
tibial and peroneal artery. The anterior tibial artery
appeared occluded. Being satisfied with our
revascularization, we turned our attention towards closure of
the wound. We removed the introducer catheter and
guidewires, and closed the defect with a Dacron patch using 6-
0 Prolene suture. We obtained good hemostasis in the right
groin incision, and the incision was closed in multiple
layers using ___ Vicryl suture in a running fashion, and a 3-
0 Vicryl suture in the deep dermal layer, and the skin was
closed using skin staples. The needle, sponge, and
instrument counts were correct at the end of the case.
Sterile dressings were placed over the top of the incision
site. The patient was extubated and brought back to the ICU
in stable condition.
Dr. ___ was present through the entirety of the
operation. At the end of the operation, the posterior tibial
artery signal was noted to be strong once again.
EBL: 200 mL.
URINE OUTPUT: 250 mL.
IV FLUIDS: 1500 mL LR.
___, ___
I was physically present during all critical and key portions of
the procedure and immediately available to furnish services
during
the entire procedure, in compliance with CMS regulations.
Dictated By: ___, MD
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ammonium lactate 12 % topical apply to legs BID PRN dryness
2. LORazepam 0.5 mg PO BID
3. OxyCODONE (Immediate Release) 5 mg PO Q4H with acetaminophen
500 mg
4. Acetaminophen 500 mg PO Q4H with oxycodone
5. Aspirin 81 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. magnesium hydroxide unknown strength oral DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
Do not take if loose stools
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
2. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Hold if loose stools
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth daily Disp #*30 Packet Refills:*3
3. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
4. Acetaminophen 1000 mg PO Q6H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every six (6)
hours Disp #*240 Tablet Refills:*0
5. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
Do not take if sedated
RX *oxycodone 5 mg ___ tablet(s) by mouth q4h prn pain Disp #*30
Tablet Refills:*0
6. ammonium lactate 12 % topical apply to legs BID PRN dryness
7. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
8. LORazepam 0.5 mg PO BID
RX *lorazepam 0.5 mg 1 tablet by mouth twice a day Disp #*30
Tablet Refills:*0
9. magnesium hydroxide unknown oral DAILY
10. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Ruptured abdominal aortic aneurysm
Right lower leg critical limb ischemia status post ruptured
abdominal aortic aneurysm
Type II Diabetes Mellitus
Chronic Obstructive Pulmonary Disease
Hypertension
Fibromyalgia
Discharge Condition:
Mental Status: Clear and coherent, intermittently anxious.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA ABD AND PELVIS
INDICATION: History: ___ with known abdominal aortic aneurysm, rupture x 2,
repair x 2, acute severe lower abdominal and back pain. Evaluate for ruptured
abdominal aortic aneurysm, endoleak
TECHNIQUE: Abdomen and pelvis CTA: Non-contrast and multiphasic post-contrast
images were acquired through the abdomen and pelvis.
Oral contrast was not administered.
MIP reconstructions were performed on independent workstation and reviewed on
PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.4 s, 48.0 cm; CTDIvol = 5.3 mGy (Body) DLP = 252.0
mGy-cm.
2) Stationary Acquisition 6.6 s, 0.5 cm; CTDIvol = 45.3 mGy (Body) DLP =
22.6 mGy-cm.
3) Spiral Acquisition 7.1 s, 46.6 cm; CTDIvol = 21.8 mGy (Body) DLP =
1,016.9 mGy-cm.
Total DLP (Body) = 1,292 mGy-cm.
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
VASCULAR:
As before, the patient is status post endovascular repair of an abdominal
aortic aneurysm with a suprarenal aortobi-iliac stent. There is high density
fluid draping outside the confines of the partially calcified aneurysm,
consistent with aneurysmal rupture. There is high density fluid within the
excluded aneurysmal sac (for example, ___ and ___). Notably, the iliac
portions of the stent are above the bifurcation, concerning for type 1B
endoleak. The excluded aneurysmal sac measures 6.8 x 7.1 cm (___), minimally
decreased compared to ___, when it measured 8.4 x 6.7 cm. No
significant change in near complete occlusion of the left common iliac artery
(___), with distal reconstitution. There is a 1.4 cm left common femoral
artery aneurysm, new compared to ___. (___).
There is a very focal high density along the small bowel, just anterior to
infrarenal aorta, which is not well seen on pre-contrast images (___).
Fistulous connection cannot be excluded. No additional evidence to suggest an
aorto-enteric fistula.
LOWER CHEST: Again seen is scarring and atelectasis in the lung bases. There
is no pleural or pericardial effusion. There are coronary artery
calcifications.
ABDOMEN:
HEPATOBILIARY: There is focal fatty infiltration near the falciform ligament.
There is a punctate calcification in the right hepatic lobe, likely a
calcified granuloma. The liver otherwise demonstrates homogenous attenuation
throughout. There is no evidence of focal lesions. There is no evidence of
intrahepatic biliary dilatation. There is mild dilatation of the central
intrahepatic bilary tree and common bile duct, measuring up to 0.8 cm, likely
secondary to cholecystectomy.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions. The pancreatic duct is prominent, though unchanged and
non-enlarged. 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 an
unchanged heterogeneous left adrenal gland nodule, consistent with an adrenal
adenoma as characterized on MRI from ___.
URINARY: There multiple unchanged hypodense lesions throughout the kidneys,
some are simple cysts and others are too small to characterize. There is a
right lower pole hypodense lesion, which measures slightly above expected for
a simple cyst and may represent a hemorrhagic cyst. It is minimally increased
in size compared to ___. There is bilateral cortical thinning, consistent
with remote scarring. The kidneys are of normal and symmetric size with
normal nephrogram. There is no evidence of stones or hydronephrosis. There are
no urothelial lesions in the kidneys or ureters. There is no perinephric
abnormality.
GASTROINTESTINAL: Small bowel loops demonstrate normal caliber, wall thickness
and enhancement throughout. Diverticulosis without evidence diverticulitis.
Colon and rectum are otherwise within normal limits. Appendix contains air,
has normal caliber without evidence of fat stranding. There is no evidence of
mesenteric lymphadenopathy.
RETROPERITONEUM: There is no evidence of retroperitoneal lymphadenopathy.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
evidence of pelvic or inguinal lymphadenopathy. There is high density fluid
in the pelvis, likely representing blood from AAA rupture.
REPRODUCTIVE ORGANS: The reproductive organs are atrophic.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
As before the patient is status post ORIF of the right femur. There are
moderate degenerative changes with facet arthropathy, disc space narrowing and
osteophytosis.
SOFT TISSUES: There is a small fat containing umbilical hernia and two small
fat containing ventral hernias (___, 106). The abdominal and pelvic wall is
otherwise within normal limits.
IMPRESSION:
1. Acute rupture of an infrarenal abdominal aneurysm. The patient is status
post suprarenal aorto bi-iliac stent with the iliac portions of the stent
located superiorly to the aortic bifurcation, concerning for endoleak type 1B.
High-density material is visualized in the excluded aneurysm sac.
2. There is a very focal high density along the small bowel, just anterior to
infrarenal aorta, which is not well seen on pre-contrast images (___).
Fistulous connection cannot be excluded. No additional evidence to suggest an
aorto-enteric fistula.
3. 1.4 cm left common femoral artery aneurysm, new compared to ___.
NOTIFICATION:
The findings were discussed with ___, M.D. by ___, M.D. on
the telephone on ___ at 9:24 AM, 1 minutes after discovery of the
findings.
Radiology Report
EXAMINATION: Right lower extremity arterial ultrasound
INDICATION: ___ year old woman w/ re-ruptured AAA originally repaired with
EVAR, now s/p re-stenting distal EVAR graft, now without distal pulses right
foot. // Assess for right lower extremity arterial patency
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the right lower extremity arteries was obtained.
COMPARISON: None available.
FINDINGS:
The right common femoral artery is patent with a peak systolic velocity of 120
cm/sec. The deep femoral artery is patent with a peak systolic velocity 104
cm/sec. There is occlusive thrombus within the right proximal SFA. Flow is
reconstituted in the distal SFA however there are very low velocities of 24
cm/sec. The right popliteal artery is patent with a low peak systolic
velocity of 12 cm/sec. There is no flow seen in the right posterior tibial or
dorsalis pedis arteries. The peroneal artery is not visualized.
IMPRESSION:
Occlusive thrombus within the right proximal SFA.
Flow reconstitutes in the distal SFA however there are very low velocities in
the distal SFA and popliteal artery.
No flow seen in the right posterior tibial or dorsalis pedis arteries. The
peroneal artery is not visualized.
NOTIFICATION: After review of OMR notes, the ordering physician was already
aware of the findings on ___.
Radiology Report
EXAMINATION: VENOUS MAPPING
INDICATION: ___ year old woman w/ re-ruptured AAA originally repaired with
EVAR, now s/p re-stenting distal EVAR graft, now without distal pulses right
foot. // Assess veins for possible bypass
TECHNIQUE: Real-time grayscale and Doppler ultrasound imaging of both lower
extremity veins was performed.
COMPARISON: None available.
FINDINGS:
RIGHT:
The great saphenous vein is patent and ranges in diameter from 0.31 to 0.70
cm. The small saphenous vein is patent and ranges in diameter from 0.22 to
0.36 cm.
LEFT:
The great saphenous vein has been surgically removed. The left small
saphenous vein is patent and ranges in diameter from 0.24 to 0.30 cm.
IMPRESSION:
The right great saphenous and small saphenous veins are patent with diameters
above.
The left great saphenous vein has been surgically removed. The small
saphenous vein is patent with diameters above.
Radiology Report
EXAMINATION: VENOUS MAPPING FOR DIALYSIS ACCESS
INDICATION: ___ year old woman w/ re-ruptured AAA originally repaired with
EVAR, now s/p re-stenting distal EVAR graft, now without distal pulses right
foot. // Assess for possible bypass
TECHNIQUE: Real-time grayscale and Doppler ultrasound imaging of left
cephalic veins, radial artery, brachial artery, basilic vein and subclavian
veins was performed.
COMPARISON: None available.
FINDINGS:
RIGHT:
Examination was not performed as the patient had multiple IVs in the right arm
veins.
LEFT:
The cephalic vein is not visualized in the upper arm. In the forearm, the
cephalic vein is patent and measures 0.18 cm. The basilic vein is patent and
ranges in diameter from 0.13 to 0.33 cm.
IMPRESSION:
The cephalic vein is not visualized in the left upper arm. In the left
forearm, the cephalic vein is patent with diameters above. The left basilic
vein is patent with diameters above.
Examination of the right arm was not performed as the patient had multiple IVs
in the right arm veins.
Radiology Report
INDICATION: ___ year old woman with PMH rAAA s/p EVAR req ex-lap for hematoma
evac, PAD s/p L fem-peroneal bypass, now s/p b/l iliac stents to re-seal EVAR
graft for re-rAAA // new oxygen requirement postoperatively
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Interval increase in heart size, dilatation of the azygos vein, widened
vascular pedicle and cephalization of upper lobe pulmonary blood vessels. Mild
indistinctness of the blood vessels. No large effusion. No airspace
consolidation. Subsegmental atelectasis in the left lung base.
IMPRESSION:
Findings in keeping with pulmonary edema.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Back pain
Diagnosed with Abdominal aortic aneurysm, ruptured
temperature: 95.1
heartrate: 80.0
resprate: 20.0
o2sat: 97.0
sbp: 227.0
dbp: 91.0
level of pain: 9
level of acuity: 2.0 | Ms. ___ is an ___ year old female with history of type 2
diabetes, ruptured AAA s/p EVAR complicated by failure of left
femoral perclose requiring patch angioplasty and ex-lap for
hematoma evacuation (___), PAD s/p L fem-peroneal bypass, who
presented with abdominal and back pain, found to have re-rupture
of her AAA.
She was initially found to be hypertensive to a SBP of 220s, and
an esmolol gtt was started. A CTA was performed, which showed
what appeared to be contained rupture without active
extravasation of contrast. Vascular surgery was consulted for
assessment of surgical repair of ruptured AAA.
She was emergently taken to the operating room for re-rupture of
her AAA, and type 1B bar graft leak. She underwent coil
embolization of the right internal iliac artery, as well as
bilateral extension of previously placed EVAR iliac limbs with
two additional limbs into the iliac arteries on both sides to
reseal her previous EVAR graft. Upon transfer to the PACU, there
was some concern initially for right leg ischemia, but the
ultrasound showed that there was some flow in the superficial
femoral artery distal to the puncture site, and she was
transferred to the ICU for recovery.
Postoperatively, she had initially been doing well, but was
noted to have a cooler right foot over the course of the
subsequent hours and loss of her posterior tibial Doppler
signal. Arterial duplex confirmed occlusion of the right lower
extremity lower leg arteries, prompting concern for proximal
occlusion. As such, the patient was prepped for immediate right
groin exploration. Intraoperatively it was noted that the
Perclose closure appeared to have raised a flap of plaque from
the posterior aspect of the common femoral artery. This
appeared to be the cause of her occlusion. She then underwent
right femoral patch angioplasty with Dacron graft, right femoral
endarterectomy, selective catheterization of right external
iliac artery, second order vessel, and angiogram of the right
lower extremity. It was determined that revascularization had
been successful, as her posterior tibial
artery signal was noted to be strong again intraoperatively and
postoperatively. The patient was transferred to the PACU in
stable condition.
Post-operatively she continued to experience intermittent pain
and anxiety. Her home medications were restarted and she
received medications as needed for adequate pain control. She
was also seen by social work and spoke with her outpatient
psychiatrist, which helped to alleviate her anxiety.
She was discharged to rehab. She should continue frequent
incentive spirometer use daily. Anticipate rehab stay less to be
than 30 days.
She should follow up with Dr. ___ at her scheduled
outpatient appointment. She should continue taking aspirin 81mg
daily as well as her other medications as prescribed. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / Biaxin / Morphine / Doxycycline / Erythromycin
Base / Penicillins / Percocet / Flagyl / fluconazole
Attending: ___
Chief Complaint:
Fever/nausea/vomiting/diarrhea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Patient is a ___ woman with a history of left breast IDC s/p
lumpectomy ___ f/b XRT, DMI on insulin pump, s/p renal
transplant ___ and ___ for diabetic nephropathy, presenting
with N/V/D fevers x 1 day. She has experienced a cough for
approximately two weeks and a slight runny nose but otherwise
felt relatively well until the evening of ___, when she
experienced acute nausea/vomiting/diarrhea and some transient
LLQ pain that has now improved. Also had subjective fevers and
chills. Of note, ate a salade with leftover chicken (several
days old) on the afternoon of ___ and her friend who ate the
same food now has the same symptoms as she does. She also ate a
similar salad several hours prior to the development of her
symptoms on ___.
In the ED, initial vitals were 100.8 95 132/58 16 100% ra.
Patient was given acetaminophen and zofran.
Past Medical History:
1) DM type I (on insulin pump with complications of nephropathy,
retinopathy, PVD)
2) s/p kidney transplant - originally in ___, most recently
LURT in ___ Hypothyroidism
4) GERD
5) Hyperlipidemia
6) Peripheral vascular disease
7) Hypertension
8) Osteoporosis
9) PCP pneumonia in ___
10) Sepsis of urinary origin in ___
11) Primary varicella infection (hospitalized ___ to
___
12) History of left breast cancer. infiltrating ductal carcinoma
in ___ cores, grade 1, ER and PR positive, and HER-2/neu
negative by
immunohistochemistry and FISH. She had a lumpectomy in ___
followed by radiation therapy, now on tamoxifen
Social History:
___
Family History:
Grandmother with kidney disease.
No family history of DM.
Physical Exam:
Admission physical:
VS: 100.3 117/61 103 20 98% SpO2
General: Lying in bed appearing fatigued but in no acute
distress.
HEENT: Normalocephalic/atraumatic, no lymphadenopathy, mucous
membranes dry
Neck: supple
CV: RRR, no M/G/R
Lungs: CTAB, no wheezes/crackles
Abdomen: Soft, nontender, nondistended, + bs
GU: deferred
Ext: 1+ pitting edema in the bilateral lower extremities
Neuro: A&O x 3, conversing appropriately but fatigued, moving
all extremities, gait not assessed
Skin: No rashes or lesions
Discharge physical:
VS: Tm=c 98.5, BP 119/50 (SBP 119-134), RR 18, 98% RA
General: Lying in bed appearing fatigued but comfortable
HEENT: Normalocephalic/atraumatic
Neck: supple
CV: RRR, no M/G/R
Lungs: CTAB, no wheezes/crackles; slightly decreased BS in bases
Abdomen: Soft, nontender, nondistended, + bs
GU: no foley
Ext: trace pitting edema in the bilateral lower extremities
Neuro: A&O x 3, conversing appropriately but fatigued, lying
quietly inbed gait not assessed
Skin: No rashes or lesions
Pertinent Results:
Admission labs:
___ 10:45PM BLOOD WBC-12.3*# RBC-5.25 Hgb-13.8 Hct-44.7
MCV-85 MCH-26.3* MCHC-30.9* RDW-14.0 Plt ___
___ 10:45PM BLOOD Neuts-94.2* Lymphs-2.7* Monos-2.8 Eos-0.3
Baso-0.1
___ 10:45PM BLOOD Glucose-230* UreaN-34* Creat-1.3* Na-143
K-4.2 Cl-104 HCO3-30 AnGap-13
___ 10:45PM BLOOD ALT-21 AST-30 AlkPhos-100 Amylase-15
TotBili-0.5
___ 10:45AM BLOOD Albumin-3.3* Calcium-7.7* Phos-2.3*
Mg-1.3*
Pertinent labs:
___ 11:13PM BLOOD Lactate-1.8
___ 10:45AM BLOOD tacroFK-LESS THAN
___ 10:45AM BLOOD Cyclspr-66* tacroFK-LESS THAN
___ 06:00AM BLOOD Cyclspr-84*
___ 10:45PM BLOOD HCG-<5
___ 06:15AM BLOOD 25VitD-46
___ 10:45PM BLOOD Lipase-16
Micro:
___ 9:06 am STOOL CONSISTENCY: FORMED Source:
Stool.
MICROSPORIDIA STAIN (Pending):
CYCLOSPORA STAIN (Pending):
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___:
NO ENTERIC GRAM NEGATIVE RODS FOUND.
NO SALMONELLA OR SHIGELLA FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
Other urine cx: negative
Other blood cx: pending
Imaging:
___ CXR
IMPRESSION:
previously visible small lung the opacities have resolved since
however small
bilateral pleural effusions are new, and increased since ___.
Heart size is
normal. Mediastinal contour unremarkable.
___
IMPRESSION:
1. Peribronchial thickening and adjacent peribronchial lung
opacities,
potentially due to multifocal aspiration or an early infection.
Since the
time of this radiograph, followup chest ___
shows resolution
of these opacities favoring an uncomplicated aspiration event.
2. Small bilateral pleural effusions.
___ CT abd/pelvis
FINDINGS: The lung bases are clear. There is no pleural or
pericardial
effusion. There are calcifications in the coronary arteries.
The lack of
intravenous contrast limits evaluation of the abdominal
structures. The
liver, gallbladder, pancreas, spleen and adrenal glands appear
normal. The
kidneys are atrophic. The bladder and uterus appear normal.
The stomach is decompressed. There are non-dilated loops of
small bowel
without evidence of wall thickening or obstruction. The
appendix is
visualized in the right lower quadrant and there is no evidence
of acute
appendicitis. An atrophic renal transplant in the right lower
quadrant is
identified. A renal transplant within the left lower quadrant
appears normal
without evidence of hydronephrosis or stones. There are marked
vascular
calcifications throughout the abdomen. The aorta is normal in
caliber. There
is no free fluid, free air or pathologic lymphadenopathy by CT
size criteria.
OSSEOUS STRUCTURES: No concerning osteoblastic or osteolytic
lesions
identified.
IMPRESSION: No acute intra-abdominal process.
Discharge labs:
___ 06:15AM BLOOD WBC-4.6 RBC-4.25 Hgb-11.0* Hct-35.5*
MCV-84 MCH-25.9* MCHC-31.0 RDW-14.2 Plt ___
___ 06:12AM BLOOD Neuts-73.2* ___ Monos-4.7 Eos-0.6
Baso-0.3
___ 06:15AM BLOOD Glucose-197* UreaN-15 Creat-0.8 Na-141
K-3.8 Cl-110* HCO3-21* AnGap-14
___ 06:00AM BLOOD ALT-14 AST-25 AlkPhos-57 TotBili-0.2
___ 06:15AM BLOOD Calcium-8.0* Phos-2.6* Mg-1.5*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Atorvastatin 60 mg PO DAILY
3. Furosemide 20 mg PO QHS:PRN edema
4. Levothyroxine Sodium 112 mcg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Mycophenolate Mofetil 500 mg PO BID
7. Nitroglycerin SL 0.3 mg SL PRN chest pain
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
9. Tamoxifen Citrate 20 mg PO DAILY
10. PredniSONE 3 mg PO DAILY
11. CycloSPORINE (Neoral) MODIFIED 100 mg PO Q12H
12. Lubiprostone 8 mcg PO BID
13. Aspirin 81 mg PO DAILY
14. Atenolol 6.25 mg PO DAILY
15. Vitamin D ___ UNIT PO DAILY
16. Citracal Regular (calcium citrate-vitamin D3) 315/250 mg
oral daily
17. cilostazol 50 mg oral BID
18. Insulin Pump SC (Self Administering Medication)Insulin
Aspart (Novolog) (non-formulary)
Basal rate minimum: 0.1 units/hr
Basal rate maximum: 0.3 units/hr
Target glucose: 80-180
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 60 mg PO DAILY
4. Levothyroxine Sodium 112 mcg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. Mycophenolate Mofetil 500 mg PO BID
7. PredniSONE 3 mg PO DAILY
8. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
9. Tamoxifen Citrate 20 mg PO DAILY
10. Atenolol 6.25 mg PO DAILY
11. cilostazol 50 mg oral BID
12. Citracal Regular (calcium citrate-vitamin D3) 315/250 mg
oral daily
13. Furosemide 20 mg PO QHS:PRN edema
please take this daily at least until your renal appointment
next week
14. Lubiprostone 8 mcg PO BID
15. Nitroglycerin SL 0.3 mg SL PRN chest pain
16. Vitamin D ___ UNIT PO DAILY
17. CycloSPORINE (Neoral) MODIFIED 75 mg PO Q12H
18. Phosphorus 250 mg PO BID
RX *sod phos,di & mono-K phos mono [K-Phos-Neutral] 250 mg 1
tablet(s) by mouth twice a day Disp #*60 Tablet Refills:*0
19. Ciprofloxacin HCl 500 mg PO Q12H Duration: 14 Days
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
20. Insulin Pump SC (Self Administering Medication)Insulin
Aspart (Novolog) (non-formulary)
Basal rate minimum: 0.1 units/hr
Basal rate maximum: 0.3 units/hr
Target glucose: ___
Fingersticks: QAC and HS
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
#Gastroenteritis
#Pyelonephritis
#Acute kidney injury
#Hypophosphatemia
Secondary diagnoses:
# S/p renal transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CLINICAL INDICATION: Renal transplant, fever and abdominal pain. Now with
severe nausea and vomiting.
TECHNIQUE: Multidetector CT scan of the abdomen and pelvis was performed
without intravenous contrast. Reformatted images were provided.
DLP: 613.41 mGy-cm.
CTDIvol: 11.47 mGy.
COMPARISON: CT abdomen and pelvis, ___.
FINDINGS: The lung bases are clear. There is no pleural or pericardial
effusion. There are calcifications in the coronary arteries. The lack of
intravenous contrast limits evaluation of the abdominal structures. The
liver, gallbladder, pancreas, spleen and adrenal glands appear normal. The
kidneys are atrophic. The bladder and uterus appear normal.
The stomach is decompressed. There are non-dilated loops of small bowel
without evidence of wall thickening or obstruction. The appendix is
visualized in the right lower quadrant and there is no evidence of acute
appendicitis. An atrophic renal transplant in the right lower quadrant is
identified. A renal transplant within the left lower quadrant appears normal
without evidence of hydronephrosis or stones. There are marked vascular
calcifications throughout the abdomen. The aorta is normal in caliber. There
is no free fluid, free air or pathologic lymphadenopathy by CT size criteria.
OSSEOUS STRUCTURES: No concerning osteoblastic or osteolytic lesions
identified.
IMPRESSION: No acute intra-abdominal process.
Radiology Report
PA AND LATERAL CHEST RADIOGRAPH ___
COMPARISON: ___.
The initial report for this dictation was lost, and the radiograph has been
resubmitted for evaluation on ___, with note made of an interval
chest ___ on ___.
FINDINGS: Cardiomediastinal contours are unchanged. Peribronchial thickening
in the juxtahilar regions is new, as well as scattered peribronchiolar
opacities in the left mid and lower lung regions. Small pleural effusions are
also new.
IMPRESSION:
1. Peribronchial thickening and adjacent peribronchial lung opacities,
potentially due to multifocal aspiration or an early infection. Since the
time of this radiograph, followup chest ___ shows resolution
of these opacities favoring an uncomplicated aspiration event.
2. Small bilateral pleural effusions.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)CHEST (PA AND LAT)i
INDICATION: ___ year old woman with decreased breath sounds in bilateral bases
// eval for pneumonia
COMPARISON: Chest radiographs since ___ most recently ___ in
___
IMPRESSION:
previously visible small lung the opacities have resolved since however small
bilateral pleural effusions are new, and increased since ___. Heart size is
normal. Mediastinal contour unremarkable.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: n/v/d
Diagnosed with FEVER, UNSPECIFIED, NAUSEA WITH VOMITING, DIARRHEA
temperature: 100.8
heartrate: 95.0
resprate: 16.0
o2sat: 100.0
sbp: 132.0
dbp: 58.0
level of pain: 5
level of acuity: 2.0 | Patient is a ___ woman with a history of left breast ___ s/p
lumpectomy ___ f/b XRT, DMI on insulin pump, s/p renal
transplant ___ and ___ for diabetic nephropathy, presenting
with N/V/D fevers x 1 day, found to have pyelonephritis.
# Gastroenteritis (N/v/d and cough): Likely viral
gastroenteritis given rapid onset and similar symptoms in her
lunch companion after eating suspicious meal. Leukocytosis and
fever without localizing signs and symptoms supports this
diagnosis. Other possibilities included URI or a more serious
infection (ie bacteremia) given her immunosuppression. As her
symptoms were ongoing for 2 weeks prior to presentation, an
acute URI presentation was less likely and respiratory swab not
necessary. She also was recently hospitalized for pneumonia but
CXR was clear and would not explain her cough. Still spiking
fevers on ___ but resolved by ___ on antibiotics. She was
found to have Enterobacter cloacae growing in her urine: was
initially treated empirically with with vanc/cipro for fevers of
unclear origin but suspected GI source, then was switched to
ceftriaxone empirically for UTI, and was ultimately discharged
to complete a course of ciprofloxacin given sensitivity data.
She initially required IVF given poor po intake but fluids were
stopped when the patient was taking good po's. Blood cultures
negative to date, stool cultures also negative to date. By the
time of discharge, her nausea/vomiting/diarrhea had resolved and
she was complaining of some constipation.
#Pyelonephritis: patient's first UA/UCx initially negative for
infection but positive on ___ and growing G+ bacteria. Ucx from
___ grew Enterobacter cloacae per above; patient discharged on
ciprofloxacin.
# ___: RESOLVED. Cr 1.3 up from baseline of 1.0. Likely prerenal
given dehydration from poor po intake/vomiting. Taking better
po's by ___. Creatinine back to normal at discharge.
# S/p renal transplant: Continued cellcept and cyclosporine. Her
cyclosoporine dose was decreased at discharge given high levels.
#Hypophosphatemia: patient had low phos during her hospital
stay, question renal phosphorous wasting. Vitamin D was within
normal limits. Patient was discharged on phos supplementation
with close renal f/u.
#DMI: patient uses an insulin pump at home. She was followed
closely by ___ and was maintained on her basal dose rate from
her insulin pump as well as supplemental SS carb counting with
humolog. Towards the time of discharge, she was switched back to
her pump. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
morphine
Attending: ___
Chief Complaint:
fall, shakiness, mild confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old gentleman with a history of ETOH
cirrhosis complicated by portal hypertension, hepatic
encephalopathy, recurrent variceal bleeds as well as diabetes
and hypertension, s/p recent hospitalization at ___ in ___
for variceal bleed who presents with shaking in his extremities
and hyperglycemia. He states that his lactulose was increased
last week for the shaking. He notes that usually his shaking
progresses to altered mental status and he is worried that this
is imminent. He also reports generalized fatigue over the past
few months as well as 30 pound weight gain since ___. He denies
any new BLE edema. He also says that he has been intermittently
confused, forgetting the year and his social security number. He
has been compliant with his home lactulose and has been having ~
___ BMs/day.
With regards to his hyperglycemia, he reports poor glucose
control and that his home FSBGs typically run in the 300s. He
has been taking 50 u Lantus qam + HISS at home but was recently
switched to U500 100u BID yesterday which he has not started;
this was prescribed by his Diabetes doctor at ___. He did
take his home Lantus this evening.
He denies fevers, chest pain, dyspnea, abdominal pain,
distention or dysuria. He called his oncologist who advised him
to come to the Emergency Department.
In the ED, initial vitals were T 98.4 HR 99 BP 126/72 RR 16 99%
RA
Labs notable for WBC 2.3 Hct 28.9 Plt 45 INR 1.2. Na 132.
Glucose 582, anion gap 7. LFTs wnl, Tbili 1.3, INR 1.2. Urine
negative for ketones. UA negative for UTI. CXR negative. CT head
negative. No ascites noted on bedside US in the ED. He was given
10 units regular insulin SQ for hyperglycemia, followed by ___s well as 1L NS; FSBG prior to transfer improved to
324.
Of note he was discharged in ___ after being transferred from
___ for a variceal bleed. He underwent TIPS procedure
during that admission and his portosystemic gradient was lowered
to 12mmHG. After the procedure, he exhibited mild asterixis and
mild difficulty concentration, but this resolved after
increasing his lactulose dose and he was discharged with intact
mental capacity. At the time, he was discharged on lactulose
TID, rifaximin, omeprazole and nadolol. He reports that he has
not been taking the rifaximin and that his PCP stopped his
nadolol (unclear why).
His ___ course prior to transfer was complicated
by hemolytic anemia. Patient received 20u PRBC at outside
hospital and hemolysis labs were positive on transfer with his
Hgb in the ___. They remained stable on the floor with no
further evidence of bleeding and did not require any further
transfusions. Hemolysis labs trended down in the Hemolysis
workup showed no autoimmune process and therefore prednisone
initially started at OSH was stopped. Transfusion medicine
evaluated his bloodwork and determined that he is not making
antibodies to either his own or others' blood. Therefore it is
likley due to something in the environment. Heme/onc was
involved but a diagnosis was never given. It was thought to be
due to splenomegaly, G6PD, or some other environmental factor.
He was scheduled to follow up with heme/onc after discharge.
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:
PAST MEDICAL HISTORY:
1. Hepatitis C and alcoholic cirrhosis c/b portal HTN, varices,
ascites and hepatic encephalopathy.
2. Portal hypertension with Grade 3 esophageal varices s/p TIPS
(no procedure note seen in OMR).
3. Diabetes.
4. Polysubstance abuse.
5. Hypertension.
6. Anxiety.
7. Chronic back pain.
8. Sleep apnea, has not been using CPAP since machine is broken
Past Surgical History:
1. Umbilical hernia repair.
2. Right lower extremity orthopedic surgery from trauma.
3. Cholecystectomy.
Social History:
___
Family History:
- strong family history of polysubstance abuse
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 98.2, 113/65, 89, 18, 100% on RA.
Wt 123.7 kg
General: well-appearing well-nourished middle-aged male lying in
bed in NAD
HEENT: MMM, NCAT, EOMI
Neck: supple, no appreciable JVD
CV: RRR, nml S1 and S2, ___ systolic murmur best heard at
cardiac base
Lungs: CTAB, no w/r/r
Abdomen: soft, obese, NTND, no fluid wave, no abdominal wall
edema
GU: no Foley
Ext: chronic venous changes of BLE, trace pitting edema to
mid-tibia bilaterally
Neuro: AOx3, normal gait, mild asterixis of BUE
Skin: some skin breakdown with chronic venous changes of BLE as
noted above
DISCHARGE PHYSICAL EXAM:
VS: 97.6, 99/58, 66, 16, 100% on RA.
Wt 123.7 kg
General: well-appearing well-nourished middle-aged male sitting
in bed in NAD
HEENT: MMM, NCAT, EOMI, no teeth
Neck: supple, no appreciable JVD
CV: RRR, nml S1 and S2, ___ systolic murmur best heard at
cardiac base
Lungs: CTAB, no w/r/r
Abdomen: soft, obese, NTND, no fluid wave, no abdominal wall
edema
GU: no Foley
Ext: chronic venous changes of BLE. Shoulder exam limited by
pain. Full passive and active ROM of shoulder joint, but pain
with both. Positive empty can sign on LUE. Unable to flex past
90 degrees.
Neuro: AOx3, normal gait, mild asterixis of BUE
Skin: some skin breakdown with chronic venous changes of BLE as
noted above
Pertinent Results:
ADMISSION LABS:
===============
___ 01:26PM BLOOD WBC-2.3* RBC-3.27* Hgb-10.2* Hct-28.9*
MCV-88 MCH-31.1 MCHC-35.2* RDW-17.7* Plt Ct-45*
___ 01:26PM BLOOD Neuts-51.7 ___ Monos-7.9 Eos-3.4
Baso-0.7
___ 01:26PM BLOOD ___ PTT-37.2* ___
___ 01:26PM BLOOD Glucose-582* UreaN-8 Creat-0.7 Na-132*
K-4.0 Cl-98 HCO3-27 AnGap-11
___ 01:26PM BLOOD ALT-24 AST-34 AlkPhos-97 TotBili-1.3
___ 01:26PM BLOOD Albumin-3.7 Calcium-8.8 Phos-4.0 Mg-2.0
___ 01:26PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
STUDIES/IMAGING:
================
___ CXR: No evidence of acute cardiopulmonary disease.
___ CT HEAD: No evidence of acute intracranial process.
DISCHARGE LABS:
===============
___ 07:13AM BLOOD WBC-3.0* RBC-3.33* Hgb-10.8* Hct-28.6*
MCV-86 MCH-32.4* MCHC-37.7* RDW-17.3* Plt Ct-45*
___ 07:13AM BLOOD ___ PTT-36.2 ___
___ 07:13AM BLOOD Glucose-292* UreaN-10 Creat-0.6 Na-136
K-4.0 Cl-103 HCO3-28 AnGap-9
___ 07:13AM BLOOD ALT-23 AST-34 AlkPhos-88 TotBili-1.6*
___ 07:13AM BLOOD Albumin-3.4* Calcium-8.3* Phos-3.2 Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 800 mg PO TID
2. Methadone 65 mg PO DAILY
3. Lactulose 30 mL PO TID
4. Glargine 50 Units Breakfast
Insulin SC Sliding Scale using UNK Insulin
Discharge Medications:
1. Lactulose 30 mL PO TID
2. Methadone 65 mg PO DAILY
3. Gabapentin 800 mg PO TID
4. Rifaximin 550 mg PO BID
RX *rifaximin [Xifaxan] 550 mg 1 tablet(s) by mouth twice daily
Disp #*60 Tablet Refills:*0
5. U500 insulin as advised by your outpatient endocrinologist
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Hepatic Encephalopathy
Secondary: Uncontrolled diabetes
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST RADIOGRAPHS
INDICATION: Worsening and attic encephalopathy.
COMPARISON: ___.
TECHNIQUE: Chest, five views.
FINDINGS:
The heart is normal in size. The aorta shows moderate tortuosity. There is no
pleural effusion or pneumothorax. The lungs appear clear.
IMPRESSION:
No evidence of acute cardiopulmonary disease.
Radiology Report
EXAMINATION: HEAD CT
INDICATION: Status post fall. History of cirrhosis.
COMPARISON: None.
TECHNIQUE: Non-contrast head CT.
FINDINGS:
There is no evidence of intracranial hemorrhage. There is no mass effect or
shift of the normally midline structures. The gray-white matter distinction
appears preserved. Mild calcification is noted along cavernous carotid
arteries. Surrounding soft tissue structures are unremarkable. The visualized
paranasal sinuses and mastoid air cells appear clear. There is no evidence
for fracture or bone destruction.
IMPRESSION:
No evidence of acute intracranial process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: s/p Fall
Diagnosed with ABN INVOLUN MOVEMENT NEC, ALCOHOL CIRRHOSIS LIVER, DIABETES UNCOMPL ADULT, LONG-TERM (CURRENT) USE OF INSULIN, HYPERTENSION NOS
temperature: 98.4
heartrate: 99.0
resprate: 16.0
o2sat: 99.0
sbp: 126.0
dbp: 72.0
level of pain: 6
level of acuity: 2.0 | Patient is a ___ with a h/o ETOH cirrhosis s/p TIPS who
presents with mild confusion and shakes consistent with hepatic
encephalopathy, also found to have hyperglycemia. His confusion
and shakes improved with lactulose administration. Patient also
presented with a recent fall (last 10 days ago) that on history
appeared consistent with syncope.
# Hepatic Encephalopathy: The patients history of TIPS procedure
with current symptoms of shakiness and mild confusion consistent
hepatic encephalopathy. His symptoms improved with lactulose TID
and the addition of rifaximin BID. He had no evidence of
infection.
# Hyperglycemia: The patient presented with severe hyperglycemia
to the 500s without evidence of diabetic ketoacidosis. He is
followed by outpatient endocrinologist. He is currently on
lantus 50U qAM and was told to switch to U500 BID on ___.
Lantus 50U qAM and insulin sliding scale was continued while
inpatient and patient was advised to switch to U500 as
prescribed by his endocrinologist on discharge.
# Shoulder pain: Patient also had bilateral shoulder pain for
the last few weeks. Exam revealed pain with both active and
passive range of motion, positive empty can test on LUE and
restricted active range of motion. Patient has seen ortho as an
outpatient for other injuries.
# GIB/Varices: Patient has a history of variceal bleed, now s/p
TIPS in ___. Last EGD in ___ revealed no evidence of
varices.
# Ascites: Patient has a h/o TIPS in ___ and had no evidence
of ascites on bed side ultrasound in the ED.
# ETOD Cirrhosis: Patient is currently followed by Dr. ___
___ in liver clinic. MELD on admission was 9 and is currently
not on the transplant list. Patient will follow up in liver
clinic in early ___.
# Polysubstance abuse/chronic pain: Patient on methadone which
he gets from ___ in ___, ___).
Patient was continued on methadone while hospitalized.
#Fall: patient presented with fall ___ days ago. CT head
negative. Patient endorsed loss of vision prior to fall and
buckling of knees. Fall was felt to be consistent with syncope. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
bilateral ureteral stones
Major Surgical or Invasive Procedure:
___: cystoscopy, placement of bilateral ureteral stents
Past Medical History:
nephrolithiasis ___ s/p lithotripsy ___
UTI
Social History:
___
Family History:
Her father is alive with HTN and HL. Her mother is alive with
HL.
Physical Exam:
Gen NAD AAOX3
Non labored breathing on room air
Soft NT ND
GU no catheter, no CVA ttp
Ext WWP, no edema
Pertinent Results:
___ 12:00PM GLUCOSE-122* UREA N-10 CREAT-0.7 SODIUM-140
POTASSIUM-4.2 CHLORIDE-100 TOTAL CO2-23 ANION GAP-17*
___ 12:00PM WBC-13.5*# RBC-4.99 HGB-14.6 HCT-42.8 MCV-86
MCH-29.3 MCHC-34.1 RDW-12.8 RDWSD-39.0
___ 12:00PM NEUTS-86.1* LYMPHS-10.7* MONOS-2.1* EOS-0.1*
BASOS-0.3 IM ___ AbsNeut-11.66* AbsLymp-1.45 AbsMono-0.28
AbsEos-0.01* AbsBaso-0.04
___ 12:00PM PLT COUNT-451*
___ 11:50AM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-TR*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-SM*
___ 11:50AM URINE RBC-86* WBC-3 BACTERIA-FEW* YEAST-NONE
EPI-2 TRANS EPI-<1
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. amLODIPine 2.5 mg PO DAILY
2. Oxybutynin 5 mg PO Q8H:PRN bladder spasms
3. Tamsulosin 0.4 mg PO QHS
4. Phenazopyridine 200 mg PO Q8H:PRN bladder discomfort
5. Docusate Sodium 100 mg PO BID
6. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. amLODIPine 2.5 mg PO DAILY
3. Docusate Sodium 100 mg PO BID
4. Oxybutynin 5 mg PO Q8H:PRN bladder spasms
5. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain - Severe
6. Phenazopyridine 200 mg PO Q8H:PRN bladder discomfort
7. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home
Discharge Diagnosis:
bilateral ureteral stones
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen pelvis
INDICATION: ___ with bilateral lower abd discomfort, recent KUB with L sided
___, concern over bilateral stonesNO_PO contrast// eval for stones
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
with patient in prone position 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 4.7 s, 51.4 cm; CTDIvol = 10.8 mGy (Body) DLP = 554.3
mGy-cm.
Total DLP (Body) = 554 mGy-cm.
COMPARISON: CT abdomen pelvis ___.
FINDINGS:
LOWER CHEST: There is mild bibasilar atelectasis. There is no evidence of
pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no evidence
of focal renal lesions within the limitations of an unenhanced scan. There is
mild bilateral hydronephrosis. There are bilateral punctate hyperdensities
consistent with nephrolithiasis, the largest in the right kidney measuring 3
mm in the right interpolar region (2; 33) and the largest in the left kidney
in the interpolar region measuring 4 mm (2; 33). An obstructing 6 mm ___ in
the left proximal to mid ureter is noted (2; 51). A possible obstructing
___ is noted in the right distal ureter measuring 3 mm (2; 76). There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber and wall thickness throughout. Diverticulosis of the sigmoid
colon is noted, without evidence of wall thickening and fat stranding. The
appendix is normal.
PELVIS: The urinary bladder is unremarkable. There is no free fluid in the
pelvis.
REPRODUCTIVE ORGANS: Large fibroid uterus, the largest measuring 7.7 x 7.4 x
8.0 cm extending from the anterior lower uterine segment. Interval removal of
IUD.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
There is evidence of bilateral sacroiliitis with sclerosis of the ileum and
widening of bilateral SI joints.
SOFT TISSUES: An umbilical hernia containing fat is noted.
IMPRESSION:
1. Mild bilateral hydronephrosis with bilateral kidney stones and bilateral
ureteral stones, 6 mm in the left proximal ureter and 3 mm in the right distal
ureter.
2. Diverticulosis without evidence of diverticulitis.
3. Bilateral sacroiliitis.
4. Large fibroid uterus.
NOTIFICATION: The findings were discussed with Dr. ___. by ___,
M.D. on the telephone on ___ at 4:03 pm, 15 minutes after discovery of
the findings.
Radiology Report
INDICATION: History: ___ with bilateral ureteral stones.// Visualize
bilateral ureteral stones on KUB
COMPARISON: Same-day CT of the abdomen and pelvis
FINDINGS:
Single upright view of the abdomen and pelvis provided. The known ureteral
stones are not clearly visualized on radiograph. Bowel gas pattern is
unremarkable.
IMPRESSION:
As above.
Radiology Report
INDICATION: ___ year old woman with bilateral ureteral stones// Visualize
ureteral stones
TECHNIQUE: Supine abdominal radiograph was obtained.
COMPARISON: Upright abdominal radiograph and CT abdomen and pelvis dated ___.
FINDINGS:
Compared to the recent CT dated ___, no radiopaque densities are
seen within the left kidney or expected position of the left ureter. On the
right side, an 8 mm radio opaque density is seen projecting just lateral to
the vertebral body at the level of L2, which likely represents a partially
visualized transverse process as there is no renal stone correlate on recent
CT. No other right-sided radiopaque densities are noted.
There are no abnormally dilated loops of large or small bowel. Supine
assessment limits detection for free air; there is no gross pneumoperitoneum.
Osseous structures are unremarkable.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Compared to the recent CT dated ___, no radiopaque densities are
seen within the left kidney or expected position of the left ureter. On the
right side, an 8 mm radio opaque density is seen projecting just lateral to
the vertebral body at the level of L2, which likely represents a partially
visualized transverse process as there is no renal stone correlate on recent
CT. No other right-sided radiopaque densities are noted.
Radiology Report
EXAMINATION: COMPLETE GU U.S. (BLADDER AND RENAL)
INDICATION: ___ woman with bilateral obstructing ureteral stones;
Visualize bilateral ureteral stones or hydronephrosis.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys and
bladder were obtained.
COMPARISON: CT urogram dated ___.
FINDINGS:
The right kidney measures 10.2 cm. The left kidney measures 11.5 cm. A 5 mm
right lower pole renal stone is similar the prior exam. Right renal pelvis
dilation without caliceal dilation is similar to prior CT. Mild fullness of
the right proximal ureter is also unchanged. Echogenic focus in the left
lower renal pole may correspond to the 4 mm nonobstructing stone seen on prior
CT. Left hydronephrosis is mild, improved. No masses bilaterally. Normal
cortical echogenicity and corticomedullary differentiation are seen
bilaterally.
The bladder is normal in appearance. Bilateral ureteral jets are
demonstrated.
Prevoid volume of the bladder is 71 cc.
Postvoid volume of the bladder is 7.5 cc.
IMPRESSION:
1. Persistent right lower pole 5-mm stone with mild dilation of the renal
pelvis and fullness of the proximal ureter, similar to prior CT.
2. Mild left hydronephrosis, improved from prior CT allowing for difference
in technique.
3. Bilateral ureteral jets visualized.
4. Post void residual of 7.5 cc.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: L Flank pain
Diagnosed with Hydronephrosis with renal and ureteral calculous obstruction
temperature: 97.1
heartrate: 72.0
resprate: 18.0
o2sat: 98.0
sbp: 177.0
dbp: 88.0
level of pain: 10
level of acuity: 3.0 | Patient found to have bilateral ureteral stones in ER on
___. As patient was making urine, renal function was at
baseline, and there were no occult signs of infection, she was
observed overnight on ___ to see if she would be able to pass
as least one of these stones. Repeat labs on HD2 remained
stable. Repeat renal US on HD2 showed persistent mild
hydronephrosis on both sides. Patient was additionally still
having intermittent flank pain, and was thus taken to OR on ___
for cystoscopy and placement of bilateral ureteral stents.
Procedure was uncomplicated and patient was transferred to the
recovery area in stable condition. She was observed in the
recovery area and was discharged after voiding. At the time of
discharge, she was ambulating on her own, tolerating diet, pain
was controlled with oral meds, and was voiding on her own. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
Central line placement
A-line
History of Present Illness:
Mrs. ___ is a ___ female with alcohol-induced
cirrhosis, decompensated with ascites, history of celiac disease
who presents with 2 days of worsening constant non-radiating RUQ
and epigastric pain. She reports her ascites has been well
controlled on direutics and she does not have any history of
SBP. Other associated symptoms include nausea, 10 episdoes of
small amount vomiting (bilious but non-bloody), 10 episodes of
loose bowel movements which has been improving since this
morning. Patient denies any hematemesis or melena. She reports
feeling very dehydrated and has not had much po intake in the
past two days. She denies any UTI symptoms. She denies any chest
pain, coughing. She denies any recent alcohol intake. She
reports being complaint with her celiac diet of no gluten. She
reports feeling chills/night sweats but did not measure
temperature.
Of note patient had injection to her right shoulder on ___ but
no joint swelling or pain.
In the ED her initial vitals: 97.8 117 109/70 16 96%. Labs
were notable for WBC of 20 with 85% PMN and 6% bands. Cr 1.6 up
from baseline Cr of 1. ALT/AST 79/86, Alk phos 235, T- bili 4.2.
UA negative. Lactate was 7.5 which improved to 5.2 after 3L
IVF. RUQ ultrasound showed cholelithiasis, no evidence of acute
cholecystitis. CT abdomen showed new, small partially occlusive
thrombus in the main portal vein just beyond the confluence new
since ___. Hepatology was consulted who recommended
broad spectrum antibiotics. Patient was started on cefepime and
flagyl. She received 3L IVF and 25g IV albumin. She did not
have paracetnesis as no tapable ascites was found.
On arrival to the MICU, vitals: 106 ___ 95%. Patient
reports improvement in nausea, vomiting, diarrhea. Reports
abdominal pain is controlled on narcotics.
Past Medical History:
- Right shoulder rotator cuff tendinitis
- Alcoholic Cirrhosis: Acute decompensation ___ slow
recovery requiring nutrition supplementation, prednisone. ___
flare of hep with hospitalization
- Celiac
___ - egd outside; 45 lb weight loss; elevated LFTs.
Consultation ___ Loffler; ___ diarrhea admission-celiac
antibodies normalized. Thought to be secondary to profound
response to infection (___) - trial of Entocort helpful
- Anemia
- Depression
- s/p appendectomy
- History MSSA bacteremia with normal TTE ___
Social History:
___
Family History:
___, mother and 2 brothers have insulin dependent diabetes.
Mother died 6 months ago. Father died of heart disease ___
years ago, suffered from recurring GI problems suggestive of
celiac dz prior to that.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- 98.6 100 100/60 95%RA
General: appears well in no acute distress
HEENT: Mild icteric sclera, very dry mucous membranes
Neck: Supple, no JVD, No LAD
CV: Tcahycardic, nl s1, s2 no murmurs
Lungs: Unlabored breathing, clear to auscultation bilaterally
Abdomen: Soft, positive bowel sounds, tenderness to palpation in
the epigastric area and RUQ area, no rebound or guarding, no
appreciateble ascites
Ext: Warm and well perfused, no murmurs
Neuro: Alert and oriented x3, appropriately conversive,
non-focal
DISCHARGE PHYSICAL EXAM:
VS: 98.2 (99.1) 120/75 (96-136/60-95) 80 (77-93) 18 97% RA
General: Appears well in no acute distress
HEENT: Anicteric sclera
Neck: Supple, no JVD, No LAD
CV: RRR, nl s1, s2 no murmurs
Lungs: Unlabored breathing, clear to auscultation bilaterally
Abdomen: Soft, positive bowel sounds, minimal distension,
non-tender
Ext: trace ankle edema
Neuro: Alert and oriented x3, appropriately conversive,
non-focal
Pertinent Results:
ADMISSION LABS:
===============
___ 10:12AM LACTATE-5.2*
___ 09:40AM URINE HOURS-RANDOM
___ 09:40AM URINE UCG-NEGATIVE
___ 09:40AM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 09:40AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 08:10AM ___ COMMENTS-GREEN TOP
___ 08:10AM LACTATE-7.5*
___ 08:00AM GLUCOSE-106* UREA N-19 CREAT-1.6* SODIUM-139
POTASSIUM-3.2* CHLORIDE-100 TOTAL CO2-19* ANION GAP-23*
___ 08:00AM ALT(SGPT)-79* AST(SGOT)-86* ALK PHOS-235* TOT
BILI-4.2*
___ 08:00AM LIPASE-14
___ 08:00AM ALBUMIN-3.5
___ 08:00AM WBC-20.7*# RBC-4.15* HGB-12.0 HCT-36.0 MCV-87
MCH-28.9 MCHC-33.4 RDW-22.0*
___ 08:00AM NEUTS-85* BANDS-6* LYMPHS-3* MONOS-6 EOS-0
BASOS-0 ___ MYELOS-0
___ 08:00AM HYPOCHROM-NORMAL ANISOCYT-2+ POIKILOCY-NORMAL
MACROCYT-NORMAL MICROCYT-2+ POLYCHROM-NORMAL
___ 08:00AM PLT SMR-NORMAL PLT COUNT-223
___ 08:00AM ___ PTT-35.8 ___
DISCHARGE LABS:
===============
___ 05:47AM BLOOD WBC-8.5 RBC-3.22* Hgb-9.2* Hct-28.0*
MCV-87 MCH-28.7 MCHC-32.9 RDW-21.8* Plt ___
___ 05:47AM BLOOD ___ PTT-41.8* ___
___ 05:47AM BLOOD Glucose-97 UreaN-12 Creat-0.8 Na-139
K-3.7 Cl-108 HCO3-23 AnGap-12
___ 05:47AM BLOOD ALT-28 AST-27 LD(LDH)-159 AlkPhos-146*
TotBili-1.8*
___ 05:47AM BLOOD Albumin-3.1* Calcium-8.7 Phos-2.5* Mg-1.9
___ 04:30AM BLOOD Lactate-1.4
MICRO:
=====
_________________________________________________________
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
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING:
========
___ RUQ ULTRASOUND:
IMPRESSION: 1. Cholelithiasis, no evidence of acute
cholecystitis.
2. Patent portal veins with appropriate directionality of flow
and waveforms. 3. Moderate ascites.
___ CT ABDOMEN/PELVIS: IMPRESSION: 1. Small partially
occlusive thrombus in main portal vein, new since ___.
2. Moderate volume ascites. Although no definite CT findings,
SBP cannot be excluded. 3. Cholelithiasis.
___ MRCP: IMPRESSION: 1. Cholelithiasis. 2. Non occlusive
thrombus within the main portal vein. 3. Cirrhosis with evidence
of portal hypertension and ascites.
___ ERCP: Normal biliary tree with prominent cystic duct of
unknown significance. No stones/sludge was found and therefore
no sphincterotomy was performed Otherwise normal ercp to third
part of the duodenum
___ ___: IMPRESSION: No deep vein thrombosis in the right
lower extremity. Small knee joint
effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Furosemide 60 mg PO DAILY
3. Spironolactone 100 mg PO DAILY
4. Omeprazole 20 mg PO DAILY
5. Mirtazapine 15 mg PO HS
6. Multivitamins 1 TAB PO DAILY
7. Vitamin D 800 UNIT PO DAILY
8. Calcium Carbonate 500 mg PO BID
Discharge Medications:
1. Calcium Carbonate 500 mg PO BID
2. FoLIC Acid 1 mg PO DAILY
3. Furosemide 60 mg PO DAILY
4. Mirtazapine 15 mg PO HS
5. Multivitamins 1 TAB PO DAILY
6. Omeprazole 20 mg PO DAILY
7. Spironolactone 100 mg PO DAILY
8. Vitamin D 800 UNIT PO DAILY
9. Ciprofloxacin HCl 500 mg PO Q12H
Continue until ___ to complete a two week antibiotic course.
RX *ciprofloxacin [Cipro] 500 mg 1 tablet(s) by mouth Twice
daily Disp #*14 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Klebsiella Bacteremia
Secondary: Cirrhosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ woman with pain. Rule out ascites, thrombosis, stones.
COMPARISON: Prior abdominal/pelvic CT from ___.
TECHNIQUE: Grayscale and Doppler ultrasound images of the upper abdomen were
obtained.
FINDINGS: The liver demonstrates a coarsened echotexture, consistent with
known cirrhosis. There is no evidence of focal hepatic masses. A 1.6 cm
gallstone is seen in the neck of the gallbladder. However, there is no
evidence of gallbladder wall thickening or pericholecystic fluid to suggest
acute cholecystitis. The common bile duct measures 8 mm. The spleen measures
12.6 cm and demonstrates homogeneous echotexture. Representative image of the
right kidney is within normal limits. There is moderate amount of
intra-abdominal ascites, with perihepatic fluid. The main, left and right
portal veins are patent with appropriate directionality of flow. Visualized
portions of the IVC appear normal.
IMPRESSION:
1. Cholelithiasis, no evidence of acute cholecystitis.
2. Patent portal veins with appropriate directionality of flow and waveforms.
3. Moderate ascites.
Radiology Report
HISTORY: ___ year old woman with epigastric/right upper quadrant pain, meets
sepsis criteria. Rule out abscess.
COMPARISON: Prior upper abdominal ultrasound from ___ and
abdominal/pelvic CT from ___.
TECHNIQUE: Axial MDCT images were obtained through the abdomen and pelvis
after the uneventful administration of intravenous contrast. Sagittal and
coronal reformats were generated.
FINDINGS:
Lung bases demonstrate subsegmental atelectasis. There is no pleural or
pericardial effusion.
CT ABDOMEN: The liver is somewhat nodular and demonstrates enlargement of the
left hepatic lobe, consistent with patient's known history of cirrhosis. No
focal hepatic lesions are identified. There is no intra or extrahepatic
biliary duct dilatation. There is a new small partially occlusive thrombus
residing within the main portal vein, just beyond the confluence of the
splenic and superior mesenteric vein (02:31). A 4 mm calcified gallstone is
seen within the neck of the gallbladder. The gallbladder is otherwise
unremarkable. The pancreas and adrenal glands are within normal limits. The
spleen is not particularly enlarged. Kidneys enhance and excrete contrast
symmetrically with no evidence of hydronephrosis or masses.
The stomach is collapsed. There is moderate amount of intra-abdominal
ascites. There is no evidence of bowel obstruction or bowel wall
abnormalities. Varices are present with redemonstration of paraesophageal
varices. The abdominal aorta is of normal caliber. The celiac axis, SMA,
bilateral renal arteries and ___ are patent. Mild atherosclerotic
calcification is noted at the left common iliac artery. There is no free air.
CT PELVIS: There is moderate amount of pelvic free fluid. The urinary
bladder and terminal ureters are within normal limits. The uterus is within
normal limits.
OSSEOUS STRUCTURES: No blastic or lytic lesion suspicious for malignancy is
present.
IMPRESSION:
1. Small partially occlusive thrombus in main portal vein, new since ___.
2. Moderate volume ascites. Although no definite CT findings, SBP cannot be
excluded.
3. Cholelithiasis.
Radiology Report
HISTORY: Shortness of breath and sepsis.
FINDINGS: In comparison with the study of ___, there again are low lung
volumes, which result in crowding of bronchovascular structures. Bibasilar
opacifications most likely represent atelectasis. However, in the appropriate
clinical setting, developing pneumonia would have to be considered.
Radiology Report
HISTORY: ___ woman with GNR probable sepsis and concern for posterior
source.
TECHNIQUE: Multiplanar T1 and T2 weighted images were acquired on a 1.5 tesla
magnet, including dynamic 3D imaging prior to, during, and after the
administration of 7 mL of Gadavist gadolinium base contrast. Oral contrast
was also administered for the exam.
COMPARISON: CT from ___. Ultrasound from ___.
FINDINGS:
The liver is nodular in appearance consistent with cirrhosis. There is a
markedly heterogeneous enhancement pattern to the liver. No focal hepatic
mass is identified. The spleen, pancreas, adrenal glands, and kidneys are
normal. The gallbladder appears distended. Small stones are noted in the
region of the gallbladder neck. There is no evidence of wall thickening.
There is no evidence of intra or extrahepatic biliary ductal dilatation. No
evidence of biliary stricture or filling defect.
The visualized bowel loops and mesentery are unremarkable without evidence of
wall thickening or findings to suggest obstruction. There is no significant
mesenteric or retroperitoneal lymphadenopathy. There is a small to moderate
amount of ascites in the upper abdomen. The osseous structures are
unremarkable. As seen on the previous CT there is a nonocclusive thrombus
within the main portal vein. The remainder of the portal and mesenteric
vessels appear patent. Esophageal varices are present suggesting portal
hypertension.
IMPRESSION:
1. Cholelithiasis.
2. Non occlusive thrombus within the main portal vein.
3. Cirrhosis with evidence of portal hypertension and ascites.
Radiology Report
HISTORY: Right lower extremity swelling.
COMPARISON: None.
FINDINGS:
Grayscale and color Doppler ultrasonography of the bilateral common femoral
veins as well as the right femoral, popliteal, posterior tibial, and peroneal
veins were performed. All imaged vessels demonstrated normal compressibility,
flow, and augmentation. There is a small simple and suprapatellar knee joint
effusion.
IMPRESSION:
No deep vein thrombosis in the right lower extremity. Small knee joint
effusion.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with ABDOMINAL PAIN RUQ, PORTAL VEIN THROMBOSIS
temperature: 97.8
heartrate: 117.0
resprate: 16.0
o2sat: 96.0
sbp: 109.0
dbp: 70.0
level of pain: 10
level of acuity: 3.0 | ___ female with alcohol-induced cirrhosis, decompensated
with ascites, history of celiac disease presented with 2 days of
worsening RUQ and epigastric pain and admitted to MICU for
hypotension and concern for sepsis.
# Severe Sepsis: Patient met ___ SIRS criteria including WBC of
20 with 6% bands which along with ___ and elevated lactate on
admission suggested severe sepsis. Her blood culture grew GNR
bacteremia. The exact source for infection remained unclear. RUQ
ultrasound and CT abdomen did not reveal any sources. However
given localized RUQ pain there was increased suspicion for
biliary source. Patient also had symptoms of gastroenteritis
prior to admission which may suggest gut translocation. She was
initially hypotensive in the ED and in the MICU and received
total of 6L of IVF and 25 g of albumin with response in her
blood pressure. She was started on cefepime and flagyl and
showed remarkable improvement in clinical status. Her lactate,
___ and ___ WBC count improved significantly. Blood cultures
grew pan-sensitive klebsiella and surveillance cultures were
negative. Ultimately continued on IV cefepime while in-house and
transitioned to oral cipro on dsicharge to complete a 2 week
course. Underwent MRCP and ERCP without clear evidence of
billiary pathology.
# Portal vein thrombosus - Small, partially occlusive portal
vein thrombosis seens on CT and on MRCP. Decision made not to
anticoagulate in house as it was thought this may have been
related to sepsis/low-flow state and could resovle
spontaneously. Will need repeat imaging to ensure resolution as
an outpatient.
# ___: Most likely pre-renal renal. ATN also in the
differential given episodes of hypotension. Her ___ improved
with IVF.
# Cirrhosis: Alcoholic cirrhosis with history of decompensation
with ascites. No hx of SBP, HE. Her diuretics were held in the
setting of sepsis but restarted on the floor with good effect.
# Depression: Continued mirtazapine |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Oxycodone / Tramadol / Doxycycline / naproxen /
morphine / Nabumetone
Attending: ___
Chief Complaint:
dysuria, polyuria
Major Surgical or Invasive Procedure:
Endoscopy ___
History of Present Illness:
___ with autoimmune hepatitis c/b cirrhosis with known grade
one varices and portal hypertensive gastropathy, h/o GI bleeding
and multifactorial anemia who presents with polyuria found to
have UTI and acute on chronic anemia.
Reports that she started Lasix in ___ and since then
has had progressively increasing frequency of urination, up to
20 times per day over the last month. She reports that she also
has had some pain and straining with urination recently and is
concerned that she has a UTI. No f/c, back or flank pain. Pt
also reports that she has h/o overactive bladder.
Over the past ___ days, she noted some dysuria, felt feverish
(did not measure temperature) and "felt lousy". She has had
similar symptoms in the past especially with dysuria that were
not UTIs, so she was hesitant to come in, until she started not
feeling like herself.
Also reports recent black stools but was told this was due to
her iron therapy.
She was recently hospitalized from ___, for anemia ___ to
portal hypertensive gastropathy. Active bleeding was treated
with argon-plasma coagulator at that time.
Initial vital signs in the ED were T100.3, HR 102, BP 125/65,
RR 16, Spo2 99% RA.
Exam was notable for no CVA tenderness, dark brown/black stool
that was guaiac positive.
Labs showed: WBC 3.4, hemoglobin 6.8, plt 60. INR 1.1, Chem
panel WNL. LFTS notable for normal transaminases/bilirubin, AP
143 and Alb 2.9. UA with large leuks, large blood, 24 RBCs, >182
WBCs, many bacteria, but 16 epithelial cells.
Hepatology was consulted who recommended octreotide and PPI.
She was given 1u pBCs, 1g CTX, 1l NS, pantoprazole 40mg IV and
octreotide 50mcg.
Vitals prior to transfer:
T98.5, HR99, BP125/47, RR18, Spo298% RA.
She was admitted to medicine for management of GI bleeding and
acute on chronic anemia.
On the floor, admits that he has been getting winded with short
distances, and intermittent epigastric and LLQ pain with
associated abdominal bloating. She is eating and drinking well,
denies nausea, vomiting, hematochezia, changes in sleep,
episodes of confusion, chest pain, dizziness or lightheadedness.
Of note, her husband died recently (___). She states that
she is "getting on", and that his death was not unexpected.
Funeral arrangements are for some time next week.
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, hematuria.
Past Medical History:
- Cirrhosis due to autoimmune hepatitis (dx ___
- Rheumatoid arthritis: RA - diagnosed in her ___ previously on
MTX, sulfasalazine, currently on hydroxychloroquine
- Hypertension
- History of GI Bleed from CMV colitis (s/p 6 weeks valacyclovir
in ___
- GAVE
- Diverticulosis
- C. diff colitis: ___
- Status post intracranial hemorrhage (left centrum semiovale
and a right parietal posterior frontal hemorrhage) ___
followed by serial MRI; no definite cause identified
- History of DVT status post IVC filter placement
- Iron deficiency Anemia
- Recurrent UTIs
- Left foot-drop
- Breast Cancer s/p lumpectomy, radiation therapy, and chemo
(cyclophosphamide, methotrexate, and fluorouracil)
- Hx Colonic ulcer from fecal impaction
- Diverticulosis through entire colon ___
- Polyp in transverse colon ___
- R iliac crest fluid collection: admitted ___ for this,
thought seroma related to ___ R hip replacement
Past Surgical History:
-Status post hip fracture, hip replacement at the ___ on
___,
-Status post hysterectomy
-___ total right hip replacement
-___ IVC filter placement
-___ open reduction internal fixation of acetabular
fracture
-___ I&D W/CLOSURE LEFT KNEE INCISION DEHISCENCE
-___ left total knee replacement c/b MRSA infection
Social History:
___
Family History:
Her mother had rheumatic fever and died at age ___. Her father
had heart disease in his ___. Her paternal grandfather had
diabetes and she has several maternal aunts with breast cancer.
Physical Exam:
ADMISSION EXAM
Vital Signs: T98.6, BP 139/58, HR 103, RR 20, SpO2 98%RA.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx with 1cm flesh colored
nodule on the palate, EOMI, PERRL, neck supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, systolic murmur
heard best in the aortic position without radiation to the
carotids
Lungs: Clear to auscultation bilaterally, although air movement
was somewhat poor
Abdomen: Soft, TTP in epigastrium, LUQ with palpable spleen
tip, normal bowel sounds; no obvious fluid wave
GU: No foley
Ext: Warm, well perfused, 2+ pulses, trace edema to the
mid-shins. Ulnar deviation at the MCP joints bilaterally.
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, no asterixis.
DISCHARGE EXAM
Vitals: 98.4 134-143/64-66 ___ 20 96RA
General: deformed joints, no distress
HEENT: no scleral icterus
Heart: RRR no murmurs
Lungs: CTAB
Abdomen: soft, slightly TTP diffusely. No rebound or guarding
Extremities: 1+ pitting edema up to knees
Neuro: no asterixis, able to say days of the week backwards
Skin: no lesions appreciated
Pertinent Results:
ADMISSION LABS
___ 05:15PM BLOOD WBC-3.4* RBC-2.33*# Hgb-6.8*# Hct-22.5*#
MCV-97 MCH-29.2 MCHC-30.2* RDW-17.6* RDWSD-60.9* Plt Ct-60*
___ 05:15PM BLOOD Neuts-62.9 Lymphs-18.1* Monos-16.0*
Eos-2.1 Baso-0.6 Im ___ AbsNeut-2.12# AbsLymp-0.61*
AbsMono-0.54 AbsEos-0.07 AbsBaso-0.02
___ 07:01PM BLOOD ___ PTT-34.0 ___
___ 05:15PM BLOOD Glucose-154* UreaN-18 Creat-0.7 Na-139
K-3.7 Cl-105 HCO3-29 AnGap-9
___ 05:15PM BLOOD ALT-20 AST-36 AlkPhos-143* TotBili-0.9
___ 05:15PM BLOOD Albumin-2.9* Calcium-8.7 Phos-3.1 Mg-1.6
DISCHARGE LABS
___ 04:55AM BLOOD WBC-3.3* RBC-3.04* Hgb-8.8* Hct-29.0*
MCV-95 MCH-28.9 MCHC-30.3* RDW-17.9* RDWSD-60.9* Plt Ct-64*
___ 04:55AM BLOOD ___ PTT-31.4 ___
___ 04:55AM BLOOD Glucose-104* UreaN-12 Creat-0.7 Na-137
K-4.0 Cl-104 HCO3-24 AnGap-13
___ 04:55AM BLOOD ALT-12 AST-30 AlkPhos-122* TotBili-1.4
___ 04:55AM BLOOD Calcium-7.7* Phos-3.2 Mg-2.0
MICRO
___ 5:58 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
PRESUMPTIVE IDENTIFICATION.
Cefazolin interpretative criteria are based on a dosage
regimen of
2g every 8h.
PREDOMINATING ORGANISM INTERPRET RESULTS WITH CAUTION.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ <=2 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
IMAGING
RUQ US ___. Liver contains calcified granulomas, but is otherwise
unremarkable.
2. Patent hepatic vasculature.
3. Splenomegaly.
4. No ascites.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO BID:PRN pain
2. Docusate Sodium 100 mg PO BID:PRN constipation
3. Ferrous Sulfate 325 mg PO DAILY
4. Furosemide 20 mg PO DAILY
5. Hydroxychloroquine Sulfate 200 mg PO BID
6. Polyethylene Glycol 17 g PO DAILY:PRN constipation
7. Simethicone 120 mg PO QID:PRN gas
8. Ursodiol 600 mg PO BID
9. Vitamin D ___ UNIT PO DAILY
10. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit oral TID
11. Pantoprazole 40 mg PO Q12H
12. Bethanechol 10 mg PO TID
Discharge Medications:
1. Acetaminophen 1000 mg PO BID:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Hydroxychloroquine Sulfate 200 mg PO BID
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Simethicone 120 mg PO QID:PRN gas
6. Ursodiol 600 mg PO BID
7. Vitamin D ___ UNIT PO DAILY
8. Ciprofloxacin HCl 500 mg PO Q12H Duration: 3 Days
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every 12 hours
Disp #*5 Tablet Refills:*0
9. Calcium Citrate + D (calcium citrate-vitamin D3) 315-200
mg-unit oral TID
10. Ferrous Sulfate 325 mg PO DAILY
11. Furosemide 20 mg PO DAILY
12. Pantoprazole 40 mg PO Q12H
13. Bethanechol 10 mg PO TID
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Complicated urinary tract infection
GAVE s/p thermal therapy
Secondary:
Autoimmune cirrhosis
Rheumatoid arthritis
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: DUPLEX DOPP ABD/PEL
INDICATION: Assess for ascites, portal vein thrombus
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: CT abdomen/ pelvis ___
FINDINGS:
Liver: The hepatic parenchyma contains a few calcified granulomas, but the
echotexture is otherwise within normal limits. No focal liver lesions are
identified. There is no ascites.
Bile ducts: There is no intrahepatic biliary ductal dilation. The common
hepatic duct measures 6 mm.
Gallbladder: The gallbladder appears within normal limits, without stones,
abnormal wall thickening, or edema.
Pancreas: The imaged portion of the pancreas appears within normal limits,
with portions of the pancreatic tail obscured by overlying bowel gas.
Spleen: The spleen demonstrates normal echotexture, and measures 14.9 cm.
Kidneys: There is a 2.8 x 2.0 cm simple cyst in the interpolar region of the
left kidney.
Doppler evaluation:
The main portal vein is patent, with flow in the appropriate direction.
Main portal vein velocity is 26 cm/sec.
Right and left portal veins are patent, with antegrade flow.
The main hepatic artery is patent, with appropriate waveform.
Right, middle and left hepatic veins are patent, with appropriate waveforms.
Splenic vein and superior mesenteric vein are patent, with antegrade flow.
IMPRESSION:
1. Liver contains calcified granulomas, but is otherwise unremarkable.
2. Patent hepatic vasculature.
3. Splenomegaly.
4. No ascites.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Polyuria
Diagnosed with Urinary tract infection, site not specified, Gastrointestinal hemorrhage, unspecified
temperature: 100.3
heartrate: 102.0
resprate: 16.0
o2sat: 99.0
sbp: 125.0
dbp: 65.0
level of pain: 0
level of acuity: 3.0 | ___ yo F with history of autoimmune hepatitis c/b cirrhosis,
Childs A c/b GI bleeding (last EGD ___ pt has known grade I
varices and portal hypertensive gastropathy vs GAVE causing
significant GI bleed with Hgb dropping to 4 ___ who
presents with urinary frequency and dysuria and found to be
anemic Hgb 6.8. EGD performed showed GAVE which was treated
with APC. Found to have UTI so treated with ciprofloxacin. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
nausea, emesis, dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ man with history notable for
hypertension, hyperlipidemia, and prostate cancer transferred
from ___ after presenting with nausea, vomiting, transient
speech
disturbance, and hypertension, found to have a small right
cerebellar IPH. History obtained with assistance of ___ telephone interpreter no. ___.
Mr. ___ reports abrupt onset of dizziness today at
approximately 15:00 while changing to his street clothes in the
locker room at work. He describes the sensation as
"unsteadiness"
on his feet rather than vertigo or lightheadedness. After some
time, he then developed nausea and an episode of small-volume
emesis, prompting referral to the ___ ED. Per the ___ ED
records,
Mr. ___ was also noted to have a transient episode of
'slurred' speech at that time. He otherwise denies headache or
vision change. On arrival in the CHA ED, Mr. ___ was noted to
be hypertensive to 233/107, prompting administration of
hydralazine and subsequently a nitroglycerin infusion, with
systolic blood pressures ultimately stabilizing below 150 over
the course of about two hours. A non-contrast head CT was
performed, demonstrating a small cerebellar IPH; laboratory
testing was otherwise unrevealing.
Mr. ___ denies a similar prior history of dizziness, but does
recall an unusual episode of palpitations and malaise on ___
that resolved without intervention. He reports taking two
medications, but is unable to recall their names; on prompting,
he recalled one medication as aspirin, but did not identify the
other. He otherwise reports adherence to his medications.
On review of systems, aside from the above, Mr. ___ denies
recent headaches, vision change, diplopia, hearing change,
dysarthria, dysphagia, focal weakness, paresthesiae, bowel or
bladder incontinence, gait disturbance, fevers, chills, cough,
dyspnea, chest discomfort, abdominal pain, or changes in bowel
or
bladder habits.
Past Medical History:
HTN
HLD
Prostate cancer (per ___ records)
Social History:
___
Family History:
Denies family history of stroke or other neurologic disorders
Physical Exam:
Admission exam:
Vitals: T: 97.7 HR: 60 BP: 135/67 RR: 24 SpO2: 91% RA
General: NAD
HEENT: NCAT, neck supple
___: RRR
Pulmonary: No tachypnea or increased WOB
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Somnolent but rousable to voice, having some
difficulty following examination. Oriented to "hospital" but
identified BWH on multiple choice; oriented to time. Speech
fluent in ___. Naming intact to high- and
low-frequency objects. No apparent hemineglect. Follows both
midline and appendicular commands.
- Cranial Nerves: PERRL 3->2 mm ___. VF full to number counting.
EOMI, no nystagmus; normal saccades. V1-V3 without deficits to
light touch bilaterally. Very subtle L NLFF. Hearing intact to
conversationt. Palate elevation symmetric. Trapezius strength
___
bilaterally. Tongue midline.
- Motor: No pronator drift, no adventitious movements.
[Delt][Bic][Tri][ECR][FEx][FFl][IP][Quad][Ham][TA]
L 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5
- Reflexes:
[Bic] [Tri] [___] [Quad] [Gastroc]
L 1+ 1+ 1+ 1+ 0+
R 1+ 1+ 1+ 1+ 0+
Plantar response flexor on right and mute on left.
- Sensory: No deficits to light touch or pinprick bilaterally.
No
extinction to DSS.
- Coordination: No dysmetria with finger-to-nose or heel-to-shin
testing bilaterally. Subtle dysdiadochokinesia on left, no
dysmetria with normal cadence on tapping of finger crease.
Unable
to cooperate with mirroring. No clear truncal ataxia.
- Gait: Wide-based, markedly unsteady.
====================================
Discharge exam:
General: NAD
HEENT: NCAT, neck supple
___: ext WWP
Pulmonary: No tachypnea or increased WOB
Abdomen: Soft, NT, ND
Extremities: Warm, no edema
Neurologic Examination:
- Mental status:Awake, alert, answers questions appropriately.
Follows midline and appendicular commands
- Cranial Nerves: PERRL. restricted upgaze and restricted
abduction bilaterally. V1-V3 without deficits to
light touch bilaterally. face symmetric at rest and with
activation. Hearing intact to
conversation. Palate elevation symmetric. Trapezius strength ___
bilaterally. Tongue midline.
- Motor: No pronator drift.
[Delt][Bic][Tri][ECR][FEx][FFl][IP][Quad][Ham][TA]
L 5 5 5 5 5 5 5 5 5 5
R 5 5 5 5 5 5 5 5 5 5
- Reflexes:
deferred
- Sensory: grossly intact to light touch in all 4 extremities
- Coordination: Dysmetria with FNF in RUE slightly improved. No
dysmetria in LUE. no dysmetria HTS bilaterally. No clear truncal
ataxia.
- Gait: fairly steady walking from bathroom though not fully
assessed
Pertinent Results:
___ 10:30AM URINE HOURS-RANDOM
___ 10:30AM URINE UHOLD-HOLD
___ 10:30AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 10:30AM URINE BLOOD-MOD* NITRITE-NEG PROTEIN-30*
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 10:30AM URINE RBC-142* WBC-20* BACTERIA-FEW*
YEAST-NONE EPI-0 TRANS EPI-<1
___ 10:30AM URINE MUCOUS-RARE*
___ 05:25AM GLUCOSE-111* UREA N-12 CREAT-1.1 SODIUM-143
POTASSIUM-4.5 CHLORIDE-105 TOTAL CO2-23 ANION GAP-15
___ 05:25AM CK-MB-10 cTropnT-0.01
___ 05:25AM CALCIUM-9.5 PHOSPHATE-3.0 MAGNESIUM-1.7
___ 05:25AM WBC-9.3 RBC-4.63 HGB-12.4* HCT-40.1 MCV-87
MCH-26.8 MCHC-30.9* RDW-13.8 RDWSD-43.1
___ 05:25AM PLT COUNT-156
___ 08:10PM GLUCOSE-141* UREA N-13 CREAT-1.3* SODIUM-140
POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-24 ANION GAP-11
___ 08:10PM estGFR-Using this
___ 08:10PM ALT(SGPT)-12 AST(SGOT)-17 ALK PHOS-99 TOT
BILI-0.4
___ 08:10PM cTropnT-<0.01
___ 08:10PM ALBUMIN-3.9
___ 08:10PM TSH-2.1
___ 08:10PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
tricyclic-NEG
___ 08:10PM WBC-9.8 RBC-4.52* HGB-12.4* HCT-39.4* MCV-87
MCH-27.4 MCHC-31.5* RDW-13.4 RDWSD-42.5
___ 08:10PM NEUTS-87.1* LYMPHS-9.7* MONOS-2.5* EOS-0.1*
BASOS-0.3 IM ___ AbsNeut-8.54* AbsLymp-0.95* AbsMono-0.25
AbsEos-0.01* AbsBaso-0.03
___ 08:10PM PLT COUNT-163
___ 08:10PM ___ PTT-26.0 ___
CTA head and neck
IMPRESSION:
1. 1.3 cm intraparenchymal hemorrhage of the right
posterosuperior cerebellar
lobe, stable compared to the prior study 5 hours earlier. There
is possible
mild mass effect on the adjacent fourth ventricle which remains
patent. No
midline shift or hydrocephalus.
2. No CT evidence of mass or vascular abnormality at the area of
intraparenchymal hemorrhage.
3. No new hemorrhage.
4. Focal nonobstructive stenosis of a 3 mm segment of the
superior division of
the left MCA with distal reconstitution. Diffuse mild
irregularity throughout
the distal left MCA branches.
MRI brain
IMPRESSION:
1. Stable 1.2 cm right cerebellar intraparenchymal hemorrhage
with no evidence
of underlying mass or vascular abnormality. No mass effect or
midline shift.
No evidence of new hemorrhage.
2. Numerous central and peripheral microhemorrhages affecting
the pons and
bilateral cerebral and cerebellar hemispheres, compatible with
hypertensive
microangiopathy.
3. Nonocclusive focal stenosis of the superior division of left
MCA with
distal reconstitution, better evaluated on recent CTA.
4. 6 mm cystic lesion in the left medial pons, likely a chronic
lacunar
infarct.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Atenolol 25 mg PO DAILY
3. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Labetalol 200 mg PO TID
2. Lisinopril 40 mg PO DAILY
3. Phenazopyridine 100 mg PO TID Duration: 3 Days
you should take it for 3 days
4. amLODIPine 10 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Intraparenchymal hemorrhage
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with right cerebellar IPH as well as
encephalopathy following hypertensive emergency// Evaluate for mass/vascular
malformation, PRES
TECHNIQUE: 3 dimensional time-of-flight MRA was performed through the brain.
Sagittal and axial T1 weighted imaging were performed along with diffusion
imaging.
After administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, T2, and T1 technique. Sagittal MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images.
COMPARISON: CT head and CTA head and neck ___
FINDINGS:
MRI BRAIN:
There is no evidence of infarction. Re-demonstrated is a 1.2 cm right
cerebellar intraparenchymal hemorrhage with a surrounding T2 FLAIR
hyperintense rim. Accounting for differences in technique, the lesion appears
unchanged in size when compared to prior CT from ___. No
underlying mass or vascular abnormality is identified. The lesion does not
enhance. There is a 6 x 6 mm T1 hypointense, T2 hyperintense nonenhancing
rounded focus in the left medial pons (11:08, 13:08), likely sequelae of a
prior lacunar infarct. There are multiple scattered microhemorrhages
throughout the bilateral cerebellum, parieto-occipital lobes, pons, left
thalamus, bilateral temporal and frontal lobes, consistent with hypertensive
microangiopathy.
Extensive T2 FLAIR hyperintense foci are scattered throughout the
periventricular and subcortical white matter, which are nonspecific, however
are likely sequelae of age-related chronic microangiopathic ischemic disease.
There is prominence of the ventricles and sulci, likely secondary to
age-related global parenchymal volume loss.
MRA brain: There is focal stenosis of a left superior segment M2 branch with
distal reconstitution, which was also seen on CT head and neck from ___. No evidence obstructive mass or infarct. The intracranial vertebral
and internal carotid arteries and their major branches appear normal without
evidence of stenosis, occlusion, or aneurysm formation.
IMPRESSION:
1. Stable 1.2 cm right cerebellar intraparenchymal hemorrhage with no evidence
of underlying mass or vascular abnormality. No mass effect or midline shift.
No evidence of new hemorrhage.
2. Numerous central and peripheral microhemorrhages affecting the pons and
bilateral cerebral and cerebellar hemispheres, compatible with hypertensive
microangiopathy.
3. Nonocclusive focal stenosis of the superior division of left MCA with
distal reconstitution, better evaluated on recent CTA.
4. 6 mm cystic lesion in the left medial pons, likely a chronic lacunar
infarct.
Gender: M
Race: BLACK/CARIBBEAN ISLAND
Arrive by AMBULANCE
Chief complaint: ICH, Transfer
Diagnosed with Altered mental status, unspecified
temperature: 97.7
heartrate: 60.0
resprate: 24.0
o2sat: 91.0
sbp: 135.0
dbp: 67.0
level of pain: 0
level of acuity: 2.0 | ___ man with history notable for hypertension,
hyperlipidemia, and prostate cancer transferred
from CHA after presenting with nausea, vomiting, transient
speech
disturbance, and hypertension, found to have a small right
cerebellar IPH. Etiology thought to be related to hypertension.
CTH showed left small cerebellar IPH. CTA head and neck showed
left M2 focal stenosis. MRI brain again showed the cerebellar
IPH as well as evidence of small vessel disease, and
hypertensive microbleeds.
He was noted to be hypertensive during admission and was started
on the following medications: lisinopril 40mg daily, Amlodipine
10mg daily and labetalol 200mg TID. His aspirin was stopped
given his intraparenchymal hemorrhage, microbleeds seen on MRI.
Of note, he was found to have a UTI on admission for which he
completed a 3 day course of ceftriaxone. He was seen by ___
who recommended rehab.
He has outpatient stroke follow up scheduled.
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No.
If no, reason why:
2. DVT Prophylaxis administered? (x) Yes - () No. If no, why not
(bleeding risk, hemorrhage, etc.)
3. Smoking cessation counseling given? () Yes - (x) No [reason
(x) non-smoker - () unable to participate]
4. Stroke education (personal modifiable risk factors, how to
activate EMS for stroke, stroke warning signs and symptoms,
prescribed medications, need for followup) given in written
form?
(x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No. If no, why not? (I.e. patient at
baseline functional status) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
Radiation therapy ___
History of Present Illness:
___ w/ hx of renal cell CA met to lungs s/p IL-2 p/w atraumatic
LBP x 2 weeks. Pain is in lumbar area and radiating down b/l
legs to back of thigh. Pain has been worsening, esp last several
days and is worsened by movement. It is associated w/ tingling,
numbness of b/l feet and decreased sensation over buttocks and
posterior thighs. Two days ago, she noticed decreased sensation
in perineal area when wiping. She had plain films of lumbar
spine earlier this week that did not show any lesions. She had
CT abd/pelvis today and had two episodes of stool incontinence
which she attributes to PO contrast. No urinary
incontinence/retention. No fevers or chills.
Initial ED vitals: 98.3 88 120/73 16 99%. Neuro exam notable for
decr rectal tone, sensory loss S2, weakness L5, S1. MRI revealed
1.4 x 1.9 x 2.2 cm metastases in the spinal cord posterior to
the L1 vertebral body. She was given morphine 5mg IV x 1, 1mg po
Ativan, and 10mg IV dex. Morphine helped with pain, and she had
been using Ativan at home for muscle spasm with some relief.
Past Medical History:
Oncologic Hx:
- ___: developed acute onset left flank pain and nausea,
seen
at ___. A CT scan showed a 6 x 8 cm left
exophytic renal mass with perinephric hemorrhage. Her
hematocrit
was found to be 26 and she was transferred to ___ for further
management.
- ___: laparoscopic left radical nephrectomy with
retroperitoneal lymph node dissection with Dr. ___.
Pathology from this procedure showed a 9 x 7 x 7 cm clear cell
renal carcinoma, which was grade III/grade IV with tumor
extending into the perinephric tissues and tumor extension into
the renal vein. It was a stage pT3aN0Mx or stage III renal cell
carcinoma. Margins were uninvolved. The adrenal gland was
removed and was not involved. LVI was present.
- ___: CT torso with bilateral pulmonary nodules, new since
___
- ___: wedge resection of left lingula showed metastatic
clear cell carcinoma from the kidney.
- ___ cycle 1 week 1 HD-IL2
- ___ cycle 1 week 2 HD-IL2
- ___ cycle 2 week 1 HD-IL2
- ___ cycle 2 week 2 HD-IL2
.
Other PMH:
-breast fibroadenoma
-depression
Social History:
___
Family History:
Her grandfather had esophageal cancer. Her father had basal
cell carcinoma, squamous cell carcinoma and melanoma. He died
of an MI at the age of ___ and had an extensive cardiac history.
Her mother is alive and is well. She has two sisters and one
brother who are overall healthy without any history of
malignancy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
T99.1, BP 116/78, HR 66, RR 18, 96% RA
General: Well-appearing F in NAD
CV: S1, S2 RRR
Lungs: CTAB
Abdomen: soft, NT, ND
Ext: warm, no edema
Neuro exam deferred at pt's request given diesire to sleep and
multiple ED exams.
DISCHARGE PHYSICAL EXAM:
PHYSICAL EXAM:
Vitals: 97.8 116/65 60 20 94/ra
General: NAD
CV: regular rhythm, S1/S2, no m/r/g
Lungs: CTAB, no w/r/r
Abdomen: soft, NT, ND
Ext: warm, no edema
Neuro: CN II-XII intact, moving extremities well grossly, ___ ___
on R and 4+/5 on left, more detailed neuro exam deferred given
neurology, neurosurgery, and rad onc involvement
Pertinent Results:
___ 07:20PM GLUCOSE-87 UREA N-15 CREAT-1.0 SODIUM-139
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-22 ANION GAP-16
___ 07:20PM WBC-8.4 RBC-4.64 HGB-13.9 HCT-41.1 MCV-89
MCH-30.0 MCHC-33.9 RDW-12.6
___ 07:20PM NEUTS-50.4 ___ MONOS-3.4 EOS-4.8*
BASOS-0.6
___ 07:20PM PLT COUNT-237
___ 07:20PM ___ PTT-35.6 ___
.
CT CAP ___:
Patient is status post left nephrectomy and adrenalectomy
without evidence of residual or recurrent disease at this time.
.
MRI L-spine *wet read*
There is an inhomogeneous, largely solid, but partially cystic,
intramedullary enhancing mass centered at L1. There is
extensive spinal cord edema surrounding this lesion. There is
somewhat prominent enhancement of the lumbar nerve roots,
raising a concern of leptomeningeal seeding of tumor. Given the
clinical history, this appears most likely to represent a
metastasis. The appearance alone could be observed in
hemangioblastoma. However, the lesion was not detectable on a
torso CT ___, but is clearly present on the torso
CT of ___. CT is a low sensitivity technique for
characterizing intraspinal soft tissue lesions. However, there
has been at a minimum a dramatic increase in size of this lesion
over nine months, if it was present at all in ___. This would
argue against a more benign etiology such as a hemangioma. The
intramedullary location and extensive cord edema make a nerve
sheath tumor extremely unlikely and effectively exclude a
meningioma.
Other than the possible abnormal nerve root enhancement, no
other intradural abnormalities are detected. There are mild
changes of degenerative disc disease with loss of signal of the
intervertebral discs from L2 through S1 on the long TR images.
CONCLUSION: Intramedullary enhancing mass with extensive edema.
Possible leptomeningeal seeding of tumor. These findings are
most compatible with metastatic disease. This finding was
described on the wet read interpretation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. BuPROPion (Sustained Release) 300 mg PO QAM
2. Lorazepam 0.5-1 mg PO BID:PRN anxiety, insomnia
3. MethylPHENIDATE (Ritalin) 5 mg PO BID
4. Cetirizine *NF* 10 mg Oral daily
5. Sertraline 200 mg PO DAILY
Discharge Medications:
1. BuPROPion (Sustained Release) 300 mg PO QAM
2. Lorazepam 0.5-1 mg PO BID:PRN anxiety, insomnia
3. MethylPHENIDATE (Ritalin) 5 mg PO BID
4. Sertraline 200 mg PO DAILY
5. Dexamethasone 4 mg PO Q6H
RX *dexamethasone 4 mg 1 tablet(s) by mouth every six (6) hours
Disp #*120 Tablet Refills:*0
6. Cetirizine *NF* 10 mg Oral daily
7. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
spinal tumor with concern for cord compression
metastatic renal cell carcinoma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Metastatic renal cell carcinoma status post 2 cycles of IL2.
Restaging exam.
TECHNIQUE: Helical CT acquisition through the chest abdomen and pelvis with 3
minutes delayed series through the torso. Uneventful administration of 130 cc
Omnipaque IV contrast and 900 cc PO contrast. Coronal and sagittal reformats
provided by technologist.
DLP: 1,879 mGy-cm.
COMPARISON: ___ CT torso.
FINDINGS:
No lower cervical adenopathy. Normal appearance of the thyroid gland. No
mediastinal adenopathy by size criteria. Heart size within normal limits.
Normal appearance of the gastroesophageal junction. At.
Lungs demonstrate normal background parenchymal pattern. No suspicious lung
nodules are seen. The patient is status post lingular wedge resection. The
central pulmonary arteries and airways are patent.
Liver demonstrates stable sub cm hypodensities most consistent with simple
cysts. No suspicious liver lesions identified. Patient is status post
cholecystectomy. Normal appearance of the chest spleen and right kidney and
adrenals, right ureter and bladder. Pelvic organs within normal limits for
size. Bilateral ovarian follicles are noted. There is postsurgical shift of
the pancreatic tail to lie adjacent to the left psoas muscle. The spleen is
also mildly shifted. No resection bed lesions are identified. No
retroperitoneal adenopathy is evident.
Small and large bowel are unobstructed. No focal bowel wall thickening is
seen.
Aorta and IVC are normal in caliber without evidence of acute or suspicious
abnormality.
Osseous structures are appropriate for age without suspicious lytic or blastic
lesion.
IMPRESSION:
Patient is status post left nephrectomy and adrenalectomy without evidence of
residual or recurrent disease at this time.
Radiology Report
MR LUMBAR SPINE WITHOUT AND WITH CONTRAST ___
HISTORY: Renal cell carcinoma with low back pain, sensory loss, weakness, and
decreased rectal tone.
Sagittal imaging was performed with long TR, long TE fast spin echo, short TR,
short TE spin echo, and T2-weighted IDEAL technique. Axial long TR, long TE
fast spin echo and short TR, short TE spin echo images were performed. After
administration of 9 cc of Gadovist intravenous contrast, sagittal and axial
short TR, short TE spin echo imaging were performed.
Comparison to CT torso examinations of ___ and ___.
FINDINGS: There is an inhomogeneous, largely solid, but partially cystic,
intramedullary enhancing mass centered at L1. There is extensive spinal cord
edema surrounding this lesion. There is somewhat prominent enhancement of the
lumbar nerve roots, raising a concern of leptomeningeal seeding of tumor.
Given the clinical history, this appears most likely to represent a
metastasis. The appearance alone could be observed in hemangioblastoma.
However, the lesion was not detectable on a torso CT ___, but is
clearly present on the torso CT of ___. CT is a low sensitivity
technique for characterizing intraspinal soft tissue lesions. However, there
has been at a minimum a dramatic increase in size of this lesion over nine
months, if it was present at all in ___. This would argue against a more
benign etiology such as a hemangioma. The intramedullary location and
extensive cord edema make a nerve sheath tumor extremely unlikely and
effectively exclude a meningioma.
Other than the possible abnormal nerve root enhancement, no other intradural
abnormalities are detected. There are mild changes of degenerative disc
disease with loss of signal of the intervertebral discs from L2 through S1 on
the long TR images.
CONCLUSION: Intramedullary enhancing mass with extensive edema. Possible
leptomeningeal seeding of tumor. These findings are most compatible with
metastatic disease. This finding was described on the wet read
interpretation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R/O CORD COMPRESSION
Diagnosed with LUMBAGO, SKIN SENSATION DISTURB
temperature: 98.3
heartrate: 88.0
resprate: 16.0
o2sat: 99.0
sbp: 120.0
dbp: 73.0
level of pain: 0
level of acuity: 2.0 | ___ with metastatic RCC s/p left nephrectomy, left VATS
resection for pulmonary nodules, and HD IL-2 who presents with
LBP and perineal sensory loss, found to have L1 intradural,
intramedullary metastatic lesion while staging CT torso on day
of admission showed no other evidence of metastatic disease.
#) L1 spinal met: Has associated radiculopathy and new perianal
sensory loss, fecal incontinence. Pt was seen by neurosurgery
and neurology in the ED and started on dexamethasone.
Neurosurgery has determined that she would not be an optimal
candidate for resection, and so she was started on radiation
therapy on ___ and ___. Per her request, the patient was
discharged home on ___ and will complete the remainder of her
radiation therapy on ___ as an outpatient. She will continue
on oral dexamethasone 4mg q6h for now. She also should make
appointments to follow up with her primary oncologists Dr.
___ Dr. ___ new neuro-oncologist Dr. ___
___ ___ weeks.
#) Metastatic RCC: She has undergone resection for pulmonary
metastases, and high-dose IL-2 systemic therapy, most recently
in ___. There was no other evidence of disease on CT torso
done the day of admission. To complete staging workup, she will
complete an MRI head, C-spine, and T-spine as an outpatient
(currently scheduled for ___, since it could not be achieved
during her inpatient time due to the restriction preventing her
from receiving contrast twice within a 48-hour window given her
GFR<60.
#) Depression: continued on home medications. Patient has a
follow-up appointment scheduled with her psychiatrist. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
oxaliplatin
Attending: ___.
Chief Complaint:
RUQ/Right chest pain; rising bilirubin
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
Mr. ___ is a ___ year old man with metastatic rectal cancer
(KRAS wild type, NRAS mutation, MSS) who is admitted from the ED
with right chest/abdomen pain and rising bilirubin.
Patient was in his usual state of health until about a week ago
when he developed a cough thought due to a cold. He also noted
associated RUQ pain that has now moved into his right
chest/flank, especially with coughing. ___ the last two days he
has noticed increasing shortness of breath while speaking. He
was
seen in his oncologists office today, where his bilirubin was
also noted to have increased from 1.0 on ___ to 2.8. Given
concern for possible PE, and concern about his bilirubin, he was
directed to the ED for further management.
In the ED, initial VS were pain 4, T 98.9, HR 116, BP 127/81, RR
12, O2 98%RA. Initial labs notable for WBC 9.9, HCT 36.6, PLT
433, Na 135, K 3.9, HCO3 22, Cr 0.7, ALT 103, AST 151, ALP 725,
TBIli 2.8, Dbili 2.0. INR 1.3. EKG whowed NSR at 103, NA, no
concerning ischemic changes. CTA chest showed no evidence of PE
but did show increase in numerous pulmonary metastatic disease.
RUQ US showed known hepatic metastatic disease without evidence
of obstruction. VS prior to transfer were pain 0, HR 99, BP
108/68, RR 22, O2 99%RA.
On arrival to the floor, patient reports shortness of breath,
cough, and pleuritic RUQ/right chest pain as above. No frank
chest pain and no chest pain at rest. He has intermittent
subjective fevers at home. No N/V. His appetite is poor. No
diarrhea, and has been a bit constipated with small hard BM
yesterday. He had a headache today that improved with IVF in the
ED. No dysuria. No new joint pains, swelling, or rash.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Mr. ___ was diagnosed with metastatic rectal cancer
___ when Rectal EUS identified a rectal mass at
approximately 10 cm from the anal verge during work-up for 20lb
weight loss and constipation, as well as leg, buttock and
scrotal
pain. ___ CT demonstrated multiple hepatic lesions- Sclerotic
right acetabular/ischial metastatic lesion with a soft tissue
component bilateral pulmonary nodules with cavitation. Treated
with radiation to the bone and started chemotherap.
Treatment with FOLFOX ___ complicated by oxali
reaction. Maintained on ___ ___ (avastin
exposure only ___ and on single agent irinotecan
starting ___. Overall doing well with slowly progressive
disease in ___. Extended RAS testing at that time
determined that he was not a candidate for the available trial.
Started FOLFIRI-avastin ___. Stable disease on imaging
___. Progression on imaging ___. Signed consent for trial
___ regorafenib dose optimization study (ReDOX): a
phase 2 randomized study of lower drug regorafenib compared to
standard dose regorafenib in patients with refractory metastatic
colorectal cancer.
admitted ___ with colitis likely due to
regorafenib and taken off trial.
PAST MEDICAL HISTORY:
- Insomnia
- Impotence
Social History:
___
Family History:
No known cancers.
Physical Exam:
Vitals: 99.3 BP:121/86 HR:98 R:16 O2:99 RA
HEENT: EOMI, MMM, Neck Supple
CARDIAC: Regular rate and rhythm
LUNG: Clear B/l on auscultation.
ABD: Soft, nontender, nondistended, no hepatomegaly, no
splenomegaly.
EXT: Warm, well perfused, no lower extremity edema
NEURO: Alert, oriented, no focal deficits.
SKIN: No significant rashes
Pertinent Results:
___ 08:05AM BLOOD WBC-9.9 RBC-4.73 Hgb-11.0* Hct-36.6*
MCV-77* MCH-23.3* MCHC-30.1* RDW-18.0* RDWSD-50.7* Plt ___
___ 06:12AM BLOOD WBC-7.5 RBC-4.05* Hgb-9.1* Hct-31.3*
MCV-77* MCH-22.5* MCHC-29.1* RDW-18.2* RDWSD-51.3* Plt ___
___ 03:55PM BLOOD ___ PTT-34.3 ___
___ 06:12AM BLOOD Glucose-86 UreaN-7 Creat-0.6 Na-137 K-3.9
Cl-104 HCO3-23 AnGap-14
___ 08:05AM BLOOD ALT-103* AST-151* AlkPhos-725*
TotBili-2.8* DirBili-2.0* IndBili-0.8
___ 06:12AM BLOOD ALT-113* AST-197* ___
AlkPhos-682* TotBili-2.2*
___ 06:12AM BLOOD Calcium-8.2* Phos-2.4* Mg-1.9
RUQ U/S:
Multiple hypoechoic hepatic masses, compatible with known
metastases. No
evidence of biliary dilatation.
Chest CTA:
1. No evidence of pulmonary embolism or acute aortic
abnormality.
2. Since ___, numerous pulmonary metastatic
nodules are slightly larger in size. The largest of these
measures 13 mm in the right lower lobe, previously 12 mm.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. LORazepam 0.5 mg PO Q6H:PRN nausea/anxiety
3. Ondansetron 8 mg PO Q8H:PRN nausea
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Senna 8.6 mg PO BID:PRN constipation
6. Mirtazapine 15 mg PO QHS
7. Prochlorperazine 10 mg PO Q6H:PRN nausea
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. LORazepam 0.5 mg PO Q6H:PRN nausea/anxiety
3. Mirtazapine 15 mg PO QHS
4. Ondansetron 8 mg PO Q8H:PRN nausea
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Prochlorperazine 10 mg PO Q6H:PRN nausea
7. Senna 8.6 mg PO BID:PRN constipation
Discharge Disposition:
Home
Discharge Diagnosis:
Rectal Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ year old man with metastatic rectal cancer and new elevated
bili. Evaluate for biliary obstruction.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT abdomen and pelvis of ___.
FINDINGS:
LIVER: Multiple hypoechoic masses are identified throughout the liver,
compatible with known metastases. The contour of the liver is otherwise
smooth. The main portal vein is patent with hepatopetal flow. There is no
ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 4 mm.
GALLBLADDER: The gallbladder is collapsed. No evidence of cholelithiasis.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity, measuring 7.3 cm.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
Multiple hypoechoic hepatic masses, compatible with known metastases. No
evidence of biliary dilatation.
Radiology Report
EXAMINATION: CTA CHEST
INDICATION: ___ with hx rectal cancer, now with pleuritic CP, tachycardia.
Evaluate for pulmonary embolism.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Total DLP (Body) = 365 mGy-cm.
COMPARISON: Chest CT of ___.
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no
evidence of penetrating atherosclerotic ulcer or aortic arch atheroma present.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect within the main, right, left, lobar, segmental or
subsegmental pulmonary arteries. The main and right pulmonary arteries are
normal in caliber, and there is no evidence of right heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
The thyroid gland appears unremarkable.
The right-sided Port-A-Cath tip terminates in the proximal right atrium.
There is no evidence of pericardial effusion. A small nonhemorrhagic right
pleural effusion has slightly increased in size since the prior study.
Numerous pulmonary metastatic nodules appear slightly larger in size since the
study of ___ (2:26, 43, 47, 55, 58, 68, 69). For instance, a
right lower lobe nodule now measures 8 mm compared with 6-7 mm previously
(3:137). The largest of these measures approximately 13 mm in the right lower
lobe (2:67), previously 12 mm. No new focal consolidation or pneumothorax.
Mild atelectasis is noted in both lower lobes. The airways are patent to the
subsegmental level.
Limited images of the upper abdomen reveal multiple innumerable hypodense
lesions throughout the liver, compatible with known metastases. The adrenal
glands are normal in size and shape..
No lytic or blastic osseous lesion suspicious for malignancy is identified.
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic abnormality.
2. Since ___, numerous pulmonary metastatic nodules are slightly
larger in size. The largest of these measures 13 mm in the right lower lobe,
previously 12 mm.
Gender: M
Race: BLACK/CAPE VERDEAN
Arrive by AMBULANCE
Chief complaint: Dyspnea, Chest pain
Diagnosed with Shortness of breath
temperature: 98.9
heartrate: 116.0
resprate: 12.0
o2sat: 98.0
sbp: 127.0
dbp: 81.0
level of pain: 4
level of acuity: 2.0 | ___ year old man with metastatic rectal cancer (KRAS wild type,
NRAS mutation, MSS) who was admitted from the ED with right
chest/abdomen pain and rising bilirubin most
consistent with disease progression.
Metastatic Rectal Cancer
- The likely cause of the patients abdominal pain and elevated
liver function tests are due to disease progression. Chest CTA
and RUQ ultrasound done in the ED were unremarkable. He had a
previous oxaliplatin reaction. His primary oncologist decided to
start treatment with FOLFOX. He received oxaliplatin
desensitization with pre-medications per protocol while admitted
and tolerated it well. He will return to clinic tomorrow to
receive the rest of the regimen. His liver function tests will
be followed up by his primary oncologist as an outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Percocet
Attending: ___
___ Complaint:
hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with history of non-ischemic dilated
cardiomyopathy (EF 25%), insulin-dependent DM, and dementia
presents with low O2 saturation to 88% on room air at her
nursing home. Per nursing home records, she has also been having
worsening dyspnea on exertion and lower extremity edema, along
with a poor appetite.
She was recently discharged from ___ on ___ after a 5-day
hospitalization for an acute change in mental status and
bradycardia at her ECF. She was evaluated by Cardiology during
this time for her bigeminy and bradycardia, and deemed not a
candidate for an AICD due to her lack of symptoms and no
significant bradycardia noted on telemetry. She was noted to
have dissociation between her heart rate measurements on her
bedside vitals sign and telemetry/physical exam. They were not
able to identify a cause for her acute change in mental status,
but she was alert and oriented to name but no longer oriented to
place. Her renal failure was deemed secondary to cardiorenal
syndrome and her diuretics and ACE-i were started upon
discharge.
She was last seen in the Cardiology clinic on ___, noted to
be volume overloaded. Her furosemide was changed to torsemide
and she was scheduled for follow-up with Dr. ___.
In the ED, initial VS were: 97.8 66 118/80 24 98% NRB (weaned to
95% 2L NC). Of note, sats were in the mid ___ on room air at
times, but would dip when pt went into prolonged bigeminy
rhythm. Exam notable for pt AOx1 w/ lungs clear, minimal pedal
edema. CXR notable for increased interstitial markings with labs
showing hypernatremia to 148, BNP to 28175, and D-dimer to 2933.
Creatinine of 1.4 (baseline 1.3-1.6). She was given furosemide
40mg IV x1, a Foley was placed and she was admitted for CHF
exacerbation. VS on transfer were: 98 62 117/81 16 95%2LNC.
On arrival to the floor, pt is sleeping but arousable. She
denies any complaints but requests that "we do this tomorrow."
Past Medical History:
- Dementia
- Non-ischemic Dilated cardiomyopathy (EF ___
- Diabetes
- Left bundle-branch block
- Chronic pancreatitis
- Hypothyroidism
- Hypercalcemia
- hyperparathyroidism
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION
VS - Temp 97.4F, BP 118/70, HR 92, R 18, O2-sat 91-97% RA
GENERAL - well-appearing eldelry woman in NAD, comfortable;
pleasant but in appropriately answers questions, inattentive and
only intermittently follows commands
HEENT - NC/AT, EOMI, sclerae anicteric, dry MM
NECK - supple, JVD at line of jaw at 30 degrees
LUNGS - limited exam ___ poor patient cooperation but CTAB
anteriorly, resp unlabored, no accessory muscle use
HEART - RRR, no MRG, nl S1-S2
ABDOMEN - soft/NT/ND, no rebound/guarding
EXTREMITIES - 1+ ankle edema b/l; WWP, no c/c 2+ peripheral
pulses (radials, DPs); + bony deformities of fingers and toes
GU: Foley in place
NEURO - awake, alert and oriented to name; motor and sensation
grossly intact
DISCHARGE
VS - 98 109/64 83 20 96RA
136 lbs
GENERAL - well-appearing eldelry woman in NAD, comfortable; AOx2
pleasant but inappropriately answers questions, inattentive and
only intermittently follows commands
HEENT - NC/AT, EOMI, sclerae anicteric, dry MM
NECK - supple, JVD at line of jaw at 30 degrees
LUNGS - limited exam ___ poor patient cooperation but CTAB
anteriorly, resp unlabored, no accessory muscle use
HEART - Regular rate with very prominent S3 and also possible S2
wide splitting
ABDOMEN - soft/NT/ND, no rebound/guarding
EXTREMITIES - 1+ ankle edema b/l; WWP, no c/c 2+ peripheral
pulses (radials, DPs); + bony deformities of fingers and toes
NEURO - awake, alert and oriented to name; motor and sensation
grossly intact
Pertinent Results:
ADMISSION
___ 09:45PM BLOOD WBC-5.0 RBC-5.16 Hgb-13.9 Hct-44.8 MCV-87
MCH-26.9* MCHC-31.1 RDW-18.8* Plt ___
___ 09:45PM BLOOD Glucose-180* UreaN-43* Creat-1.4* Na-148*
K-4.1 Cl-111* HCO3-26 AnGap-15
___ 09:45PM BLOOD CK-MB-2 cTropnT-0.07* ___
___ 09:45PM BLOOD Calcium-11.0* Phos-2.4* Mg-2.2
___ 09:45PM BLOOD D-Dimer-2933*
___ 09:45PM BLOOD TSH-65*
DISCHARGE
___ 07:50AM BLOOD WBC-4.1 RBC-4.67 Hgb-12.4 Hct-40.8 MCV-87
MCH-26.5* MCHC-30.4* RDW-18.9* Plt ___
___ 08:05AM BLOOD Glucose-164* UreaN-31* Creat-1.2* Na-145
K-4.1 Cl-108 HCO3-28 AnGap-13
WEIGHT ON DISCHARGE 136 LBS
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Levothyroxine Sodium 150 mcg PO DAILY
Do not take with Calcium. Please take on an empty stomach.
2. Aspirin 325 mg PO DAILY
3. Mirtazapine 15 mg PO HS
4. Quetiapine Fumarate 12.5 mg PO BID
5. Senna 2 TAB PO HS
6. Simvastatin 20 mg PO DAILY
7. Spironolactone 25 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Fluticasone Propionate NASAL 1 SPRY NU DAILY
one spray each nostril
10. Lisinopril 2.5 mg PO DAILY
11. Allopurinol ___ mg PO DAILY
12. MetFORMIN (Glucophage) 250 mg PO DAILY
13. Megestrol Acetate 200 mg PO DAILY
liquid form; plan for 2 week course per ___ home records
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Docusate Sodium 100 mg PO BID
3. Fluticasone Propionate NASAL 1 SPRY NU DAILY
one spray each nostril
4. Lisinopril 2.5 mg PO DAILY
5. Spironolactone 25 mg PO DAILY
6. Mirtazapine 15 mg PO HS
7. Quetiapine Fumarate 12.5 mg PO BID
8. Senna 2 TAB PO HS
9. Simvastatin 20 mg PO DAILY
10. Megestrol Acetate 200 mg PO DAILY
liquid form; plan for 2 week course per ___ home records
11. MetFORMIN (Glucophage) 250 mg PO DAILY
12. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
13. Outpatient Lab Work
Please draw chem 7, Ca, Mg, Phos on ___ and fax to Dr.
___ at ___.
14. Outpatient Lab Work
Please draw chem 7, Ca, Mg, Phos on ___ and fax to Dr.
___ at ___.
15. Aspirin EC 325 mg PO DAILY
16. Levothyroxine Sodium 150 mcg PO HS
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute on Chronic Systolic Heart Failure exacerbation
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
HISTORY: Hypoxia.
COMPARISON: ___ through ___
FINDINGS:
Moderate pulmonary edema is new since ___. Severe cardiomegaly is
similar. The lungs are well expanded. There is no effusion or pneumothorax.
IMPRESSION:
New moderate CHF since ___.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: HYPOXIA
Diagnosed with HYPOXEMIA, DIABETES UNCOMPL ADULT, HYPOTHYROIDISM NOS, DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE
temperature: 97.8
heartrate: 66.0
resprate: 24.0
o2sat: 98.0
sbp: 118.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | BRIEF HOSPITAL COURSE AND ACTIVE ISSUES
___ year old female with history of non-ischemic dilated CM (EF
25%), DM type 2, and dementia, presenting with hypoxemia,
dyspnea on exertion, and lower extremity edema consistent with a
CHF exacerbation with BNP in 20,000s.
# Acute on chronic heart failure: Pt w/ non-ischemic CMP w/ EF
___ on last TTE in ___. She had been maintained on
furosemide 20 mg daily, but was recently switched to torsemide
10 mg PO daily per outpatient cardiology notes on ___ as she
was volume overloaded at that time. She was further diuresed
with a net total output of about 4.2L over course of admission.
She was continued on her spironolactone and lisinopril. We are
discharging her on Furosemide 40mg with plans for chem 7 draw on
___ and ___ to be faxed to Dr. ___ in cardiology. ON
DISCHARGE HER WEIGHT IS 136 LBS.
# Hypothyroidism: She had an elevated TSH and normal T4 during
last admission and her Levothyroxine had been increased to 150
mcg daily. However on this admission TSH remained elevated at
65. It should be confirmed after discharge that she takes her
levothyroxine separately from her other medications and on an
empty stomach. If TSH remains elevated after these
interventions, her dose should be further uptitrated.
INACTIVE ISSUES
# Asymptomatic Bradycardia: Pt with previous admission for
reported bradycardia to ___ recorded at ECF. Stable for now. Not
AICD candidate.
# Diabetes mellitus: Insulin dependent on home ISS and fairly
well controlled w/ last A1c 6.3% in ___. Metformin was
discontinued during last hospitalization ___ ___ but was
restarted in the nursing home at 250 mg daily. Metformin was
held in-house.
# Hyperparathyroidism with hypercalcemia: Stable. No further
intervention per endocrine.
# CKD: stable
# Dementia: Pt with relatively advanced dementia that has been
progressive. Currently oriented x1 which seems to be new
baseline. Continued on quetiapine and remeron.
# Gout: Stable. Continued on home allopurinol
TRANSITIONAL ISSUES
-- DAILY WEIGHTS, adjust Lasix based on volume status and
weight. ON DISCHARGE SHE IS 136LBS. If >3lb weight gain, call
and let Dr. ___ know at ___.
-- O/P chem 7 on ___ and ___ to be faxed to Dr. ___
in cardiology
-- Make sure Levothyroxine is taken on empty stomach without
other medications
-- Changed ASA to enteric coated |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Codeine / ertapenem
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
ADMISSION LABS
==============
___ 10:03AM BLOOD WBC-10.9* RBC-2.82* Hgb-9.6* Hct-28.9*
MCV-103* MCH-34.0* MCHC-33.2 RDW-13.1 RDWSD-48.8* Plt ___
___ 10:03AM BLOOD Neuts-63.8 Lymphs-18.7* Monos-12.1
Eos-3.2 Baso-0.3 NRBC-0.2* Im ___ AbsNeut-6.93*
AbsLymp-2.03 AbsMono-1.32* AbsEos-0.35 AbsBaso-0.03
___ 10:03AM BLOOD Glucose-174* UreaN-34* Creat-1.8* Na-133*
K-4.5 Cl-95* HCO3-23 AnGap-15
___ 10:03AM BLOOD ALT-14 AST-28 AlkPhos-58 TotBili-<0.2
___ 10:03AM BLOOD Lipase-38
___ 10:03AM BLOOD proBNP-1796*
___ 10:03AM BLOOD cTropnT-0.03*
___ 03:32PM BLOOD cTropnT-0.03*
___ 10:05AM BLOOD Lactate-1.7
OTHER LABS
==========
___ 11:05AM URINE Color-Straw Appear-Clear Sp ___
___ 11:05AM URINE RBC-1 WBC-0 Bacteri-FEW* Yeast-NONE
Epi-<1
___ 11:05AM URINE Hours-RANDOM UreaN-256 Creat-28
___ 11:05AM URINE Osmolal-256
___ 07:37AM BLOOD Glucose-173* UreaN-26* Creat-1.4* Na-137
K-4.3 Cl-101 HCO3-25 AnGap-11
MICRO
=====
___ 11:05 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
___ Blood culture NGTD, pending
IMAGING
=======
CXR ___
Improved aeration in the lower lungs when compared with prior
exam with small residual right pleural effusion and mild
residual atelectasis at the left lung base.
Renal U/s ___
1. Abnormal waveform within the main renal artery with absence
of antegrade flow during diastole.
2. Elevated intrarenal resistive indices though somewhat
improved when
compared with prior exam.
3. Multiple cysts within the transplant kidney, 1 of which in
the midpole
region contains thin septations, attention on follow-up advised.
CXR ___
Small bilateral pleural effusions with slightly worse bibasilar
airspace
opacities, possibly atelectasis with aspiration or infection not
excluded. No
pulmonary edema.
DISCHARGE LABS
==============
___ 09:03AM BLOOD WBC-8.2 RBC-3.06* Hgb-10.3* Hct-32.4*
MCV-106* MCH-33.7* MCHC-31.8* RDW-13.2 RDWSD-51.1* Plt ___
___ 09:03AM BLOOD Glucose-140* UreaN-24* Creat-1.4* Na-136
K-5.6* Cl-101 HCO3-23 AnGap-12
___ 09:03AM BLOOD Calcium-8.4 Phos-3.8 Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ascorbic Acid ___ mg PO BID
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO QPM
4. CARVedilol 12.5 mg PO BID
5. Diltiazem Extended-Release 180 mg PO DAILY
6. Docusate Sodium 100 mg PO BID
7. Ferrous Sulfate 325 mg PO DAILY
8. Fluticasone Propionate NASAL 2 SPRY NU BID
9. Furosemide 40 mg PO BID
10. HydrALAZINE 10 mg PO TID
11. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
wheeze/sob
12. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
13. Loratadine 10 mg PO EVERY OTHER DAY
14. Mycophenolate Mofetil 250 mg PO BID
15. Omeprazole 20 mg PO DAILY
16. PredniSONE 5 mg PO DAILY
17. Sodium Bicarbonate 650 mg PO BID
18. Tiotropium Bromide 1 CAP IH DAILY
19. TraZODone 25 mg PO QHS:PRN insomnia
20. Vitamin D ___ UNIT PO 1X/WEEK (WE)
21. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheezing
22. Fosfomycin Tromethamine 3 g PO 1X/WEEK (___)
23. NovoLIN ___ FlexPen U-100 (insulin NPH and regular human)
100 unit/mL (70-30) subcutaneous QAM
24. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN shortness of breath
25. Repaglinide 1 mg PO TIDAC
26. ValACYclovir 500 mg PO Q24H
27. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID:PRN sob
28. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
29. LevETIRAcetam 500 mg PO BID
Discharge Medications:
1. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth QAM Disp #*30 Tablet
Refills:*0
2. NovoLIN ___ FlexPen U-100 (insulin NPH and regular human)
12 units subcutaneous DAILY
RX *insulin NPH and regular human [Novolin ___ FlexPen U-100]
100 unit/mL (70-30) 12 units SC once a day Disp #*15 Syringe
Refills:*0
3. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB, wheezing
4. Ascorbic Acid ___ mg PO BID
5. Aspirin 81 mg PO DAILY
6. Atorvastatin 20 mg PO QPM
7. CARVedilol 12.5 mg PO BID
8. Diltiazem Extended-Release 180 mg PO DAILY
9. Docusate Sodium 100 mg PO BID
10. Ferrous Sulfate 325 mg PO DAILY
11. Fluticasone Propionate NASAL 2 SPRY NU BID
12. Fosfomycin Tromethamine 3 g PO 1X/WEEK (___)
13. HydrALAZINE 10 mg PO TID
14. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
wheeze/sob
15. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
16. LevETIRAcetam 500 mg PO BID
17. Loratadine 10 mg PO EVERY OTHER DAY
18. Mycophenolate Mofetil 250 mg PO BID
19. Omeprazole 20 mg PO DAILY
20. PredniSONE 5 mg PO DAILY
21. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q6H:PRN shortness of breath
22. Repaglinide 1 mg PO TIDAC
23. Sodium Bicarbonate 650 mg PO BID
24. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
25. Symbicort (budesonide-formoterol) 160-4.5 mcg/actuation
inhalation BID:PRN sob
26. Tiotropium Bromide 1 CAP IH DAILY
27. TraZODone 25 mg PO QHS:PRN insomnia
28. ValACYclovir 500 mg PO Q24H
29. Vitamin D ___ UNIT PO 1X/WEEK (WE)
30.Equipment
Please provide portable home nebulizer
ICD code: ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
Acute Kidney Injury ___ hypovolemia
CHRONIC DIAGNOSES
=================
ESRD ___ HTN and DM s/p DDRT c/b CKD of renal allograft
Heart Failure with Preserved Ejection Fraction
Type II diabetes
Chronic Obstructive Pulmonary Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: ___ with recent pna, sob // eval for pna
TECHNIQUE: Chest AP upright and lateral
COMPARISON: Multiple prior chest radiographs, most recently ___. CT chest performed ___.
FINDINGS:
There has been interval removal of the previously seen left-sided PICC line.
There is a small residual right pleural effusion. Mild left basal atelectasis
noted. Cardiomediastinal silhouette is grossly unchanged.
IMPRESSION:
Improved aeration in the lower lungs when compared with prior exam with small
residual right pleural effusion and mild residual atelectasis at the left lung
base.
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: History: ___ with renal transplant // eval for flow
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: CT abdomen and pelvis dated ___.
FINDINGS:
There is redemonstration of multiple cystic lesions in the right iliac fossa
transplant kidney. The majority of the cysts appear relatively simple and
unchanged in overall size. There is a mildly complex cyst in the midpole
region which contains several thin septations which appears size stable. 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 0.76 to 0.84, mildly
elevated though improved from previous study (previously measuring 0.91 to
0.98). The main renal artery waveform is abnormal with absence of antegrade
flow during diastole with peak systolic velocity ranging from 80.5 cm/s to 154
cm/s. Vascularity is symmetric throughout transplant. The transplant renal
vein is patent and shows normal waveform.
The urinary bladder is grossly unremarkable.
IMPRESSION:
1. Abnormal waveform within the main renal artery with absence of antegrade
flow during diastole.
2. Elevated intrarenal resistive indices though somewhat improved when
compared with prior exam.
3. Multiple cysts within the transplant kidney, 1 of which in the midpole
region contains thin septations, attention on follow-up advised.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with h/o renal transplant, CHF with new hypoxia from
earlier today // newly hypoxic, eval for aspiration, edema, or other etiology
of new hypoxia
TECHNIQUE: Upright AP view of the chest
COMPARISON: CT chest ___, chest radiograph ___ and ___ at 09:24
FINDINGS:
Cardiac silhouette size remains mildly enlarged. Mediastinal and hilar
contours are similar. Pulmonary vasculature is not engorged. Persistent
small bilateral pleural effusions. Bibasilar airspace opacities may be
minimally worse since the most recent chest radiograph. No new areas of focal
consolidation. No pneumothorax. No acute osseous abnormality.
IMPRESSION:
Small bilateral pleural effusions with slightly worse bibasilar airspace
opacities, possibly atelectasis with aspiration or infection not excluded. No
pulmonary edema.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Weakness
Diagnosed with Acute kidney failure, unspecified
temperature: 97.8
heartrate: 66.0
resprate: 22.0
o2sat: 100.0
sbp: 167.0
dbp: 46.0
level of pain: 0
level of acuity: 2.0 | TRANSITIONAL ISSUES
===================
[ ] Discharge Cr 1.4
[ ] Patient should have repeat BMP at next appointment
[ ] Patient's home diuretics were held during admission due to
hypovolemia. Restarted at lower dose 40mg PO daily. Likely will
need close titration of diuretics as PO intake improves.
[ ] Patient was noted to be hypoglycemic prior to admission
likely ___ poor PO intake as she was recovering from recent PNA.
Intake increased as appetite improved, will be discharged on
slightly lower dose of insulin but may need further adjustment
as outpatient.
BRIEF HOSPITAL COURSE
=====================
___ woman with a history of ESRD ___ HTN and DM s/p
kidney transplant (___), rectal cancer (s/p resection and
ostomy), HFpEF, COPD, DM2, DVT s/p IVC filter, and multiple MDR
UTIs who presented with weakness, found to be orthostatic and
with ___ likely ___ hypovolemia. Patient had recent admission
for multifocal pneumonia and heart failure exacerbation. She had
little PO intake at home and continued to take her home
diuretics. Patient was given IV fluids and her renal function as
well as orthostatics improved. She was restarted on Furosemide
40mg Once daily down from BID and discharged in stable condition
with improving kindey function, Cr. 1.4.
ACUTE ISSUES
=============
#Weakness
#Orthostasis
Presenting with lightheadedness after trying to get up, in
setting of recent hospitalization and decreased PO intake
coupled with diuretic use. No focal weakness on exam.
Orthostatic vital signs positive on ___. Received 500cc NS on
___ with improvement in symptoms and repeat orthostatic vital
signs negative. Patient discharged on lower dose diuretics.
___ on CKD of renal allograft
#ESRD s/p DDRT in ___
Cr 1.8 on admission (baseline 0.9-1.3). Likely elevated in the
setting of hypovolemia. Renal function downtrended to baseline
after IV fluids and holding diuretics. Seen by transplant
nephrology. FeUrea was oddly elevated at 48% with is borderline
suggestive of intrinsic renal disease but may be impacted by CKD
of renal allograft. Renal U/s also showing "abnormal waveform
within the main renal artery with absence of antegrade flow
during diastole." UA positive for protein. Continued on
mycophenolate 250mg BID and prednisone 5mg daily. She was also
continued on prophylactic Bactrim and valacyclovir. Cr on
discharge 1.4.
CHRONIC/RESOLVED ISSUES
=========================
#Multifocal PNA (resolved)
Recent admission for multifocal pneumonia, completed
levofloxacin course on ___. Still having productive cough but
not hypoxemic during admission. CXR looked improved.
#HFpEF
Mild diastolic dysfunction, EF 65% on last TTE ___. Last
discharge weight 115.7 lbs. On admission, proBNP elevated 1796
and trop x2 flat. Home Lasix held in setting of hypovolemia.
Euvolemic on discharge exam, discharged on 40 mg once daily
diuretic.
#HTN
Initially held home hydralazine given orthostasis, but restarted
as BPs improved and hypertensive to 160-170s systolic. Patient
continued on home carvedilol and diltiazem.
#DM2
Patient reports hypoglycemic episode to ___ at home on recent
70/30 regimen. Discharged on decreased dose of
#COPD
Patient continued home tiotropium. Held home Symbicort as non
formulary.
#Urinary retention
Has required Q6Hr catheterization in the past, although patient
doesn't describe performing at home. Patient urinating well
during admission.
#CAD
Patient continued on home ASA and statin.
#CODE: Full (confirmed)
#CONTACT: ___ (daughter) ___
>30 min spent on discharge planning including face to face time |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Pleuritic chest pain and fevers
Major Surgical or Invasive Procedure:
TEE
History of Present Illness:
PCP: ___. [Affiliated Physician ___.
CC: ___ chest pain x 2 days and fevers x 4 days along with
malaise x 4 days
HPI: The patient is a ___ year old healthy male with h/o HTN who
developed fever chills weakness sweats x 4 days, increased
sleep/fatigue. associated 2 days of pleuritic R Upper chest
pain. He denies no cough, congestion, or sob. He recently
traveled to ___ and returned at the end of ___. His
family also traveled with pt to CR but no other family members
are ill. Did get flu shot this year. He does not have neck
stiffnes or a headache. He took one dose of Azithro 500 mg this
___. Took Tamiflu 2 doses (last dose this AM)
His CXR from ___ demonstrated Right upper lobe rounded
cavitary lesion warrants further evaluation with CT. His lyme
and malaria tests were negative.
Blood cultures drawn in his PCP's office yesterday returned
positive for staph aureus in aerobic and anerobic bottles.
In ER: (Triage Vitals:0 |98.3 |88 |204/99 |18 |100% RA | )
Tmax = ___
Meds Given:
Acetaminophen 1000 mg po| Ibuprofen 400 mg |IV Ceftriaxone 1g
|vancomycin
IVF x 3 L
Radiology Studies: chest CT w/o contrast
.
PAIN SCALE: ___- pleuritic chest pain much improved
.
REVIEW OF SYSTEMS:
CONSTITUTIONAL: As per HPI including malaise and fatigue
sleeping 14 hours per day
HEENT: [X] All normal
RESPIRATORY: [X] All normal- I again clarified that he does not
have a cough
CARDIAC: [X] All normal
GI: [X] WNL
GU: [X] All normal
SKIN: [X] All normal
MUSCULOSKELETAL: [X] All normal
NEURO: [X] All normal
ENDOCRINE: [X] All normal
HEME/LYMPH: [X] All normal
PSYCH: [X] All normal
All other systems negative except as noted above
Past Medical History:
HYPERTENSION
MIGRAINES
H/O PRESUMED MSSA CELLULITIS TREATED WITH AMOXICILLIN IN ___
Social History:
___
Family History:
Mother LUNG CANCER - died at age ___
Father HYPERTENSION
Brother HYPERTENSION
Physical Exam:
Vitals: 97.7 PO 144 / 80 64 18 97 RA
CONS: NAD, comfortable appearing. He looks very well.
HEENT: ncat anicteric MMM
CV: s1s2 rr no m/r/g
RESP: b/l ae no w/c/r
GI: +bs, soft, NT, ND, no guarding or rebound
MSK:no c/c/e 2+pulses
SKIN: no rash
NEURO: face symmetric speech fluent
PSYCH: calm, cooperative, pleasant
Pertinent Results:
___ 04:50PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 03:57PM LACTATE-1.9
___ 03:50PM GLUCOSE-118* UREA N-15 CREAT-1.1 SODIUM-139
POTASSIUM-3.2* CHLORIDE-97 TOTAL CO2-28 ANION GAP-17
___ 03:50PM estGFR-Using this
___ 03:50PM WBC-9.4 RBC-5.39 HGB-15.7 HCT-44.0 MCV-82
MCH-29.1 MCHC-35.7 RDW-12.2 RDWSD-36.1
___ 03:50PM NEUTS-80.9* LYMPHS-10.5* MONOS-7.8 EOS-0.1*
BASOS-0.4 IM ___ AbsNeut-7.61* AbsLymp-0.99* AbsMono-0.73
AbsEos-0.01* AbsBaso-0.04
___ 03:50PM PLT COUNT-159
___ 05:25PM ALT(SGPT)-70*
___ 05:25PM WBC-7.7 RBC-5.54 HGB-15.9 HCT-44.8 MCV-81*#
MCH-28.7 MCHC-35.5 RDW-12.1 RDWSD-35.6
___ 05:25PM NEUTS-79.4* LYMPHS-11.5* MONOS-7.9 EOS-0.3*
BASOS-0.3 IM ___ AbsNeut-6.13* AbsLymp-0.89* AbsMono-0.61
AbsEos-0.02* AbsBaso-0.02
___ 05:25PM PLT COUNT-162
___ 05:25PM PARST SMR-NEG
++++++++++++++++++++++
. 2.8 cm centrally cavitating opacity in the periphery of the
right upper
lobe with adjacent ground-glass. An additional 1.1 cm subpleural
nodular
opacity is seen in the lateral right upper lobe. Findings likely
represent aninfectious process. Recommend follow-up imaging with
radiographs of ___ weeks after treatment. 2. ___
nodularity in the superior segment of the right lower lobe is
compatible with small airways infection.
3. Trace right pleural effusion with adjacent right lower lobe
atelectasis.
4. Several prominent mediastinal lymph nodes are likely
reactive.
5. Hepatic steatosis. Mild splenomegaly.
___ 08:30AM BLOOD WBC-6.9 RBC-4.92 Hgb-14.0 Hct-40.0
MCV-81* MCH-28.5 MCHC-35.0 RDW-12.1 RDWSD-36.0 Plt ___
___ 07:05AM BLOOD ___ PTT-29.1 ___
___ 08:30AM BLOOD Glucose-155* UreaN-15 Creat-0.8 Na-137
K-3.6 Cl-100 HCO3-25 AnGap-16
___ 05:25PM BLOOD ALT-70*
___ 08:30AM BLOOD ALT-65* AST-28 AlkPhos-76 TotBili-0.9
___ 08:30AM BLOOD HBsAb-Positive HAV Ab-Positive
___ 08:30AM BLOOD CRP-177.8*
___ 07:20AM BLOOD HIV Ab-Negative
___ 08:30AM BLOOD HCV Ab-Negative
___ 10:35AM BLOOD QUANTIFERON-TB GOLD-PND
___ TEE (Prelim Report **NOT FINAL**): No atrial septal
defect is seen by 2D or color Doppler. Overall left ventricular
systolic function is normal (LVEF>55%). with normal free wall
contractility. The aortic valve leaflets (3) appear structurally
normal with good leaflet excursion. No masses or vegetations are
seen on the aortic valve. No aortic valve abscess is seen. No
aortic regurgitation is seen. The mitral valve leaflets are
structurally normal. No mass or vegetation is seen on the mitral
valve. Mild to moderate (___) mitral regurgitation is seen.
IMPRESSION: No definite mass or vegetation identified. Mild to
moderate mitral regurgitation.
Medications on Admission:
chlorthalidone 25 mg tablet 1 tablet(s) by mouth once a day
___
zolmitriptan 2.5 mg disintegrating tablet
vitamin D 1000 IU daily
Aspirin 81 mg daily
Discharge Medications:
1. CeFAZolin 2 g IV Q8H
RX *cefazolin in dextrose (iso-os) 2 gram/50 mL 2 gm IV q8hr
Disp #*125 Intravenous Bag Refills:*0
2. Aspirin 81 mg PO DAILY
3. Chlorthalidone 25 mg PO DAILY
4. Vitamin D 1000 UNIT PO DAILY
5. Zomig (ZOLMitriptan) 2.5 mg oral PRN
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
MSSA bacteremia with cavitary penumonia
Elevated ALT
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with known right cavitary lesion seen on CXR// eval
for pneumonia, further characterize cavitary lesion
TECHNIQUE: Contiguous axial images were obtained through the chest without
intravenous contrast. Coronal and sagittal reformats were obtained.
COMPARISON: Chest radiograph dated ___
FINDINGS:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber. The heart,
pericardium, and great vessels are within normal limits based on an unenhanced
scan. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary or supraclavicular lymphadenopathy.
Several mediastinal lymph nodes are prominent, although not pathologically
enlarged, such as an 8 mm right upper paratracheal lymph node. No hilar
lymphadenopathy within the limitations of this noncontrast enhanced study.
PLEURAL SPACES: A small right pleural effusion is present. No pneumothorax.
LUNGS/AIRWAYS: There is a 2.8 x 2.8 cm centrally cavitating opacity with
surrounding ground-glass in the peripheral right upper lobe. A 1.1 x 0.7 cm
subpleural nodular opacity is also seen in the lateral peripheral aspect of
the right upper lobe. Foci of ___ nodularity are seen within the
superior segment of the right upper lobe, compatible with small airways
disease. Mild dependent atelectasis is seen within the right lower lobe.
Left lung is clear. 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 unenhanced upper abdomen is notable for mild
splenomegaly. The liver appears diffusely hypoattenuating, compatible with
steatosis. Otherwise imaged upper abdominal structures are grossly
unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. 2.8 cm centrally cavitating opacity in the periphery of the right upper
lobe with adjacent ground-glass. An additional 1.1 cm subpleural nodular
opacity is seen in the lateral right upper lobe. Findings likely represent an
infectious process. Recommend follow-up imaging with radiographs of ___ weeks
after treatment.
2. ___ nodularity in the superior segment of the right lower lobe is
compatible with small airways infection.
3. Trace right pleural effusion with adjacent right lower lobe atelectasis.
4. Several prominent mediastinal lymph nodes are likely reactive.
5. Hepatic steatosis. Mild splenomegaly.
RECOMMENDATION(S): Recommend follow-up imaging with radiographs of ___ weeks
after treatment.
Radiology Report
INDICATION: ___ year old man with 47cm left arm SL power PICC. ___ ___//
47cm left arm SL power PICC. ___ ___ Contact name: ___: ___
TECHNIQUE: Single portable view of the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
There has been interval placement of left PICC with tip projecting over the
mid SVC. Focal opacity projecting over the anterior right first rib at the
right lung apex was better delineated on prior exam. Lungs are otherwise
clear. Cardiomediastinal silhouette is within normal limits.
IMPRESSION:
Left PICC tip over the mid SVC.
NOTIFICATION: IV nurse was notified at 13:20 on ___.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever, Pneumonia
Diagnosed with Pneumonia due to methicillin suscep staph
temperature: 98.3
heartrate: 88.0
resprate: 18.0
o2sat: 100.0
sbp: 204.0
dbp: 99.0
level of pain: 0
level of acuity: 2.0 | ___ year old male with h/o HTN who presents with staph aureus
bacteremia and a cavitary pneumonia.
# PNEUMONIA/FEVERS/CAVITARY LUNG LESION/ S aureus bacteremia:
Placed on Vanocmycin and tapered to Cefazolin 2gm q8hr per
sensitivities. TEE done with mild MR but no obvious ___.
FInal report pending. Has PICC placed. Will go home with home
infusion ABX in place. OPAT will follow labs (BUN, Cr, CBC
w/diff). If final TEE without ___ likely get 4wk IV
ABx (OPAT will determine). Quantiferon gold sent prior to
discharge and is pending (annual PPD negative per his report)
# Transaminitis: elevated ALT on admission and repeat. Imaging
suggested hepatic steatosis and borderlined splenomegaly. No
other clinical findings to suggest occult cirrhosis. HAV and
HBV immune per serology. No HCV exposure. Drinks ___ ETOH
daily which could contribute. Patient will f/u with PCP for
further evaluation -- may be ___.
# HTN: continue chlorthalidone
#Migraines: continue zomeg prn |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ceftin / Bactrim / Zocor / Lopressor / Rezulin / Ultram / Flagyl
/ Keppra / Compazine
Attending: ___.
Chief Complaint:
fever, dysuria
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS: ___ with history of gastric ulcers,
CAD s/p CABG, AVR with bovine valve not on anticoagulation, HTN,
DM, recent admission for urosepsis c/b e.coli bactermia and
NSTEMI, presents with 4 days of dysuria, increased frequency,
rigors and low grade fevers today to 100.0F, per daughter. ___
culture was obtained by ___ yesterday, and processed at ___
___, reportedly showing a urinary tract infection. No
antibiotics given as an outpatient. Patient and family deny
cough, congestion, sore throat, nausea, vomiting, or diarrhea.
Possibly has some left flank pain. Her last bowel movement was
yesterday and was formed. During her previous admission, her
NSTEMI sypmtoms consisted of shortness of breath.
In the ED intial vitals were: 99.3 75 115/54 20 100%RA. Labs
were significant for lactate 2.1, Cr 1.6, BUN 44, hct 32, WBC
10.1 (90%N). Blood cultures x2 sent. Urine not tested, patient's
daughter refused straight cath. CXR shows hardware from previous
surgery, enlarged heart, no obvious focal area of consolidation.
Patient was given tylenol and ceftriaxone. Vitals prior to
transfer were: 100.4 104 117/44 18 96% RA.
On the floor, patient is comfortable. No chest pain, shortness
of breath, lightheadedness, abdominal pain or suprapubic pain.
Her last episode of rigors was yesterday afternoon.
Review of Systems:
(+) as above
(-) night sweats, headache, vision changes, rhinorrhea,
congestion, sore throat, cough, shortness of breath, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, hematuria.
Past Medical History:
- Coronary artery disease
* CABG (___): LIMA-LAD, TSVG-RI, TSVG-OM, and PLA of RCA.
* Unstable angina ___, stress MIBI with fixed defect
- Chronic systolic heart failure (LVEF 40% in ___. Estimated
Dry Weight 150lbs.
- History of critical aortic stenosis. s/p bovine AVR (___)
- Hypertension
- Dyslipidemia
- CKD
- Diabetes mellitus, type II
- Carcinoid tumor of the lung (right middle lobe, s/p resection)
- Obstructive sleep apnea (oxygen-dependent since lung
resection; utilizes 2L nasal cannula O2 only at nighttime; no
BiPAP)
- Restrictive lung disease
- History of deep venous thrombosis (in ___ twice, s/p IVC
filter placement; no chronic anticoagulation since ___
- Carpel tunnel syndrome (bilateral decompressions, ___
- Anemia of chronic disease (baseline HCT ___
- Seizure disorder with first convulsive seizure ___ (noted
to have multiple episodes of non-convulsive status epilepticus
durng continuous EEG monitoring during that admission; on keppra
now) Thought to be due to some antibiotic ? and tramadol
PAST SURGICAL HISTORY:
- s/p right middle lobe resection, VATS for carcinoid tumor
(___)
- s/p intramedullary rod fixation of left subtrochanteric femur
fracture (___)
- s/p irrigation debridement left hip joint, arthrotomy,
exchange bipolar component left hip hemiarthroplasty (___)
- s/p debridement and irrigation of hip abscess, removal of
arthroplasty hardware components, antibiotic spacer placement,
VAC application for wound closure (___)
- s/p debridement irrigation hip hematoma, removal of antibiotic
spacer and placement of functional antibiotic spacer and
application of surface VAC sponge (___) for left septic hip
joint
Social History:
___
Family History:
Denies significant family history of cardiovascular disease,
early MI, arrhythmia or sudden cardiac death. Father with a
history of lung cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - 99.0, 91/43, 100, 18, 96% 2L
GENERAL: NAD, lying flat, breathing comfortably
HEENT: AT/NC, EOMI, PERRLA, anicteric sclera, pink conjunctiva,
patent nares, MMM, hirsuitism, good dentition, nontender supple
neck, no LAD, no JVD
CARDIAC: tachy, RR, S1/S2, ___ murmur, no gallops or rubs
LUNG: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles lying flat
ABDOMEN: obese, mildly distended, +BS, nontender in all
quadrants, no rebound/guarding, no hepatosplenomegaly. Bluish
hue over abd c/w old ecchymoses. No suprapubic tenderness.
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema, no obvious deformities
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vitals: 98.3/97.6 98/48 76 20 100% 2L sleeping (on RA during my
exam)
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, hard to evaluate JVP because patient has thick
neck
Lungs: Bibasilar crackles, otherwise CTAB with good air movement
CV: Regular rate and rhythm, normal S1 + S2, ___ systolic
ejection murmur best at LLSB
Abdomen: normoactive bowel sounds, soft, obese, non-tender,
non-distended, no rebound tenderness or guarding, could not
appreciate organomegaly but exam limited by body habitus
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: Warm, dry
Neuro: Mental status wnl, speech fluent and coherent, adequate
historian, Moving all extremities with full strength
Pertinent Results:
ADMISSION LABS:
___ 11:00PM BLOOD WBC-10.1# RBC-3.76* Hgb-10.5* Hct-32.1*
MCV-85 MCH-28.0 MCHC-32.7 RDW-15.0 Plt ___
___ 11:00PM BLOOD Neuts-89.7* Lymphs-5.6* Monos-4.2 Eos-0.3
Baso-0.2
___ 08:00AM BLOOD ___ PTT-30.7 ___
___ 11:00PM BLOOD Glucose-105* UreaN-44* Creat-1.6* Na-137
K-4.6 Cl-98 HCO3-23 AnGap-21*
___ 08:00AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.4*
___ 11:07PM BLOOD Lactate-2.1*
DISCHARGE LABS:
___ 08:30AM BLOOD WBC-4.2 RBC-3.56* Hgb-9.7* Hct-31.1*
MCV-87 MCH-27.3 MCHC-31.2 RDW-15.0 Plt ___
___ 08:30AM BLOOD Glucose-281* UreaN-28* Creat-1.3* Na-138
K-4.7 Cl-97 HCO3-28 AnGap-18
___ 08:30AM BLOOD ALT-91* AST-21 AlkPhos-332* TotBili-0.4
PERTINENT LABS/MICROBIOLOGY:
********OSH labs from ___
___ UA - Leuk esterase 3+, pH 7.5, ketones negative, WBC >
100, bacteria 1+
___ URINE CULTURE ___ labs) - Prot. mirabilis >100,000
cfu/mL
AMPICILLIN Sensitive MIC
CEFAZOLIN Sensitive MIC
CEFOXITIN Sensitive MIC
CEFTAZIDIME Sensitive MIC
CEFTRIAXONE Sensitive MIC
CEPHALOTHIN Sensitive MIC
CIPROFLOXACIN Sensitive MIC
Cefuroxime - Oral Sensitive MIC
Cefuroxime- I.V. Sensitive MIC
GENTAMICIN Sensitive MIC
LEVOFLOXACIN Sensitive MIC
NITROFURANTOIN Resistant MIC
TETRACYCLINE Resistant MIC
TOBRAMYCIN Sensitive MIC
TRIMETHOPRIM/SULFAMETHOXAZOLE Sensitive MIC
___ labs while inpatient********
___ 08:00AM BLOOD calTIBC-215* Ferritn-3267* TRF-165*
___ 08:00AM BLOOD Calcium-8.3* Phos-3.6 Mg-1.4* Iron-25*
___ 09:52AM URINE Color-Yellow Appear-Hazy Sp ___
___ 09:52AM URINE Blood-TR Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-LG
___ 09:52AM URINE RBC-3* WBC-65* Bacteri-FEW Yeast-NONE
Epi-3 TransE-<1
URINE CULTURE (Final ___:
ENTEROCOCCUS SP.. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS SP.
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ <=0.5 S
___ 06:25AM BLOOD ALT-557* AST-465* AlkPhos-562*
TotBili-1.6*
___ 06:00PM BLOOD ALT-476* AST-306* AlkPhos-563*
TotBili-1.1
___ 07:20AM BLOOD ALT-344* AST-156* AlkPhos-506*
TotBili-0.8
___ 07:30AM BLOOD ALT-228* AST-54* AlkPhos-409* TotBili-0.6
___ 08:30AM BLOOD ALT-168* AST-32 AlkPhos-386* TotBili-0.5
___ 07:55AM BLOOD ALT-126* AST-24 AlkPhos-361* TotBili-0.4
IMAGING:
___
FINDINGS:
There is normal in echogenicity without evidence focal mass.
These
gallbladder appears distended. Wall was mildly thickened, but
improved
compared with the prior ultrasound. Multiple small stones are
noted. There is no evidence pericholecystic fluid in it was a
negative sonographic ___ sign. There is no significant intra
or extrahepatic biliary ductal dilatation with the CBD measuring
1.9 mm. The visualized portions of the pancreas are
unremarkable without evidence of the mass or ductal dilatation.
D main portal vein was widely patent hepatopetal flow.
Visualized portions of the aorta an IVC are unremarkable.
IMPRESSION:
Cholelithiasis without sonographic evidence of cholecystitis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. NPH 14 Units Breakfast
NPH 4 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
2. Lidocaine 5% Patch 1 PTCH TD QAM right knee
3. Multivitamins 1 TAB PO DAILY
4. Nitroglycerin SL 0.3 mg SL ASDIR
5. Acetaminophen 650 mg PO ASDIR
6. Atorvastatin 40 mg PO DAILY
7. Calcium Carbonate 500 mg PO DAILY
8. Vitamin D 1000 UNIT PO DAILY
9. Docusate Sodium 100 mg PO BID:PRN constipation
10. Metoprolol Succinate XL 25 mg PO HS
11. Pantoprazole 40 mg PO Q24H
12. Polyethylene Glycol 17 g PO DAILY:PRN constipation
13. Senna 8.6 mg PO DAILY:PRN constipation
14. Torsemide 40 mg PO DAILY
15. bromfenac 0.07 % ophthalmic Qhs
16. ___ (cranberry extract) 500 mg oral BID
17. Nystatin Cream 1 Appl TP BID breasts
18. Guaifenesin 10 mL PO Q6H:PRN cough
Discharge Medications:
1. Atorvastatin 40 mg PO DAILY
2. bromfenac 0.07 % ophthalmic Qhs
3. Calcium Carbonate 500 mg PO DAILY
4. Docusate Sodium 100 mg PO BID:PRN constipation
5. Guaifenesin 10 mL PO Q6H:PRN cough
6. Lidocaine 5% Patch 1 PTCH TD QAM right knee
7. Metoprolol Succinate XL 25 mg PO HS
Hold for systolic blood pressure < 100 or HR < 60
8. Multivitamins 1 TAB PO DAILY
9. Nystatin Cream 1 Appl TP BID breasts
10. Pantoprazole 40 mg PO Q24H
11. Polyethylene Glycol 17 g PO DAILY:PRN constipation
12. Senna 8.6 mg PO DAILY:PRN constipation
13. Torsemide 40 mg PO DAILY
Hold for systolic blood pressure < 100 or HR < 60.
14. Vitamin D 1000 UNIT PO DAILY
15. Cepastat (Phenol) Lozenge 1 LOZ PO Q2H:PRN cough or sore
throat
RX *phenol [Cepastat] 14.5 mg Take 1 lozenge Up to every 2 hours
Disp #*90 Lozenge Refills:*0
16. Ciprofloxacin HCl 500 mg PO Q12H
Last dose is on ___
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth Every 12 hours
Disp #*5 Tablet Refills:*0
17. ___ (cranberry extract) 500 mg oral BID
18. Nitroglycerin SL 0.3 mg SL ASDIR
19. Amoxicillin 500 mg PO Q8H
last day = ___
RX *amoxicillin 500 mg 1 capsule(s) by mouth Every 8 hours Disp
#*30 Capsule Refills:*0
20. NPH 14 Units Breakfast
NPH 4 Units Dinner
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
------------------
PRIMARY DIAGNOSES
------------------
Urinary tract infection
Sepsis
Hypotension
Shock liver
------------------
SECONDARY DIAGNOSES
------------------
Chronic systolic congestive heart failure
Coronary artery disease
Acute renal failure
Chronic kidney disease, stage III
Diabetes mellitus type II, insulin dependent
Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
HISTORY: Abnormal LFTs, fever.
TECHNIQUE: Grayscale an Doppler ultrasound imaging of the abdomen was
performed.
COMPARISON: Ultrasound from ___ hand CT from ___.
FINDINGS:
There is normal in echogenicity without evidence focal mass. These
gallbladder appears distended. Wall was mildly thickened, but improved
compared with the prior ultrasound. Multiple small stones are noted. There
is no evidence pericholecystic fluid in it was a negative sonographic ___
sign. There is no significant intra or extrahepatic biliary ductal dilatation
with the CBD measuring 1.9 mm. The visualized portions of the pancreas are
unremarkable without evidence of the mass or ductal dilatation.
D main portal vein was widely patent hepatopetal flow. Visualized portions of
the aorta an IVC are unremarkable.
IMPRESSION:
Cholelithiasis without sonographic evidence of cholecystitis.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: FEVER/DYSURIA
Diagnosed with URIN TRACT INFECTION NOS
temperature: 99.3
heartrate: 75.0
resprate: 20.0
o2sat: 100.0
sbp: 115.0
dbp: 54.0
level of pain: 6
level of acuity: 3.0 | Ms. ___ is a ___ with history of gastric ulcers, CAD s/p
CABG, sCHF (LVEF 35-40%), AVR with bovine valve not on
anticoagulation, HTN, DM, recent admission for UTI with
resultant e/coli bacteremia, who presented with rigors and
dysuria and was admitted for sepsis with urinary tract
infection. She was stabilized, narrowed to PO antibiotics, and
is now being discharged home on a 10 day course of ciprofloxacin
(ending ___ and 14 day course of amoxicillin (ending
___.
--------------- |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / Sulfa (Sulfonamide Antibiotics) / minoxidil /
amlodipine
Attending: ___.
Chief Complaint:
Chest discomfort, shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ year old man with ESRD on HD TTS, HTN,
Prostate cancer, Mechanical heart valve on Coumadin, who
presented with chest pain and hematuria.
Patient reported central, nonradiating chest pressure that began
around midnight when he was going to sleep. The chest pressure
was associated w/ some sob and at times with non productive
coughs. Patient states he has had ___ months of intermittent
left sided (under his breast) chest pain that is not continuous
and he had it three times last week. He can walk long distances
without any pain but the chest pain is associated with SOB at
times. He was recently seen by cardiologist here (Dr. ___
and had a cardiac ECHO that shows a well seated aortic
mechanical valve with mild para-valvular leak and normal
Biventricular function. He also had a Holter monitor placed for
palpitations but results are unknown to patient for this test.
He denied any nausea, vomiting, or diaphoresis associated with
this pain. He had a cardiac catheterization reportedly in
___ with no coronary artery disease.
Also, he complained of hematuria since having a cystoscopy at
___ about 20 days ago. He has a history of prostate cancer that
was treated ___ years ago with radiation and he is followed by
Urology at ___. He also has a history of low grade bladder
cancer and recently underwent a cystoscopy with resection of
bladder tumor. He continued to have hematuria post-procedure,
sometimes with clots, and low urine output (has a little bit of
urine at baseline). Upon further asking him about his urine
output, patient reported very minimal-to-low urine output at
baseline. He saw his urologist 5 days prior to presentation, and
got bladder irrigation as outpatient. He reported lower
abdominal pain and "burning" associated with this, also since
the cystoscopy.
Per review of records, patient was seen back on ___ for
severe upper abdominal pain. At times, it was epigastric and at
other times seem more right-sided and radiating into the
subscapular area on the right side. CT scan the day prior to
the onset of this more
significant pain had revealed cholelithiasis with some very mild
wall thickening to suggest chronic cholecystitis. The patient's
very high risk for surgery given his need for long-term
anticoagulation and his other medical issues, we wanted to make
sure that the pain was from biliary colic and not another
etiology. Upper endoscopy on ___ revealed multiple erosions
in the gastric mucosa and a single antral AVM which was
nonbleeding. Given these findings, the patient was placed on a
PPI twice a day for an 8-week course, with improvement of his
symptoms.
#In the ED, initial vital signs were: 97.6 75 187/90 16 100% RA
- Exam notable for: a&o, well appearing, RRR, CTAB, abdomen w/
multiple old scars, non-distended, ttp in lower quadrants, no
CVAT
no leg edema
- Labs were notable for H/H 10.2/32.3, INR: 2.2, Trop T: 0.04
x2, CK: 102 MB: 2,
- Studies performed include CXR (see below) and EKG (NSR at 77
PR 154 QRS 95 QTc 475 NA/NI)
- Consults included renal
During workup of the patient's chest pain in the ___ ED today,
the patient stated that he was having difficulty urinating. As
such, there were several attempts to place a urethral catheter,
although the ED team was unsure of correct location. They
reported having tried a ___ three way, 20 and ___ coudes, and a
___ straight catheter. All were without return of urine. It
should be noted, however, that bladder scan in the ED showed no
detectable urine in the bladder. Urology was contacted for
further recommendations
Also, patient had an HD session before arrival to the floor. He
had excruciating abdominal pain that was treated with dilaudid.
Urology successfully put a foley catheter.
#Upon arrival to the floor, the patient was comfortable and in
no acute distress. He described burning in the bladder and
urethra, as well as burning in the mid-back. He confirmed the
history detailed above.
Past Medical History:
PMH: ESRD due to hypertensive nephropathy on HD ___,
hypertension, valvular heart disease s/p St ___ valve
replacement, prostate CA with radiation treatment (___)
PSH: PD catheter placement, replacement of PD catheter
(___), removal of PD catheter (___), incisional hernia
repair with mesh (___), right inguinal hernia repair with
mesh
(___), LUE brachiocephalic AV fistula (___), revision
with
banding of LUE AV fistula (___), feducial placement ___
years ago) for XRT of prostate at ___ per pt
Social History:
___
Family History:
Denies FH of heart disease, diabetes, and "stomach problems"
Physical Exam:
PHYSICAL EXAMINATION ON ADMISSION:
==================================
Vitals: 98.2 180/94 70 18 100%RA
General: Alert, oriented, no acute distress, ___ speaking
but knows a little ___
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, mechanical heart sounds, no
murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Signs of multiple scars, soft, tender to palpation in
RUQ, epigastric region, non-distended, bowel sounds present, no
organomegaly, no rebound or guarding
Back: endorses pain to palpation over mid-back, no vertebral or
paravertebral tenderness
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait
deferred.
PHYSICAL EXAMINATION ON DISCHARGE:
==================================
Vitals: 98.7 140-160/80-100 70's 18 100%RA
General: Alert, oriented, no acute distress, ___ speaking
but knows a little ___
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, mechanical heart sounds, no
murmurs, rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Signs of multiple scars, soft, non-tender to
palpation, non-distended, bowel sounds present, no organomegaly,
no rebound or guarding
Back: No vertebral or paravertebral tenderness to palpation
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
Pertinent Results:
LABS ON ADMISSION:
==================
___ 05:15AM BLOOD WBC-8.8 RBC-3.37* Hgb-10.2* Hct-32.3*
MCV-96 MCH-30.3 MCHC-31.6* RDW-14.1 RDWSD-48.8* Plt ___
___ 05:15AM BLOOD Neuts-61.9 ___ Monos-11.8 Eos-3.2
Baso-1.0 Im ___ AbsNeut-5.46 AbsLymp-1.93 AbsMono-1.04*
AbsEos-0.28 AbsBaso-0.09*
___ 05:15AM BLOOD ___ PTT-42.9* ___
___ 05:15AM BLOOD Plt ___
___ 05:15AM BLOOD Glucose-86 UreaN-67* Creat-13.8*# Na-140
K-5.3* Cl-94* HCO3-27 AnGap-24*
___ 05:15AM BLOOD ALT-13 AST-22 LD(LDH)-225 CK(CPK)-102
AlkPhos-57 TotBili-0.4
___ 05:15AM BLOOD CK-MB-2
___ 05:15AM BLOOD cTropnT-0.04*
___ 08:35AM BLOOD cTropnT-0.04*
___ 07:25PM BLOOD CK-MB-1 cTropnT-0.05*
___ 05:15AM BLOOD Calcium-10.0 Phos-5.8* Mg-2.2
LABS ON DISCHARGE:
==================
___ 06:20AM BLOOD WBC-8.2 RBC-3.26* Hgb-9.9* Hct-31.7*
MCV-97 MCH-30.4 MCHC-31.2* RDW-14.3 RDWSD-50.4* Plt ___
___ 06:20AM BLOOD Plt ___
___ 06:20AM BLOOD ___ PTT-38.5* ___
___ 06:20AM BLOOD Glucose-81 UreaN-31* Creat-8.5*# Na-141
K-4.8 Cl-99 HCO3-32 AnGap-15
___ 06:20AM BLOOD CK(CPK)-68
___ 06:20AM BLOOD CK-MB-<1 cTropnT-0.06*
___ 06:20AM BLOOD Calcium-9.0 Phos-4.6* Mg-2.0
PERTINENT TESTS:
================
___ CXR:
1. Slightly increased pulmonary vascular congestion with new
mild pulmonary edema.
2. Stable mild cardiomegaly.
#EKG:
Sinus rhythm, no ST-T wave changes
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 20 mg PO DAILY
2. Metoprolol Succinate XL 100 mg PO DAILY
3. Warfarin 6 mg PO DAILY16
4. Simvastatin 20 mg PO QPM
5. Cinacalcet 30 mg PO DAILY
6. Omeprazole 40 mg PO BID
7. Vitamin E 400 UNIT PO DAILY
8. Calcitriol 1 mcg PO 3X/WEEK (___)
9. saw ___ Dose is Unknown oral Unknown
10. Placebo #00 (cellulose (bulk)) unknown ORAL DAILY
Discharge Medications:
1. Cinacalcet 30 mg PO DAILY
2. Lisinopril 20 mg PO DAILY
3. Metoprolol Succinate XL 100 mg PO DAILY
4. Omeprazole 40 mg PO BID
5. Simvastatin 20 mg PO QPM
6. Vitamin E 400 UNIT PO DAILY
7. Warfarin 6 mg PO DAILY16
8. Oxybutynin 5 mg PO Q8H:PRN Bladder pain
9. saw ___ Dose is Unknown ORAL Frequency is Unknown
10. Calcitriol 1 mcg PO 3X/WEEK (___)
11. Placebo #00 (cellulose (bulk)) unknown ORAL DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Atypical chest pain
Hematuria
SECONDARY DIAGNOSES:
End-stage renal disease
Gastritis
Anemia
Hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with chest pain, SOB, evaluate for acute process.
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior chest radiographs dating back to ___.
FINDINGS:
Mild pulmonary vascular congestion has increased compared with the prior study
with new Kerley B lines consistent mild pulmonary edema. 6 intact median
sternotomy wires and an aortic valve prosthesis are unchanged. There is no
focal consolidation, pleural effusion, or pneumothorax. The cardiomediastinal
silhouette, including mild cardiomegaly, is unchanged.
IMPRESSION:
1. Slightly increased pulmonary vascular congestion with new mild pulmonary
edema.
2. Stable mild cardiomegaly.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 8:05 AM, 6 minutes
after discovery of the findings.
Gender: M
Race: HISPANIC/LATINO - DOMINICAN
Arrive by AMBULANCE
Chief complaint: Chest pain, Cough
Diagnosed with Hematuria, unspecified
temperature: 97.6
heartrate: 75.0
resprate: 16.0
o2sat: 100.0
sbp: 187.0
dbp: 90.0
level of pain: 3
level of acuity: 2.0 | ___ year old man with ESRD on HD TTS, HTN and mechanical heart
valve on Coumadin here with chest pain and hematuria. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
amoxicillin / codeine / Sulfa (Sulfonamide Antibiotics) / niacin
/ latex / Augmentin
Attending: ___
Chief Complaint:
Leak around anastomosis
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ PMH diabetes, Factor V leiden on Coumadin, recent
laparoscopic colectomy due to polyposis ___ at ___
presenting with redness around surgical incision. She refers
feeling fine and home but htat the wound started to look red and
have some fluid exudate. She was CT scan in ___ which
found no abscess but some evidence of cellulitis. CT scan also
shows mesenteric vein thrombosis and possible hepatic infarct.
INR subtherapeutic at 1.52. She denies any significant abdominal
pain, citing only mild lower abdominal pain on palpation. Denies
fevers, chills, vomiting or diarrhea. Was seen at ___ where
she underwent a CT scan showing a mesenteric vein thrombosis for
which she was started on heparin, and given meropenem to cover
for possible pseudomonal infection.
Past Medical History:
PMH:
Diabetes
HTN
asthma
Factor V leiden
Bronchitis
Attenuated polyposis syndrome
PSH:
COLECTOMY ___
laparoscopic total abdominal colectomy and ileocolonic
anastomosis
Social History:
___
Family History:
___ cousin with ___ disease, mother with kidney cancer,
father
with attenuated polyposis.
pulmonary embolism
Physical Exam:
Vitals: Stable
General: AAOx3
Cardiac: WNL
Respiratory: RA, equal breath sounds
Abdomen: Soft, non-tender, no rebound or guarding
Radiology Report
EXAMINATION: CT ABD AND PELVIS W AND W/O CONTRAST, ADDL SECTIONS
INDICATION: ___ year old woman s/p lap colectomy with primary anastomosis now
with anastamotic leakPR CONTRAST ONLY// ?abscess
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.
Rectal contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 8.7 s, 56.4 cm; CTDIvol = 31.0 mGy (Body) DLP =
1,727.8 mGy-cm.
Total DLP (Body) = 1,728 mGy-cm.
COMPARISON: CT from ___.
FINDINGS:
LOWER CHEST: Bibasilar atelectasis is noted. There is no evidence of pleural
or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. A wedge-shaped area of peripheral hypodensity in the right hepatic lobe
is unchanged and consistent with fatty changes after known hepatic infarction.
there is no evidence of intrahepatic or extrahepatic biliary dilatation. The
gallbladder is within normal limits. Small volume ascites.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no evidence
of focal renal lesions within the limitations of an unenhanced scan. A 2.2 cm
cyst is seen arising from the interpolar region of the right kidney. There is
no hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: The stomach is unremarkable. The patient is status post
colectomy and primary anastomosis. Contrast reaches and extends beyond the
anastomosis without evidence of leak. A focus of high-density material in the
left hemiabdomen is likely within a loop of small bowel (2; 52). Adjacent to
the anastomosis there is a 6.1 x 6 soft tissue density collection which
contains multiple foci of gas (2; 62). There is extensive surrounding soft
tissue stranding.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are grossly within
normal limits.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Mild atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture. A
chronic left tenth posterolateral rib fracture is noted.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. No evidence ongoing anastomotic leak.
2. 6.1 cm area of phlegmonous changes adjacent to the anastomosis with
internal foci of gas. No clear or well circumscribed fluid component is
identified.
3. Small volume ascites.
Radiology Report
EXAMINATION: CT interventional procedure
INDICATION: ___ with Factor V Leiden disease on Coumadin, lap ileo sigmoid
colectomy with primary anastomosis on ___, recently surgical admission for
mesenteric vein thrombosis and hepatic infarct now w/ abscess on CT on ___//
drain and send for cultures
COMPARISON: CT abdomen and pelvis ___ and CT of the abdomen ___
PROCEDURE: CT-guided drainage placement.
OPERATORS: Dr. ___, radiology fellow and Dr. ___,
attending radiologist. Dr. ___ personally supervised the trainee
during the key components of the procedure planning and reviewed and agrees
with the trainee's findings.
TECHNIQUE: Preprocedural images were obtained to evaluate the abdomen.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.3 s, 33.2 cm; CTDIvol = 40.4 mGy (Body) DLP =
1,351.1 mGy-cm.
Total DLP (Body) = 1,351 mGy-cm.
SEDATION: None.
FINDINGS:
There is no drainable fluid collection present. There are mild phlegmonous
changes present with significantly decreased foci of gas in comparison to the
prior CT examinations of ___ and ___. These changes are
adjacent to the anastomosis. No clear well-circumscribed fluid component is
identified.
IMPRESSION:
No drainable fluid collection present. Improving phlegmonous changes adjacent
to the anastomosis with decreased internal foci of gas. No clear
well-circumscribed fluid component is identified for drainage. Overall
appearance is significantly improved in comparison to prior CT examinations of
___ and ___.
NOTIFICATION: The decision to defer the procedure due to no drainable
collection was discussed by Dr. ___ with Dr. ___ at 628pm on
___.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with Factor V Leiden disease on Coumadin, lap ileo sigmoid
colectomy with primary anastomosis on ___, recently surgical admission for
mesenteric vein thrombosis and hepatic infarct now with leak around surgical
anastomosis.// CXR as patient newly wheeze and sats in ___ now in ___ on 3L
nasal cannula
TECHNIQUE: Portable AP radiograph of the chest.
COMPARISON: Radiograph of the chest performed 5 days prior
FINDINGS:
Mild cardiomegaly is seen. Mild pulmonary vascular congestion mild pulmonary
edema has progressed compared to the prior exam. Small bilateral pleural
effusions are seen. Bibasilar atelectasis. No evidence of pneumothorax.
Visualized osseous structures are unremarkable.
IMPRESSION:
-Mild pulmonary vascular congestion and mild pulmonary edema, progressed
compared to the prior exam.
-Small bilateral pleural effusions.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with Factor V Leiden disease on Coumadin, lap ileo sigmoid
colectomy with primary anastomosis on ___, recently surgical admission for
mesenteric vein thrombosis and hepatic infarct now with leak around surgical
anastomosis w/ SOB// eval for interval change eval for interval change
IMPRESSION:
Comparison to ___. Stable low lung volumes. Stable moderate
cardiomegaly. Mild pulmonary edema is present. No pneumonia, no pleural
effusions. No pneumothorax.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS BILATERAL
INDICATION: ___ year old woman with factor V leiden def on coumadin// ?DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
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.
Neck focus adjacent to the right common femoral vein, likely calcifications
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: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Transfer
Diagnosed with Unspecified abdominal pain
temperature: 98.5
heartrate: 66.0
resprate: 18.0
o2sat: 96.0
sbp: 120.0
dbp: 76.0
level of pain: 0
level of acuity: 3.0 | Patient was admitted after recently being discharged. A CT A/P
was performed in the emergency room demonstrating a phelgmon
proximal to the anastomosis consistent with a leak. However, the
patient appeared very well. She was hemodynamically stable and
denied any abdominal pain. Patient was started on Zosyn and a
regular diet. ___ was called for potential drainage with no
drainable collection.
However, patient continue to do well. Patient did not spike
fever, did not experience nausea/vomiting. She will be
discharged home on a total of 14 days of antibiotics as well as
therapeutic lovenox. We recommend that she follow-up with her
PCP for bridging from Lovenox to Coumadin. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
weakenss
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ yo woman with a history of multiple punctate
strokes in the right hemisphere and a single punctate stroke in
the left frontal lobe in ___, s/p right CEA ___, DM, HLD,
HTN who presents with left arm shaking and bilateral leg
weakness.
She was normal at 6 am. She did housework and then took a nap.
When she woke up at 10:30 am, her left arm was shaking
(trembling) and both legs felt weak. The onset of these symptoms
is unclear, as is the time course of resolution. She called her
daughter, who brought her to the ED. It is unclear if she was
able to ambulate at the time.
The left arm is now normal in the ED. She thinks her legs are
getting better but hasn't been up to walk yet. However she
states she still feels weak and not back to normal. She denies
vertigo.
Past Medical History:
Past Medical History:
DM, glaucoma (legally blind), HLD, HTN
Past Surgical History:
cholecystectomy, L eye surgery ___
Social History:
___
Family History:
DM
Physical Exam:
exam:
VITALS - 98.5 ___ 100% on RA
GENERAL - pleasant, well-appearing, in no apparent distress
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, pupils unequal R>L, EOMI, OP clear
NECK - supple, no LAD, no thyromegaly, JVP =
CARDIAC - regular rate & rhythm, normal S1/S2, no murmurs rubs
or gallops
PULMONARY - clear to auscultation bilaterally, without wheezes
or rhonchi
ABDOMEN - normal bowel sounds, soft, non-tender, non-distended,
no organomegaly
EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or
edema
SKIN - without rash
NEUROLOGIC - A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout. Gait assessment deferred
PSYCHIATRIC - listen & responds to questions appropriately,
pleasant
Pertinent Results:
___ 05:00AM GLUCOSE-129* UREA N-12 CREAT-0.9 SODIUM-141
POTASSIUM-4.2 CHLORIDE-101 TOTAL CO2-29 ANION GAP-15
___ 05:00AM CALCIUM-9.8 PHOSPHATE-3.5 MAGNESIUM-1.9
CHOLEST-260*
___ 05:00AM %HbA1c-7.1* eAG-157*
___ 05:00AM TRIGLYCER-70 HDL CHOL-90 CHOL/HDL-2.9
LDL(CALC)-156*
___ 05:00AM TSH-2.0
___ 05:00AM WBC-6.2 RBC-4.41 HGB-12.7 HCT-39.8 MCV-90
MCH-28.8 MCHC-31.9* RDW-12.2 RDWSD-40.1
___ 05:00AM PLT COUNT-207
___ 04:48PM URINE HOURS-RANDOM
___ 04:48PM URINE HOURS-RANDOM
___ 04:48PM URINE UHOLD-HOLD
___ 04:48PM URINE GR HOLD-HOLD
___ 04:48PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:48PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-NEG
___ 03:49PM GLUCOSE-129* UREA N-13 CREAT-1.0 SODIUM-142
POTASSIUM-4.0 CHLORIDE-104 TOTAL CO2-26 ANION GAP-16
___ 03:49PM estGFR-Using this
___ 03:49PM CALCIUM-10.1 PHOSPHATE-3.5 MAGNESIUM-1.9
___ 03:49PM WBC-5.4 RBC-4.49 HGB-12.9 HCT-40.0 MCV-89
MCH-28.7 MCHC-32.3 RDW-12.2 RDWSD-40.2
___ 03:49PM NEUTS-71.3* ___ MONOS-5.9 EOS-0.6*
BASOS-0.6 IM ___ AbsNeut-3.88 AbsLymp-1.16* AbsMono-0.32
AbsEos-0.03* AbsBaso-0.03
___ 03:49PM PLT COUNT-220
___ 03:49PM ___ PTT-30.7 ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO DAILY
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
4. bimatoprost 0.01 % ophthalmic QHS
5. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
6. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
7. glipiZIDE-metformin 2.5-500 mg oral BID
8. Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Atorvastatin 40 mg PO DAILY
RX *atorvastatin 40 mg 1 tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES BID
RX *brimonidine 0.15 % 1 drop optho twice a day Refills:*0
4. Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
RX *dorzolamide 2 % 1 drop eye three times a day Refills:*0
5. Lisinopril 10 mg PO DAILY
RX *lisinopril 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
6. Timolol Maleate 0.5% 1 DROP BOTH EYES BID
RX *timolol [Betimol] 0.5 % 1 drop eye twice a day Refills:*0
7. bimatoprost 0.01 % ophthalmic QHS
RX *bimatoprost [Lumigan] 0.01 % 1 drop eye at night Refills:*0
8. glipiZIDE-metformin 2.5-500 mg oral BID
RX *glipizide-metformin 2.5 mg-500 mg 1 tablet(s) by mouth twice
a day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
left hand weakness
SECONDARY DIAGNOSIS:
hypertension
type 2 diabetes
glaucoma
hyperlipidemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T9113 MR HEAD
INDICATION: ___ year old female with history of stokes, status post recent
episode of transient weakness. Evaluate for acute infarct.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON ___ head and neck CTA.
___ brain MRI/ MRA and neck MRA.
FINDINGS:
Study is mildly degraded by motion. There is no evidence of hemorrhage,
edema, masses, mass effect, midline shift or infarction. There is prominence
of the ventricles and sulci suggestive involutional changes. Periventricular
and subcortical T2 and FLAIR hyperintensities are noted. There is a new
punctate focus of susceptibility in the right frontal lobe. The major
vascular flow voids are preserved.
Left cataract extraction changes are seen. Air-fluid level seen in the
sphenoid sinus. Mastoid air cells are normal.
IMPRESSION:
1. Study is mildly degraded by motion.
2. No acute infarct.
3. Paranasal sinus disease concerning for acute sinusitis as described.
4. Chronic changes as described.
5. New probable right frontal punctate microhemorrhage.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Dizziness
Diagnosed with Weakness, Oth symptoms and signs involving the circ and resp systems
temperature: 99.2
heartrate: 104.0
resprate: 16.0
o2sat: 100.0
sbp: 165.0
dbp: 76.0
level of pain: 0
level of acuity: 2.0 | Mrs. ___ is a ___ with history of stroke and CAE in ___ who
presented with weakness on the left arm and lower limb which
resolved spontaneously by the time she reached the ED (<3
hours). She was seen by neurology and was found to have
reassuring neurologic exam. A CTA head and neck was obtained
which showed no acute pathology. She was noted to be mildly
hypertensive and she reported she had not been taking any of her
home medications for several months as she was feeling well
previously. She was admitted to medicine service for stroke
workup and medication counseling. MRI brain was obtained, which
showed no acute infarct and she was started on her home
medications without issue.
CHRONIC ISSUES
================
# T2DM: The patient has T2DM on oral agents. during her
admission period we held her glipizide/metformin and started her
on ___ while inpatient.
# CV risk modification:
- Continued Aspirin 81 mg PO DAILY
- Continued Atorvastatin 40 mg PO DAILY
# Glaucoma:
- Continued Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES
BID
- Substituted latanoprost for bimatoprost while in house
- Continued Dorzolamide 2% Ophth. Soln. 1 DROP BOTH EYES TID
- Continued Timolol Maleate 0.5% 1 DROP BOTH EYES BID
# Hypertension:
- Continued lisinopril
TRANSITIONAL:
======================
[] please continue patient medication education and encourage
taking home medications.
[] restarted aspirin 81mg daily which we recommend continuing
indefinitely.
[] recommend outpatient echocardiogram to evaluate for PFO or
valve dysfunction that may lend to embolism.
[] follow-up with neurology.
# CONTACT: ___ (son) ___
# CODE STATUS: Full presumed |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Niacin Preparations / Novocain
Attending: ___.
Chief Complaint:
Lightheadedness/Dizziness
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with PMH afib, ___, HTN, prior CVA x2, presenting from
___ with dizziness/weakness. Dizziness described as
feeling "lightheaded" on standing and like she is unsteady on
her feet, usually in the morning or after lying in bed for a
long time. Admits to poor appetite and po intake at baseline
which has been stable. Did have an episode of nausea, vomiting
yesterday shortly after eating a muffin. No nausea or vomiting
currently. Denies diarrhea. No fevers, chills, sweats. Has not
noticed any blood in her urine or stool, though she reports she
does not examine her stool. No other bleeding that patient has
noticed. She was sent in for dehydration per NH report. Pt fell
on ___ and ___, no injuries from the fall. No head injury.
Of note, pt was recently seen in ED on ___ also for mechanical
fall - head/neck CT negative. INR 2.5 as of ___. No falls since
___.
.
In the ED, VS 99.7 72 138/78 18 95%. orthostatic BP's
___ on sitting. Lungs CTAB. CV - irregularly
irregular. Abdomen benign. No neurologic deficits. AOx3.
+Several areas of ecchymosis on R thigh/elbow from fall. Guaiac
negative. Labs significant for Hct 33.9 (39.3 on ___, INR
3.7, K 3.5, Mg 1.9. CT head - no acute intracranial process.
EKG: a-flutter. Pt given 500cc NS gently at 100cc/hr. Admitted
for symptomatic anemia
Past Medical History:
1. Atrial fibrillation
2. H/O CVA x2 ___ and ___
3. Hypertension
4. Hyperlipidemia
5. Hypothyroidism
6. Myeloproliferative disorder, polycythemia ___
7. H/O malignant left parotid tumor now s/p resection and
radiation in ___
8. H/O nonmalignant right parotid mass s/p resection benign
9. GERD with hiatal hernia
10. Scattered non-calcified pulmonary nodules-followed with
yearly CT scans
Social History:
___
Family History:
Perimenopausal daughter with breast CA.
HTN
Hyperlipidemia
DM
Physical Exam:
Admission PE:
VITALS: 98.5, 150/88, 88, 18, 93% RA
GENERAL: elderly female in NAD
HEENT: PERRL, EOMI
LUNGS: CTAB, poor inspiratory effort
HEART: rapid rate, irregularly irregular, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no HSM
EXTREMITIES: No c/c/e
Neuro:CN grossly intact, no focal defecits. A&Ox3
Discharge PE
VITALS: 98.3, 118/66, 75, RR18, 97% RA. Not orthostatic.
GENERAL: elderly female in NAD
HEENT: PERRL, EOMI
LUNGS: fine crackles base of LLL, poor inspiratory effort
HEART: rrr, normal S1 S2, no MRG
ABDOMEN: Soft, NT, NABS, no HSM
EXTREMITIES: No c/c/e
Neuro:CN grossly intact, no focal defecits. A&Ox3
Pertinent Results:
Admission Labs:
___ 03:00PM BLOOD WBC-4.9 RBC-3.27* Hgb-11.3* Hct-33.9*
MCV-104* MCH-34.6* MCHC-33.4 RDW-14.8 Plt ___
___ 03:00PM BLOOD Plt ___
___ 03:00PM BLOOD Glucose-106* UreaN-14 Creat-0.8 Na-137
K-3.5 Cl-100 HCO3-27 AnGap-14
___ 03:00PM BLOOD Calcium-8.1* Phos-2.9 Mg-1.9 UricAcd-5.2
Discharge Labs
___ 08:30AM BLOOD WBC-4.1 RBC-3.59* Hgb-12.3 Hct-38.0
MCV-106* MCH-34.4* MCHC-32.5 RDW-14.8 Plt ___
___ 08:30AM BLOOD ___ PTT-38.1* ___
___ 08:30AM BLOOD Glucose-140* UreaN-10 Creat-0.9 Na-138
K-4.1 Cl-99 HCO3-28 AnGap-15
___ 08:30AM BLOOD Phos-3.5 Mg-2.1
___ 01:10PM BLOOD TSH-0.77
___ 03:00PM BLOOD VitB12-369 Folate-7.4 Hapto-166
Head CT:
IMPRESSION: No acute intracranial process. No change from ___.
CXR:IMPRESSION: No evidence of acute disease.
Medications on Admission:
Preadmissions medications listed are incomplete and require
futher investigation. Information was obtained from
Family/Caregiver.
1. Atorvastatin 20 mg PO DAILY
2. Hydroxyurea 500 mg PO 3X/WEEK (___)
3. Levothyroxine Sodium 112 mcg PO DAILY
4. Mirtazapine 30 mg PO HS
5. Aspirin 81 mg PO DAILY
6. Furosemide 40 mg PO DAILY
7. Warfarin 1 mg PO DAILY16
Do not give on ___. Give 2mg instead
8. Omeprazole 20 mg PO DAILY
9. Warfarin 2 mg PO ___
2mg on ___
10. azelastine *NF* 0.05 % ___ BID PRN
1 drop to affected eye
11. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
12. Loratadine *NF* 10 mg Oral daily
13. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
14. Metoprolol Tartrate 75 mg PO BID
15. Vitamin D 1000 UNIT PO DAILY
16. Proctosol HC *NF* (hydrocorTISone) 2.5 % Rectal BID
17. Nitroglycerin SL 0.3 mg SL PRN chest pain
1 tab under tongue every 5 min as needed for chest pain, up to 3
doses
18. Senna 1 TAB PO BID:PRN constipation
19. tetrahydrozoline *NF* 0.05 % ___ prn conjunctivitis
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 20 mg PO DAILY
3. Furosemide 20 mg PO DAILY
4. Levothyroxine Sodium 112 mcg PO DAILY
5. Metoprolol Tartrate 75 mg PO BID
6. Mirtazapine 30 mg PO HS
7. Omeprazole 20 mg PO DAILY
8. Senna 1 TAB PO BID:PRN constipation
9. Vitamin D 1000 UNIT PO DAILY
10. Warfarin 1 mg PO DAILY16
Do not give on ___. Give 2mg instead
11. azelastine *NF* 0.05 % ___ BID PRN
1 drop to affected eye
12. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
13. Hydroxyurea 500 mg PO 2X/WEEK (___)
___
14. Loratadine *NF* 10 mg Oral daily
15. Nitroglycerin SL 0.3 mg SL PRN chest pain
1 tab under tongue every 5 min as needed for chest pain, up to 3
doses
16. Proctosol HC *NF* (hydrocorTISone) 2.5 % Rectal BID
17. tetrahydrozoline *NF* 0.05 % ___ prn conjunctivitis
18. Warfarin 2 mg PO ___
2mg on ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Orthostasis secondary Afib and volume depletion
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
CHEST RADIOGRAPHS
HISTORY: Atrial fibrillation and congestive heart failure, presenting with
weakness and dizziness.
COMPARISONS: ___.
TECHNIQUE: Chest, PA and lateral.
FINDINGS: The heart is mildly enlarged. There is similar unfolding and
calcification along the aorta. The mediastinal and hilar contours appear
unchanged. There is no pleural effusion or pneumothorax. There is mild
background coarsening of lung markings but no definite pulmonary vascular
congestion or focal consolidation. There is no pneumothorax. Mild
degenerative changes are similar along the mid thoracic spine. The bones are
probably demineralized to some extent.
IMPRESSION: No evidence of acute disease.
Radiology Report
INDICATION: ___ with A-Fib, evaluate for bleed.
TECHNIQUE: CT of the head.
COMPARISON: Head CT from ___.
FINDINGS:
CT OF THE HEAD:
There are stable encephalomalacic changes in the right frontal and parietal
lobes consistent with prior unchanged regions of infarction in a
watershed-type distribution between major arterial vascular territories. A
lacular infarct in the right basal ganglia is also unchanged. There are
moderate confluent centrum semiovale and periventricular hypodensities most
consistent with sequela of chronic small vessel disease. There is unchanged
mild dilatation of the ventricles due to ex vacuo dilatation from mild brain
atrophy. There is no acute hemorrhage, no acute large territorial infarction
or mass effect. There are no suspicious lytic or sclerotic bony lesions, no
fractures.
IMPRESSION: No acute intracranial process. No change from ___.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: DIZZY/WEAK
Diagnosed with HEAD INJURY UNSPECIFIED, CONTUSION OF FACE, SCALP, & NECK EXCEPT EYE(S), VERTIGO/DIZZINESS, OTHER FALL, HYPERTENSION NOS, DEMENTIA, UNSPECIFIED, WITHOUT BEHAVIORAL DISTURBANCE
temperature: 99.7
heartrate: 72.0
resprate: 18.0
o2sat: 95.0
sbp: 138.0
dbp: 78.0
level of pain: 0
level of acuity: 3.0 | ___ with PMH afib, dCHF, HTN, prior CVA x2, presenting from
___ with dizziness/weakness. Dizziness described as
feeling "lightheaded" on standing usually in the morning
# Orthostasis/dizziness: Patinet came in complaining of
lightheadedness and the sensation of the room tilting when she
was standing up. This unsteadiness resulted in several falls
over the last few days. In the ED, a head CT was negative for
any acute intracranial process. An EKG showed atrial
fibrillation with rvr (~150bpm) and on orthostatic exam the
patients SBP dropped from 135 to 95 upon standing. Pt responded
well to 100mg of metoprolol and soon converted back into sinus
rhythm. Causes of the patient's orthostasis werer thought to be
related to volume depletion as she has had poor PO intake
recently and her afib . Anemia was also considered as etiology
of symptoms as her admission CBC showed a drop of HCT from 39 to
34 over 3 days. This was felt to be less likelty as patient had
no fatigue/weakness and relatively high hct with no signs of
bleeding or hemolysis. The patient remained in SR for the
duration of the admission and orthostatis removed. She received
several liters throughout admission and showed no signs of fluid
overload. On discharge, her dizziness is greatly improved.
# Polycythemia ___: HCT, while below baseline on ED CBC,
trended up on repeat labs to 38. Hemolysis labs were
unremarkable and there was no signs of bleeding (guiac neg in
ED). Patient's CBC has trended lower over the last year with
fluctuance in HCT. Uncertain cause but may be secondary to
progressive fibrosis. However, other cell lines appear normal.
Hydroxyurea was held throughout admission in setting of low HCT
and should be started back as 2x a week medication instead of 3x
per Heme. She will follow up with them as an outpt next month.
She should have a CBC drawn in 2 weeks prior to appointment. TSH
and B12 were wnl.
.
# Afib with RVR: patient converted back to sinus rhythm soon
after admission. She required 100mg metoprolol for RVR to
150bpm. Pt was maintained on daily dose of metroprolol 75mg BID
throughout the admission without complication. Pt's ECG shows
enlarged P waves making conversion back into afib likely in the
future. Pt will follow up with cardiologist as an outpatient.
Warfarin was restarted after being held for several days for
supratheraputic INR. INR is 2.2 on discharge.
# H/o atypical cells on urine cytology: Found ___ hematuria at
last hospitalization. N hematuria since then or during this
admission. It was believed that with a clean UA, this previous
finding was not contributing to current symtoms. Pt was made an
appointment with urology to follow up.
#Family meeting: Prior to discharge, a family meeting was held
with daughter and 2 sons, ___ (___ work), Dr.
___, and Dr. ___. Pts recent falls
were discussed and ___ were made in her medication to
prevent dizziness and lightheadedness. It was decided to
continue pt on warfarin and make changes in living situation and
family was informed that an added level of care would be optimal
at this time. The pros and cons of wafarin therapy were
discussed. Patient's PVC and atypical urine cytology findings
were also discussed and a follow up plan was established. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Right flank pain
Major Surgical or Invasive Procedure:
Ureteral stent placement
History of Present Illness:
___ year old female who
presents with worsening right flank pain and nausea. She was
seen
at ___ 2 days ago with similar symptoms. CT
imaging
at the OSH did not show any obstructing stones however patient
was told that she likely had passed a stone. She has developed
worsening flank pain, nausea and chills which prompted her to
return to the ___ ED. She was noted to be tachycardic HR 115
and febrile to ___. Lab work significant for white count of
9.8,
normal Cr 0.7 and positive UA (nitrite positive, 93 wbc per hpf
and few bacteria). CT imaging was performed which confirmed a
3-4mm stone at he right UVJ and associated
hydroureteronephrosis.
She reports dysuria, urinary urgency and frequency. No gross
hematuria.
No prior urologic history, no prior history of nephrolithiasis.
Past Medical History:
healthy
Social History:
___
Family History:
n/a
Physical Exam:
Gen: Alert and oriented
Heart: RR
Lungs: Respirations non-labored
Abd: Soft, ND
Flank: Non tender
Ext: WWP
Pertinent Results:
___ 05:57AM BLOOD WBC-8.9 RBC-3.35* Hgb-10.4* Hct-31.4*
MCV-94 MCH-31.0 MCHC-33.1 RDW-11.6 RDWSD-40.2 Plt ___
___ 01:05AM BLOOD WBC-7.7 RBC-3.10* Hgb-9.8* Hct-29.2*
MCV-94 MCH-31.6 MCHC-33.6 RDW-11.7 RDWSD-40.4 Plt ___
___ 05:45AM BLOOD WBC-10.3* RBC-3.53* Hgb-11.0* Hct-33.0*
MCV-94 MCH-31.2 MCHC-33.3 RDW-11.5 RDWSD-38.6 Plt ___
___ 05:57AM BLOOD Glucose-86 UreaN-7 Creat-0.6 Na-138 K-4.0
Cl-106 HCO3-20* AnGap-12
___ 01:05AM BLOOD Glucose-87 UreaN-5* Creat-0.5 Na-137
K-3.9 Cl-105 HCO3-21* AnGap-11
Medications on Admission:
n/a
Discharge Medications:
1. Oxybutynin 5 mg PO TID:PRN bladder spasms
RX *oxybutynin chloride 5 mg 1 tablet(s) by mouth three times
daily as needed for bladder spasms Disp #*20 Tablet Refills:*0
2. Phenazopyridine 100 mg PO TID PRN dysuria Duration: 3 Days
RX *phenazopyridine 100 mg 1 tablet(s) by mouth three times
daily as needed for urinary pain Disp #*20 Tablet Refills:*0
3. Sulfameth/Trimethoprim DS 1 TAB PO BID urinary tract
infection Duration: 14 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth every 12 hours Disp #*28 Tablet Refills:*0
4. Tamsulosin 0.4 mg PO QHS Pain related to stent
RX *tamsulosin 0.4 mg 1 capsule(s) by mouth once daily Disp #*30
Capsule Refills:*1
Discharge Disposition:
Home
Discharge Diagnosis:
Obstructing ureteral stone
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: ABDOMEN (SUPINE ONLY) IN O.R.
INDICATION: CYSTOSCOPY STENT PLACEMENT RIGHT
IMPRESSION:
Intraoperative cystoscopy images demonstrated a right-sided stent placement.
Please see operative note for details.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dysuria, N/V, Vomiting, Weakness
Diagnosed with Hydronephrosis with renal and ureteral calculous obstruction
temperature: 99.3
heartrate: 127.0
resprate: 19.0
o2sat: 98.0
sbp: 115.0
dbp: 75.0
level of pain: 0
level of acuity: 3.0 | The patient was admitted from the ED and was taken urgently to
the OR for ureteral stent placement. The procedure was
uncomplicated. Please see dictate operative report for full
details. After the procedure, she was returned to the floor and
monitored for signs of sepsis. No complications were encountered
and the patient remained afebrile. At the time of discharge, she
was tolerating a regular diet, her pain was well-controlled, and
she was ambulating without aid. The patient was discharged on a
14 day regimen of antibiotics due to her positive UA and concern
for infection. She will follow up with Dr. ___
definitive stone management. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
altered mental status
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of hiatal hernia and GERD, POD2 from
laparoscopic hiatal hernia repair with fundoplication, umbilical
hernia repair and gastroscopy who presents with altered mental
status. She was discharged yesterday and has been doing well
until yesterday evening when she got her oxycodone and became
confused. Her sister reports that she was with her the entire
time and she had only one tab of oxycodone and she denies
possibility of narcotic pain medication overdose at this point.
This morning she found her in the bed, confused and difficult to
arouse. EMS was called and she was found to be tachycardia to
130s, satting 80% on RA. She was brought to ___ ED. Her
discharge summary is not available at this time but reportedly
she had a relatively uneventful recovery from her surgery. Her
barium swallow study was negative, she was successfully advance
in diet and was discharged home on POD1.
Currently she denies abdominal pain, nausea or vomiting. She
states that she hasn't passed flatus since discharge. Sister
reports that she hasn't urinated at least for the past 8 hours.
She also denies fever/chills, shortness of breath or chest pain.
Past Medical History:
- Hypertension
- Asthma, on rescue inhaler and fluticasone
- Reactive arthritis - treated in past with sulfasalizine, but
resolved
- Hepatitis C, likely acquired from transfusion in ___. She
participated in a clinical trial and she has had an undetectable
viral load after 48 weeks of treatment in ___. She no longer
sees gastroenterology.
- s/p hysterectomy for menorrhagia
- s/p right ankle fx with surgical repair
Social History:
___
Family History:
Father and Aunt alive with alzheimers, mother with alcoholism,
No fam hx of syncope, MI, or sudden cardiac death
Physical Exam:
DISCHARGE EXAM:
AVSS
Gen: NAD, A&Ox3
Heart: rrr
Lungs: CTAB
Abd: soft, incisionally tender, nondistended
Ext: wwp
Pertinent Results:
___ 05:53PM LACTATE-1.0
___ 05:41PM GLUCOSE-99 UREA N-17 CREAT-1.0 SODIUM-134
POTASSIUM-3.7 CHLORIDE-98 TOTAL CO2-27 ANION GAP-13
___ 05:41PM ALT(SGPT)-707* AST(SGOT)-467* LD(LDH)-511*
ALK PHOS-61 TOT BILI-0.5
___ 05:41PM ALBUMIN-3.4* CALCIUM-8.1* PHOSPHATE-2.6*#
MAGNESIUM-2.1
___ 05:41PM WBC-11.1* RBC-3.59* HGB-10.4* HCT-32.9*
MCV-92 MCH-29.0 MCHC-31.6* RDW-13.1 RDWSD-44.2
___ 05:41PM NEUTS-85.3* LYMPHS-6.8* MONOS-6.8 EOS-0.2*
BASOS-0.2 IM ___ AbsNeut-9.50* AbsLymp-0.76* AbsMono-0.76
AbsEos-0.02* AbsBaso-0.02
___ 05:41PM PLT COUNT-113*
___ 05:41PM ___ PTT-25.2 ___
___ 04:30PM URINE HOURS-RANDOM
___ 04:30PM URINE bnzodzpn-NEG barbitrt-NEG opiates-POS
cocaine-NEG amphetmn-NEG oxycodn-POS* mthdone-NEG
___ 04:30PM URINE COLOR-Yellow APPEAR-Clear SP
___
___ 04:30PM URINE BLOOD-LG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 04:30PM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-0
___ 04:30PM URINE HYALINE-5*
___ 04:30PM URINE MUCOUS-RARE
___ 04:17PM TYPE-ART PO2-71* PCO2-49* PH-7.36 TOTAL
CO2-29 BASE XS-0
___ 04:17PM O2 SAT-92
___ 03:30PM OTHER BODY FLUID FluAPCR-NEGATIVE
FluBPCR-NEGATIVE
___ 03:27PM VoidSpec-UNABLE TO
___ 03:26PM ___ PTT-25.3 ___
___ 02:10PM ___ PO2-29* PCO2-61* PH-7.30* TOTAL
CO2-31* BASE XS-0
___ 01:28PM LACTATE-1.8
___ 01:15PM GLUCOSE-93 UREA N-17 CREAT-1.2* SODIUM-136
POTASSIUM-4.2 CHLORIDE-97 TOTAL CO2-30 ANION GAP-13
___ 01:15PM ALT(SGPT)-823* AST(SGOT)-562* LD(LDH)-538*
ALK PHOS-69 AMYLASE-47 TOT BILI-0.5
___ 01:15PM cTropnT-0.03*
___ 01:15PM ALBUMIN-3.8 IRON-39
___ 01:15PM calTIBC-255* FERRITIN-1043* TRF-196*
___ 01:15PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 01:15PM WBC-12.3* RBC-3.85* HGB-11.3 HCT-36.2 MCV-94
MCH-29.4 MCHC-31.2* RDW-13.3 RDWSD-45.7
___ 01:15PM NEUTS-86.7* LYMPHS-5.6* MONOS-7.1 EOS-0.0*
BASOS-0.1 IM ___ AbsNeut-10.63* AbsLymp-0.69* AbsMono-0.87*
AbsEos-0.00* AbsBaso-0.01
___ 01:15PM PLT COUNT-118*
___ 04:24AM GLUCOSE-121* UREA N-11 CREAT-0.7 SODIUM-137
POTASSIUM-3.4 CHLORIDE-99 TOTAL CO2-34* ANION GAP-7*
___ 04:24AM estGFR-Using this
___ 04:24AM CALCIUM-8.1* PHOSPHATE-4.6* MAGNESIUM-2.0
___ 04:24AM WBC-10.6* RBC-3.80* HGB-11.0* HCT-35.4
MCV-93# MCH-28.9# MCHC-31.1* RDW-13.2 RDWSD-45.3
___ 04:24AM PLT COUNT-132*#
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron ___ mg PO Q8H:PRN nausea
2. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
3. amLODIPine 5 mg PO DAILY
4. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation
5. Hydrochlorothiazide 25 mg PO DAILY
6. Levothyroxine Sodium 50 mcg PO DAILY
7. Lisinopril 40 mg PO DAILY
8. OxycoDONE Liquid ___ mg PO Q4H:PRN moderate to severe pain
9. Senna 17.2 mg PO BID:PRN constipation
10. Albuterol Inhaler 2 PUFF IH Q6H:PRN cough/wheezing
11. fluticasone 50 mcg/actuation inhalation BID:PRN allergy
symptoms
12. TraZODone 50 mg PO QHS:PRN insomnia
13. Lotrimin AF Powder (miconazole nitrate) 2 % topical TID:PRN
itching/rash
Discharge Medications:
1. Docusate Sodium (Liquid) 100 mg PO BID:PRN constipation
2. Levothyroxine Sodium 50 mcg PO DAILY
3. Senna 17.2 mg PO BID:PRN constipation
4. Diltiazem 30 mg PO Q6H
RX *diltiazem HCl [Cardizem] 30 mg 1 tablet(s) by mouth every
six (6) hours Disp #*120 Tablet Refills:*0
5. FoLIC Acid 1 mg PO DAILY
6. Ibuprofen 600 mg PO Q8H:PRN pain
7. Metoprolol Tartrate 37.5 mg PO Q6H
RX *metoprolol tartrate 37.5 mg 1 tablet(s) by mouth twice a day
Disp #*60 Tablet Refills:*0
8. QUEtiapine Fumarate 50 mg PO QHS Insomnia
RX *quetiapine 50 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*0
9. Thiamine 100 mg PO DAILY
10. Warfarin 2.5 mg PO ONCE Duration: 1 Dose
RX *warfarin [Coumadin] 2.5 mg 1 tablet(s) by mouth once a day
Disp #*10 Tablet Refills:*0
11. Acetaminophen (Liquid) 650 mg PO Q6H:PRN pain
RX *acetaminophen 500 mg/5 mL 10 mL by mouth every six (6) hours
Refills:*2
12. Albuterol Inhaler 2 PUFF IH Q6H:PRN cough/wheezing
13. amLODIPine 5 mg PO DAILY
14. fluticasone 50 mcg/actuation inhalation BID:PRN allergy
symptoms
15. Hydrochlorothiazide 25 mg PO DAILY
16. Lisinopril 40 mg PO DAILY
17. Lotrimin AF Powder (miconazole nitrate) 2 % topical TID:PRN
itching/rash
18. Ondansetron ___ mg PO Q8H:PRN nausea
19. OxycoDONE Liquid ___ mg PO Q4H:PRN moderate to severe pain
RX *oxycodone 5 mg/5 mL 5 mL by mouth every six (6) hours
Refills:*0
20. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Alcohol withdrawal
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with shortness of breath, evaluate for pneumonia.
TECHNIQUE: Single upright AP chest radiograph
COMPARISON: Chest radiographs dating back to ___.
FINDINGS:
Small bilateral pleural effusions are new from the prior study with associated
bibasilar opacity, left greater than right. Findings most likely represent
partial lower lobe atelectasis although it pneumonia cannot be entirely
excluded. Clinical correlation is recommended. There is no pulmonary edema
or pneumothorax. The cardiomediastinal silhouette is stable.
IMPRESSION:
New small bilateral pleural effusions with probable adjacent atelectasis,
although pneumonia critically at the left base cannot be entirely excluded.
Clinical correlation is recommended.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: ___ woman with altered mental status. 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: Acquisition sequence:
1) Sequenced Acquisition 18.0 s, 18.1 cm; CTDIvol = 50.0 mGy (Head) DLP =
903.1 mGy-cm.
2) Sequenced Acquisition 4.0 s, 4.0 cm; CTDIvol = 50.0 mGy (Head) DLP =
200.7 mGy-cm.
3) Sequenced Acquisition 2.0 s, 2.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
100.3 mGy-cm.
Total DLP (Head) = 1,204 mGy-cm.
COMPARISON: CT orbits of ___.
FINDINGS:
Images are severely limited due to motion artifact. Within this limitation,
no evidence of large territorial infarction, large acute intracranial
hemorrhage, edema, or mass. There is prominence of the ventricles and sulci
suggestive of involutional changes.
There is no evidence of fracture. There is mucosal thickening of the
bilateral sphenoid and maxillary sinuses. 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:
Severely limited study, due to motion artifact. Within this limitation, no
large acute intracranial hemorrhage detected.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ with chest pain dyspnea. Recent laparoscopic repair of
hiatal hernia, with fundoplication. Evaluate for acute process such as
pulmonary embolism.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE:
Acquisition sequence:
1) Stationary Acquisition 2.5 s, 0.5 cm; CTDIvol = 7.6 mGy (Body) DLP = 3.8
mGy-cm.
2) Spiral Acquisition 4.2 s, 32.9 cm; CTDIvol = 14.7 mGy (Body) DLP = 481.8
mGy-cm.
Total DLP (Body) = 486 mGy-cm.
COMPARISON: Chest radiograph from earlier on the same date. Barium swallow
study of ___.
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level on the right and segmental level on the left, without
filling defect to indicate a pulmonary embolus. The thoracic aorta is normal
in caliber without evidence of dissection or intramural hematoma. The heart,
pericardium, and great vessels are within normal limits. No pericardial
effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
Small locules of air in the anterior mediastinum likely relate to recent
postoperative status.
PLEURAL SPACES: No evidence of pneumothorax. There is a small nonhemorrhagic
left and trace nonhemorrhagic right pleural effusion. Adjacent compressive
atelectasis is worse on the left. Additionally, left lower lobe dependent
consolidation is likely due to collapse/atelectasis.
LUNGS/AIRWAYS: No large focal parenchymal consolidation. Evaluation for
pulmonary nodules is limited by respiratory motion artifact. The airways are
patent to the level of the segmental bronchi bilaterally.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen demonstrates postsurgical
changes from recent hiatal hernia repair with fundoplication. Residual barium
from the recent swallow study causes streak artifact. A subcentimeter left
renal hypodensity is too small to characterize by CT, but statistically likely
a cyst. Small amount of air in the subcutaneous tissues along the
posterolateral left upper abdomen, tracking into the left chest, are also
likely postsurgical in nature.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. No acute pulmonary embolus or acute aortic abnormality.
2. Bilateral, left greater than right, nonhemorrhagic pleural effusions.
3. Adjacent mild compressive atelectasis, left greater than right, with more
moderate collapse in the posterior and medial segments of the left lower lobe.
4. Postsurgical changes from recent hiatal hernia repair with gastric
fundoplication, including small locules of air in the anterior mediastinum and
in the soft tissues of the left posterolateral chest and abdominal walls.
Radiology Report
INDICATION: ___ year old woman s/p laparoscopic hiatal hernia repair now with
abdominal distention and with b/l pleural effusions evaluate for cause
abdominal distension.
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.0 s, 55.4 cm; CTDIvol = 16.2 mGy (Body) DLP = 898.4
mGy-cm.
Total DLP (Body) = 898 mGy-cm.
COMPARISON: CTA chest dated ___ and barium swallow dated ___,
FINDINGS:
LOWER CHEST: Left greater than right small bilateral pleural effusions are
noted with adjacent compressive atelectasis. A small amount of epicardial air
is likely normal in the recent postoperative setting.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogeneous attenuation throughout.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder mildly distended without wall thickening or
pericholecystic fluid.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions within the limitations of an unenhanced scan. There is no
pancreatic ductal dilatation. There is no peripancreatic stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size. There is no evidence
of focal renal lesions within the limitations of an unenhanced scan. Numerous
hypodensities bilaterally are too small to fully characterize but likely
represent simple cysts. There is no hydronephrosis. There is no
nephrolithiasis. There is no perinephric abnormality.
GASTROINTESTINAL: The patient is status post recent fundoplication with
surgical clips seen at the GE junction. A small collection of fluid and air
to the right of the esophagus measuring up to 2.0 x 1.4 cm (02:13) is
unchanged from the recent prior chest CTA, likely a small postoperative
collection rather than a leak in the setting of a normal recent swallow study.
There is no free intraperitoneal air. Minimal retroperitoneal and perigastric
stranding is likely related to the recent procedure. Small bowel loops
demonstrate normal caliber and wall thickness. Hyperdense contrast within the
proximal stomach and distal colon from recent barium swallow somewhat limit
evaluation of these areas, although no gross abnormality is detected.
PELVIS: The urinary bladder is decompressed around a Foley catheter. There is
no free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal abnormality is
seen.
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. A
T11 vertebral body hemangioma is incidentally noted (02:19).
SOFT TISSUES: There is a fat containing umbilical hernia with fat stranding.
Subcutaneous air is noted in the soft tissues.
IMPRESSION:
1. Postoperative changes as described above related to recent hiatal hernia
repair with fundoplication including an unchanged small collection of fluid
and air adjacent to the esophagus.
2. Left greater than right small pleural effusions
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 7:49PM, 5 minutes after
discovery of the findings.
Radiology Report
INDICATION: Bilateral pleural effusions, initially presented with hypoxia and
altered mental status.
TECHNIQUE: Frontal chest radiograph.
COMPARISON: Radiograph from ___. Chest CT from ___.
IMPRESSION:
Prominence of the right mediastinum is has no concerning correlate on the
recent CT examination from ___, and is unchanged from prior
radiographs. A small left pleural effusion has slightly enlarged since the
radiograph from ___. There is increased density at the left
retrocardiac region, likely the result of increased left pleural effusion, but
underlying consolidation cannot be excluded.
Radiology Report
INDICATION: ___ year old woman s/p hiatal hernia repair now with AMS and a fib
RVR // ?leak Please use gastrografin first to rule out large perforation and
then repeat with barium.
TECHNIQUE: Single contrast upper GI.
DOSE: Acc air kerma: 8 mGy; Accum DAP: 182.6 uGym2; Fluoro time: 30 seconds
COMPARISON: Upper GI ___
FINDINGS:
Water-soluble contrast (Optiray) was administered followed by thin consistency
barium with the patient angled semi-upright.
Scout image demonstrates a small amount of residual oral contrast in the
stomach.
Barium passed freely through the esophagus into the stomach and then into the
proximal small bowel. There is no evidence of leak or obstruction.
IMPRESSION:
No evidence of leak or obstruction.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with O2 requirement after presenting with b/l
effusions following a lap hiatal hernia repair // pls eval interval change in
appearance of effusions pls eval interval change in appearance of
effusions
IMPRESSION:
Heart size and mediastinum are stable. Left retrocardiac consolidation and
left pleural effusion are unchanged. Small amount of right pleural effusion
is unchanged. There is no pneumothorax.
Radiology Report
EXAMINATION: US ABD LIMIT, SINGLE ORGAN
INDICATION: ___ woman with transaminitis and altered mental status
after laparoscopic hiatal hernia repair on ___ evaluate for acute hepatic
or biliary pathology and evaluate hepatic vascular flow.
TECHNIQUE: Gray scale, color, and spectral Doppler evaluation of the abdomen
was performed.
COMPARISON: Abdominal ultrasound dated ___.
CT abdomen and pelvis without contrast dated ___.
FINDINGS:
This exam is somewhat limited by patient body habitus and overlying bowel gas.
Liver: The hepatic parenchyma is within normal limits. No focal liver
lesions are identified. There is mild perihepatic ascites.
Bile ducts: There is no intrahepatic biliary ductal dilation. The common
hepatic duct measures 5 mm.
Gallbladder: The gallbladder appears within normal limits, without stones,
abnormal wall thickening, or edema.
Pancreas: The imaged portion of the pancreas appears within normal limits,
with portions of the pancreatic tail obscured by overlying bowel gas.
Spleen: The spleen demonstrates normal echotexture, and measures 10.9 cm.
Kidneys: Limited views of the kidneys do not show hydronephrosis.
Other: There is a small right pleural effusion.
Doppler evaluation:
The main, left, and right portal veins are patent. Although the color flow
appears reversed, the spectral Doppler waveforms support that the main, right,
and left portal veins have antegrade flow.
The main hepatic artery is patent, with appropriate waveform.
Right, middle and left hepatic veins are patent.
Splenic vein and superior mesenteric vein are patent, with antegrade flow.
IMPRESSION:
1. Patent hepatic vasculature.
2. No intrahepatic or extrahepatic biliary ductal dilation.
3. Mild perihepatic ascites.
4. Small right pleural effusion.
NOTIFICATION: The findings were discussed with ___, M.D., the
physician requesting ___ wet read, by ___, M.D. on the telephone on
___ at 5:15 ___, 15 minutes after discovery of the findings.
Gender: F
Race: WHITE
Arrive by UNKNOWN
Chief complaint: Altered mental status, Dyspnea
Diagnosed with Unspecified atrial fibrillation, Altered mental status, unspecified
temperature: 100.5
heartrate: 131.0
resprate: 30.0
o2sat: 96.0
sbp: 154.0
dbp: 92.0
level of pain: 0
level of acuity: 1.0 | Patient was admitted to the ICU from the ED for management of
her altered mental status. Her ICU course by systems is the
following:
Neuro: She was placed on a phenobarbital taper for potential
alcohol withdrawal. Toxicology screens were negative, including
an ETOH level. Her source of her mental status decline was not
fully diagnosed. Her CT head was normal. Her mental status began
to improve and by transfer, she was AAOx3 without any deficits
CV: She was in rapid afib upon arrival and started on a
diltiazem drip with IV metoprolol for breakthrough. Cardiology
was consulted who recommended cardioversion with a TEE
before-hand. Given her recent surgery, it was decided to forgo
the TEE. A TTE was obtained which showed preserved EF with some
moderate pulmonary artery hypertension. She converted to sinus
on ___ and was transitioned to PO diltiazem and metoprolol.
Resp: She was protecting her airway throughout this time. CT
scan showed b/ pulmonary effusions but she was stable on nasal
cannula.
GI: She was initially made NPO. CT A/P just showed post-surgical
changes, an UGI was negative for a leak and she was advanced to
a mechanical soft diet on ___ and tolerated it well. She
presented with a significiant transaminitis of an unknown cause.
Her enzymes trended down. A liver duplex was negative for any
flow issues.
GU: She had adequate urine output.
Heme: She was initially started on a heparin drip for afib which
was transitioned to pradaxa.
ID: On arrival, there was concern for sepsis given her slightly
elevated WBC, hemodynamic changes, and altered mental status.
She was started on empiric cefepime. Her WBC normalized and her
hemodynamics imrpoved without any signs of a septic source. UCx
and BCx were negative. Her antibiotics were discontinued and her
clinical status was monitored.
On ___, she was stable for transfer to the floor for further
management. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ yo F with h/o hypertrophic cardiomyopathy, severe GERD, HTN
p-afib presenting with episode of burning substernal CP lasting
45 minutes, occurring intermittently over the past few weeks. On
the night she presented to the ED she had a typical episode of
substernal burning with radiation up into her throat that rose
to an intensity that was greater than any prior episode, such
that she felt "acid was about to come out of my ears" with
tremendous pressure diffusely in her head. This improved by the
time she called the ambulance and came to the ED. She states
that her typical substernal chest burning episodes are worst
after eating, worse with laying down, at night, often associated
with acid/burning in the back of her throat. She was treated for
h. pylori several years ago and was heart burn-free for a couple
years before symptoms returned in the last ___ weeks. In the ED
she was admitted to observation for 2-day stress test which
showed a reversible defect in setting of suboptimal study.
Troponins were negative and EKG showed no changes but given
abnomal stress she was admitted to cardiology for further work
up and monitoring.
Past Medical History:
Pre-diabetes A1c 5.8 in ___
LDL 125 in ___
CKD baseline 1.1
Iron deficiency anemia baseline hct ___
OSA
Morbid obesity
GERD, h/o h.pylori
Asthma
Colonic polyps
Cholelithiasis
Social History:
___
Family History:
Father died of MI age ___
Brother MI age ___, s/p 3V CABG at age ___ also SLE
Mother colon ca s/p colectomy, died while on dialysis.
Mother's death certificate states: "asymmetric septal
hypertrophy"
Son CAD s/p stent @ age ___
Physical Exam:
PHYSICAL EXAMINATION on day of admission and discharge:
VS: T=97.9 BP=149/84 HR=65 RR=18 O2 sat=99%RA
GENERAL: WDWN obese woman in NAD. Oriented x3. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink,
rhinophyma noted, large palatine tonsils, large tongue, OP
clear, MMM
NECK: Supple without ___, unable to see JVP
CARDIAC: RR, normal S1, S2. ___ holosysotlic murmur over LUSB.
No thrills, lifts. No S3 or S4.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
unlabored, no accessory muscle use. CTAB, no crackles, wheezes
or rhonchi.
ABDOMEN: Soft, obese, NTND. +BS No HSM or tenderness.
EXTREMITIES: 1+ bilat lower extremity edema
PULSES: bilateral Carotid 2+ DP 2+ radial 2+
NEURO: CN II-XII intact and symmtric, strength ___ thoughout
Pertinent Results:
ADMISSION LABS:
___ 02:15AM BLOOD WBC-11.9* RBC-4.26 Hgb-10.9* Hct-34.3*
MCV-81* MCH-25.6* MCHC-31.8 RDW-15.8* Plt ___
___ 02:15AM BLOOD Neuts-65.4 ___ Monos-4.8 Eos-1.1
Baso-0.2
___ 02:15AM BLOOD Glucose-97 UreaN-28* Creat-1.0 Na-142
K-4.0 Cl-105 HCO3-29 AnGap-12
___ 08:53AM BLOOD Cholest-133
___ 08:53AM BLOOD Triglyc-67 HDL-39 CHOL/HD-3.4 LDLcalc-81
LDLmeas-88
___ 04:45PM BLOOD %HbA1c-PND at discharge
___ 02:15AM BLOOD cTropnT-0.01
___ 08:53AM BLOOD cTropnT-0.02*
___ 03:55PM BLOOD cTropnT-0.02*
___ Stress
IMPRESSION: No anginal symptoms during or after Regadenoson
infusion.
EKG nondiagnostic for ischemia. Appropriate hemodynamic response
to
Regadenoson. Nuclear report posted separately.
___ ECG
Sinus rhythm. Non-specific intraventricular conduction delay of
left bundle-branch block type. Left axis deviation. Left
ventricular hypertrophy. Poor R wave progression could be due to
left ventricular hypertrophy. Non-specific ST-T wave
abnormalities could be due to left ventricular hypertrophy.
Compared to the previous tracing of ___ ventricular rate is
faster.
___ nuclear stress test
IMPRESSION: Limited study which is probably abnormal with a
moderate reversible inferior wall defect most pronounced at the
base.
___ CXR
IMPRESSION:
1. No acute cardiac or pulmonary findings.
2. Unchanged mild-to-moderate cardiomegaly, including left
atrial enlargement.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Disopyramide CR 300 mg PO Q12H
3. Furosemide 20 mg PO DAILY
4. Metoprolol Succinate XL 100 mg PO DAILY
5. Montelukast Sodium 10 mg PO DAILY:PRN during allergy season
6. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB or wheeze
7. fluticasone *NF* 220 mcg/actuation Inhalation DAILY:PRN
allergy season
8. Pantoprazole 40 mg PO Q12H
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN SOB or wheeze
2. Aspirin 325 mg PO DAILY
3. Disopyramide CR 300 mg PO Q12H
4. Furosemide 20 mg PO DAILY
5. Metoprolol Succinate XL 100 mg PO DAILY
6. Pantoprazole 40 mg PO Q12H
7. fluticasone *NF* 220 mcg/actuation Inhalation DAILY:PRN
allergy season
8. Montelukast Sodium 10 mg PO DAILY:PRN during allergy season
Discharge Disposition:
Home
Discharge Diagnosis:
Acid reflux
Esophageal spasm
Secondary:
Hypertrophic cardiomyopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Chest pain.
COMPARISON: Chest radiograph from ___.
FINDINGS: Lung volumes are slightly low, causing exaggeration of the heart
size and accentuation of the pulmonary vasculature. The lungs are clear.
There is unchanged mild-to-moderate cardiomegaly with persistent left atrial
enlargement. The descending thoracic aorta is tortuous, as before.
Mediastinal contours are otherwise normal. There are no pleural effusions.
No pneumothorax is seen.
IMPRESSION:
1. No acute cardiac or pulmonary findings.
2. Unchanged mild-to-moderate cardiomegaly, including left atrial
enlargement.
Gender: F
Race: PORTUGUESE
Arrive by AMBULANCE
Chief complaint: CP
Diagnosed with CHEST PAIN NOS, HYPERTENSION NOS
temperature: 97.2
heartrate: 117.0
resprate: 18.0
o2sat: 100.0
sbp: 93.0
dbp: 67.0
level of pain: 10
level of acuity: 3.0 | ___ yo F with h/o hypertrophic cardiomyopathy, GERD, HTN p-afib
presenting with episode of burning substernal CP consistent with
severe GERD or esophageal spasm, ruled out for MI but with
likely false positive stress test in setting of habitus,
discharged shortly after arrival to cardiology service.
# Abnormal stress test: Patient presented with symptoms typical
for GERD with negative troponins x3 and no EKG changes. Stress
test showed reversible defect that was discussed with her
outpatient cardiologist as well. It was felt that in light of
typical GERD symptoms and negative MI rule out, as well as poor
study due to habitus, this was most likely a false positive.
Additionally, pt with clean coronaries in ___.
# GERD: Patient has severe typical GERD symptoms, was treated in
past for H. pylori but symptoms have recurred. ___ also now have
element of esophageal spasm. Encourage patient to discuss repeat
EGD or referral to GI with her PCP after discharge. Continued
pantoprazole 50mg BID
# Hypertrophic cardiomyopathy: Continued disopyramide,
metoprolol, furosemide, aspirin
#Asthma: continued albuterol PRN. Patient states does not take
fluticasone or singulair this time of year.
TRANSITIONAL ISSUES:
- Hgb A1c pending at discharge
- Patient instructed to f/u with GI or with EGD referral
- Instructed to make cardiology clinic appointment during
business hours to ___ this week |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / peanut
Attending: ___
Chief Complaint:
Chest and abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ man with H/O CAD (s/p 3 DES in mid-distal AV groove
RCA and in the distal AV groove RCA between the RPDA and RPL1
and DES to mid RPDA ___, chronic back pain, diastolic heart
failure/HFpEF (EF >60%), DJD, diabetes mellitus with
nephropathy, hyperlipidemia, hypertension, peripheral arterial
disease, prostate cancer, sleep apnea, GERD, ___ esophagus
and anxiety, presenting with chest and abdominal pain.
Patient says that he developed chest and abdominal pain 5 months
ago. He noted worsening shortness of breath with ambulation. He
underwent cardiac catheterization on ___, during which time
he had 3 DES placed in the RCA over 2 successive procedures on
the same day with a significant amount of radiation exposure. He
says that since the stents were placed, he had no resolution of
his symptoms. He also had worsening abdominal pain. He underwent
a CTA abdomen and pelvis to look for abdominal angina, and no
flow limiting lesions were seen. He had a doctor's appointment
today, did more walking than normal and developed shortness of
breath, chest pressure, and abdominal pain. He denied nausea,
sweating, or palpitations during the episodes. He states he just
feels weak and uncomfortable. He states that, per his cardiac
medication instructions, he took 3 nitroglycerin without relief,
at which point he presented to the Emergency Department. He
denies pain elsewhere. He has had no worsening orthopnea, sleeps
flat at baseline. He has noted lightheadedness and dizziness in
the morning when standing up quickly. Since his PCIs in ___,
he has had elevated Cr.
In the ED, initial vitals were: T 97.5 HR 80 BP 134/85 RR 18
SaO2 100% on RA. Labs were significant for WBC 6, H/H 12.4/37.5,
plt 213. BUN 44, Cr 1.7 (baseline 1.2-1.5), Troponin-T <0.01.
CXR negative for cardiopulmonary process. EKG with HR 57, sinus
rhythm, T wave inversions in aVL, normal intervals and axis. No
ST elevations and unchanged from prior tracing. The patient was
given 1L NS and Morphine 2 mg IV x2. Vitals prior to transfer
were T 97.9 HR 66 BP 143/73 RR 18 SaO2 99% on RA.
Upon arrival to the cardiology ward, vitals T 97.8, BP 173/95,
HR 63, RR 18, SaO2 97% on RA. Patient was complaining of chest
pain, epigastric, radiating around both sides towards his back,
as well as chest pressure. He rated it as ___ at rest, which is
slightly worse than baseline. He was given hydralazine 25 mg PO
for hypertension and additional morphine 2 mg which he says
helped for a little bit. Chest pain returned, EKG unchanged and
at baseline. He was given nitroglycerin SL x3 with minimal
effect. He remained hemodynaimcally stable. He was also given
Maalox. Repeat troponin negative.
Past Medical History:
1. CAD RISK FACTORS:
- Hypertension
- Hyperlipidemia
- Diabetes on insulin/metformin
2. CARDIAC HISTORY:
- PUMP FUNCTION: EF >60% on ___
- Cardiac catheterization in ___, done for recurrent chest pain
and depressed ejection fraction, showed mild disease of the LAD
and RCA.
- S/P 3 DES to the RCA in ___
- CHF/HFpEF
- DJD
- PAD s/p prior intervention
- ___ esophagus
- Reflux
- Prostate Ca
- Anxiety
Social History:
___
Family History:
Non-contributory
Physical Exam:
On admission
General: Overweight middle aged white man, alert, oriented,
lying in bed comfortably, talking in full sentences, in no acute
distress
Vitals: T 97.8, BP 173/95, HR 63, RR 18, SaO2 97% on RA
HEENT: Sclera anicteric, mucous membranes moist, oropharynx
clear, EOMI, PERRL
Neck: Supple, JVP difficult to assess due to body habitus
CV: intermittently bradycardic, regular rhythm, normal S1 + S2;
no murmurs, rubs, or gallops
Lungs: Clear to auscultation bilaterally--no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, hypoactive bowel
sounds, no organomegaly, no rebound or guarding
GU: No Foley
Ext: Warm, well perfused, 2+ pulses; no clubbing, cyanosis or
edema
Neuro: CN II-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
At discharge
General: in NAD
Vitals: T 97.4 Tmax 98.0 HR ___ BP ___ RR ___
SaO2 96-100% on RA
Last 8 hours I/O: 1400/bathroom privileges
24 Hr I/O: 1240/1200
Lungs: CATB
CV: RRR, S1, S2; no no murmurs, rubs or gallops
Abdomen: BS+, soft, non-tender, not distended
Ext: warm without edema
Pertinent Results:
___ 07:30PM BLOOD WBC-6.0 RBC-4.36* Hgb-12.4* Hct-37.5*
MCV-86 MCH-28.4 MCHC-33.1 RDW-13.7 RDWSD-42.0 Plt ___
___ 07:30PM BLOOD Neuts-34 Bands-0 Lymphs-59* Monos-2*
Eos-4 Baso-0 Atyps-1* ___ Myelos-0 AbsNeut-2.04 AbsLymp-3.60
AbsMono-0.12* AbsEos-0.24 AbsBaso-0.00*
___ 07:30PM BLOOD Hypochr-NORMAL Anisocy-NORMAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-NORMAL Polychr-NORMAL
___ 07:30PM BLOOD ___ PTT-26.9 ___
___ 07:30PM BLOOD Glucose-165* UreaN-44* Creat-1.7* Na-138
K-4.2 Cl-103 HCO3-23 AnGap-16
___ 07:30PM BLOOD ALT-34 AST-25 AlkPhos-46 TotBili-0.4
___ 07:30PM BLOOD Lipase-49
___ 07:30PM BLOOD Albumin-4.2 Phos-2.9
___ 07:30PM BLOOD cTropnT-<0.01
___ 03:55AM BLOOD CK-MB-3 cTropnT-<0.01 proBNP-90
___ 04:50PM BLOOD CK-MB-3 cTropnT-<0.01
___ 07:45AM BLOOD WBC-5.0 RBC-4.61 Hgb-13.0* Hct-39.7*
MCV-86 MCH-28.2 MCHC-32.7 RDW-13.7 RDWSD-42.4 Plt ___
___ 07:45AM BLOOD ___ PTT-40.9* ___
___ 07:45AM BLOOD Glucose-138* UreaN-20 Creat-1.3* Na-138
K-4.2 Cl-101 HCO3-26 AnGap-15
___ 07:45AM BLOOD Calcium-9.4 Phos-3.0 Mg-1.8
ECG ___ 7:20:40 AM
Sinus bradycardia. Consider left atrial abnormality. Possible
prior inferior wall myocardial infarction. Poor R wave
progression. Non-specific lateral T wave abnormalities. Compared
to the previous tracing of ___ bradycardia is new.
CHEST (PA & LAT) ___ 4:32 ___
The lungs are clear. The cardiomediastinal silhouette is within
normal limits. No acute osseous abnormalities identified.
IMPRESSION: No acute cardiopulmonary process.
Pharmacological Nuclear Stress Test ___
This was an inactive ___ year old DM2 man with CAD (MI/Stent
___, HTN, HLD, remote smoking and a BMI of 37, who was
referred to the lab from the ED after negative serial cardiac
markers for an evaluation of exertional dyspnea and chest
discomfort. He received 0.142mg/kg/min of IV Persantine infused
over 4 minutes. He complained of ___ chest pressure and
shortness of breath at rest, which remained unchanged throughout
the duration of the study. There were no significant changes in
ST segments or T waves noted during the infusion or in recovery.
The rhythm was sinus with no ectopy seen throughout the duration
of the study. The heart rate and blood pressure responded
appropriately to the Persantine infusion. At 2 minutes post
infusion, 125mg IV Aminophylline was given to prevent any
potential Persantine side effects.
IMPRESSION: No ischemic ECG changes noted in the presence of
non-anginal
type symptoms. Appropriate hemodynamic response to Persantine.
IMAGING:
The image quality is adequate but limited due to soft tissue
attenuation and motion. There is activity adjacent to the heart
in the stress images.
Left ventricular cavity size is increased.
Rest and stress perfusion images reveal a reversible, mild
reduction in photon counts involving the mid and basal inferior
wall.
Gated images reveal hypokinesis of the mid and basal inferior
wall.
The calculated left ventricular ejection fraction is 46% with
an EDV of 110 ml.
IMPRESSION:
1. Reversible, small, mild perfusion defect involving the RCA
territory.
2. Increased left ventricular cavity size. Mild systolic
dysfunction with hypokinesis of the mid and basal inferior wall.
In the setting of recent MI, the perfusion defect may
represent microvascular dysfunction.
Compared with prior study of ___, the defect now
appears reversible.
CTA Chest ___
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. Coronary artery
calcifications noted. Scattered calcifications of the thoracic
aorta and great vessels. There is common origin of the
brachiocephalic and left common carotid arteries.
Right upper lobe subsegmental pulmonary embolus (03:85). The
main and right pulmonary arteries are normal in caliber, and
there is no evidence of right heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar
lymphadenopathy. The thyroid gland appears unremarkable.
There is no evidence of pericardial effusion. There is no
pleural effusion.
Bilateral dependent hypoventilatory/atelectatic changes. The
airways are otherwise patent to the subsegmental level.
Limited images of the upper abdomen demonstrates an exophytic
cyst in the upper pole the left kidney, seen best on coronal
imaging. The liver demonstrates decreased attenuation, likely
secondary to fatty liver. Replaced left hepatic artery.
No lytic or blastic osseous lesion suspicious for malignancy
is identified.
IMPRESSION:
1. Right upper lobe subsegmental pulmonary embolus. No imaging
evidence of right heart strain.
2. Hepatic Steatosis.
Radiology Report
INDICATION: ___ with sob and cp s/p stents,, // r/o chf
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: ___.
FINDINGS:
The lungs are clear. The cardiomediastinal silhouette is within normal
limits. No acute osseous abnormalities identified.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: CTA chest with contrast
INDICATION: ___ year old man with known CAD p/w refractopry chest pain of
unclear etiology. // Please eval for e/o PE or aortic dissection.
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of 100 cc of Omnipaque 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) = 717 mGy-cm.
COMPARISON: CTA chest ___
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. There is no evidence
of penetrating atherosclerotic ulcer or aortic arch atheroma present. Coronary
artery calcifications noted. Scattered calcifications of the thoracic aorta
and great vessels. There is common origin of the brachiocephalic and left
common carotid arteries.
Right upper lobe subsegmental pulmonary embolus (03:85). The main and right
pulmonary arteries are normal in caliber, and there is no evidence of right
heart strain.
There is no supraclavicular, axillary, mediastinal, or hilar lymphadenopathy.
The thyroid gland appears unremarkable.
There is no evidence of pericardial effusion. There is no pleural effusion.
Bilateral dependent hypoventilatory/atelectatic changes. The airways are
otherwise patent to the subsegmental level.
Limited images of the upper abdomen demonstrates an exophytic cyst in the
upper pole the left kidney, seen best on coronal imaging. The liver
demonstrates decreased attenuation, likely secondary to fatty liver. Replaced
left hepatic artery.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
IMPRESSION:
1. Right upper lobe subsegmental pulmonary embolus. No imaging evidence of
right heart strain.
2. Hepatic Steatosis.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Chest pain, Dyspnea
Diagnosed with CHEST PAIN NOS, DIABETES UNCOMPL ADULT, HYPERTENSION NOS, CAD UNSPEC VESSEL, NATIVE OR GRAFT
temperature: 97.5
heartrate: 80.0
resprate: 18.0
o2sat: 100.0
sbp: 134.0
dbp: 85.0
level of pain: 6
level of acuity: 2.0 | ___ with CAD (s/p 3 DES in mid-distal AV groove RCA and in the
distal AV groove RCA between the RPDA and RPL1 and DES to mid
RPDA in ___ during 2 successive procedures during the same
day with significant fluoroscopic radiation exposure) presenting
with persistent chest and abdominal pain.
# Chest and abdominal pain: This pain is chronic and did not
improve after ___ in ___. His ECG remained
unchanged and his troponins were negative, arguing against
ongoing ischemia which would be expected to result in cardiac
myonecrosis. Pharmacological vasodilator nuclear stress test
showed small reversible defect that was felt unlikely to be
contributing to chest pain and was more likely a false positive
result from endothelial dysfunction after his recent ___ MI
and from the PCIs themselves. There was no improvement in pain
with SL NTG or other long acting anti-anginal agents. Pain,
therefore, felt to be less likely from cardiac ischemia. Patient
underwent CTA to look for pulmonary embolus or aortic
dissection. A small RUL subsegmental pulmonary embolus was
noted on CTA; given its size, this was again felt to be unlikely
explanation for extent of pain. Highest suspicion is for GI
etiology. He was treated with omeprazole, GI cocktail, and
sucralfate. Sucralfate was most helpful in resolving symptoms
(although not consistently or persistently), so he was given
sucralfate to take as an outpt. He will have a GI work up
(EGD/Colonoscopy) as outpt to further investigate possible GI
etiology of pain.
# Pulmonary embolus: RUL subsegmental PE found on CTA. No
evidence of right heart strain. Normal hemodynamics. Patient was
started on warfarin with an enoxaparin bridge and encouraged to
undergo colonoscopy as part of age-appropriate cancer screening. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Vomiting
Major Surgical or Invasive Procedure:
Upper endoscopy
History of Present Illness:
CC: vomiting
HPI:
___ is a ___ year old woman with ___
syndrome,
history of multiple colonic and duodenal polyps and recurrent
SBOs and intussusceptions, who presented with 4 days of
vomiting.
She underwent upper and lower endoscopy in ___ which showed
polyps in the colon, duodenum, and jejunum, She had been
admitted
in ___ to the colorectal service, at which time she had
lap-assisted enterotomies with polypectomies and uterine mass
excision (calcified subseroas leiomyoma), which was complicated
by partial SBO requiring readmission. However since that time
she
reports she had been mostly doing well. She does note a couple
isolated episodes of vomiting in recent weeks. However her
current symptoms began 4 days prior to presentation. She states
that "out of the blue" she felt like food would not go down her
esophagus and was stuck in her chest, which then led to severe
nausea and vomiting. She denies abdominal pain although she does
endorse burning in her chest from the vomiting. She states that
the vomit had been clear until yesterday, at which time it
appeared dark red. She reports some associated chills and
weakness but no fever. She denies changes to her BMs, the last
of
which was yesterday. She initially went to ___,
where she underwent a CT scan that was unrevealing. She received
fluids (4.5 L NS), potassium, diladudid, protonix, compazine,
and
benadryl, and has had some improvement in her nausea and
vomiting, although she also notes that she has not been eating
anything.
In the ED she was afebrile with HRs ___, BP
110s-120s/50s-70s. Labs with WBC 10.3, hgb 9.8, bicarb 19 (AG
13), normal LFTs, and UA with >182 RBCs, 1 ketones, 8 WBCs. She
received 40 mg IV pantoprazole
Past Medical History:
PMH:
___ syndrome c/b recurrent small bowel obstructions
and intussusceptions
PSH:
C-section - ___
Laparoscopic-assisted multiple enterotomy/polypectomies, removal
of mass from uterus (___)
Social History:
___
Family History:
No colon or other cancers referable to ___ syndrome
Maternal aunt - polyps.
Maternal first cousin - ovarian cancer in young age, now
deceased
Physical Exam:
Exam:
Vital signs:
97.7 PO 95 / 67 L Lying 77 18 100 RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round, EOMI
ENT: Ears and nose without visible erythema, masses, or trauma.
moist mucous membranes
CV: NS1/S2, RRR
RESP: Lungs clear to auscultation with good air movement
bilaterally. Breathing is non-labored
GI: Abdomen soft, non-distended, non-tender to palpation.
GU: No CVA/suprapubic tenderness
MSK: No swollen or erythematous joints
SKIN: No rashes or ulcerations noted
NEURO: Alert, interactive, face symmetric, gaze conjugate with
EOMI, speech fluent, motor function grossly intact/symmetric, CN
II-XII grossly
Pertinent Results:
Chest X-ray ___
FINDINGS:
Lungs are well expanded and clear of consolidation, pleural
effusion or
pneumothorax. Cardiomediastinal silhouette is normal.
IMPRESSION:
No acute cardiopulmonary findings.
CT A/P ___ ___:
"Impression: No significant or acute pathology detected"
EXAMINATION: Small bowel follow through ___
FINDINGS:
Barium passes through the small bowel, reaching the colon within
90 minutes which is within normal limits. There are scattered
filling defects throughout the visualized jejunum, duodenum, and
ileum which did not appear to move on subsequent real-time
evaluation, compatible with polyps. The duodenum, jejunum, and
ileum appear within normal limits in caliber. There is normal
fold pattern, with no stricture. The terminal ileum could not
be fully separated from nearby small bowel, but what was seen
appears unremarkable.
IMPRESSION:
Scattered small-bowel polyps as can be seen with patient's known
___-___
syndrome. No evidence of intussusception or obstruction.
EGD ___:
Normal mucosa of the esophagus and duodenum
Multiple polyps stomach (3-5 mm)
Multiple polyps second duodenum (1-1.5 cm)
Multiple polyps proximal jejunum (1-2 cm)
___ 07:06AM BLOOD WBC-5.8 RBC-4.33 Hgb-11.1* Hct-36.7
MCV-85 MCH-25.6* MCHC-30.2* RDW-16.2* RDWSD-50.6* Plt ___
___ 07:06AM BLOOD Creat-0.7 Na-138 K-3.8 HCO3-27 AnGap-12
___ 05:18AM BLOOD ALT-9 AST-13 AlkPhos-47 TotBili-0.7
___ 05:28AM BLOOD Calcium-8.9 Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
Discharge Medications:
1. Ondansetron 4 mg PO TID
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*24 Tablet Refills:*0
2. Pantoprazole 40 mg PO Q24H
RX *pantoprazole 40 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
3. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild/Fever
Discharge Disposition:
Home
Discharge Diagnosis:
Peutz-Jehgers syndrome, nausea and vomiting
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 hemtemesis// eval for pneumoediastinum
TECHNIQUE: Chest PA and lateral
COMPARISON: None
FINDINGS:
Lungs are well expanded and clear of consolidation, pleural effusion or
pneumothorax. Cardiomediastinal silhouette is normal.
IMPRESSION:
No acute cardiopulmonary findings.
Radiology Report
INDICATION: ___ year old woman with severe nausea, vomiting, chest pain post
EGD// R/O perforated viscus
TECHNIQUE: Supine and upright abdominal radiographs were obtained.
COMPARISON: CT dated ___
FINDINGS:
There are no abnormally dilated loops of large or small bowel.
There is no free intraperitoneal air.
Osseous structures are unremarkable. Surgical clips are seen in the left mid
abdomen and overlying the pelvis.
There are no unexplained soft tissue calcifications or radiopaque foreign
bodies.
IMPRESSION:
Nonspecific, nonobstructive bowel gas pattern. No free intraperitoneal air.
Radiology Report
EXAMINATION: Small bowel follow through
INDICATION: ___ year old woman with Pe___ syndrome,history of multiple
colonic and duodenal polyps and recurrent SBOs and intussusceptions. Had an
EGD on ___ which showed multiple polyps. Assess for chronic intussusceptions
or dynamic obstruction.
TECHNIQUE: Following ingestion of thin barium, multiple radiographs and spot
fluoroscopic images were obtained during the transit of barium through the
small bowel.
DOSE: Acc air kerma: 71.2 mGy; Accum DAP: 1035.95 uGym2; Fluoro time: 04:06
COMPARISON: Reference CT abdomen ___
FINDINGS:
Barium passes through the small bowel, reaching the colon within 90 minutes
which is within normal limits. There are scattered filling defects throughout
the visualized jejunum, duodenum, and ileum which did not appear to move on
subsequent real-time evaluation, compatible with polyps. The duodenum,
jejunum, and ileum appear within normal limits in caliber. There is normal
fold pattern, with no stricture. The terminal ileum could not be fully
separated from nearby small bowel, but what was seen appears unremarkable.
IMPRESSION:
Scattered small-bowel polyps as can be seen with patient's known ___
syndrome. No evidence of intussusception or obstruction.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Hemoptysis, Transfer
Diagnosed with Hematemesis
temperature: 98.7
heartrate: 80.0
resprate: 18.0
o2sat: 99.0
sbp: 115.0
dbp: 51.0
level of pain: 0
level of acuity: 2.0 | #Nausea and vomiting with streaks of blood
Differential includes ___ tear (most likely) vs
bleeding polyp or ulcer. Reassuringly her imaging failed to show
obstruction and she is passing gas, and her Hgb appears stable.
EGD ___ showed multiple polyps without active bleeding or
obstruction, due to persistent symptoms small bowel follow
through was done and also failed to show obstruction.
- PO PPI daily dose
- As inpatient scheduled Zofran, promethazine and
Ativan were used to control symptoms, weaned off to Zofran
before discharge, will continue for 3 days.
- Patient tolerated full diet before discharge without issues,
but she was still very anxious about having the symptoms again
and requested if the polyps could be removed. I discussed with
her in length with help of the GI team that decision for surgery
can't be taken lightly, especially there is no guarantee it will
cure the symptoms. She understood and somewhat accepted the plan
to discuss further management with her GI doctor ___
___ in the clinic. |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Amoxicillin / clindamycin / Erythromycin Base / lidocaine /
Vicodin / atenolol
Attending: ___.
Chief Complaint:
Headache
Major Surgical or Invasive Procedure:
Phlebotomy (___)
History of Present Illness:
___ is a ___ F with a h/o migraines, polycythemia
___, fibromylagia who is admitted to the OMED service. She
complains of a severe headache which is accompanied by right arm
tingling and blurry vision. The patient has migraines at
baseline, which she describes as predominantly left sided,
though they have occurred on the right, sharp and constant in
nature.
Today the patient describes a headache on the right side of the
head which is constant and sharp in nature. The headache came on
gradually over an hour starting just after 1pm on the day of
presentation. She describes a later onset (difficulty
quantifying) of tingling in the fingertips (all 5) of the right
hand that was present intermittently, lasting ___ minutes at a
time and sometimes radiating to the elbow and seeming to
involved the whole forearm circumferentially. She states that
this headache seemed different from her typical headaches due to
involvement of the right side instead of the left (though she
has had less severe right sided headaches in the past) and the
higher intensity and duration of the headache. It otherwise
unchanged in quality from prior headaches.
On neuro ROS, the pt denies loss of vision, diplopia,
dysarthria, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denies difficulties producing or
comprehending speech. No bowel or bladder incontinence or
retention. Denies difficulty with gait.
On general review of systems, the pt denies recent fever or
chills. No night sweats or recent weight loss or gain. Denies
cough, shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation or
abdominal pain. No recent change in bowel or bladder habits. No
dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Pt noted to have thrombocytosis since at least ___. She
states she had blood tests at a hospital at ___ for
cholecystectomy in ___ and the blood tests were normal. Her
Plt count was 489 on ___ and has been fluctuated from 459
to 538 in the past year. Her WBC counts were normal. Her Hgb
was still normal but slowly increased to 15.7 on ___. She
c/o prolonged bleeding time after knife cut. Lab results on
___ showed elevated Plt and Hgb, low EPO, JAK2 positive,
suggesting myeloproliferative disease. BM biopsy was performed
on ___, which showed moderately hypercellular marrow with
trilineage hematopoiesis, including increased and clustered
megakaryocytes. Diagnostic features of involvement by a
lymphoproliferative or myeloproliferative disorder are not seen.
Her mammogram in ___ showed calcification in upper outer
quadrant of right breast. Core Biopsy of the calcification
showed atypical ductal hyperplasia. She had a left breast biopsy
which was benign when she was at her ___. She had total
abdominal
hysterectomy with right salpingo-oophorectomy on ___ for
pelvic pain and endometriosis. Pathology showed uterus with
adenomyosis.
PAST MEDICAL HISTORY:
Eczematous dermatitis
Liver cyst
S/P TAH-RSO
Asthma
Myeloproliferative disease / POLYCYTHEMIA ___
___ headache
Low back pain
Hypertension
Fibromyalgia
DCIS (ductal carcinoma in situ) of breast
___ neuroma left
PVD (posterior vitreous detachment)
Social History:
___
Family History:
Paternal aunt with breast cancer but no history of blood
diseases or other malignancy.
Physical Exam:
EXAM ON ADMISSION:
======================
General: NAD
VITAL SIGNS: 97.7 ___ 18 96% RA
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis
SKIN: No rashes or skin breakdown
NEURO: Cranial nerves II-XII are within normal limits excluding
visual acuity which was not assessed, no nystagmus; strength is
___ of the proximal and distal upper and lower extremities;
reflexes are 2+ of the biceps, triceps, patellar, and Achilles
tendons, toes are down bilaterally; coordination is intact. No
tremor/asterixis
EXAM ON DISCHARGE:
======================
VS: 97.9 122/84 83 18 99% RA
VS Range: Tmax=98.0 BP (122-148/70-86) HR (64-83)
General: in no acute distress
CV: RRR, normal s1/s2, no m/r/g
Lungs: CTAB
Abdomen: BS+
Neuro: alert, oriented, EOMI, CN ___ intact, no sensory
deficits, pain in right shoulder/hip upon resistance (thus was
not able to dependably determine strength in these muscle
groups); ___ strength in LUE/LLE
Pertinent Results:
PERTINENT RESULTS ON ADMISSION:
==============================
___ 03:50PM BLOOD WBC-9.3 RBC-7.72* Hgb-16.4* Hct-57.6*
MCV-75* MCH-21.3* MCHC-28.5* RDW-16.9* Plt ___
___ 03:50PM BLOOD Neuts-69.9 Lymphs-17.4* Monos-2.7
Eos-8.9* Baso-1.2
___ 03:50PM BLOOD Glucose-77 UreaN-9 Creat-0.7 Na-142 K-3.9
Cl-104 HCO3-26 AnGap-16
___ 07:35AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.2
PERTINENT RESULTS ON DISCHARGE:
===============================
___ 06:40AM BLOOD WBC-9.8 RBC-6.69* Hgb-14.7 Hct-50.9*
MCV-76* MCH-22.0* MCHC-28.9* RDW-17.2* Plt ___
IMAGING:
===============================
MR HEAD W/O, MRA BRAIN W/O, MRA NECK W&W/O, MRV HEAD W/O
(___):
1. No acute intracranial process.
2. Normal MRA and MRV of the head and neck.
3. Nonspecific periventricular and subcortical white matter
T2/FLAIR hyperintensities, which are non specific and may be
seen in the setting of early small vessel ischemic disease.
CT HEAD W/O CONTRAST (___):
No acute intracranial process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 325 mg PO DAILY
2. Losartan Potassium 100 mg PO DAILY
3. Xopenex Neb ___ puffs inhalation every ___ hours
4. Gabapentin 600 mg PO QHS:PRN fibromyalgia
5. Topiramate (Topamax) 30 mg PO QHS:PRN migraine
Discharge Medications:
1. Aspirin 325 mg PO DAILY
2. Gabapentin 600 mg PO QHS:PRN fibromyalgia
3. Losartan Potassium 100 mg PO DAILY
4. Topiramate (Topamax) 30 mg PO QHS:PRN migraine
5. Xopenex Neb ___ puffs inhalation every ___ hours
Discharge Disposition:
Home
Discharge Diagnosis:
Polycythemia ___
___ Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: Headache. Evaluate for acute intracranial process.
TECHNIQUE: Multi detector CT images were obtained of the head without the
administration of intravenous contrast material. Multiplanar reformatted
images in coronal and sagittal planes are provided.
DOSE: DLP: 891.93 mGy-cm
CTDI: 54.81 mGy
COMPARISON: None.
FINDINGS:
There is no acute hemorrhage, edema, mass effect or acute large vascular
territorial infarction. The ventricles and sulci are normal in size and
configuration. The basal cisterns appear patent and there is preservation of
gray-white matter differentiation.
No fracture is identified. The mastoid air cells, middle ear cavities, and
visualized paranasal sinuses are clear. The globes are unremarkable.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: MRI AND MRA BRAIN AND MRA NECK
INDICATION: ___ year old woman with polycythemia ___, headache, blurry
vision, arm weakness // r/o stroke or venous/arterial thrombus. Please do
head MRI without contrast, MRA head and neck and please also do MRV
TECHNIQUE: Sagittal T1 weighted and axial T1 weighted, T2 weighted, FLAIR,
susceptibility and diffusion weighted images were obtained through the head.
Uneventful administration of 13 mL MultiHance intravenous contrast. Three
dimensional time of flight MR arteriography and venography of the head, and
two dimensional time of flight and three dimensional pre and post contrast
enhanced MR arteriography and venography of the neck were performed with
rotational reconstructions.
COMPARISON: CT brain without contrast ___.
FINDINGS:
MRI HEAD: No intra or extra-axial mass, acute infarct or hemorrhage. There are
moderate diffusely scattered periventricular and subcortical white matter
T2/FLAIR hyperintensities, which are nonspecific, but commonly seen in the
setting of small vessel ischemic disease. Sulci, ventricles and cisterns are
within expected limits. The major flow voids are preserved. The orbits and
soft tissues are unremarkable. The paranasal sinuses and mastoid air cells are
well-aerated.
HEAD MRA: Normal flow related enhancement is seen in the intracranial
internal carotid, middle cerebral and anterior cerebral arteries without
significant mural irregularity or stenosis. There is normal symmetric
arborization of the MCA branches. There is no aneurysm greater than 3 mm;
there is a 1-2 mm outpouching of the para clinoid right ICA, which likely
represents an infundibulum. In addition, there is mild contour irregularity of
the basilar artery without evidence of stenosis, thrombosis or aneurysm.
Normal flow related enhancement is seen in the intracranial vertebral arteries
(with incidental note of a left dominant intracranial vertebral artery), the
basilar artery, and the bilateral superior cerebellar and posterior cerebral
arteries. There is fetal type origin of the left posterior cerebral artery.
Head MRV: The left transverse sinus is diminutive, a normal physiologic
variant. Otherwise, there is normal flow related signal and postcontrast
enhancement of the intracranial venous sinuses.
NECK MRA: Incidental note is made of a 2 vessel arch. Otherwise, the cervical
common carotid, internal carotid and external carotid arteries are normal in
course, caliber and contour. Estimates of internal carotid artery stenosis is
based on NASCET criteria. They demonstrate normal enhancement without mural
irregularity, stenosis or evidence of dissection. The essentially codominant
vertebral arteries are normal in course, caliber and contour. They demonstrate
normal enhancement without mural irregularity, stenosis or evidence of
dissection.
Next MRV: Normal flow related signal and enhancement of study the internal
jugular vein.
IMPRESSION:
1. No acute intracranial process.
2. Normal MRA and MRV of the head and neck.
3. Nonspecific periventricular and subcortical white matter T2/FLAIR
hyperintensities, which are non specific and may be seen in the setting of
early small vessel ischemic disease.
Gender: F
Race: ASIAN
Arrive by AMBULANCE
Chief complaint: Headache
Diagnosed with HEADACHE, POLYCYTHEMIA VERA
temperature: 98.0
heartrate: 70.0
resprate: 18.0
o2sat: 99.0
sbp: 162.0
dbp: 82.0
level of pain: 10
level of acuity: 3.0 | # Headache:
1-day history of throbbing ___ right-sided headache (different
from her migraine headaches in the past) accompanied by blurry
vision and right hand tingling. She presented to Dr. ___
office, who told her to go to the ED. After presenting to ___,
___ Head without contrast revealed no acute intracranial process.
MRI Head, MRA Brain/Neck, and MRV Head revealed no acute
intracranial process. Hematocrit was 57.6, and the patient's
symptoms were found to be due to her PV. IV fluids were given
and the patient received a 1-unit phlebotomy on ___.
Post-phlebotomy hematrocit was 50.9. By ___, patient's
right-sided headache have resolved.
# Polycythemia ___:
In addition to receiving phlebotomy, patient received baby
aspirin, but did not receive heparin prophylaxis (declined,
stating she preferred to walk and move her legs instead). The
patient will likely need another phlebotomy treatment within the
next week, and should follow-up with Dr. ___.
# Atypical ductal hyperplasia of right breast:
Found on core biopsy after mammogram in ___ showed
calcification in upper outer quadrant of right breast. Nothing
was done for this problem during this hospitalization. Follow-up
with Dr. ___.
TRANSITIONAL CARE ISSUES;
============================
- Follow-up with Dr. ___ need for further phlebotomy
- Follow-up with Dr. ___ atypical ductal hyperplasia
of right breast |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Left ankle pain
Left trimalleolar ankle fracture
Major Surgical or Invasive Procedure:
___: Left ankle ORIF (with syndesmotic screw)
History of Present Illness:
This patient is a ___ year old female who complained of left
ankle injury at an outside hospital and noted to have complex
trimalleolar fracture. She was transferred here for operative
management.
Past Medical History:
HTN
Social History:
___
Family History:
Non-contributory
Physical Exam:
Exam on presentation:
Temp: 97.1 HR: 90 BP: 110/60 Resp: 18 O(2)Sat: 98 Normal
Constitutional: uncomfortable
HEENT: Normocephalic, atraumatic
Neck supple
Cardiovascular: intact distal pulses
Abdominal: Soft
Extr/Back: Left ankle markedly tender and swollen
Skin: Warm and dry
Neuro: Speech fluent
Psych: Normal mood, Normal mentation
Exam at discharge:
VS: AVSS
GEN: WDWN woman in NAD, AOx3
LLE: WWP, wiggle toes, SILT dp/sp
Pertinent Results:
___ 06:15PM BLOOD WBC-11.7* RBC-4.86 Hgb-14.2 Hct-43.0
MCV-88 MCH-29.3 MCHC-33.1 RDW-12.7 Plt ___
___ 06:15PM BLOOD Glucose-118* UreaN-16 Creat-0.8 Na-135
K-4.1 Cl-99 HCO3-25 AnGap-15
___ 06:15PM BLOOD Calcium-9.3 Phos-3.9 Mg-2.0
Medications on Admission:
Metoprolol succinate
Lorazepam
Risperidone
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every six (6) hours Disp #*60 Tablet Refills:*0
2. Bisacodyl 10 mg PO/PR DAILY:PRN Constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
4. Enoxaparin Sodium 40 mg SC QHS Duration: 14 Days
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 1 at bedtime Disp #*14 Syringe
Refills:*0
5. Metoprolol Succinate XL 25 mg PO DAILY
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
7. RISperidone 0.25 mg PO HS
8. Lorazepam 0.5 mg PO HS:PRN anxiety
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left trimalleolar ankle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: Left ankle, three views.
INDICATION: History: ___ with ankle fracture, reduction, splint // eval
reduction
COMPARISON: None available.
FINDINGS:
The overlying splint obscures fine bony detail. There is a medial malleolar
fracture with 5 mm displacement of the distal fragment. There is a distal
fibular fracture also with 5 mm inferolateral displacement of the distal
fragment. There is widening of the medial lateral aspects of the ankle
mortise. There is a small nondisplaced fracture at the posterior distal
tibia.
IMPRESSION:
Trimalleolar fracture as above with mortise widening medially.
Radiology Report
EXAMINATION: ANKLE (AP, MORTISE AND LAT) LEFT IN O.R.
INDICATION: ORIF ANKLE FRACTURE
TECHNIQUE: Fluoroscopic assistance provided to the surgeon in the OR without
the radiologist present. 11 spot views obtained. Fluoro time recorded as 19.9
seconds on the electronic requisition.
COMPARISON: None.
FINDINGS:
Views demonstrate steps associated with fixation of medial malleolar and
distal fibular fractures.
IMPRESSION:
Correlation with real-time findings and when appropriate conventional
radiographs is recommended for full assessment.
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: L Ankle injury
Diagnosed with FX TRIMALLEOLAR-CLOSED, FALL FROM SIDEWALK CURB
temperature: 97.1
heartrate: 90.0
resprate: 18.0
o2sat: 98.0
sbp: 110.0
dbp: 60.0
level of pain: 5
level of acuity: 3.0 | The patient was transferred directly from an OSH and was
evaluated by the orthopedic surgery team. The patient was found
to have left trimal ankle fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for Left ankle ORIF (with syndesmotic
screw), which the patient tolerated well (for full details
please see the separately dictated operative report). The
patient was taken from the OR to the PACU in stable condition
and after recovery from anesthesia was transferred to the floor.
The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given perioperative
antibiotics and anticoagulation per routine. The patients home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to home 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 non weight-bearing in the left
lower extremity, and will be discharged on Lovenox for DVT
prophylaxis. The patient will follow up in two weeks per
routine. A thorough discussion was had with the patient
regarding the diagnosis and expected post-discharge course, and
all questions were answered prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
left foot erythema and swelling
Major Surgical or Invasive Procedure:
left fourth toe ray resection
PICC line placement
History of Present Illness:
HPI: ___ y/o M with hx diabets, Afib on coumadin, HTN,
presenting with 3 month hx of worsening left foot infection. Pt
states that he was being treated by podiatry at ___ for what
started ___ ___ as an ulcer on the dorsal aspect of his left
foot. Ulcer became purulent with expanding erythema, swelling,
tenderness and malodorous drainage. He was started on augmentin
875mg BID and was seeing his podiatrist weekly with intermittent
debridements. He states that he took Augmentin throughout this 2
and a half month course. He has been having some diarrhea with
the abx, with ROS otherwise negative. Given none improvement he
was sent to the ED from ___ clinic.
On arrival to the ED, initial vitals were Tc: 98.6 HR: 109 BP:
131/69 RR: 18 98% RA
He was seen by podiatry with deep cultures taken and started on
vanc/cipro flagyll. XRay of the foot revealed osteomyeltis of
the left fourth toe, with plan for left ___ ray resection.
Currently VSS, pain ___, increasing to ___ with foot
manipulation.
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:
Diabetes
Atrial fibrillation on Coumadin
Angina
Diabetic Neuropathy
Social History:
___
Family History:
non contributory
Physical Exam:
ADMISSION EXAM:
VS - Temp: 97.9 BP:129/ 65 HR: 99 RR: 16 O2-sat 97.9 % RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - left foot with swelling, erythema, tenderness. 1cm x 1cm
ulcer with necrotic base noted on left dorsal foot, no deep
tracking. Black eschar overlying left fourth toe. No blisters,
vesicles, frank pus.
White scale bilateral feet.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, gait deferred.
DISCHARGE EXAM:
VS - Temp: 98.3 BP:104/79 HR: 79 RR: 16 O2-sat 95 % RA
GENERAL - NAD, comfortable, appropriate
HEENT - NC/AT, PERRLA, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - left foot with decreased swelling erythema. s/p left ___
ray dissection. Non tender. White scale bilateral feet.
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, DTRs 2+ and
symmetric, cerebellar exam intact, gait deferred.
Pertinent Results:
ADMISSION LABS:
___ 09:10PM ___ PTT-64.9* ___
___ 02:19PM LACTATE-1.7
___ 02:05PM GLUCOSE-137* UREA N-9 CREAT-0.7 SODIUM-136
POTASSIUM-4.9 CHLORIDE-96 TOTAL CO2-25 ANION GAP-20
___ 02:05PM WBC-17.0*# RBC-5.31 HGB-15.4 HCT-46.7 MCV-88
MCH-28.9 MCHC-32.9 RDW-13.6
___ 02:05PM NEUTS-80.9* LYMPHS-13.7* MONOS-3.7 EOS-1.2
BASOS-0.4
___ 02:05PM PLT COUNT-219
___ 01:35PM URINE COLOR-Orange APPEAR-Clear SP ___
___ 01:35PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-4* PH-7.0 LEUK-TR
___ 01:35PM URINE RBC-0 WBC-1 BACTERIA-FEW YEAST-NONE
EPI-0
___ 01:35PM URINE HYALINE-4*
DISCHARGE LABS:
___ 05:03AM BLOOD WBC-4.6 RBC-3.91* Hgb-11.9* Hct-34.1*
MCV-87 MCH-30.4 MCHC-34.8 RDW-13.8 Plt Ct-59*
___ 05:03AM BLOOD Plt Ct-59*
___ 09:30AM BLOOD ___ 09:30AM BLOOD ___
___ 09:30AM BLOOD Ret Aut-1.1*
___ 05:03AM BLOOD
___ 05:03AM BLOOD Glucose-85 UreaN-7 Creat-0.6 Na-135 K-3.7
Cl-99 HCO3-29 AnGap-11
___ 05:03AM BLOOD Calcium-7.9* Phos-3.1 Mg-2.1
MICRO:
___ TISSUE GRAM STAIN-FINAL; TISSUE-FINAL;
ANAEROBIC CULTURE-FINAL
GRAM STAIN (Final ___:
1+ (<1 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
4+ (>10 per 1000X FIELD): GRAM NEGATIVE ROD(S).
4+ (>10 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS, CHAINS, AND
CLUSTERS.
TISSUE (Final ___:
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT ___ this culture..
ANAEROBIC CULTURE (Final ___:
Mixed bacterial flora-culture screened for B. fragilis, C.
perfringens, and C. septicum. None isolated.
___ BLOOD CULTURE Blood Culture,
Routine-FINAL EMERGENCY WARD
___ SWAB GRAM STAIN-FINAL; WOUND
CULTURE-FINAL; ANAEROBIC CULTURE-FINAL EMERGENCY WARD
___ BLOOD CULTURE Blood Culture,
Routine-FINAL
GRAM STAIN (Final ___:
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
2+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CHAINS.
2+ ___ per 1000X FIELD): GRAM NEGATIVE ROD(S).
1+ (<1 per 1000X FIELD): GRAM POSITIVE ROD(S).
SMEAR REVIEWED; RESULTS CONFIRMED.
WOUND CULTURE (Final ___:
This culture contains mixed bacterial types (>=3) so an
abbreviated
workup is performed. Any growth of P.aeruginosa, S.aureus
and beta
hemolytic streptococci will be reported. IF THESE BACTERIA
ARE NOT
REPORTED BELOW, THEY ARE NOT PRESENT ___ this culture..
ANAEROBIC CULTURE (Final ___:
NO ANAEROBES ISOLATED AS OF ___.
DUE TO LABORATORY ERROR, UNABLE TO CONTINUE MONITORING FOR
ANAEROBES.
TEST CANCELLED, PATIENT CREDITED.
___ URINE URINE CULTURE-FINAL NEGATIVE
___ FOOT AP,LAT & OBL LEFT
XRAY
FINDINGS: AP, lateral, oblique views of the left foot were
provided. There
is osseous destruction centered at the head of the fourth
metatarsal which is
compatible with osteomyelitis. ___ addition, there is osseous
destruction at
the base of the proximal phalanx of the fourth toe. There is
neighboring soft
tissue gas, could indicate the site of ulceration. No
additional foci of
osteomyelitis evident. Plantar and retrocalcaneal spurs noted.
IMPRESSION: Findings concerning for osteomyelitis at the fourth
toe centered
at the head of the fourth metatarsal and proximal aspect of the
fourth
proximal phalanx. Probable soft tissue ulceration at this
level, findings are
new from the prior exam from ___.
___ repeat FOOT AP,LAT & OBL LEFT
FINDINGS: ___ comparison with study of ___, there has been
resection of the
phalanges and a portion of the head of the fourth metatarsal.
The remainder of the study is unchanged.
___ CXR
FINDINGS: As compared to the previous radiograph, the right
PICC line has
been pulled back. The tip now projects over the mid to lower
SVC. No
evidence of complications, notably no pneumothorax. No other
relevant change.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Digoxin 0.375 mg PO 4X/WEEK (___)
2. Digoxin 0.5 mg PO 3X/WEEK (___)
3. Glargine 60 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
4. Atorvastatin 10 mg PO DAILY
5. Warfarin 10 mg PO DAILY16
6. Lisinopril 5 mg PO DAILY
HOLD FOR BP<100
7. Metoprolol Succinate XL 100 mg PO DAILY
Discharge Medications:
1. Warfarin 10 mg PO DAILY16
2. Atorvastatin 10 mg PO DAILY
3. Digoxin 0.375 mg PO 4X/WEEK (___)
4. Digoxin 0.5 mg PO 3X/WEEK (___)
5. Glargine 60 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
6. Lisinopril 5 mg PO DAILY
HOLD FOR BP<100
7. CefePIME 2 g IV Q12H
RX *cefepime 2 gram 1 infusion every 12 hours Disp #*17 Unit
Refills:*0
8. Miconazole 2% Cream 1 Appl TP BID
RX *miconazole nitrate 2 % apply to both tops and bottoms of
feet and to toe webspaces twice a day Disp #*1 Tube Refills:*1
9. Vancomycin 1250 mg IV Q 8H
RX *vancomycin 500 mg 1500mg dose every 8 hours Disp #*25 Unit
Refills:*0
10. Outpatient Lab Work
Please check CBC, CHEM 10, INR and vancomycin trough (1 hour
prior to next dose of vancomycin) on ___ and fax results to
Dr ___ platelet monitoring, Creatinine monitoring,
vancomycin dose adjustment, goal vancomycin level ___ and
coumadin dose adjustment, goal INR ___
Dr ___: ___
Fax: ___
11. Metoprolol Succinate XL 100 mg PO DAILY
12. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
RX *metronidazole 500 mg 1 tablet(s) by mouth every eight hours
Disp #*25 Tablet Refills:*0
13. Nicotine Polacrilex 2 mg PO Q1H:PRN smoking urge
RX *nicotine (polacrilex) [Nicorette] 2 mg 1 gum every hour as
needed to curb the urge to smoke Disp #*100 Gum Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary
Osteomyelitis
Secondary
Diabetes
Atrial Fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
LEFT FOOT RADIOGRAPH PERFORMED ON ___
COMPARISON: Prior exam from ___.
CLINICAL HISTORY: Non-healing left foot ulcer, assess osteo.
FINDINGS: AP, lateral, oblique views of the left foot were provided. There
is osseous destruction centered at the head of the fourth metatarsal which is
compatible with osteomyelitis. In addition, there is osseous destruction at
the base of the proximal phalanx of the fourth toe. There is neighboring soft
tissue gas, could indicate the site of ulceration. No additional foci of
osteomyelitis evident. Plantar and retrocalcaneal spurs noted.
IMPRESSION: Findings concerning for osteomyelitis at the fourth toe centered
at the head of the fourth metatarsal and proximal aspect of the fourth
proximal phalanx. Probable soft tissue ulceration at this level, findings are
new from the prior exam from ___.
Radiology Report
HISTORY: Resection.
FINDINGS: In comparison with study of ___, there has been resection of the
phalanges and a portion of the head of the fourth metatarsal.
The remainder of the study is unchanged.
Radiology Report
CHEST RADIOGRAPH
INDICATION: PICC line placement.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the patient has received a
right-sided PICC line. The tip of the line projects over the superior
portions of the right atrium. It should be pulled back by approximately 2 to
3 cm. The course of the line is unremarkable, no complications, notably no
pneumothorax.
Radiology Report
CHEST RADIOGRAPH
INDICATION: PICC line placement. Evaluation.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the right PICC line has
been pulled back. The tip now projects over the mid to lower SVC. No
evidence of complications, notably no pneumothorax. No other relevant change.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: WOUND EVAL
Diagnosed with LOCAL SKIN INFECTION NOS
temperature: 95.6
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 7
level of acuity: 3.0 | BRIEF HOSPITAL COURSE:
This was a ___ y/o M with DM2, HTN, afib on digoxin, presenting
with 3 month hx left foot infection treated with augmentin for
three months with x-ray evidence of osteomyeltis involving his
fourth left ray.. As he was a diabetic with necrotic ulceration
concerning for pseudomonal involvement, he was treated with
vancomycin and zosyn initially and underwent fourth left ray
resection. He received a picc line for continued outpatient
intravenous antibiotics. He developed thrombocytopenia during
his hospitalization was seen by hematology who felt that the
thrombocytopenia was related to his infection and consequent
inflammation. It is likely that the zosyn also contributed to a
drug induced thrombocytoepenia. He was switched from vanc/zosyn
to vancomycin and cefepime and his platelet count stopped
dropping. He will have vancomycin trough drawn on ___ for
review by his PCP for dose adjustment, as well as creatinine
while on intravenous antibiotics, and CBC to trend his platelet
count. Additionally he will have his INR followed by his PCP
while being treated with coumadin for his atrial fibrillation
with goal INR ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodine / Iodinated Contrast Media - IV Dye / shellfish derived
Attending: ___
Chief Complaint:
SOB
Major Surgical or Invasive Procedure:
Radiation therapy
History of Present Illness:
___ with stage IIIb lung cancer currently undergoing
chemotherapy, COPD on home 2L O2, presenting with SOB and
hypoxia.
He reports that over the past ___ days he has had increasing
dyspnea and says that his breathing has been labored. He has a
cough at baseline due to his COPD, which is often dry but
sometimes productive of clear sputum. His cough has not recently
changed. He denies any fevers. He has not had any recent travel
or leg pain or swellinh. Normally he can walk a block before
feeling short of breath, but today was only able to walk ___
feet. He has had no recent URI symptoms. He presented to clinic
for chemotherapy treatment, where he felt short of breath and
requested a nebulizer treatment. He also described severe
chills. At the time he was noted to have O2 sats in the ___ off
of oxygen. He was sent to the ED for further evaluation.
In the ED, initial vitals: 99 100 149/00 36 100% 2L
Labs were significant for WBC 7.8 with 92% PMNs, H/H 11.8/35.1,
platelet 102, lactate 1.1. VBG 7.30/57/38, Cr 1.5 (baseline
~1.0), troponin 0.2.
EKG: sinus 100, Qtc 406, mild ST depression in V4
CXR showed hyperinflated lungs, L mid lung nodule, no evidence
of pna.
Bilateral LENIs were negative.
He was given 750mg levofloxacin IV, cefepime 2g IV, vancomycin
1g IV, 125mg methylprednisolone, 2L IVFs, and
albuterol/ipratropium nebs.
On transfer patient's vitals were: 110 110/68 21 97% Nasal
Cannula
On arrival to the FICU, he reported that his breathing was back
to baseline. He had no chest pain or other complaints other than
feeling anxious relating to ICU stay.
Of note, he was admitted ___ for COPD exacerbation, and then
again more recently ___ for MRSA/enterobacter pneumonia for
which he was discharged on cefuroxime and vancomycin until
___. He was also discharged on prednisone and azithromycin.
He had almost completed his prednisone taper. At time of
presentation to clinic, he was taking 5mg of prednisone and had
three days remaining.
Past Medical History:
PAST ONCOLOGIC HISTORY:
The patient was in his usual state of health until late ___
when he developed URI symptoms associated with cough and
progressing to production of white and then green sputum. He
was
seen by primary care physician and had ___ chest x-ray on
___, at which time chest x-ray demonstrated a new left
upper lobe 2.6 cm nodule. He was treated empirically with
levofloxacin and prednisone with only subtle improvement. A
followup chest x-ray one month later on ___ demonstrated
an increase in the left upper lobe nodule to 3 cm, prompting
referral to Pulmonary at ___. He presented on ___ for
CT scan of the chest, but ultimately was admitted through the ED
after he was found to be hypotensive.
CT chest on ___ demonstrated a 3.7 x 3.3 cm mass in the
left upper lobe with lobular margins and central cavitation,
right lower paratracheal lymph node that was enlarged to 1.6 x
1.3 cm, paraaortic lymph node measuring 6 mm in the short axis,
but enlarged from prior. In addition, spiculated nodules were
noted in the anterior segment of the right upper lobe in
numerous
areas of the bilateral lower lobe. There were also areas in the
posterior lower lobes that were indeterminate for scarring or
spiculated nodules. The left lower lobe had ___
opacities consistent with infectious etiology. There was also
evidence of progressive emphysema with scarring, cachexia, and
hyperinflation as compared to ___.
On ___, the patient underwent transbronchial biopsy of
the
left upper lobe mass, the final pathology of which is still
pending. He also underwent EBUS-TBNA, with station 11R negative
and 4L negative, but poorly differentiated squamous cell
carcinoma identified at stations 11L, 4R, and at 7.
On ___, patient underwent MRI of the brain, which did not
demonstrate any intracranial metastasis. An echocardiogram
was also obtained that demonstrated normal LV systolic function
with an EF greater than 55% as well as normal left atrial size
and pressure. The pulmonary artery systolic pressure could not
be determined, and there was no significant evidence of valvular
disease.
PAST MEDICAL HISTORY:
- COPD, FEV1 25% predicted, on 2L Home O2
-NSTEMI ___, complicated by ___ briefly necessitating RRT
and cardiogenic shock now recovered to an EF of 55%
-emphysema
-upper extremity arterial thrombosis ___ status post
amputation of the first and second digits on the right hand
-hepatitis C
-anxiety
-neuropathy of feet
-previous alcohol abuse, now sober since ___
-s/p amputation of ___ and ___ left digit in ___
Social History:
___
Family History:
-Father with MI in his ___
-Mother with esophageal cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
Vitals: 114 96/54 28 94% 2L
GENERAL: Alert, oriented, no acute distress, speaking in full
sentences but with pursed lip breathing
HEENT: Sclera anicteric, multiple lesions on mucuous membranes
NECK: supple
LUNGS: decreased breath sounds throughout lung with scattered
expiratory wheezes in upper lung fields
CV: Decreased heart sounds, tachycardic, regular rhythm, normal
S1 S2, no murmurs, rubs, gallops
ABD: soft, non-tender, non-distended
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: large area of erythema over mid to upper back
NEURO: CN II-XII grossly intact, moving all extremities equally
DISCHARGE PHYSICAL EXAM:
========================
Vitals: 97.9 89 154/89 20 100/2.5L
GENERAL: No acute distress
HEENT: Sclera anicteric, multiple lesions on mucuous membranes
NECK: supple
LUNGS: decreased breath sounds throughout lung with scattered
expiratory wheezes
CV: Decreased heart sounds, tachycardic, regular rhythm, normal
S1 S2, no murmurs, rubs, gallops
ABD: soft, non-tender, non-distended
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
SKIN: large area of erythema over mid to upper back. Port
removed
NEURO: CN II-XII grossly intact, moving all extremities equally
Pertinent Results:
ADMISSION LABS:
===============
___ 12:50PM BLOOD WBC-7.8 RBC-4.00* Hgb-11.8* Hct-35.1*
MCV-88 MCH-29.4 MCHC-33.5 RDW-16.5* Plt ___
___ 12:50PM BLOOD Neuts-92.4* Lymphs-5.6* Monos-1.0*
Eos-0.9 Baso-0.2
___ 12:50PM BLOOD Plt ___
___ 12:50PM BLOOD UreaN-42* Creat-1.5* Na-137 K-4.8 Cl-100
HCO3-28 AnGap-14
___ 12:50PM BLOOD ALT-35 AST-34 AlkPhos-117 TotBili-0.4
___ 12:50PM BLOOD Calcium-9.4 Phos-4.4 Mg-2.1
___ 03:26PM BLOOD ___ pO2-38* pCO2-57* pH-7.30*
calTCO2-29 Base XS-0
MICRO:
=======
___ 3:10 pm BLOOD CULTURE
Blood Culture, Routine (Preliminary):
ENTEROBACTER CLOACAE COMPLEX. FINAL SENSITIVITIES.
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.
Cefepime sensitivity testing confirmed by ___.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROBACTER CLOACAE COMPLEX
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Aerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___ @ ___ ON ___
- ___.
GRAM NEGATIVE ROD(S).
Anaerobic Bottle Gram Stain (Final ___: GRAM
NEGATIVE ROD(S).
IMAGING:
========
___ CXR:
Left mid lung nodule corresponds to known lung cancer.
Hyperinflated lungs. No superimposed process.
___ ___:
No evidence of deep venous thrombosis in the bilateral lower
extremity veins.
___ CXR
IMPRESSION:
NO RELEVANT CHANGE AS COMPARED TO THE PREVIOUS IMAGE. KNOWN LUNG
CANCER, KNOWN OVERINFLATION. NO EVIDENCE OF PNEUMONIA,
PULMONARY EDEMA OR PLEURAL EFFUSIONS. NORMAL SIZE OF THE CARDIAC
SILHOUETTE.
___ RUE US
IMPRESSION:
No thrombosis or vessel wall thickening to suggest
thrombophlebitis.
LABS ON DISCHARGE:
==================
Refused
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Enalapril Maleate 5 mg PO DAILY
2. Mag-Al Plus (alum-mag hydroxide-simeth) 200-200-20 mg/5 mL
oral QID
3. Gabapentin 800 mg PO TID
4. Prochlorperazine 5 mg PO Q6H:PRN nausea
5. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
6. Tiotropium Bromide 1 CAP IH DAILY
7. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
8. Lorazepam 0.5 mg PO BID:PRN nausea
9. Metoprolol Tartrate 25 mg PO BID
10. Diphedryl (diphenhydrAMINE HCl) 12.5 mg/5 mL oral QID
11. Multivitamins W/minerals 1 TAB PO DAILY
12. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
13. budesonide-formoterol 160-4.5 mcg/actuation inhalation Other
14. Omeprazole 20 mg PO DAILY
15. Aspirin 81 mg PO DAILY
16. albuterol sulfate 2.5 mg /3 mL (0.083 %) inhalation Q4H:PRN
shortness of breath/wheezing
17. Sertraline 100 mg PO DAILY
18. TraZODone 50 mg PO QHS
19. Ondansetron 8 mg PO Q8H:PRN nausea
20. Azithromycin 250 mg PO Q24H
21. PredniSONE 5 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Azithromycin 250 mg PO Q24H
3. Gabapentin 800 mg PO TID
4. Ipratropium-Albuterol Neb 1 NEB NEB Q6H
5. Lorazepam 0.5 mg PO BID:PRN nausea
6. Metoprolol Tartrate 25 mg PO BID
7. Multivitamins W/minerals 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Ondansetron 8 mg PO Q8H:PRN nausea
10. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
11. PredniSONE 40 mg PO DAILY Duration: 4 Weeks
40 mg daily and decrease as per taper
RX *prednisone 10 mg 4 tablet(s) by mouth once a day Disp #*50
Tablet Refills:*0
12. Sertraline 100 mg PO DAILY
13. Tiotropium Bromide 1 CAP IH DAILY
14. TraZODone 50 mg PO QHS
15. Maalox/Diphenhydramine/Lidocaine ___ mL PO QID:PRN mouth
pain
RX *alum-mag hydroxide-simeth [Antacid M] 200 mg-200 mg-20 mg/5
mL ___ ml by mouth qid prn Refills:*3
16. albuterol sulfate 2.5 mg /3 mL (0.083 %) inhalation Q4H:PRN
shortness of breath/wheezing
17. budesonide-formoterol 160-4.5 INHALATION BID
18. Diphedryl (diphenhydrAMINE HCl) 12.5 mg/5 mL ORAL QID
19. Guaifenesin-CODEINE Phosphate ___ mL PO Q6H:PRN cough
20. Mag-Al Plus (alum-mag hydroxide-simeth) 200 mg/5 mL ORAL QID
21. Prochlorperazine 5 mg PO Q6H:PRN nausea
22. Ertapenem Sodium 1 g IV DAILY Duration: 13 Doses
last day ___
RX *ertapenem [Invanz] 1 gram 1 gram IV Q24H Disp #*13 Vial
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Enterobacter bacteremia
COPD exacerbation
SECONDARY DIAGNOSES:
___
CAD
GERD
Depression
Insomnia
Neuropathy
___
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 c/o SOB with Hx lung CA // ? PNA
COMPARISON: ___
FINDINGS:
AP portable upright view of the chest. Port-A-Cath resides over the right
upper chest wall with catheter tip again seen in the level of the mid SVC.
There is a nodular opacity projecting over the left mid lung appears slightly
smaller than on prior with gross measurements approximating 1.5 x 2.1 cm.
Lungs are hyperinflated. No evidence of pneumonia or edema. No pneumothorax or
large effusion. Cardiomediastinal silhouette appears normal. Bony structures
appear grossly intact.
IMPRESSION:
Left mid lung nodule corresponds to known lung cancer. Hyperinflated lungs.
No superimposed process.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ with hypoxia, dye allergy // eval dvt
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow and augmentation of the bilateral common
femoral, 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 bilateral lower extremity veins.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with stage IIIb lung cancer currently undergoing
chemotherapy, COPD on home 2L O2, presenting with SOB and hypoxia, +BCx x4 w/
GNRs // ?PNA ?intrapulm process
COMPARISON: ___.
IMPRESSION:
NO RELEVANT CHANGE AS COMPARED TO THE PREVIOUS IMAGE. KNOWN LUNG CANCER, KNOWN
OVERINFLATION. NO EVIDENCE OF PNEUMONIA, PULMONARY EDEMA OR PLEURAL
EFFUSIONS. NORMAL SIZE OF THE CARDIAC SILHOUETTE.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US
INDICATION: ___ year old man with bacteremia and right sided PORT, evaluate
for thrombophlebitis
TECHNIQUE: Grey scale and Doppler evaluation was performed on the right upper
extremity veins.
COMPARISON: None.
FINDINGS:
Central catheter is seen within the right subclavian vein. There is normal
flow with respiratory variation in the bilateral subclavian veins.
The right internal jugular and axillary veins are patent and compressible with
transducer pressure.
The right brachial, basilic, and cephalic veins are patent, compressible with
transducer pressure and show normal color flow and augmentation.
IMPRESSION:
No vessel wall thickening to suggest thrombophlebitis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with RESPIRATORY ABNORM NEC, HYPOXEMIA
temperature: 99.0
heartrate: 100.0
resprate: 36.0
o2sat: 100.0
sbp: 149.0
dbp: 0.0
level of pain: 0
level of acuity: 1.0 | ___ with stage IIIb lung cancer currently undergoing
chemotherapy, COPD on home 2L O2, who presented with SOB and
hypoxia likely due to a COPD exacerbation, found to have GNR
bacteremia. |
Name: ___ Unit ___: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
Penicillins
Attending: ___
Chief Complaint:
MVC
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ s/p MVC,trauma. Multi-car accident, pt rear-ended, car
turned, T-boned on passenger side. +LOC. primary and secondary
survey notable mainly for left clavicle pain, reports area to
same. Pt denies paresthesia or weakness to the LUE.
Past Medical History:
denies
Social History:
___
Family History:
non-contributory
Physical Exam:
On admission:
VS: P 94 BP 140/p RR 12 SPO2 100% RA GCS 15
Pertinent Results:
CT HEAD W/O CONTRAST Study Date of ___ 6:37 ___
___ evidence of acute intracranial process. Findings suggesting
a
history of bilateral maxillary sinusitis.
CT C-SPINE W/O CONTRAST Study Date of ___ 6:38 ___
IMPRESSION:
1. Small bony fragment the the C6 spinous process, possibly a
remote prior avulsion fracture; ___ evidence of recent injury.
2. Severe degenerative changes at C5/C6 with bridging anterior
and posterior osteophytes, including ossification of the
posterior longitudinal ligament, and fusion of the vertebral
bodies, with associated mild to moderate narrowing the spinal
canal at this level.
CT ABD & PELVIS/CHEST WITH CONTRAST Study Date of ___ 6:39
___
IMPRESSION:
1. Middle third left clavicle fracture with anterior displaced
butterfly
fragment.
2. ___ other acute injury of the chest, abdomen or pelvis.
3. Moderate-to-severely distended stomach filled with fluid.
___ 06:50PM WBC-9.3 RBC-4.88 HGB-13.8* HCT-41.6 MCV-85
MCH-28.3 MCHC-33.2 RDW-13.6
___ 06:50PM PLT COUNT-109*
___ 06:50PM ___ PTT-25.4 ___
___ 06:50PM ___ 06:47PM ___ PH-7.40
___ 06:47PM GLUCOSE-98 LACTATE-1.6 NA+-141 K+-3.4
CL--110* TCO2-24
___ 06:47PM HGB-13.9* calcHCT-42 O2 SAT-93 CARBOXYHB-3
MET HGB-0
___ 06:47PM freeCa-1.07*
___ 06:50PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 06:50PM estGFR-Using this
___ 06:50PM UREA N-16 CREAT-1.2
Medications on Admission:
none
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
RX *tramadol 50 mg 1 Tablet(s) by mouth every four (4) hours
Disp #*50 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
s/p MVC with +LOC
Left distal clavicle fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH
HISTORY: Trauma.
COMPARISONS: None.
TECHNIQUE: Chest, portable AP supine.
FINDINGS: The cardiac, mediastinal and hilar contours appear within normal
limits. There is no pleural effusion or pneumothorax. There is a comminuted
fracture of the left mid clavicle with displacement of a small free fragment
in a slightly inferior direction. No other definite bony injury is
visualized.
IMPRESSION: No radiographic evidence for intrathoracic injury. Comminuted
fracture of the mid left clavicle.
Radiology Report
INDICATION: ___ man after high speed trauma.
TECHNIQUE: Axial CT images of the head were obtained. Coronal and sagittal
reformats were acquired.
COMPARISON: There are no prior studies for comparison available.
TECHNIQUE: Non-contrast head CT.
FINDINGS: There is no evidence of acute intracranial hemorrhage, edema, mass
effect or large acute territorial infarction. Slight asymmetry in the sizes
of anterior lateral ventricles is consistent with a normal variant. There is
no calvarial or skull base fracture. The paranasal sinuses demonstrate no
hemorrhage. There is moderate mucosal thickening in both maxillary sinuses
with bilateral antrostomies. There is osseous wall thickening of the
maxillary sinus walls suggesting sequelae of chronic sinusitis.
IMPRESSION: No evidence of acute intracranial process. Findings suggesting a
history of bilateral maxillary sinusitis.
Radiology Report
INDICATION: ___ with status post MVC.
TECHNIQUE: Contiguous MDCT images of the cervical spine were obtained.
Axial, coronal and sagittal reformats were acquired.
COMPARISON: None.
FINDINGS:
CT OF THE C-SPINE:
The height of the vertebral bodies of the C-spine is preserved. A small bony
fragment near the C6 spinous process tip (602B, image 28) is well-corticated
and likely chronic, suggesting either remote prior fracture or possibly nuchal
ligament calcification.
There are severe degenerative changes at C5/C6 with fusion of both vertebral
bodies and large anterior and posterior osteophytes and mild spinal canal
narrowing at this level, as well as ossification of the posterior longitudinal
ligament at that level.
Chronic sinusitis of the maxillary sinuses is partially visualized. The
mastoid air cells are clear. There is no evidence for a large acute neck
hematoma.
IMPRESSION:
1. Small bony fragment the the C6 spinous process, possibly a remote prior
avulsion fracture; no evidence of recent injury.
2. Severe degenerative changes at C5/C6 with bridging anterior and posterior
osteophytes, including ossification of the posterior longitudinal ligament,
and fusion of the vertebral bodies, with associated mild to moderate narrowing
the spinal canal at this level.
Radiology Report
INDICATION: ___ yo male patient after MVC.
TECHNIQUE: Contiguous MDCT images of the chest, abdomen and pelvis were
performed after administration of intravenous contrast. Axial, coronal and
sagittal reformats were acquired.
COMPARISON: None.
FINDINGS:
CT OF THE CHEST:
The thyroid gland is normal. There is no axillary lymphadenopathy. Borderline
enlarged right lower paratracheal lymph nodes are seen.
There is no mediastinal hemorrhage, pneumomediastinum, pericardial or pleural
effusion. Bibasilar atelectatic changes are demonstrated.
There are no significant atherosclerotic calcifications of the coronary
arteries or the thoracic aorta.
There is a displaced left middle third clavicle fracture with an anteriorly
displaced butterfly fragment.
There are no rib fractures.
CT OF THE ABDOMEN:
The liver, gallbladder, pancreas, spleen, both adrenal glands and kidneys are
normal. There is no free air and no free fluid. There is no retroperitoneal
or mesenteric lymphadenopathy. The systemic arterial and systemic venous and
portal venous system of the abdomen and pelvis are normal. The stomach is
significantly dilated with fluid.
The small and large bowel and mesentery without evidence of acute injury.
CT OF THE PELVIS:
The urinary bladder, prostate gland and seminal vesicles are normal. There is
no pelvic hematoma and no free fluid. There are no pelvic fractures.
IMPRESSION:
1. Middle third left clavicle fracture with anterior displaced butterfly
fragment.
2. No other acute injury of the chest, abdomen or pelvis.
3. Moderate-to-severely distended stomach filled with fluid.
Gender: M
Race: ASIAN - ASIAN INDIAN
Arrive by AMBULANCE
Chief complaint: MVC
Diagnosed with FX CLAVICLE NOS-CLOSED, MV COLLISION NOS-DRIVER, ALTERED MENTAL STATUS , ABRASION HAND
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Mr. ___ was admitted on ___ under the Acute Care Surgery
service after his accident. Upon review of his films it was
determined that his only injury was a distal left clavicle
fracture. A spinous process C6 fx was seen but determined to be
old from a prior accident. C-collar was cleared.
Orthopedics was consulted for the clavicle fracture who
recommended nonoperative management with a sling and
nonweightbearing X 2 weeks. Outpatient f/u was scheduled for 2
weeks from discharge.
Occupational therapy was consulted for cognitive evaluation
cognitive + LOC, who recommended that the patient f/u with
cognitive neurology after discharge. Information regarding this
was given to the patient.
On ___ he is afebrile and hemodynamically stable. His pain is
well controlled on an oral regimen and he is able to ambulate
independently. He is tolerating a regular diet. He is being
discharged home with f/u with orthopedics and cognitive
neurology. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
aspirin
Attending: ___.
Chief Complaint:
Leg pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ lady with a ___ significant for colon
cancer with known mets to the liver, bone, and lung who is
admitted from the ED with right leg pain.
Patient reports developing right leg pain over the last eight
weeks. The pain has accelearated over the last three weeks, and
over the last few days she had difficulty ambulating. She
describes the pain as ___ aching pain in her right lateral
shin, knee, and the top of her thigh. She has associated mid
back soreness. The pain goes down to ___ for an hour with
oxycodone. She had ___ at OS___ on ___ which was negative and
had an MRI at ___ about a week ago (patient
doesn't know results). She presented to ___ on ___
and was given IM dilaudid and told to double her oxycodone to
10mg. Despite this, her symptoms progressed, so she presented to
the ED.
In the ED, initial VS were: pain 10, T 98.8, HR 108, BP 114/66,
RR 16, O2 99 RA. Initial labs were notable for WBC 6.6, HCT
39.5, PLT 309, nl chem 7. ___ showed no sign of DVT and
right leg plain films showed no fracture, dislocation or obvious
lesion. Patient was given 0.5mg IV dilaudid x2 and admitted to
the floorfor further management.
On arrival to the floor, patient reports ___ right leg pain as
above. No other complaints. No recent fevers or chills. No sore
throat or recent cold. No chest pain, SOB, or cough. No N/V or
abdominal pain. Occaisional constipation, but has been regular
recently. She has poor appetite and has lost some weight. No new
rashes. Prior knee pain several years ago, but no other
injuries. No trauma. No falls.
REVIEW OF SYSTEMS:
A complete 10-point review of systems was performed and was
negative unless otherwise noted in the HPI.
Past Medical History:
PAST ONCOLOGIC HISTORY:
Stage IV colon cancer with bony, liver and lung mets with
elevated CEA. Liver biopsy from ___ confirm adenocarcinoma in
___. She was treated with radiation to her bony met in the
hip
and then started chemotherapy. After 6 cycles of ___ CT
scan in ___ demonstrates excellent response to chemotherapy
->
liver lesions decreased by 50% and bony lesions look sclerotic
(treated). She continued with ___ until ___ when
oxali was stopped due to neuropathy. Her CEA started to rise on
___. CT scan from ___ of ___ demonstrated small and
new pulm mets but stable liver/bony disease. She was started on
___ in ___, but CEA continued to rise after 3
cycles. She elected to skip ___ cycle on ___ and her CEA has
increased dramatically off of chemo. Again, elected to skip
chemo
on ___.
PAST MEDICAL HISTORY:
-Sickle cell trait
-Anemia
-Vitamin D Deficiency
-Sciatica
-Metastatic colon cancer
Social History:
___
Family History:
MGM with DM and stroke, maternal uncle with DM2 . PGM with HTN.
Uncle with colon cancer.
Physical Exam:
Admission Exam:
VS: T 98.4 HR 87 BP 110/78 SAT 100% O2 on RA
GENERAL: Pleasant, lying in bed comfortably
HEENT: Anicteric. PERLL 2-->1 b/l. OP clear. No LAD
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Scaphoid. Normal bowel sounds, soft, nontender,
nondistended, no hepatomegaly, no splenomegaly
EXT: Cool, 1+ DP bilaterally with good cap refill, no lower
extremity edema. No spinal tenderness. Pain with right hip
external rotation. No significant joint effusion. TTP over
lateral tibial plateau
NEURO: Alert, oriented, CN II-XII intact, FTN and HTS intact,
motor and sensory function grossly intact
SKIN: No significant rashes
Discharge Exam:
Vitals: 98.0 115/65 99 18 100%RA
Gen: Appears well, seated upright in bed and in good humor.
Eyes: EOMI, sclerae anicteric
ENT: MMM, OP clear
GI: soft, NT, ND, BS+
MSK: No pain to palpation of the right lower extremity. Negative
straight leg or crossed leg pain. ___ strength in flexion and
extenstion of proximal and distal muscle groups. There is a
blanching, reticular rash over the right thigh
circumferentially, non-tender to palpation and with a bluish
hue.
Skin: Warm and dry
Neuro: AAOx3.
Pertinent Results:
ADMISSION LABS:
___ 01:17AM BLOOD WBC-6.6 RBC-4.46 Hgb-12.7 Hct-39.5 MCV-89
MCH-28.5 MCHC-32.2 RDW-14.1 RDWSD-45.1 Plt ___
___ 01:17AM BLOOD Glucose-101* UreaN-9 Creat-0.6 Na-135
K-4.1 Cl-97 HCO3-23 AnGap-19
___ 07:10AM BLOOD ALT-73* AST-77* AlkPhos-601* TotBili-0.4
Imaging:
EXAMINATION: DX FEMUR AND TIB/FIB
INDICATION: History: ___ with metastatic colon cancer with 6
wks of right
femur/knee/tib/fib pain // ? fracture, lucency, mass
TECHNIQUE: 6 TOTAL VIEWS OF THE RIGHT FEMUR AND TIBIA/FIBULA
COMPARISON: None available
FINDINGS:
No acute fracture is identified. The femoral head appears
seated in the
acetabulum. No evidence of dislocation. There is no radiopaque
foreign body.
Images of the knee are without significant degenerative changes.
There is
note joint effusion. Although suboptimal technique, the tibia
and fibula
appear symmetric about the talus. No lytic or blastic lesion is
identified.
There is no periosteal reaction.
IMPRESSION:
No definite lytic or sclerotic lesion. If there is continued
clinical concern
for metastatic disease, MRI is recommended.
INDICATION: ___ year old woman with PMHx notable for metastatic
colon cancer
with pain from ankle to might mid thigh worse from mid tibia to
mid thigh.
Concern for metastatic involvement. // Please eval for
metastatic disease vs
myositis.
TECHNIQUE: Multiplanar multi sequence imaging of the right
lower extremity
was performed from the distal femoral diaphysis to the distal
tibial diaphysis
before after administration of 5 cc of Gadovist IV contrast on a
1.5 Tesla
magnet utilizing the body coil. Sequences include coronal T1
and STIR images
of both lower extremities and dedicated sagittal and axial T1
and STIR imaging
of the right lower extremity as well as axial and coronal T1 pre
and
postcontrast images.
COMPARISON: CT right lower extremity ___. Radiographs
of the femur
and tib-fib ___.
FINDINGS:
There is no fracture or dislocation in the included osseous
structures. Bone
marrow signal is normal. No osseous or soft tissue mass is
detected. There
is no focal fluid collection. Visualized muscles and tendons
are within
normal limits. No muscle edema or atrophy identified. No
fascial edema is
detected. This examination is not optimized for evaluation of
vessels, but
visualized vessels are grossly unremarkable.
Although this study is not designed for evaluation of the knees,
no gross
derangement is detected and there is no joint effusion on either
side.
IMPRESSION:
Imaging localized to the patient's maximal site of pain from the
distal
femoral diaphysis to the distal tibial diaphysis of the right
lower extremity
reveals no evidence of metastatic disease in the bones or
surrounding soft
tissues.
Lower extremity pain can occasionally be referred from the
lumbar spine
--clinical correlation is requested in that regard.
EXAMINATION: MR ___ AND W/O CONTRAST.
INDICATION: ___ year old woman with metastatic colon cancer with
known mets to
the spine. // ? Metastatic disease causing pain in the right
lower extermity.
TECHNIQUE: Sagittal T1, T2 and sagittal IDEAL sequences were
obtained through
the lumbar spine, axial T2 weighted images were also obtained.
After the
intravenous administration of 4.5 mL of Gadavist contrast
material agent, the
T1 weighted images were repeated in axial sagittal projections.
COMPARISON: No prior examinations of the lumbar spine are
available.
FINDINGS:
There is sacralization of the fifth lumbar vertebral body,
otherwise, the
alignment of the lumbar vertebral bodies appears maintained, the
conus
medullaris terminates at the level of T12/L1 and is
unremarkable, the signal
intensity in the bone marrow of the lower thoracic spine, lumbar
vertebral
bodies, sacrum and iliac bones is notable for heterogeneous
signal in the
different sequences, consistent with bone marrow infiltration
from metastatic
disease. After administration of gadolinium contrast, there is
moderate
pattern of heterogeneous enhancement throughout the lumbar
vertebral bodies,
however, with no evidence of enhancement to indicate
leptomeningeal disease.
At T12/L1 level, there is no evidence of neural foraminal
narrowing or spinal
canal stenosis.
At L1/L2 level, there is minimal diffuse disc bulge, causing
minimal
left-sided neural foraminal narrowing, there is no evidence of
spinal canal
stenosis (image 11, series 15). Schmorl's node is identified at
the superior
endplate of L2.
At L2/L3 level, there is diffuse disc bulge, causing mild
bilateral neural
foraminal narrowing, apparently contacting the traversing nerve
roots
bilaterally, moderate articular joint facet hypertrophy is
present. .
At L3/L4 level, there is no evidence of neural foraminal
narrowing spinal
canal stenosis, mild articular joint facet hypertrophy is
present.
At L4/L5 level, there is disc desiccation and diffuse disc
bulge, causing
anterior thecal sac deformity and bilateral neural foraminal
narrowing, the
disc bulge is contacting the traversing nerve roots bilaterally,
moderate
articular joint facet hypertrophy is seen. Schmorl's node is
identified at
the superior endplate of L5.
At L5/S1 level, there is disc desiccation and Schmorl's node,
mild disc
bulging, slightly asymmetric towards the left, contacting the
traversing nerve
roots bilaterally (image 16, series 17), heterogeneous signal is
noted in the
sacral as as well as in both iliac bones consistent with bone
marrow
infiltration from metastatic disease. Heterogeneous signal is
noted in the
sacrum at S1 and S2 level, with focal areas of hyperintensity
signal on the
STIR sequence, and areas of low signal, likely consistent with a
combination
of sclerotic changes and metastatic disease.
IMPRESSION:
1. Heterogeneous signal throughout the lumbar vertebral bodies,
lower
thoracic spine, sacrum and iliac bones, consistent with bone
marrow
infiltration from metastatic disease. There is mild to moderate
pattern of
enhancement in the lumbar vertebral bodies with patchy areas of
low signal
also consistent with a combination of the sclerotic changes and
metastatic
disease.
2. Multilevel multifactorial degenerative changes throughout
the lumbar spine
as described above, more significant at L4/L5 and L5/S1 levels.
Medications on Admission:
The Preadmission Medication list is accurate and complete
1. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain - Moderate
2. Vitamin D 1000 UNIT PO DAILY
3. LORazepam 0.5 mg PO Q8H:PRN anxiety
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Prochlorperazine 10 mg PO Q6H:PRN nausea
6. Ondansetron 8 mg PO Q8H:PRN nausea
7. Docusate Sodium 100 mg PO BID
8. Senna 8.6 mg PO BID:PRN constipation
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
Do not take more than 8 extra strength tablets per day
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*180 Tablet Refills:*0
2. Bisacodyl 10 mg PR QHS:PRN constipation
RX *bisacodyl 10 mg 1 suppository(s) rectally Daily Disp #*30
Suppository Refills:*0
3. Fentanyl Patch 75 mcg/h TD Q72H
RX *fentanyl 75 mcg/hour Apply as directed Q72Hr Disp #*10 Patch
Refills:*0
4. Docusate Sodium 100 mg PO BID
5. LORazepam 0.5 mg PO Q8H:PRN anxiety
6. Ondansetron 8 mg PO Q8H:PRN nausea
7. OxyCODONE (Immediate Release) 5 mg PO Q6H:PRN Pain -
Moderate
8. Polyethylene Glycol 17 g PO DAILY:PRN constipation
9. Prochlorperazine 10 mg PO Q6H:PRN nausea
10. Senna 8.6 mg PO BID:PRN constipation
11. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Leg Pain
Metastatic Colon Cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: DX FEMUR AND TIB/FIB
INDICATION: History: ___ with metastatic colon cancer with 6 wks of right
femur/knee/tib/fib pain // ? fracture, lucency, mass
TECHNIQUE: 6 TOTAL VIEWS OF THE RIGHT FEMUR AND TIBIA/FIBULA
COMPARISON: None available
FINDINGS:
No acute fracture is identified. The femoral head appears seated in the
acetabulum. No evidence of dislocation. There is no radiopaque foreign body.
Images of the knee are without significant degenerative changes. There is
note joint effusion. Although suboptimal technique, the tibia and fibula
appear symmetric about the talus. No lytic or blastic lesion is identified.
There is no periosteal reaction.
IMPRESSION:
No definite lytic or sclerotic lesion. If there is continued clinical concern
for metastatic disease, MRI is recommended.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT
INDICATION: History: ___ with right leg pain // ? dvt
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the right common
femoral, femoral, and popliteal veins. Normal color flow and compressibility
are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right lower extremity veins.
Radiology Report
INDICATION: ___ year old woman with metastatic colon cancer with known bony
mets with severe right lower extremity pain from the ankle to the knee.
Concern for bony lesion vs pathologic fracture // ? bony lesion vs pathologic
fracture
TECHNIQUE: Contiguous helical MDCT images were obtained through the right
lower extremity from the distal femur through the foot without IV contrast.
Multiplanar axial, coronal, sagittal and thin section bone algorithm
reconstructed images were generated.
COMPARISON: Radiographs of the femur and tib-fib ___
FINDINGS:
There is no fracture, dislocation, or sclerotic or lytic lesion. The knee
appears grossly intact without joint effusion. Similarly the ankle appears
normal. The ankle mortise is congruent. There is no osteochondral defect of
the tailor dome. Os perineum is incidentally noted. Included soft tissues
are unremarkable. Within the limitations of noncontrast CT there is no gross
soft tissue mass or fluid collection.
IMPRESSION:
Unremarkable examination of the right lower extremity from the distal femur
through the toes. No osseous lesion or fracture detected. If there is
continued concern for metastatic disease or other occult bone or soft tissue
abnormality, then MRI would provide a more sensitive examination.
Radiology Report
INDICATION: ___ year old woman with PMHx notable for metastatic colon cancer
with pain from ankle to might mid thigh worse from mid tibia to mid thigh.
Concern for metastatic involvement. // Please eval for metastatic disease vs
myositis.
TECHNIQUE: Multiplanar multi sequence imaging of the right lower extremity
was performed from the distal femoral diaphysis to the distal tibial diaphysis
before after administration of 5 cc of Gadovist IV contrast on a 1.5 Tesla
magnet utilizing the body coil. Sequences include coronal T1 and STIR images
of both lower extremities and dedicated sagittal and axial T1 and STIR imaging
of the right lower extremity as well as axial and coronal T1 pre and
postcontrast images.
COMPARISON: CT right lower extremity ___. Radiographs of the femur
and tib-fib ___.
FINDINGS:
There is no fracture or dislocation in the included osseous structures. Bone
marrow signal is normal. No osseous or soft tissue mass is detected. There
is no focal fluid collection. Visualized muscles and tendons are within
normal limits. No muscle edema or atrophy identified. No fascial edema is
detected. This examination is not optimized for evaluation of vessels, but
visualized vessels are grossly unremarkable.
Although this study is not designed for evaluation of the knees, no gross
derangement is detected and there is no joint effusion on either side.
IMPRESSION:
Imaging localized to the patient's maximal site of pain from the distal
femoral diaphysis to the distal tibial diaphysis of the right lower extremity
reveals no evidence of metastatic disease in the bones or surrounding soft
tissues.
Lower extremity pain can occasionally be referred from the lumbar spine
--clinical correlation is requested in that regard.
Radiology Report
EXAMINATION: MR ___ AND W/O CONTRAST.
INDICATION: ___ year old woman with metastatic colon cancer with known mets to
the spine. // ? Metastatic disease causing pain in the right lower extermity.
TECHNIQUE: Sagittal T1, T2 and sagittal IDEAL sequences were obtained through
the lumbar spine, axial T2 weighted images were also obtained. After the
intravenous administration of 4.5 mL of Gadavist contrast material agent, the
T1 weighted images were repeated in axial sagittal projections.
COMPARISON: No prior examinations of the lumbar spine are available.
FINDINGS:
There is sacralization of the fifth lumbar vertebral body, otherwise, the
alignment of the lumbar vertebral bodies appears maintained, the conus
medullaris terminates at the level of T12/L1 and is unremarkable, the signal
intensity in the bone marrow of the lower thoracic spine, lumbar vertebral
bodies, sacrum and iliac bones is notable for heterogeneous signal in the
different sequences, consistent with bone marrow infiltration from metastatic
disease. After administration of gadolinium contrast, there is moderate
pattern of heterogeneous enhancement throughout the lumbar vertebral bodies,
however, with no evidence of enhancement to indicate leptomeningeal disease.
At T12/L1 level, there is no evidence of neural foraminal narrowing or spinal
canal stenosis.
At L1/L2 level, there is minimal diffuse disc bulge, causing minimal
left-sided neural foraminal narrowing, there is no evidence of spinal canal
stenosis (image 11, series 15). Schmorl's node is identified at the superior
endplate of L2.
At L2/L3 level, there is diffuse disc bulge, causing mild bilateral neural
foraminal narrowing, apparently contacting the traversing nerve roots
bilaterally, moderate articular joint facet hypertrophy is present. .
At L3/L4 level, there is no evidence of neural foraminal narrowing spinal
canal stenosis, mild articular joint facet hypertrophy is present.
At L4/L5 level, there is disc desiccation and diffuse disc bulge, causing
anterior thecal sac deformity and bilateral neural foraminal narrowing, the
disc bulge is contacting the traversing nerve roots bilaterally, moderate
articular joint facet hypertrophy is seen. Schmorl's node is identified at
the superior endplate of L5.
At L5/S1 level, there is disc desiccation and Schmorl's node, mild disc
bulging, slightly asymmetric towards the left, contacting the traversing nerve
roots bilaterally (image 16, series 17), heterogeneous signal is noted in the
sacral as as well as in both iliac bones consistent with bone marrow
infiltration from metastatic disease. Heterogeneous signal is noted in the
sacrum at S1 and S2 level, with focal areas of hyperintensity signal on the
STIR sequence, and areas of low signal, likely consistent with a combination
of sclerotic changes and metastatic disease.
IMPRESSION:
1. Heterogeneous signal throughout the lumbar vertebral bodies, lower
thoracic spine, sacrum and iliac bones, consistent with bone marrow
infiltration from metastatic disease. There is mild to moderate pattern of
enhancement in the lumbar vertebral bodies with patchy areas of low signal
also consistent with a combination of the sclerotic changes and metastatic
disease.
2. Multilevel multifactorial degenerative changes throughout the lumbar spine
as described above, more significant at L4/L5 and L5/S1 levels.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: R Leg pain
Diagnosed with Pain in right leg
temperature: 98.8
heartrate: 108.0
resprate: 16.0
o2sat: 99.0
sbp: 114.0
dbp: 66.0
level of pain: 10
level of acuity: 2.0 | Ms. ___ is a ___ lady with a PMH significant for colon
cancer with known mets to the liver, bone, and lung who is
admitted from the ED with right leg pain.
# Right leg pain:
Concerning for complication of her known metastatic malignancy.
Ultrasound showed no DVT, and plain films of leg showed no
fracture or obvious lesion. She has known spinal mets and MRI of
the ___ in the last 2 weeks did not show any cause for the
right ___ pain. Had CT scan of ___ to eval for pain but CT scan
showed no fracture or osseous lesion to explain the pain. MRI of
the leg was obtained to evaluate for metastatic disease and was
negative. MRI of the back was obtained to see if any interval
change had occurred in the last 2 weeks and there is mild
progression of disk buldging now touching the thecal sack but
there are no unstable process or any operable features for pain
control. Aldolase level mildly elevated with normal CK and no
muscle enhancement on MRI makes myositis unlikely. She was
started on oxycodone ___ PO Q4 hours, Tylenol, ibuprofen,
and fentanyl patch with the assistance of the palliative care
team who followed the patient while she was in the hospital. She
continued to demonstrate improved pain control requiring only
minimal oxycodone PRNs while on Fentanyl 72mcg Q72H. She will
likely benefit from outpatient palliative care involvement.
# Levido Reticularis
On day prior to admission the patient was noted to have evidence
of levido reticularis of her right thigh which appeared
unchanged over a 24 hour period. She has not had new symptoms
and all of her imaging including LENIs were recently negative
only a few days prior. Given clinical stability, normal labs,
negative imaging and lack of new symptoms I believe it is safe
for patient to be discharged home to continue her maintenance
pain management as directed by oncology and palliative care
consultations. I discussed the plan with patient who is in
agreement to not pursue additional work up in house and she will
discuss with her PCP if she wants to evaluate for underlying
pathology such as embolic phenomena, vascular disease,
rheumatologic disease etc. I also discussed this with the
oncology consultant who is also in agreement. Given her goals of
care and focus on quality of life work up for Livedo Reticularis
may not be warranted at all. However, will defer that final
decision to outpatient providers.
# Metastatic colon cancer:
Most recently on FOLFIRI. Patient has elected to forgo chemo
therapy during last two treatment sessions. Case discussed with
Dr. ___ ___ (primary oncologist).
# Sickle Cell Trait
# Anemia: Stable
# Vitamin D Deficiency: Continued home Vitamin D 1000 units
daily |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
MSG / dust ,pollen
Attending: ___.
Chief Complaint:
Hyponatremia
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ PMH angioimmunoblastic T cell lymphoma / Burkitt lymphoma,
on
azacitidine, SIADH, who was admitted from her SNF with
hyponatremia
As per review of chart, patient was admitted at ___ from
___ for nausea and vomiting. She was found to have a
UTI with urine cultures growing pan-sensitive e. coli. She was
started on CTX and then transitioned to cefpodoxime and
completed
a 5 day course. Of note, patient has a hx of SIADH attributed to
her malignancy, managed with fluid restriction, concentrated
tube
feeds and salt tabs. At time of discharge Na was 132.
Patient noted that since discharge she generally felt well
except
for generalized fatigue. She denied nausea, vomiting, fever,
chills, shortness of breath, chest discomfort, abdominal pain,
dysuria, diarrhea or increased urinary frequency. She noted that
she had decreased appetite, and was adhering to fluid
restriction
set by rehab. She noted that she received tube feeds overnight
but doesn't know the specifics of what she receives. Denied
mental status changes.
As per notes, pt had sodium of 123 on ___. She was given 1L NS
at 100ml/hr. UA was positive at the time for leuk/nitr but
little
pyuria. Dr. ___ requested pt be brought in for
admission for hyponatremia with N/V and infectious work-up
Initial vitals in the ED were: T 96.5 HR 89 BP 137/84 R 18 SpO2
99% RA. Labs were notable for sNa 130->128 sOsm 266. UA with
significant pyuria, nitr pos, lg leuk. lactate/trop wnl.
ECG: NSR Rate 87. Normal Intervals. No ST-T wave changes
Renal was consulted who rec'd continuing to trend Na for now
without change in mgmt. as patient had already corrected target
amt in 24 hours. Patient was given CTX for presumed UTI and
admitted for further care.
ROS: 10 point review of systems discussed with patient and
negative unless noted above
Past Medical History:
PAST ONCOLOGIC HISTORY:
Ms ___ is a ___ YO F with PMH HTN, Osteoporosis who was
diagnosed with both Burkitt and angioimmunoblastic T cell
lymphoma, discharged from ___ on ___. Her admission from
___ to ___ was complicated by newly diagnosed HFrEF,
altered mental status, volume overload, VRE bacteremia, PNA,
hyponatremia, and a LLE DVT with PE, as well as a GI bleed.
She was admitted again from ___ to ___ for profound
hyponatremia. Her hyponatremia was multifactorial: related to
SIADH and possibly drugs. We stopped her lisinopril, restarted
salt tablets and introduced water restriction.
She stared C11D1 on ___ but on D4 presented with severe
hyponatremia again and was admitted. During admission CT torso
was performed and there was no evidence disease progression but
enlarging thoracic aorta aneurysm was noticed. She underwent
TEVAR procedure on ___. PLT back to baseline, BMbx did not
reveal obvious pathology.
PAST MEDICAL HISTORY:
- AITCL / Burkitt lymphoma, as above
- Hx of GIB
- LLE DVT with PE
- CHF
- VRE bacteremia
- Recurrent hyponatremia
- HL
- HTN
- GERD
- Depression/Anxiety
PAST SURGICAL HISTORY:
- ___ Endovascular thoracic aneurysm repair (TEVAR)
- ___: L3-5 laminectomy/fusion
- ___: Right ___ metatarsophalangeal joint total
replacement implant arthroplasty.
- ___: Left anterior ethmoidectomy and maxillary
antrostomy with removal of tissue from the left maxillary sinus.
- ___: Excision of right breast mass
Social History:
___
Family History:
No known family history of leukemia or lymphoma.
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
___ 2301 Temp: 98.6 PO BP: 135/77 L Sitting HR: 81
RR: 18 O2 sat: 95% O2 delivery: ra Dyspnea: N/A RASS: 0 Pain
Score: ___
GENERAL: sitting upright in bed, appears comfortable, NAD
HEENT: OP clear, MMM
EYES: PERRLA, anicteric
NECK: Supple
RESP: CTA b/l, no wheezes/rales/rhonchi, normal RR
___: RRR no murmur, normal distal perfusion, no edema
GI: soft, NT, ND< normoactive BS, no rebound or guarding
EXT: warm, dry, decreased muscle bulk
SKIN: warm, dry, no rash
NEURO: AOx3, fluent speech
ACCESS: PORT in right chest dressing c/d/i
DISCHARGE PHYSICAL EXAM:
========================
Vital Signs:24 HR Data (last updated ___ @ 748)
Temp: 97.9 (Tm 99.0), BP: 149/83 (119-149/75-84), HR: 94
(86-94), RR: 16 (___), O2 sat: 97% (93-98), O2 delivery: Ra,
Wt: 116.84 lb/53.0 kg
General: well-appearing, no acute distress.
Lungs: clear bilaterally
Heart: s1, s2 normal, nl rate, regular rhythm
Abd: soft, non-tender.
Lower extremities: no edema
Skin: no rash
Pertinent Results:
ADMISSION LABS:
===============
___ 01:08PM BLOOD WBC-4.8 RBC-3.69* Hgb-11.7 Hct-34.3
MCV-93 MCH-31.7 MCHC-34.1 RDW-17.0* RDWSD-57.6* Plt ___
___ 01:08PM BLOOD Neuts-59.6 ___ Monos-14.1*
Eos-3.1 Baso-0.6 Im ___ AbsNeut-2.86 AbsLymp-1.07*
AbsMono-0.68 AbsEos-0.15 AbsBaso-0.03
___ 01:08PM BLOOD Glucose-95 UreaN-13 Creat-0.5 Na-130*
K-4.3 Cl-94* HCO3-24 AnGap-12
___ 01:08PM BLOOD Osmolal-266*
___ 01:17PM BLOOD Lactate-1.4
___ 01:08PM BLOOD cTropnT-<0.01
PERTINENT LABS/MICRO/IMAGING:
============================
___ 03:00PM URINE Osmolal-781
___ 03:00PM URINE Hours-RANDOM Na-152
MICRO:
----------
___ 01:40PM URINE Color-Yellow Appear-Hazy* Sp ___
___ 01:40PM URINE Blood-NEG Nitrite-POS* Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG*
___ 01:40PM URINE RBC-11* WBC-125* Bacteri-MOD* Yeast-NONE
Epi-<1
___ 1:40 pm URINE
URINE CULTURE (Preliminary):
CITROBACTER FREUNDII COMPLEX. >100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
CITROBACTER FREUNDII COMPLEX
|
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- 16 R
CIPROFLOXACIN--------- 0.5 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 32 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
___ 1:08 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 3:05 pm BLOOD CULTURE 2 OF 2.
Blood Culture, Routine (Pending): No growth to date.
IMAGING:
-------------
___ CXR:
No focal consolidations.
DISCHARGE LABS:
===============
___ 12:00AM BLOOD WBC-3.7* RBC-3.33* Hgb-10.4* Hct-31.2*
MCV-94 MCH-31.2 MCHC-33.3 RDW-16.9* RDWSD-58.1* Plt ___
___ 12:00AM BLOOD Neuts-48.2 ___ Monos-12.5
Eos-11.1* Baso-1.1* Im ___ AbsNeut-1.77 AbsLymp-0.98*
AbsMono-0.46 AbsEos-0.41 AbsBaso-0.04
___ 12:00AM BLOOD Glucose-121* UreaN-16 Creat-0.5 Na-134*
K-4.2 Cl-100 HCO3-25 AnGap-9*
___ 08:55AM BLOOD Na-134*
___ 12:00AM BLOOD Calcium-8.8 Phos-3.0 Mg-1.8
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Acyclovir 400 mg PO Q8H
3. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
4. Docusate Sodium 100 mg PO DAILY
5. Enoxaparin Sodium 40 mg SC DAILY
6. HydrALAZINE 10 mg PO Q6H:PRN SBP >160
7. LamoTRIgine 125 mg PO QHS
8. Mirtazapine 15 mg PO QHS
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Ondansetron ODT 4 mg PO Q8H:PRN nausea
11. OxyCODONE (Immediate Release) 5 mg PO DAILY:PRN rib
discomfort
12. Pravastatin 40 mg PO QPM
13. Prochlorperazine 10 mg PO BID:PRN for nausea before the car
ride to ___
14. Ranitidine 150 mg PO BID
15. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
16. Sodium Chloride 2 gm PO QID
17. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
18. Bisacodyl 10 mg PR QHS:PRN Constipation - First Line
19. Cyanocobalamin 100 mcg PO DAILY
20. Fleet Enema (Saline) ___AILY:PRN constipaton
21. LOPERamide 2 mg PO QID:PRN diarrhea
22. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - Third
Line
23. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
24. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Acyclovir 400 mg PO Q8H
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PR QHS:PRN Constipation - First Line
5. Brimonidine Tartrate 0.15% Ophth. 1 DROP BOTH EYES Q8H
6. CefTRIAXone 1 gm IV Q24H
7. Cyanocobalamin 100 mcg PO DAILY
8. Docusate Sodium 100 mg PO DAILY
9. Enoxaparin Sodium 40 mg SC DAILY
10. Fleet Enema (Saline) ___AILY:PRN constipaton
11. HydrALAZINE 10 mg PO Q6H:PRN SBP >160
12. LamoTRIgine 125 mg PO QHS
13. LOPERamide 2 mg PO QID:PRN diarrhea
14. Milk of Magnesia 30 mL PO DAILY:PRN Constipation - Third
Line
15. Mirtazapine 15 mg PO QHS
16. Multivitamins W/minerals 1 TAB PO DAILY
17. Ondansetron ODT 4 mg PO Q8H:PRN nausea
18. OxyCODONE (Immediate Release) 5 mg PO DAILY:PRN rib
discomfort
19. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - First
Line
20. Pravastatin 40 mg PO QPM
21. Prochlorperazine 10 mg PO BID:PRN for nausea before the car
ride to ___
22. Ranitidine 150 mg PO BID
23. Senna 8.6 mg PO DAILY:PRN Constipation - First Line
24. Sodium Chloride 2 gm PO QID
25. TraMADol 50 mg PO Q8H:PRN Pain - Moderate
Discharge Disposition:
Extended Care
Discharge Diagnosis:
# Hyponatremia
# Urinary Tract Infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ w/hx leukemia and with nausea vomiting, positive UA// PNA
present?
TECHNIQUE: Chest PA and lateral
COMPARISON: CT chest dated ___.
FINDINGS:
Right chest Port-A-Cath terminates in the right atrium. The lungs are well
inflated and clear. No focal consolidations or pulmonary edema. Unchanged
appearance of the cardiomediastinal silhouette. A stent is seen within the
descending thoracic aorta. No large pleural effusion. No pneumothorax.
IMPRESSION:
No focal consolidations.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal sodium level
Diagnosed with Hypo-osmolality and hyponatremia
temperature: 96.5
heartrate: 89.0
resprate: 18.0
o2sat: 99.0
sbp: 137.0
dbp: 84.0
level of pain: 0
level of acuity: 2.0 | PATIENT SUMMARY:
================
___ with PMH of angioimmunoblastic T cell lymphoma and Burkitt
lymphoma (on azacitidine ___ and SIADH, who was
admitted from her SNF with reported hyponatremia to 123 from
baseline of low 130s. S/p 1L NS with initial improvement of Na
to 130, uptrended to 134 on discharge. Also found to have
positive UA, started on CTX, with culture and sensitivities
resulting following discharge showing citrobacter sensitive to
cipro. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Darvon / Codeine
Attending: ___.
Chief Complaint:
cough
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Ms. ___ is a ___ with a poorly characterized past medical
history who presents from an outside hospital with confusion,
cough and fever. Ms. ___ and ___ family report that she
had cold-like symptoms which she was managing with ___ cold
medications such as Robitussin for the past ___ days. She also
had a productive cough. No hemoptysis or chest pain per patient.
Yesterday evening, she was found confused at her assisted living
community and specifically had entered an apartment that was not
her own.
Per OSH records, she presented there overnight into the day of
this admission with fever to ___ and a cough without a clear
infiltrate on CXR. Flu swab there was negative and patient was
noted to have rhonchi on exam. She was diagnosed clinically with
PNA and treated empirically with doxycycline and CTX as well as
duonebs X 1. While there, she was found to have a Troponin of
0.11 and BNP of 78. EKG was stable from prior but due to their
concern for NSTEMI she was transferred to ___ for further
management.
In the ED, initial vital signs were: 98.7 91 126/81 18 94% 4L.
Labs were notable for WBC 8 Ht 35 plat 80 and trop <.01. EKG
showed Patient was given Gabapentin, Clonzaepam and
Hydrochlorothiazide in the ED. On Transfer Vitals were: 99.0 98
147/66 16 92% Nasal Cannula.
Review of Systems: She reports cough and cold-like symptoms.
Denies fever, chills, chest pain, abdominal pain, N/V/D, urinary
symptoms or joint pain.
Past Medical History:
HX OF TOE AMPUTATION
MULTIPLE ORTHOPEDIC PROCEDURES
HX OF PANCREATITIS
HX OF CHOLECYSTECTOMY
Social History:
___
Family History:
Family history of diabetes.
Physical Exam:
==============
ADMISSION EXAM
==============
VITALS: 98.5F 154/71 85 18 96%4L NC
GEN: elderly, obese woman in NAD, sitting up in bed
HEENT: NC/AT, EOMI, anicteric sclerae
LYMPH: no supraclavicular lymphadenopathy
CV: regular rate and rhythm, no m/r/g
LUNGS: diffuse rhonchi and wheezing bilaterally, cough
ABD: obese, non-tender, non-distended, + bowel sounds, no
rebound tenderness or guarding
EXT: trace ___ edema
NEURO: AA+O X 3, CN II-XII grossly intact
SKIN: no rashes or lesions
==============
DISCHARGE EXAM
==============
VITALS: 98.1 140/72 102 18 95/ra
GEN: elderly, obese woman in NAD, sitting up in bed
HEENT: NC/AT, EOMI, anicteric sclerae
LYMPH: no supraclavicular lymphadenopathy
CV: regular rate and rhythm, no m/r/g
LUNGS: no ronchi. improvement in bilateral wheezing
ABD: obese, non-tender, non-distended, + bowel sounds
EXT: trace ___ edema, pedal pulses in ___
NEURO: AA+O X 3, CN grossly intact
SKIN: no rashes or lesions
Pertinent Results:
==============
ADMISSION LABS
==============
___ 06:45AM BLOOD WBC-8.7 RBC-3.94* Hgb-11.6* Hct-35.8*
MCV-91# MCH-29.4 MCHC-32.3 RDW-14.2 Plt Ct-80*
___ 06:45AM BLOOD Neuts-88.6* Lymphs-6.9* Monos-4.1 Eos-0.3
Baso-0.2
___ 06:45AM BLOOD ___ PTT-35.1 ___
___ 06:45AM BLOOD Plt Smr-LOW Plt Ct-80*
___ 06:45AM BLOOD Glucose-122* UreaN-12 Creat-0.9 Na-140
K-4.6 Cl-101 HCO3-28 AnGap-16
___ 06:45AM BLOOD ALT-14 AST-41* CK(CPK)-216* AlkPhos-82
TotBili-0.1
___ 06:45AM BLOOD CK-MB-4
___ 06:45AM BLOOD cTropnT-<0.01
___ 06:45AM BLOOD Albumin-3.5 Calcium-8.3* Phos-3.4 Mg-2.1
___ 08:30AM URINE Color-Yellow Appear-Hazy Sp ___
___ 08:30AM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-10 Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-MOD
___ 08:30AM URINE RBC-7* WBC-20* Bacteri-NONE Yeast-NONE
Epi-10 TransE-<1
==============
DISCHARGE LABS
==============
___ 06:25AM BLOOD WBC-10.8 RBC-4.87 Hgb-14.2 Hct-43.2
MCV-89 MCH-29.2 MCHC-32.9 RDW-14.9 Plt ___
___ 06:25AM BLOOD Plt ___
___ 06:25AM BLOOD Glucose-96 UreaN-16 Creat-0.9 Na-138
K-3.5 Cl-95* HCO3-30 AnGap-17
___ 06:25AM BLOOD Calcium-8.8 Phos-3.9 Mg-2.6
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 400 mg PO BID
2. Ciprofloxacin HCl 250 mg PO Q24H
3. Amitriptyline 100 mg PO QHS
4. ClonazePAM 0.5 mg PO TID
5. ARIPiprazole 5 mg PO DAILY
Discharge Medications:
1. Amitriptyline 100 mg PO QHS
2. ARIPiprazole 5 mg PO DAILY
3. ClonazePAM 0.5 mg PO TID
4. Gabapentin 400 mg PO BID
5. Hydrochlorothiazide 12.5 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Primary Diagnosis: Community acquired pneumonia
Secondary Diagnosis: Chronic pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with cough, fever // please eval for PNA
COMPARISON: ___
IMPRESSION:
As compared to the previous image, there is improved ventilation of the left
and the right lung. No evidence of pneumonia. No pulmonary edema. No
pleural effusions. Normal size of the cardiac silhouette. Bilateral shoulder
replacement.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Transfer, PNA NSTEMI
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 98.7
heartrate: 91.0
resprate: 18.0
o2sat: 94.0
sbp: 126.0
dbp: 81.0
level of pain: 1
level of acuity: 2.0 | This is a ___ year old woman with a poorly characterized past
medical history who presents for confusion and delirium in the
setting of cough and fever most concerning for
community-acquired pneumonia and an episode of elevated troponin
in the setting of concern for ECG changes at an outside
hospital. Her hospital course by problem is summarized below.
#COMMUNITY ACQUIRED PNEUMONIA: She had a productive cough with
fever to ___ and WBC 11 at ___, exam with diffuse
wheezing and ronchi R>L, and CXR without clear evidence of
consolidation. Flu swab negative. She was treated with a 5 day
course of levofloxacin for presumed CAP with notable clinical
improvement. She was also treated with duonebs for persistent
wheezing. Early in her stay she required supplemental oxygen but
was discharged to rehab stable on RA.
#TOXIC METABOLIC ENCEPHALOPATHY: Thought to be likely
multifactorial secondary to mild dementia and overlying delirium
in the setting of infection, possible overuse of OTC cold
medications. We held her home amytriptyline.Her mental status
improved over the course of her hospitalization and at the time
of discharge was at her baseline.
#TROPONINEMIA: Elevated troponin at the OSH to 0.11, repeat at
___ was <0.01. There an EKG was taken that was thought to have
lateral ST depressions but this appeared unchanged from prior
ECGs (___) when compared to those available here. Repeat ECG in
the ___ ED was also stable. Denied chest pain throughout her
stay. The troponin leak occurred in the setting of infection,
tachycardia and hypertension and thus the leading cause is
likely demand ischemia that resolved with treatment of her
underlying conditions.
#HTN: Systolic BP as high as 170-180 while at ___. She had
previously been treated for HTN (lisinopril and HCTZ) but was
discontinued in ___ during an episode ___ s/s
dehydration. Her previous HCTZ was restarted during this
admission.
#TRANSITIONAL ISSUES:
- Please consider arranging follow-up with a Cardiologist for
follow-up of this tropnoninemia. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Benadryl Decongestant / Shellfish
Attending: ___.
Chief Complaint:
RUQ abdominal pain
Major Surgical or Invasive Procedure:
Laparoscopic Cholecystectomy
History of Present Illness:
___ with no significant PMH who presents with one week
history of RUQ pain. Pt was seen at OSH where she was diagnosed
with cholelithiasis and mild pancreatitis. Pt was discharged and
she was scheduled for a RUQ U/S on ___ and an elective
cholecystectomy afterward. Pt, however, keeps having persistent
pain in RUQ with radiation to her back, worsening with food,
___
in intensity, +nausea, no vomiting, subjective fever, no chill.
Pt also reports being constipated for 1 week, last BM was
yesterday and it was normal.
Past Medical History:
Asthma, migraine
Past Surgical History: Bilateral breast reduction surgery in ___,
appendectomy in ___, R wrist ganglion cyst removal.
Social History:
___
Family History:
Family History: breast cancer, diabetes run in the family
Physical Exam:
On Admission:
Vitals: 98.6 92 151/87 18 100%
GEN: NAD. Alert, oriented x3. NAD
HEENT: No scleral icterus. Mucous membranes moist. Neck supple
CV: RRR, normal S1/S2
PULM: Unlabored breathing, CTAB
ABD: Soft, nondistended, TTP in RUQ, no guarding, no rebound, no
rigidity, normal bowel sound. No masses.
EXT: Warm without ___ edema/c/c
On Discharge:
Vitals: 116/75 95 98.1 99%RA
Gen: NAD, A/Ox3
Abd: soft, mildly distended, appropriately tender, 4 port site
incisions dressed
Pertinent Results:
___ 02:23PM GLUCOSE-83 UREA N-8 CREAT-0.9 SODIUM-143
POTASSIUM-3.9 CHLORIDE-105 TOTAL CO2-30 ANION GAP-12
___ 02:23PM ALT(SGPT)-87* AST(SGOT)-58* ALK PHOS-87 TOT
BILI-0.2
___ 02:23PM LIPASE-42
___ 02:23PM WBC-4.1 RBC-4.59 HGB-13.2 HCT-39.3 MCV-86
MCH-28.7 MCHC-33.5 RDW-13.1
Medications on Admission:
ALBUTEROL SULFATE [PROAIR HFA] - 90 mcg HFA Aerosol Inhaler - 2
puffs inhaled four times a day as needed for shortness of breath
or wheezing
EPINEPHRINE [EPIPEN] - 0.3 mg/0.3 mL (1:1,000) Pen Injector -
use as directed
ERGOTAMINE-CAFFEINE - 1 mg-100 mg tablet - 2 Tablet(s) by mouth
at onset of migraine. ___ repeat dose if needed.
FLUTICASONE - 50 mcg Spray, Suspension - 1 sprays(s) each
nostril
daily daily as symptoms improve
MEDROXYPROGESTERONE - 10 mg tablet - 1 Tablet(s) by mouth once a
day
OXYCODONE-ACETAMINOPHEN - 5 mg-325 mg tablet - 1 Tablet(s) by
mouth every six (6) hours as needed for pain
TRAMADOL - 100 mg tablet extended release 24 hr - 1 Tablet(s) by
mouth every six (6) hours as needed for hand pain
Discharge Medications:
Dilaudid ___ PO q6 hours prn pain
Discharge Disposition:
Home
Discharge Diagnosis:
symptomatic cholelithiasis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with cholelithiasis and worsening right upper
quadrant pain, question cholecystitis.
FINDINGS:
The liver is normal in echogenicity with no focal lesions present. The portal
vein is patent with hepatopetal flow. The common bile duct measures 3 mm and
is normal. There are multiple stones within the gallbladder but no evidence
of cholecystitis is noted. Patient was medicated with morphine which limits
evaluation for sonographic ___.
IMPRESSION:
Cholelithiasis without specific findings suggestive of cholecystitis.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with CHOLELITHIASIS NOS
temperature: 98.6
heartrate: 92.0
resprate: 18.0
o2sat: 100.0
sbp: 151.0
dbp: 87.0
level of pain: 6
level of acuity: 3.0 | The patient was admitted to the General Surgical Service on
___ for evaluation and treatment of abdominal pain.
Admission abdominal ultra-sound revealed Cholelithiasis without
evidence of cholecystitis. 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 on
IV fluids, and IV morphine ___ 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:
amoxicillin
Attending: ___.
Chief Complaint:
Right arm pain/erythema
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with history of poorly
differentiated adenocarcinoma of gallbladder on neoadjuvant
chemotherapy with gemcitabine and cisplatin (last dose ___ who
presents with one day of right arm erythema, swelling, and pain
concerning for cellulitis.
Patient reports a one day history of right forearm red rash and
right wrist pain and swelling. He notes the rash is not itchy.
He
has pain on movement of his right wrist joint but the pain is
more superficial than inside the joint. He denied fever/chills
or
any other symptoms. He called his outpatient Oncologist who
recommended ED evaluation.
On arrival to the ED, initial vitals were 98.5 64 121/88 18 100%
RA. No exam documented. Labs were notable for WBC 5.5, H/H
10.9/32.5, Plt 97, Na 138, K 4.3, BUN/CR ___, CRP 15.8, and
lactate 1.1. Blood culture was taken. Patient had right wrist
x-ray which showed no acute fracture and no evidence of acute
cortical destruction. Per ED, low suspicion for septic joint.
Patient was given vancomcyin 1g IV and Compazine 10mg PO. Prior
to transfer vitals were 98.3 61 139/63 18 100% RA.
On arrival to the floor, patient reports ___ right arm pain. He
also notes constipation. He believes the redness has improved.
He
denies fevers/chills, night sweats, headache, vision changes,
dizziness/lightheadedness, weakness/numbnesss, shortness of
breath, cough, hemoptysis, chest pain, palpitations, abdominal
pain, nausea/vomiting, diarrhea, hematemesis,
hematochezia/melena, dysuria, and hematuria.
REVIEW OF SYSTEMS: A complete 10-point review of systems was
performed and was negative unless otherwise noted in the HPI.
Past Medical History:
- Prostate cancer s/p prostatectomy and adjuvant external beam
radiation (under care of Dr. ___
- Multiple bone fractures and blood transfusions following plane
crash in ___
- Hypertriglyceridemia
- s/p subtotal cholecystectomy ___ ___ at
___
- s/p b/l inguinal hernia repair (___ and ___
- s/p radical retropubic prostatectomy (___)
Social History:
___
Family History:
No history of malignancy.
Physical Exam:
ADMISSION EXAM:
VS: Temp 97.5, BP 154/71, HR 62, RR 16, O2 sat 99% RA.
GENERAL: Pleasant man, in no distress, lying in bed comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, non-tender, non-distended, normal bowel sounds, no
hepatomegaly, no splenomegaly.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness. Right wrist with intact ROM.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Strength full throughout. Sensation to light touch
intact.
SKIN: Right upper extremity with blotchy mild erythema of
forearm
and slight warmth. Palpable vein on anterior forearm tender to
palpation.
DISCHARGE EXAM:
VS: Temp 98.3 BP 134/69 HR 58 RR 16 O2 97 Ra
GENERAL: Pleasant man, in no distress, lying in bed comfortably.
HEENT: Anicteric, PERLL, OP clear.
CARDIAC: RRR, normal s1/s2, no m/r/g.
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi.
ABD: Soft, non-tender, non-distended, normal bowel sounds, no
hepatomegaly, no splenomegaly.
EXT: Warm, well perfused, no lower extremity edema, erythema or
tenderness. Right wrist with intact ROM.
NEURO: A&Ox3, good attention and linear thought, CN II-XII
intact. Strength full throughout. Sensation to light touch
intact.
SKIN: Right upper extremity with blotchy mild erythema of
forearm
and slight warmth (although heating pads present). Two palpable
veins on dorsal and ventral aspects of forearm tender and
hardened to palpation. Skin is not tender or thickened.
Pertinent Results:
ADMISSION LABS:
___ 03:46PM PLT SMR-LOW* PLT COUNT-97*
___ 03:46PM NEUTS-83.9* LYMPHS-14.1* MONOS-0.6* EOS-0.6*
BASOS-0.4 IM ___ AbsNeut-4.58# AbsLymp-0.77* AbsMono-0.03*
AbsEos-0.03* AbsBaso-0.02
___ 03:46PM WBC-5.5# RBC-3.70* HGB-10.9* HCT-32.5* MCV-88
MCH-29.5 MCHC-33.5 RDW-12.9 RDWSD-41.5
___ 03:46PM CRP-15.8*
___ 03:46PM CALCIUM-9.2 PHOSPHATE-4.0 MAGNESIUM-2.3
___ 03:46PM GLUCOSE-98 UREA N-22* CREAT-0.9 SODIUM-138
POTASSIUM-4.3 CHLORIDE-100 TOTAL CO2-21* ANION GAP-17*
___ 03:54PM LACTATE-1.1
IMAGES/STUDIES:
IMPRESSION:
Completely occlusive thrombus within the right cephalic vein in
the region of swelling over the anterior lower forearm. No
evidence of a deep venous
thrombosis above the level of the elbow.
DISCHARGE LABS:
___ 07:10AM BLOOD WBC-3.5* RBC-3.61* Hgb-10.7* Hct-31.4*
MCV-87 MCH-29.6 MCHC-34.1 RDW-12.9 RDWSD-40.8 Plt Ct-78*
___ 07:10AM BLOOD ___ PTT-25.4 ___
___ 07:10AM BLOOD Glucose-95 UreaN-18 Creat-0.8 Na-139
K-4.2 Cl-100 HCO3-24 AnGap-15
___ 07:10AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID:PRN constipation
2. Senna 8.6 mg PO BID:PRN constipation
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
4. Lactulose 15 mL PO TID:PRN constipation
5. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
6. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
7. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
Discharge Medications:
1. Docusate Sodium 100 mg PO BID:PRN constipation
2. Lactulose 15 mL PO TID:PRN constipation
3. Ondansetron 8 mg PO Q8H:PRN nausea/vomiting
4. Polyethylene Glycol 17 g PO DAILY:PRN constipation
5. Prochlorperazine 10 mg PO Q6H:PRN nausea/vomiting
6. Senna 8.6 mg PO BID:PRN constipation
7. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis
-Superficial thrombophlebitis
Secondary Diagnosis
-Gallbladder cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with right wrist pain// septic joint? osteo?
TECHNIQUE: Three views of the right wrist
COMPARISON: None.
FINDINGS:
No acute fracture or dislocation is seen. There are moderate degenerative
changes at the first carpometacarpal joint and triscaphe joint. Chronic
appearing irregularity at the distal shaft of the fourth metacarpal may relate
to prior trauma. No evidence of acute cortical destruction.
IMPRESSION:
No acute fracture or dislocation. Degenerative changes. No evidence of acute
cortical destruction.
Radiology Report
EXAMINATION: VENOUS DUP UPPER EXT UNILATERAL RIGHT
INDICATION: ___ year old man with gallbladder cancer and concern for right
upper extremity superficial thrombophlebitis.// Please evaluate for
superficial thrombophlebitis and 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 right subclavian vein.
The right internal jugular and axillary veins are patent, show normal color
flow and compressibility. There is a completely occlusive thrombus within the
right cephalic vein in the region of swelling over the anterior lower forearm.
The right brachial, and basilic veins are patent, compressible and show normal
color flow and augmentation.
IMPRESSION:
Completely occlusive thrombus within the right cephalic vein in the region of
swelling over the anterior lower forearm. No evidence of a deep venous
thrombosis above the level of the elbow.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: R Arm pain
Diagnosed with Vascular comp fol infusn, tranfs and theraputc inject, init, Oth medical procedures cause abn react/compl, w/o misadvnt, Cellulitis of right upper limb
temperature: 98.5
heartrate: 64.0
resprate: 18.0
o2sat: 100.0
sbp: 121.0
dbp: 88.0
level of pain: 1
level of acuity: 3.0 | Mr. ___ is a ___ male with history of poorly
differentiated adenocarcinoma of gallbladder on neoadjuvant
chemotherapy with gemcitabine and cisplatin (C1D12, last dose
___ who presents with one day of right arm erythema, swelling,
and pain, found to have two tender cords on exam with ultrasound
confirmin superficial cephalic vein clot.
# Superficial Thrombophlebitis: Patient with symptoms
predominantly concerning for superficial thrombophlebitis of the
right upper extremity given palpable superficial vein tender to
palpation. The surrounding erythema is likely related to
inflammation from the phlebitis. Tenderness if over the cords,
but not over skin. He currently has no systemic signs of
infection. Of note, no neutropenia noted on admission. Low
suspicion for septic arthritis of the wrist at this time or for
cellulitis. Right upper extremity venous ultrasound confirmed
superficial cephalic vein thrombus, but no DVT. Erythema
demarcated and patient will be followed in clinic in three days.
Received Vancomycin for initial concern for cellulitis, but this
was discontinued. Will continue warm compresses and will treat
with NSAIDs and close follow up.
# Poorly Differentiated Adenocarcinoma of Gallbladder: Currently
on Gemcitabine/Cisplatin, C1D12. Thrombophlebitis likely related
to Gemcitabine and so discussed obtaining a port to prevent
further episodes.
# Anemia/Thrombocytopenia: Likely secondary to malignancy and
chemotherapy. No evidence of active bleeding.
# Constipation/hemorrhoids: Likely exacerbated by Zofran.
Continued bowel regimen. Patient has hemorrhoidal cream at home.
TRANSITIONAL ISSUES
======================
[] Will need a port placed for further Gemcitabine/Cisplatin
infusions.
[] NSAIDs with food and warm compresses to treat superficial
thrombophlebitis.
[] F/u FINAL blood cultures.
[] EMERGENCY CONTACT HCP: ___ (wife) ___, ___
___ (son) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Possible seizure
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
HPI: Ms. ___ is a ___ woman with L medial
parieto-occipital AVM s/p embolization and radiation with
residual R sided sensorimotor deficits, seizure disorder, and
chronic headaches who presents with altered mental status. She
was last normal around noon when she went bowling. Family thinks
she likely pushed her life alert button, which brought EMS to
the
home. A neighbor likely came out and said that her speech was
slurred and she was very confused. At baseline, Ms. ___ is
very independent. She cooks and cleans for herself, fills her
own
pillboxes, and does quite a few activities with her friends.
In terms of her seizures, based on prior notes they are complex
partial seizures with R sided twitching and likely secondary
generalization. Pt is unable to answer if she can feel these
seizures coming or if they are associated with any other
symptoms.
She saw Dr. ___ on ___ as follow-up. His exam was
documented as such:
"Neurological Examination: Mental Status: Alert and oriented x
3, intact fluency and comprehension. She was ___ immediate
recall, ___ short-term recall and ___ short-term recall with one
cue. She follows cross body commands, but
sometimes needs repetition. Cranial Nerves: No papilledema of
the optic disks. Pupils were equal, round and reactive.
Extraocular movements intact. She has a right homonymous
hemianopsia that is more noticeable in the right eye than the
left eye. Intact facial strength and symmetry. Intact tongue,
uvula, palate. Intact light touch bilaterally. Motor
Examination: ___ strength of the arms and the left leg. In the
right leg, it was 5- iliopsoas, 5 quadriceps, 5 plantar flexion,
5- hamstrings, 4+ right foot dorsiflexion, 5- right extensor
hallucis longus. Sensory examination was decreased to light
touch and pinprick of the right leg and the right arm compared
to
the left side of the body. There was extinction to double
simultaneous light touch stimulation on the right side of the
body. Coordination was intact to finger-nose-finger and rapid
alternating movement bilaterally. Gait: She had slow casual
gait. She was not using a cane today."
She appears to be waxing and waning with some moments of
clarity,
much better with daughter at bedside. She took her evening
medications without telling the ED.
Past Medical History:
- Left medial parieto-occipital AVM s/p Onyx embolization x 2 in
___ at ___ and CyberKnife radiation in ___
with residual R-sided numbness, mild R-sided weakness, and edema
in the left parieto-occipital area and the medial right
occipital
area
- seizures s/p AVM embolization
- headaches
- s/p vocal cord polyp s/p removals
- ___ ___ p/w R ear pain and decreased sensation R V2/3
- borderline DM
- glaucoma/cataracts
- hypercholesterolemia
Social History:
___
Family History:
Two daughters - one with SLE and the other with stomach cancer
diagnosed at age ___. Father died at age ___ of stomach cancer.
Sister with breast cancer at age ___. Brother with ___ HTN.
Physical Exam:
=== ADMISSION EXAM ===
PHYSICAL EXAMINATION
Vitals: T: 96.8F HR: 99 BP: 139/65 RR: 11 SaO2: 96% NC
General: NAD
HEENT: NCAT, no oropharyngeal lesions, neck supple, no
meningeal
signs
___: RRR, no M/R/G
Pulmonary: CTAB, no crackles or wheezes
Abdomen: Soft, NT, ND, +BS, no guarding
Extremities: Warm, no edema
Neurologic Examination:
- Mental status: Awake, alert, unable to say name or where she
is. Seems to be waxing and waning based on behavior in ED. Very
perseverative, only intermittently follows commands.
- Cranial Nerves: PERRL 3->2 brisk. Unable to assess visual
fields. EOMI, no nystagmus. No facial movement asymmetry. Tongue
midline.
- Motor: moves all extremities spontaneously, at least 4+ in all
muscle groups
- Reflexes: pt moving too much and rigid at times, unable to
obtain accurate reflexes
- Sensory: withdraws to tickle in all 4 extremities
- Coordination: no obvious ataxia when reaching for guard rails
- Gait: deferred
=== DISCHARGE EXAM ===
-MS: Alert and oriented to person, place, date, and details of
presentation. Speech is fluent, repetition intact to all but the
most complex phrases. Digit span is 4. Unable to do days of week
backwards. Recalls ___ objects in 3 minutes.
-CN: Right visual field cut. Face symmetric. Tongue midline.
-Mild R leg weakness (4+).
-Extinction to DSS of R arm.
Pertinent Results:
=== LABS ===
___ 08:00AM BLOOD WBC-6.7 RBC-4.02 Hgb-12.1 Hct-38.4 MCV-96
MCH-30.1 MCHC-31.5* RDW-12.8 RDWSD-44.0 Plt ___
___ 06:40PM BLOOD ___ PTT-25.5 ___
___ 08:00AM BLOOD Glucose-107* UreaN-8 Creat-0.6 Na-144
K-3.8 Cl-112* HCO3-20* AnGap-16
___ 08:00AM BLOOD Calcium-8.8 Phos-3.0 Mg-2.0 Cholest-174
___ 12:11AM BLOOD Albumin-3.8
___ 08:00AM BLOOD %HbA1c-5.3 eAG-105
___ 06:40PM BLOOD Phenyto-10.2
___ 12:11AM BLOOD Phenyto-20.2*
___ 07:03PM BLOOD Phenyto-19.5
___ 06:40PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
===IMAGING===
- ___ MR ___
1. Grossly stable treated left medial occipital lobe of
arteriovenous
malformation with extensive surrounding white matter signal
abnormality,
likely representing posttreatment changes.
2. No acute intracranial abnormality including acute infarct or
hemorrhage.
3. Previously noted subcentimeter extra-axial right medial
occipital enhancing
nodule is not well evaluated on this noncontrast examination.
===EEG===
- ___
IMPRESSION: This is an abnormal continuous EMU monitoring study
because of (1) frequent electrographic seizures originating in
the left posterior quadrant, typically lasting between 90-120
seconds without clinical correlate; (2) frequent isolated
epileptiform discharges within the same region; (3) continuous
slowing over the left hemisphere, which is most prominent in the
left parietal and occipital region, indicative of focal cerebral
dysfunction, which is non-specific by may be secondary to the
patient's known AVM. With the infusion of IV fosphenytoin, there
is improvement in the frequency and morphology of the
electrographic seizures described above. There are no pushbutton
activations.
- ___ Report pending
- ___ Report pending
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN Wheezing
2. Gabapentin 300 mg PO QHS
3. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
4. LevETIRAcetam 1000 mg PO QAM
5. LevETIRAcetam ___ mg PO QPM
6. Phenytoin Sodium Extended 200 mg PO QAM
7. Phenytoin Sodium Extended 150 mg PO QPM
8. Simvastatin 40 mg PO QPM
9. Zonisamide 100 mg PO QAM
10. Zonisamide 200 mg PO QPM
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Phenytoin Sodium Extended 200 mg PO BID
RX *phenytoin sodium extended 100 mg 2 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*2
3. Zonisamide 200 mg PO BID
RX *zonisamide 100 mg 2 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*2
4. Albuterol Inhaler ___ PUFF IH Q4H:PRN Wheezing
5. Gabapentin 300 mg PO QHS
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
7. LevETIRAcetam 1000 mg PO QAM
8. LevETIRAcetam ___ mg PO QPM
9. Simvastatin 20 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Seizure
Discharge Condition:
Mental Status: Clear and coherent. Mildly inattentive
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ woman with history of left parieto-occipital AVM
status post embolization and radiation, now with new onset aphasia. Evaluate
for infarct or hemorrhage.
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 CT.
___ contrast head MR.
___ contrast brain MRI and MRA.
FINDINGS:
Serpentine signal loss of the medial left occipital lobe is unchanged,
compatible with embolized arteriovenous malformation. Extensive adjacent
FLAIR hyperintensity extending into the left occipital and parietal lobes with
a minimal extent into the posterior left frontal lobe, also extending across
the splenium of the corpus callosum into the right occipital lobe is
unchanged.
There is no evidence of acute hemorrhage, increasing edema, masses, mass
effect, midline shift or infarction. There is prominence of the ventricles
and sulci suggesting involutional changes. Incidental note of cavum septum
pellucidum et vergae. Previously noted sub cm enhancing extra-axial lesion
adjacent to the medial right occipital lobe is not well evaluated on this
noncontrast examination. The principal intracranial vascular flow voids are
preserved.
The visualized paranasal sinuses, and mastoid air cells are grossly clear.
The orbits are grossly unremarkable.
IMPRESSION:
1. Grossly stable treated left medial occipital lobe of arteriovenous
malformation with extensive surrounding white matter signal abnormality,
likely representing posttreatment changes.
2. No acute intracranial abnormality including acute infarct or hemorrhage.
3. Previously noted subcentimeter extra-axial right medial occipital enhancing
nodule is not well evaluated on this noncontrast examination.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Slurred speech
Diagnosed with Slurred speech
temperature: 96.8
heartrate: 92.0
resprate: 18.0
o2sat: 96.0
sbp: 136.0
dbp: 80.0
level of pain: 0
level of acuity: 1.0 | Ms ___ is a ___ woman with L AVM s/p embolization and
radiation c/b seizures (on Keppra, phenytoin, and zonisamide);
who presents with slurred speech and confusion. Reportedly she
had been out bowling and was very thirsty but waited for ___
hours until she got home to drink, where she says she wasn't
feeling well and so activated her life alert. Initial exam
largely nonfocal other than waxing and waning altered mental
status, and perseveration. She was admitted due to concern for
seizure (given her history). Her mental status improved by the
next morning. MRI was stable from prior. EEG showed multiple
electrographic seizures over the L occipital lobe that were
without clinical correlate and with normal mental status. She
was loaded with additional phenytoin, with reduction in
electrographic seizure frequency -- but no change in already
normal clinical status. Her home phenytoin was increased to
200/150mg to 200 BID, and zonisamide increased from 100/200mg to
200 BID. She will follow-up with Dr. ___ have her
phenytoin levels monitored to ensure she does not become
supratherapeutic. She was at her cognitive baseline, per family.
Electrographic seizures were discussed with them, and they
agreed to return to the ED if there was any change in mental
status. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
back pain
Major Surgical or Invasive Procedure:
___ guided biopsy ___
History of Present Illness:
___ with L breast mass (pending workup) who presented with
severe
back pain.
In ___ of this year she had sudden onset right back pain
after lifting something heavy at work. Since that time she has
been seen by her primary care physician and had several days of
physical therapy however several days ago she noted acute
worsening of her back pain. She was seen in the ___ ED where she
was given ibuprofen, gabapentin, and Valium. She did not improve
with this treatment, quickly becoming bed-bound due to pain. She
is also being urinating and defecating with diapers as of 24
hours ago when pain became severe enough to prevent even trips
to
the bathroom. She denies any weakness or numbness.
In the ED vitals were stable (97.8, 69, 141/80, 16, 99% RA) and
basic labs were unremarkable. CT of the lumbar spine showed a
lytic lesion of L3 with pathologic fracture, and also lytic
lesions of the left sacrum and iliac bone. MRI confirmed no cord
compression and spine surgery said no operative intervention was
required. Rectal tone normal.
Admitted for expedited workup of metastatic malignancy.
Past Medical History:
L breast mass
C section
Social History:
___
Family History:
She is unsure if she has FH of any particular malignancy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
VITALS: all vitals since arrival on the medical ward were
reviewed
CONSTITUTIONAL: uncomfortable-appearing woman
EYE: sclerae anicteric, EOMI
ENT: audition grossly intact, MMM, OP clear
BREAST: Dense breasts decrease the sensitivity of my clinical
breast exam. 3x5 cm rubbery-textured cm at 12 o'clock on the L
breast, which is not fixed. There is an overlying pigmented bump
on the skin, which could be a skin cancer or possibly a
supernumerary nipple. I am not able to appreciate and L axillary
lymphadenopathy.
LYMPHATIC: No LAD
CARDIAC: RRR, no M/R/G, JVP not elevated, no edema
PULM: normal effort of breathing, LCAB
GI: soft, NT, ND, NABS
GU: suprapubic region soft and nontender
DERM: no visible rash. No jaundice.
NEURO: AAOx3. No facial droop, moving all extremities.
Accounting for limitations due to pain, seems to have ___
strength in lower extremities
PSYCH: Full range of affect
discharge
avss
non toxic not confused
fluent speech
mobilizes and able to walk stairs w ___
Pertinent Results:
ADMISSION LABS:
==================
___ 02:40PM BLOOD WBC-7.4 RBC-4.47 Hgb-13.1 Hct-39.8 MCV-89
MCH-29.3 MCHC-32.9 RDW-12.2 RDWSD-39.8 Plt ___
___ 02:40PM BLOOD Glucose-91 UreaN-13 Creat-0.7 Na-143
K-4.4 Cl-106 HCO3-24 AnGap-13
___ 02:40PM BLOOD TotProt-6.8 Calcium-9.5
___ 02:40PM BLOOD 25VitD-19*
IMAGING:
========
MRI L spine ___
IMPRESSION:
1. No evidence of spinal cord or cauda equina compression.
2. Evidence of an enhancing osseous lesion involving the entire
L3 vertebral body and resulting in areas of superior posterior
cortical disruption better characterized on the recent CT lumbar
spine study.
3. Associated STIR signal hyperintensity of the L2 vertebral
body
raises concern for pathologic fracture with perhaps a slight
vertebral body height loss posteriorly.
4. Associated slight 1-2 mm retropulsion versus posterior
bulging
of the L3 vertebral body as well as mild anterior epidural
enhancing soft tissue results in mild to moderate spinal canal
narrowing at L2-L3.
5. Lesser degrees of spinal canal neural foraminal narrowing are
seen at the remaining levels of the lumbar spine.
6. Additional diffuse enhancing destructive lesions involve the
visualized left sacrum/iliac bones.
7. Evidence of probable tumor infiltration of the medial aspect
of the right psoas muscle versus reactive myositis.
CT L spine ___:
Lucent destructive lesion in the L3 vertebral body with an
associated pathologic fracture additional lucent lesion
involving
the left sacrum and iliac bone. These are most concerning for
an
aggressive process such as metastatic disease.
CT Torso ___:
1. Redemonstration of expansile soft tissue lytic lesions
involving the L3
vertebral body and around the left sacroiliac joint.
2. 5.5 cm irregular, multilobulated left breast mass is
associated with left
axillary lymphadenopathy.
3. Overall, findings may represent metastatic breast cancer,
however
correlation with results of recent biopsy is recommended for
final
determination.
4. 3.9 cm area of hypoenhancement in the lower uterine segment
and cervix may
be related to patient's menstrual cycle, however further
evaluation with
pelvic ultrasound and clinical exam is recommended.
5. Enlarged 1.3 cm right paratracheal lymph node may represent
an additional
site of metastatic disease. Close attention on follow-up imaging
is
recommended.
6. 3 mm right upper lung nodule. Attention on follow-up imaging
is
recommended.
RECOMMENDATION(S): Pelvic ultrasound for impression point 3.
___ L breast ultrasound and bilateral breast mammography:
1. Large mass in the upper central left breast measures 5.8 cm
on mammogram
and at 11 o'clock 9 cm from nipple on ultrasound. There are
associated
segmental pleomorphic calcifications spanning a length of 8.8
cm. The mass
involves the skin with associated skin thickening. Findings are
highly
suspicious for malignancy.
2. left breast dermal based mass measures 1.2 cm without
definite continuity
with the dominant mass, suspicious for skin metastasis.
3. Additional hypoechoic left breast mass at 12 o'clock 4 cm
from nipple,
adjacent to the dominant mass is suspicious for extent of
disease.
4. 3 abnormal left axillary lymph nodes, suspicious for
metastatic adenopathy.
5. No specific mammographic evidence of malignancy in the right
breast.
___ pelvic u/s:
Unremarkable pelvic ultrasound. No sonographic correlate to
findings on prior
CT abdomen pelvis.
DISCHARGE LABS:
=============
___ 07:00AM BLOOD WBC-5.7 RBC-4.29 Hgb-12.7 Hct-38.8 MCV-90
MCH-29.6 MCHC-32.7 RDW-12.1 RDWSD-39.5 Plt ___
___ 08:05AM BLOOD Glucose-100 Creat-0.7 Na-139 K-5.0
HCO3-27 AnGap-13
___ 02:40PM BLOOD 25VitD-19*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H
RX *acetaminophen 500 mg 2 tablet(s) by mouth every eight (8)
hours Disp #*90 Tablet Refills:*0
2. Bisacodyl 10 mg PO/PR DAILY
RX *bisacodyl 10 mg 1 suppository(s) rectally daily Disp #*12
Suppository Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
4. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
RX *ibuprofen 200 mg 2 tablet(s) by mouth q8 Disp #*90 Tablet
Refills:*0
5. Lidocaine 5% Patch 1 PTCH TD QAM
RX *lidocaine [Lidoderm] 5 % 1 patch daily Disp #*30 Patch
Refills:*0
6. Morphine SR (MS ___ 15 mg PO Q8H
RX *morphine 15 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*25 Tablet Refills:*0
7. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*60 Tablet Refills:*0
8. Polyethylene Glycol 17 g PO DAILY
RX *polyethylene glycol 3350 [Miralax] 17 gram/dose 17gram
powder(s) by mouth ___ times daily Refills:*0
9. Polyethylene Glycol 17 g PO QID:PRN Constipation - Third
Line
10. Senna 8.6 mg PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*60 Tablet Refills:*0
11. Vitamin D ___ UNIT PO 1X/WEEK (FR) Duration: 8 Weeks
RX *ergocalciferol (vitamin D2) [Vitamin D2] 50,000 unit 1
capsule(s) by mouth weekly (every ___ Disp #*8 Capsule
Refills:*0
12.Outpatient Physical Therapy
evaluate and treat as needed
metastatic breast cancer to spine
Discharge Disposition:
Home
Discharge Diagnosis:
pathologic L3 vertebral fracture
metastatic malignancy to bone
breast cancer
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 TORSO WITH CONTRAST
INDICATION: ___ year old woman with lytic bone lesions consistent with
metastatic cancer.// Help identify primary lesion
TECHNIQUE: Oncology 2 phase: Multidetector CT of the abdomen and pelvis was
done as part of CT torso with IV contrast. A single bolus of IV contrast was
injected and the abdomen and pelvis were scanned in the portal venous phase,
followed by scan of the abdomen in equilibrium (3-min delay) phase.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5
mGy-cm.
2) Stationary Acquisition 2.7 s, 0.2 cm; CTDIvol = 45.4 mGy (Body) DLP =
9.1 mGy-cm.
3) Spiral Acquisition 10.3 s, 66.9 cm; CTDIvol = 13.2 mGy (Body) DLP =
877.0 mGy-cm.
4) Spiral Acquisition 6.1 s, 39.9 cm; CTDIvol = 12.8 mGy (Body) DLP = 502.1
mGy-cm.
Total DLP (Body) = 1,390 mGy-cm.; Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5
mGy-cm.
2) Stationary Acquisition 2.7 s, 0.2 cm; CTDIvol = 45.4 mGy (Body) DLP =
9.1 mGy-cm.
3) Spiral Acquisition 10.3 s, 66.9 cm; CTDIvol = 13.2 mGy (Body) DLP =
877.0 mGy-cm.
4) Spiral Acquisition 6.1 s, 39.9 cm; CTDIvol = 12.8 mGy (Body) DLP = 502.1
mGy-cm.
Total DLP (Body) = 1,390 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS W AND W/O CONTRAST, ADDL SECTIONS)
COMPARISON: CT L-spine from ___.
FINDINGS:
CHEST:
CHEST WALL: An irregular, multilobulated soft tissue mass in the left breast
measures approximately 3.5 x 2.5 x 5.5 cm (TV x AP x SI) (5:60, 8:60). This
is associated with prominent left axillary lymph nodes, which measure up to
1.5 x 0.2 cm (5:50). There is no evidence of right axillary lymphadenopathy.
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury. The heart, pericardium, and great vessels are
within normal limits. No pericardial effusion is seen.
HILA, AND MEDIASTINUM: An enlarged lower right paratracheal lymph node
measures up to 1.3 cm in the short axis (5:69). No other enlarged mediastinal
lymph nodes or masses are seen. There is no evidence of hilar
lymphadenopathy.
PLEURAL SPACES: No pneumothorax. Trace dependent bilateral pleural effusions
are noted.
LUNGS/AIRWAYS: Respiratory motion limits detailed evaluation. Mild bilateral
dependent atelectasis is noted. A 3 mm posterior right upper lobe nodule is
noted (5:61). No focal consolidations or large pulmonary masses are seen.
The airways are patent to the level of the segmental bronchi bilaterally.
BASE OF NECK: The imaged thyroid 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.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesion or laceration.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is mildly distended with enteric contents.
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: There is a 3.1 x 2.9 x 3.9 cm area of hypoenhancement
involving the lower uterine segment and cervix (4:105, 7:36). Hypodense
material within the endometrial cavity may be within normal limits in a
premenopausal patient. A subcentimeter hypoattenuating lesion in the left
uterine wall (4:98) likely represents a fibroid. The bilateral adnexae are
within normal limits.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma.
Mild atherosclerotic disease is noted.
BONES: A lytic, enhancing soft tissue mass is again seen in the L3 vertebral
body and measures 3.2 x 3.2 x 1.8 cm (TV by AP by SI) (7:34, 8:37), previously
3.1 x 3.0 x 2.1 cm. This mass is again noted to extend posteriorly, causing
mild-to-moderate narrowing of the spinal canal, better evaluated on prior MR
lumbar spine study from ___.
Again seen is an expansile, lytic, enhancing soft tissue mass centered about
the left sacroiliac joint, extending into the left sacral ala and left ilium,
which measures approximately 5.7 x 3.8 x 6.1 cm (TV by AP by SI) (4:93, 7:37),
similar to prior. This mass abuts the left iliacus muscle anteriorly (4:93).
No abnormal enhancement is seen in the psoas muscles.
SOFT TISSUES: A small umbilical hernia containing fat is noted. Gas in the
lower right anterior abdominal wall likely reflects sequela of subcutaneous
injections (4:83).
IMPRESSION:
1. Redemonstration of expansile soft tissue lytic lesions involving the L3
vertebral body and around the left sacroiliac joint.
2. 5.5 cm irregular, multilobulated left breast mass is associated with left
axillary lymphadenopathy.
3. Overall, findings may represent metastatic breast cancer, however
correlation with results of recent biopsy is recommended for final
determination.
4. 3.9 cm area of hypoenhancement in the lower uterine segment and cervix may
be related to patient's menstrual cycle, however further evaluation with
pelvic ultrasound and clinical exam is recommended.
5. Enlarged 1.3 cm right paratracheal lymph node may represent an additional
site of metastatic disease. Close attention on follow-up imaging is
recommended.
6. 3 mm right upper lung nodule. Attention on follow-up imaging is
recommended.
RECOMMENDATION(S): Pelvic ultrasound for impression point 3.
Radiology Report
INDICATION: ___ year old woman with lytic spinal mets// Biopsy L3 lesion for
tissue diagnosis
COMPARISON: MRI and CT from ___
PROCEDURE: CT-guided spine biopsy.
OPERATORS: Dr. ___, performed the
procedure.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a prone position on the CT scan table. Limited
preprocedure CTscan of the intended biopsy area was performed. Based on the
CT findings an appropriate position for the biopsy was chosen. The site was
marked.
The site was prepped and draped in the usual sterile fashion. 1% lidocaine
were administered to the subcutaneous and deep tissues for local anesthetic
effect. Under CT guidance, a 11 gauge coaxial needle was introduced into the
lesion using the on control drill. An 13 gauge core biopsy device was then
taken and too good core samples were obtained of the bone. These were sent to
pathology.
The procedure was tolerated well and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence:
Total DLP (Body) = 275 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of 50
mg Versed and 1 mcg fentanyl throughout the total intra-service time of 25
minutes minutes during which patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse.
FINDINGS:
1. Large L3 lytic lesion
IMPRESSION:
Successful L3 bone biopsy
Radiology Report
EXAMINATION: CT TORSO WITH CONTRAST
INDICATION: ___ year old woman with lytic bone lesions consistent with
metastatic cancer.// Help identify primary lesion
TECHNIQUE: Oncology 2 phase: Multidetector CT of the abdomen and pelvis was
done as part of CT torso with IV contrast. A single bolus of IV contrast was
injected and the abdomen and pelvis were scanned in the portal venous phase,
followed by scan of the abdomen in equilibrium (3-min delay) phase.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5
mGy-cm.
2) Stationary Acquisition 2.7 s, 0.2 cm; CTDIvol = 45.4 mGy (Body) DLP =
9.1 mGy-cm.
3) Spiral Acquisition 10.3 s, 66.9 cm; CTDIvol = 13.2 mGy (Body) DLP =
877.0 mGy-cm.
4) Spiral Acquisition 6.1 s, 39.9 cm; CTDIvol = 12.8 mGy (Body) DLP = 502.1
mGy-cm.
Total DLP (Body) = 1,390 mGy-cm.; Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 7.3 mGy (Body) DLP = 1.5
mGy-cm.
2) Stationary Acquisition 2.7 s, 0.2 cm; CTDIvol = 45.4 mGy (Body) DLP =
9.1 mGy-cm.
3) Spiral Acquisition 10.3 s, 66.9 cm; CTDIvol = 13.2 mGy (Body) DLP =
877.0 mGy-cm.
4) Spiral Acquisition 6.1 s, 39.9 cm; CTDIvol = 12.8 mGy (Body) DLP = 502.1
mGy-cm.
Total DLP (Body) = 1,390 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS W AND W/O CONTRAST, ADDL SECTIONS)
COMPARISON: CT L-spine from ___.
FINDINGS:
CHEST:
CHEST WALL: An irregular, multilobulated soft tissue mass in the left breast
measures approximately 3.5 x 2.5 x 5.5 cm (TV x AP x SI) (5:60, 8:60). This
is associated with prominent left axillary lymph nodes, which measure up to
1.5 x 0.2 cm (5:50). There is no evidence of right axillary lymphadenopathy.
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of acute injury. The heart, pericardium, and great vessels are
within normal limits. No pericardial effusion is seen.
HILA, AND MEDIASTINUM: An enlarged lower right paratracheal lymph node
measures up to 1.3 cm in the short axis (5:69). No other enlarged mediastinal
lymph nodes or masses are seen. There is no evidence of hilar
lymphadenopathy.
PLEURAL SPACES: No pneumothorax. Trace dependent bilateral pleural effusions
are noted.
LUNGS/AIRWAYS: Respiratory motion limits detailed evaluation. Mild bilateral
dependent atelectasis is noted. A 3 mm posterior right upper lobe nodule is
noted (5:61). No focal consolidations or large pulmonary masses are seen.
The airways are patent to the level of the segmental bronchi bilaterally.
BASE OF NECK: The imaged thyroid 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.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesion or laceration.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is mildly distended with enteric contents.
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: There is a 3.1 x 2.9 x 3.9 cm area of hypoenhancement
involving the lower uterine segment and cervix (4:105, 7:36). Hypodense
material within the endometrial cavity may be within normal limits in a
premenopausal patient. A subcentimeter hypoattenuating lesion in the left
uterine wall (4:98) likely represents a fibroid. The bilateral adnexae are
within normal limits.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm or retroperitoneal hematoma.
Mild atherosclerotic disease is noted.
BONES: A lytic, enhancing soft tissue mass is again seen in the L3 vertebral
body and measures 3.2 x 3.2 x 1.8 cm (TV by AP by SI) (7:34, 8:37), previously
3.1 x 3.0 x 2.1 cm. This mass is again noted to extend posteriorly, causing
mild-to-moderate narrowing of the spinal canal, better evaluated on prior MR
lumbar spine study from ___.
Again seen is an expansile, lytic, enhancing soft tissue mass centered about
the left sacroiliac joint, extending into the left sacral ala and left ilium,
which measures approximately 5.7 x 3.8 x 6.1 cm (TV by AP by SI) (4:93, 7:37),
similar to prior. This mass abuts the left iliacus muscle anteriorly (4:93).
No abnormal enhancement is seen in the psoas muscles.
SOFT TISSUES: A small umbilical hernia containing fat is noted. Gas in the
lower right anterior abdominal wall likely reflects sequela of subcutaneous
injections (4:83).
IMPRESSION:
1. Redemonstration of expansile soft tissue lytic lesions involving the L3
vertebral body and around the left sacroiliac joint.
2. 5.5 cm irregular, multilobulated left breast mass is associated with left
axillary lymphadenopathy.
3. Overall, findings may represent metastatic breast cancer, however
correlation with results of recent biopsy is recommended for final
determination.
4. 3.9 cm area of hypoenhancement in the lower uterine segment and cervix may
be related to patient's menstrual cycle, however further evaluation with
pelvic ultrasound and clinical exam is recommended.
5. Enlarged 1.3 cm right paratracheal lymph node may represent an additional
site of metastatic disease. Close attention on follow-up imaging is
recommended.
6. 3 mm right upper lung nodule. Attention on follow-up imaging is
recommended.
RECOMMENDATION(S): Pelvic ultrasound for impression point 3.
Radiology Report
EXAMINATION: BILATERAL DIGITAL 2D AND 3D TOMOSYNTHESIS DIAGNOSTIC MAMMOGRAM
INTERPRETED WITH CAD AND LEFT BREAST ULTRASOUND
INDICATION: ___ woman with a left-sided breast mass and a lytic
vertebral lesion status post vertebral biopsy concerning for metastatic
disease.
COMPARISON: CT chest ___.
TECHNIQUE: CC, MLO, left lateral, and lateral magnification 2D and 3D
tomosynthesis and selected synthesized views were obtained. Computer aided
detection was utilized and assisted with interpretation. Targeted ultrasound
was performed.
FINDINGS:
Tissue density: C- The breast tissue is heterogeneously dense which may
obscure detection of small masses.
Right breast: There is no suspicious mass, unexplained architectural
distortion or suspicious grouped microcalcifications.
Left breast: There is a palpable BB marker overlying the upper central left
breast at posterior depth. In the upper central left breast there is a
segmental area of pleomorphic calcifications measuring approximately 8.8 x 7 x
4.2 cm. There is associated spiculated mass in the upper mid to posterior
left breast measuring 5.8 x 4.2 x 3.9 cm.
BREAST ULTRASOUND:
Targeted ultrasound in the left breast at 11 o'clock 9 cm from nipple
demonstrated a large ill-defined irregular hypoechoic mass with internal
vascularity and shadowing which is difficult to measure given its size,
however measures at least 5.1 x 3.1 x 5 cm. There are punctate echogenic foci
which likely represent calcifications. The mass extends to the level of the
pectoralis muscle without discrete evidence of involvement, however the mass
does extend into the skin. The skin is thickened measuring approximately 0.5
cm. Immediately superior to the dominant mass there is a dermal based
hypoechoic mass with vascularity measuring 1.2 x 0.8 cm.
At 12 o'clock 4 cm from nipple there is an irregular hypoechoic mass with
shadowing without vascularity that measures 1.1 x 0.8 x 0.7 cm.
There are 3 abnormal left axillary lymph nodes with the largest measuring 1.5
x 1 cm lacking a fatty hilum.
IMPRESSION:
1. Large mass in the upper central left breast measures 5.8 cm on mammogram
and at 11 o'clock 9 cm from nipple on ultrasound. There are associated
segmental pleomorphic calcifications spanning a length of 8.8 cm. The mass
involves the skin with associated skin thickening. Findings are highly
suspicious for malignancy.
2. left breast dermal based mass measures 1.2 cm without definite continuity
with the dominant mass, suspicious for skin metastasis.
3. Additional hypoechoic left breast mass at 12 o'clock 4 cm from nipple,
adjacent to the dominant mass is suspicious for extent of disease.
4. 3 abnormal left axillary lymph nodes, suspicious for metastatic adenopathy.
5. No specific mammographic evidence of malignancy in the right breast.
RECOMMENDATION(S): Findings and recommendations were discussed with the
breast surgery attending, ___, MD by telephone by Dr. ___ at the
time of imaging with confirmation. Biopsy of the dominant mass in the left
breast is recommended. Fine-needle aspiration of the abnormal lymph nodes is
not recommended at this time by the referring surgeon given recent vertebral
biopsy suspicious for pathologic fracture. Decision for further management of
additional left breast mass and left axillary lymph nodes will be determined
based upon pathology results and clinical evaluation.
NOTIFICATION: Findings and recommendation for biopsy were reviewed with the
patient through an interpreter who agrees with this plan.
BI-RADS: 5 Highly Suggestive of Malignancy.
Radiology Report
EXAMINATION: LEFT BREAST ULTRASOUND GUIDED CORE BIOPSY WITH CLIP PLACEMENT
INDICATION: ___ woman with suspicious left breast mass.
Ultrasound-guided core biopsy and clip placement was requested for definitive
diagnosis.
COMPARISON: The relevant imaging was available for this procedure.
FINDINGS:
In the left breast at 11 o'clock 9 cm from the nipple is an irregular
hypoechoic mass previously described in same day ultrasound. See that report
for more details.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
Time-out certification: Performed using three patient identifiers.
Allergies and/or Medications: Reviewed prior to the procedure.
Clinicians: N. ___, N.P.. The procedure was supervised by ___. ___,
MD(attending).
Description: Using ultrasound guidance, aseptic technique and 1% lidocaine for
local anesthesia, a 13-gaugecoaxial needle was placed adjacent to the lesion
and using a 14-gauge Bard spring-loaded biopsy device, multiple cores were
obtained. Next, a percutaneous HydroMark coil was deployed under ultrasound
guidance. The needle was removed and hemostasis was achieved.
Estimated blood loss: < 1 cc.
Specimens: Sent to pathology. A rush was placed on the specimen.
Anesthesia: ___ cc 1% lidocaine
Complications: No immediate complications.
Post procedure diagnosis: Same.
IMPRESSION:
Technically successful US-guided core biopsy of the breast lesion. Pathology
is pending The patient expects to hear the pathology results from the
referring provider ___ ___ business days. Standard post care instructions were
provided to the patient.
Radiology Report
EXAMINATION: PELVIS U.S., TRANSVAGINAL
INDICATION: ___ year old woman with breast mass and metastatic bone lesions
undergoing workup. CT torso with hypoenhancement in the lower uterine segment
and cervix. Characterize uterus and cervix finding from CT.
TECHNIQUE: Grayscale ultrasound images of the pelvis were obtained with
transabdominal approach followed by transvaginal approach for further
delineation of uterine and ovarian anatomy.
COMPARISON: Comparison is made to CT abdomen pelvis performed ___.
FINDINGS:
The uterus is anteverted and measures 9.2 cm x 4.6 cm x 6.0 cm. Small
left-sided fibroid measures 1.4 x 1.6 x 1.2 cm. The endometrium is homogenous
and measures 5 mm.
The ovaries are normal. There is no free fluid. Small nabothian cyst is
visualized in the cervix.
IMPRESSION:
Unremarkable pelvic ultrasound. No sonographic correlate to findings on prior
CT abdomen pelvis.
Gender: F
Race: OTHER
Arrive by AMBULANCE
Chief complaint: Lower back pain, Urinary incontinence
Diagnosed with Low back pain
temperature: 97.8
heartrate: 69.0
resprate: 16.0
o2sat: 99.0
sbp: 141.0
dbp: 80.0
level of pain: 10
level of acuity: 2.0 | ___ with h/o recent L breast mass (pending workup) who presented
with severe back pain and was found to have multiple lytic
lesions consistent with metastatic malignancy.
#SECONDARY MALIGNANT LESION OF BONE
#SEVERE LOW BACK PAIN
Pt was found to have metastatic lesions as well lumbar vertebral
compression fracture. MRI L spine showed no cord compression.
She was seen by NSG in ED who did not recommend surgical
intervention. Appearance is most suggestive of a metastatic
solid tumor. Metastatic breast cancer was strong consideration
given her known L breast mass. CT torso was performed for
staging which showed enlarged paratracheal LN and RUL nodule as
well. She underwent ___ guided biopsy of L3 vertebral body on
___. Her MRI also shows possible tumor extension vs right psoas
muscle reactive myositis however CK was normal and CT showed no
abnormal enhancement. She underwent ___ guided L3 bone biopsy on
___. She was started on MS ___ and oxycodone PRN for pain
control, as well as APAP and lidocaine patch. She underwent
workup for breast mass as below. SPEP/UPEP negative. ___
consulted and the plan was initial to perform kyphoplasty on
___, but because of another technique with ablation technology
may cause superior pain control, kyphoplasty was deferred. ___
helped arrange follow up for return to hospital for ablation
procedure as this was not available to inpatients. ___ consulted
to help patient mobilize more and work on walking up stairs.
- ___ pathology from vertebral biopsy
#Metastatic Breast Cancer (bone path currently pending): She
underwent b/l mammogram and L breast u/s on ___ that showed 2
masses with associated skin thinking, highly suspicious for
malignancy. The dermal based nodule was not contiguous with
mass, and was suspicious for skin met. She also was found to
have 3 abnormal L axillary LNs. She underwent FNA of breast mass
on ___. Breast surgery was consulted during hospitalization.
Breast path showed: Invasive ductal carcinoma, grade 3,
measuring at least 13 mm in this limited sample, see note.
ESTROGEN RECEPTOR: POSITIVE (>95%, strong)
Internal control: Not present
PROGESTERONE RECEPTOR: POSITIVE (approximately 80%, strong)
Internal control: Not present
HER2/NEU PROTEIN: EQUIVOCAL (2+)
She was set up with Medical oncology, Dr. ___ to see
her on ___. Radiation oncology consulted and will see patient
in ___ and will contact her once they know the bone path result.
#SW Also consulted to assist ___ resources.
Met w/ Ms. ___/ interpreter and ___ ___
Ms. ___ is worried about being out of work and without pay as
well as transportation. Ms. ___ and ___ dtr came to the ___.
___
years ago after her other family members petitioned for their
arrival. She lives with her family and has a strong support
system. She has given permission to speak with her brother
regarding logistics including the ride.
Discussed the RIDE 30 day medical necessity and Ms. ___ is
agreeable to apply. She thinks that her family will help her
with
the cost of $6.30 round trip (caregiver rides free).
Discussed applying to ___ for grocery cards and for
assistance funding the RIDE.
Ms. ___ was tearful as it is her ___ y.o. dtr graduation
today.
Emotional support provided.
Will ___ once RIDE approved and re: ___. Will also
request pt to pt funding.
___
#constipation: pt had not been moving her bowel prior to
presentation due to pain with movement and decreased PO intake.
Now likely worsened by narcotics. She was started on aggressive
bowel regimen of docusate, senna, miralax, bisacodyl
#uterine and cervical lesion: seen on CT torso that was
performed for malignancy workup. Recent pap results from PCP
office performed ___ were obtained and showed no abnormality
other than inflammatory changes. Pt denied any abnormal bleeding
or vaginal discharge. Pelvic u/s was performed and showed no
abnormality.
The nature of hospitalization and pending studies and ___ plans
were communicated to RN at the ___ who
works with patient's PCP ___ : ___. I
provided my phone number and email and received the fax number
to fax over copy of this discharge summary.
>30min on discharge coordination |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Right upper quadrant pain
Major Surgical or Invasive Procedure:
ERCP.
History of Present Illness:
___ w/ prior subtotal colectomy for perforated c.diff colitis,
SBR, and LOA for pelvic abscess draining succus in ___, coming
in for RUQ pain throughout the last few weeks. Her pain has been
present typically after food for weeks now. Originally it only
occurred intermittently, but now it's occurring every time she
has a meal. Throguhotu the last few days it's been worse, with
pain lasting for an hour or two after every meal, not radiating,
and not associated with any BM changes. She only had some nausea
and vomiting yesterday, but otherwise not before. Of note,
she's also had a recent flex sig which showed a 7 mm ileorectal
anastomosis that has been dilated to 12 mm.
Past Medical History:
PMH: Afib (not on anticoagulation), perforated infectious
colitis requiring emergent subtotal colectomy with ileostomy,
GERD, HLD.
PSH:
___: Ex-lap, extensive lysis of adhesions, resection of
ileostomy and primary ileorectal anastomosis (___)
___: Ex-lap, lysis of adhesions, SBR, primary anastomosis,
and abdominal washout (___)
___: Open subtotal colectomy with ileostomy (___)
Social History:
___
Family History:
Mother had Type I DM, had MI and CHF, died at ___. Father died of
alcoholism-related complications at ___.
Physical Exam:
ADMISSION EXAM:
=================
Vital Signs: T 97.9, BP 108/58 HR 68 RR 16 98%RA
General: Alert, oriented, no acute distress. Pleasant.
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: Multiple scars. Soft, non-tender, non-distended, bowel
sounds present, no organomegaly, no rebound or guarding.
Negative ___ sign.
GU: No foley.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
Neuro: ___ strength upper/lower extremities, grossly normal
sensation, Normal gait.
DISCHARGE EXAM:
==================
Vital Signs: T 99.2 BP 105/55 HR 79 R 18 SpO2 94 ra
General: Alert, oriented, no acute distress. Pleasant.
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD.
CV: irregularly irregular, normal S1 + S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi.
Abdomen: Multiple scars. Soft, non-tender, non-distended, bowel
sounds present, no organomegaly, no rebound or guarding.
Negative ___ sign.
GU: No foley.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
Neuro: ___ strength upper/lower extremities, grossly normal
sensation, Normal gait.
Pertinent Results:
ADMISSION LABS:
===============
___ 09:10PM WBC-6.5# RBC-3.99 HGB-11.1* HCT-34.6 MCV-87
MCH-27.8 MCHC-32.1 RDW-13.0 RDWSD-41.1
___ 09:10PM ALBUMIN-4.4
___ 09:10PM ALT(SGPT)-605* AST(SGOT)-245* ALK PHOS-261*
TOT BILI-0.3
___ 09:10PM LIPASE-59
___ 09:41PM LACTATE-1.3 K+-4.4
___ 05:10AM URINE RBC-1 WBC-12* BACTERIA-NONE YEAST-NONE
EPI-<1 TRANS EPI-<1
___ 05:10AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-MOD
IMAGES/STUDIES:
================
US ___:
1. Cholelithiasis. Mild diffuse gallbladder wall thickening.
The gallbladder is distended but not hydropic. No sonographic
___. Overall, findings equivocal for acute cholecystitis.
2. CBD evaluation measuring up to 9 mm without obstructing
stone or mass visualized, although visualization of the distal
CBD is limited. This is unchanged in appearance since CT from ___.
CT ___
1. Unchanged appearance of a dilated segment of short segment
of small bowel near left hemiabdomen anastomosis. Contrast
passes distal to this site into decompressed loops of bowel. The
proximal small bowel loops are not dilated. Overall, findings
are not consistent with small bowel obstruction.
2. Status post subtotal colectomy. Unremarkable rectal
anastomosis.
3. Suggestion of gallbladder wall edema without other signs of
inflammation. Correlate clinically with laboratory data and
right upper quadrant pain.
4. Small hiatus hernia.
HIDA ___:
Serial images over the abdomen show homogeneous uptake of
tracer into the hepatic parenchyma.
At 9 minutes, the gallbladder is visualized with tracer
activity noted in the small bowel at 13 minutes.
IMPRESSION: Normal hepatobiliary scan. No evidence of acute
cholecystitis.
ENDOSCOPIC STUDIES:
Flex sig ___:
Normal rectal mucosa.
The ileorectal anastomosis was seen and appeared narrowed.
Liquid stool was freely flowing through the opening.
The endoscope was unable to traverse the stenotic anastomosis
of roughly 7mm in diameter.
The therapeutic upper endoscope was then used.
A wire-guided CRE 12mm balloon was introduced for dilation and
the diameter was progressively increased to 15 mm successfully.
The 11.3 mm therapeutic upper endoscope did not traverse the
stenotic anastomosis
Otherwise normal colonoscopy to ileo rectal anastomosis
MRCP ___:
IMPRESSION:
1. Choledocholithiasis resulting in mild common bile duct
dilation but no
evidence of intrahepatic duct dilation or cholangitis.
2. Cholelithiasis but no evidence of acute cholecystitis.
DISCHARGE LABS:
=================
___ 05:25AM BLOOD WBC-3.4* RBC-3.40* Hgb-9.7* Hct-30.4*
MCV-89 MCH-28.5 MCHC-31.9* RDW-13.1 RDWSD-42.6 Plt ___
___ 05:25AM BLOOD Glucose-126* UreaN-10 Creat-0.8 Na-140
K-4.0 Cl-103 HCO3-31 AnGap-10
___ 05:25AM BLOOD ALT-164* AST-62* AlkPhos-182* TotBili-0.2
___ 05:40PM BLOOD HBsAg-NEGATIVE HBsAb-NEGATIVE IgM
HBc-NEGATIVE IgM HAV-NEGATIVE
___ 05:40PM BLOOD HCV Ab-NEGATIVE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Gabapentin 300 mg PO TID
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Omeprazole 20 mg PO DAILY
4. Diphenoxylate-Atropine 2 TAB PO Q8H:PRN lose stool
5. Opium Tincture (morphine 10 mg/mL) 6 mg PO Q6H:PRN lose stool
6. Simvastatin 20 mg PO QPM
7. Rifaximin 550 mg PO TID
8. Acetaminophen 1000 mg PO Q6H:PRN pain
9. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
Discharge Medications:
1. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth Q6H:PRN Disp #*21
Tablet Refills:*0
2. Diphenoxylate-Atropine 2 TAB PO Q8H:PRN lose stool
3. Gabapentin 300 mg PO TID
4. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
5. Omeprazole 20 mg PO DAILY
6. Opium Tincture (morphine 10 mg/mL) 6 mg PO Q6H:PRN lose stool
RX *opium tincture 10 mg/mL (morphine) 6 mg by mouth every six
(6) hours Disp ___ Milliliter Milliliter Refills:*0
7. Rifaximin 550 mg PO TID
8. Simvastatin 20 mg PO QPM
9. Acetaminophen 1000 mg PO Q6H:PRN pain
10. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth twice a day
Disp #*10 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
Choledocholithiasis
SECONDARY DIAGNOSIS:
- Afib (not on anticoagulation),
- Perforated infectious colitis requiring emergent subtotal
colectomy with ileostomy
- GERD
- HLD
- Open subtotal colectomy with ileostomy (___)
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: +PO contrast; History: ___ with recent colonoscopy and dilation,
now with abdominal pain, nausea/vomiting, feels like an obstruction+PO
contrast // obstruction? anastomosis stenosis?
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: Total DLP (Body) = 449 mGy-cm.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
LOWER CHEST: Scattered streaky opacities at the lung bases are compatible with
subsegmental atelectasis; otherwise, the partially imaged lung bases are
clear. There is no pleural or pericardial effusion. There is a small hiatus
hernia.
CT ABDOMEN:
HEPATOBILIARY: The liver enhances homogeneously without evidence of concerning
focal lesion. There is no intrahepatic biliary ductal dilation. The portal
vein is patent. Gallbladder wall edema is noted without evidence of adjacent
fat stranding, possibly secondary to volume resuscitation.
PANCREAS: The pancreas enhances homogeneously. There is no peripancreatic
stranding or ductal dilation.
SPLEEN: There is no splenomegaly or focal splenic lesion.
ADRENALS: The adrenal glands are normal.
URINARY: The kidneys enhance normally and symmetrically. There is no
hydronephrosis.
GASTROINTESTINAL: The patient is status post subtotal colectomy. The rectal
anastomosis is visualized in the pelvis, and is unremarkable. Again seen in
the left hemi abdomen is a dilated mid abdominal anastomotic site which is
chronically dilated to 8 cm, not appreciably changed since scan from ___. Oral contrast again passes distal to this dilated segment and
appears in normal caliber small bowel loops distally. Overall, there is no
evidence of small bowel obstruction.
VASCULAR AND LYMPH NODES: Mild atherosclerotic disease is most prominent in
the infrarenal abdominal aorta. The abdominal aorta is normal in caliber
without evidence of aneurysm or dilation. Major proximal tributaries are
patent. There is no mesenteric or retroperitoneal lymphadenopathy by CT size
criteria. There is no free intraperitoneal air or fluid.
CT PELVIS:
The imaged pelvic organs, including the bladder and terminal ureters, are
unremarkable. There is no pelvic sidewall, iliac chain, or inguinal
lymphadenopathy. There is no free pelvic fluid.
MUSCULOSKELETAL: There is mild degenerative change of the imaged thoracolumbar
spine, worst at L5-S1. Alignment is normal. No concerning focal lytic or
sclerotic osseous lesions are identified.
IMPRESSION:
1. Unchanged appearance of a dilated segment of short segment of small bowel
near left hemiabdomen anastomosis. Contrast passes distal to this site into
decompressed loops of bowel. The proximal small bowel loops are not dilated.
Overall, findings are not consistent with small bowel obstruction.
2. Status post subtotal colectomy. Unremarkable rectal anastomosis.
3. Suggestion of gallbladder wall edema without other signs of inflammation.
Correlate clinically with laboratory data and right upper quadrant pain.
4. Small hiatus hernia.
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ woman with right upper quadrant pain, evaluate for
cholecystitis.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON:
1. Earlier same day CT abdomen and pelvis ___ at 00:48.
2. CT abdomen and pelvis ___.
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. There is no focal liver mass. The main portal vein is patent
with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CBD measures 9 mm.
No obstructing mass or stone is seen, although visualization of the distal CBD
is limited.
GALLBLADDER: There is small stones in the gallbladder neck. Mobility of
stones was unable to be demonstrated. The gallbladder is mildly distended but
not hydropic. There is mild diffuse gallbladder wall thickening. No
sonographic ___.
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.
KIDNEYS: Limited sagittal views of the right kidney demonstrate no evidence
of hydronephrosis.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cholelithiasis. Mild diffuse gallbladder wall thickening. The gallbladder
is distended but not hydropic. No sonographic ___. Overall, findings
equivocal for acute cholecystitis.
2. CBD evaluation measuring up to 9 mm without obstructing stone or mass
visualized, although visualization of the distal CBD is limited. This is
unchanged in appearance since CT from ___.
RECOMMENDATION(S): Recommend repeat non-urgent/routine abdominal ultrasound
to re-assess degree of CBD dilation, in ___ weeks, once acute episode has
resolved.
Radiology Report
EXAMINATION: MRCP
INDICATION: ___ year old woman w/ colicky RUQ pain, negative HIDA/CT scan,
elevated LFTs // MRCP for eval of possible cause of abd pain
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: 6 mL Gadavist
Oral contrast: 1 cc of Gadavist mixed with 50 cc of water was administered
for oral contrast.
COMPARISON: CT abdomen dated ___
FINDINGS:
Lower Thorax: The lung bases are clear. No pleural or pericardial effusion.
Liver: The liver is homogeneous in signal characteristics. There is no
chemical shift on the in or out of phase sequences to suggest the presence of
hepatic steatosis or iron deposition. The liver contours are smooth. There is
a 6 mm biliary hamartoma/cyst adjacent to the gallbladder. No concerning
solid or cystic lesions.
Biliary: There are multiple 2 mm calculi in the distal common bile duct. The
common bile duct measures up to 12 mm. No intra-hepatic duct dilatation. No
abnormal peribiliary or segmental hyperenhancement to suggest cholangitis.
There is cholelithiasis but no evidence of acute cholecystitis. The
previously seen mural edema is no longer evident on today's exam.
Pancreas: There is mild diffuse fatty replacement of the pancreatic
parenchyma but a normal enhancement pattern. No focal lesion or ductal
abnormality is seen.
Spleen: The spleen is normal in size and signal characteristics. There are no
focal lesions.
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.
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: The bone marrow demonstrates normal signal
characteristics. No concerning osseous lesions.
IMPRESSION:
1. Choledocholithiasis resulting in mild common bile duct dilation but no
evidence of intrahepatic duct dilation or cholangitis.
2. Cholelithiasis but no evidence of acute cholecystitis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Hypo-osmolality and hyponatremia, Unspecified abdominal pain
temperature: 98.3
heartrate: 81.0
resprate: 16.0
o2sat: 97.0
sbp: 167.0
dbp: 90.0
level of pain: 7
level of acuity: 3.0 | Mrs. ___ is a ___ year old woman with a PMH of afib (not on
anticoagulation), HLD, GERD, Fibromyalgia, perforated
diverticulitis in ___ s/p sigmoid resection, bowel perforation
from C diff colitis s/p emergent subtotal colectomy with end
ileostomy in ___ and ostomy takedown in ___, IBS and
chronic diarrhea, presenting with abdominal pain triggered by
meals, nausea, vomiting, and elevated LFTs concerning for a
hepatobiliary process.
# Transaminitis/abdominal pain: Patient initially admitted to
___ for concern of cholecystitis. However HIDA scan was
negative. Patient was found to have cholelithiasis and mild CBD
dilation of 9mm. Patient was transferred to medicine for further
management. MRCP showed choledocholithiasis. Patient underwent
ERCP on ___. LFTs continued to downtrend.
- GI consulted.
- Hep panel negative; also not immune to Hep B.
- Pain control w/ Dilaudid, and home gabapentin.
- Pt sent home with plan for elective CCY as soon as possible.
- 10 day course of Cipro for cholangitis ppx after ERCP.
# Lose stools: Patient notes this has been her baseline since
her C.diff colitis and complications. She has seen a
nutritionist and has improved slightly, but still has lose,
watery stools. Rifaximin was started for SIBO. Diarrhea starting
to improve slightly.
- Continue Opium Tincture (morphine) PO ___ PRN TID-QID.
- Continue Diphenoxylate-Atropine 2 tab PO TID.
- Continue Rifaximin 550mg PO TID. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
codeine / Penicillins / adhesive tape
Attending: ___.
Chief Complaint:
Pancytopenia
Major Surgical or Invasive Procedure:
Bone marrow biopsy ___
Lumbar puncture ___
History of Present Illness:
The patient is a ___ lady with past medical history of
hypogammaglobulinemia, depression, anxiety, localized
scleroderma, IBS who was referred from OSH for evaluation of
pancytopenia.
Patient reports that for about ___ weeks she has been
increasingly lethargic. She initially attributed her weakness of
grief and depression, as she, unfortunately, lost her father in
the first week of ___. She started having increased
shortness of breath, esp when climbing stairs and also noted
easy
bruising in her upper and lower extremities; she noted a
petechial rash on her legs that was new and decided to get
evaluated. At OSH, she was noted to have pancytopenia and was
transferred for further workup.
She reported that she was started yesterday on Bactrim for
folliculitis and has taken two doses until her hospitalization
yesterday. Otherwise, she denies any changes in medication.
She stated that she had URI about a month ago and did endorse
early satiety and intermittent nausea for the past ___ weeks.
Past Medical History:
IBS-C
MDD
anxiety
scleroderma
hypogammaglobulinemia
Social History:
___
Family History:
Mother - T2DM, CHF
Father - Unknown cancer
Physical Exam:
ADMISSION PHYSICAL EXAM
==============================
Vitals: ___ 1822 Temp: 98.2 PO BP: 132/87 HR: 83 RR: 18 O2
sat: 94% O2 delivery: Ra
Gen: Emotionally distressed female in no obvious distress.
HEENT: Mild conjunctival pallor. No icterus. MMM. OP clear.
NECK: JVP not elevated
LYMPH: No cervical or supraclav LAD
CV: RRR. Normal S1,S2. No MRG.
LUNGS: No incr WOB. CTAB. No wheezes, rales, or rhonchi.
ABD: NABS. Obese, soft, NT, ND.
EXT: No edema
SKIN: Scattered petechiae throughout R lower extremity,
ecchymosis on R knee and R arm. 1cm circular erythematous
fluctuant area on mons pubis
NEURO: A&Ox3. CN ___ intact
LINES: PIV
DISCHARGE PHYSICAL EXAM
===============================
VS: 24 HR Data (last updated ___ @ 509)
Temp: 98.5 (Tm 99.0), BP: 129/78 (114-142/70-85), HR: 62
(60-90), RR: 18 (___), O2 sat: 98% (92-98), O2 delivery: Ra
Gen: Well appearing female lying in bed, NAD
HEENT: No scleral icterus, MMM, no oral ulcerations
CV: RRR, no m/r/g
LUNGS: CTAB, no wheezes, rhonchi, or rales, no increased work of
breathing
ABD: soft, non-distended, +BS
EXT: No edema
SKIN: Scattered petechiae throughout R lower extremity,
ecchymosis on R knee and R arm.
NEURO: A&Ox3, moving all four extremities with purpose
LINES: ___ placed ___
Pertinent Results:
ADMISSION LABS:
___ 09:49PM BLOOD WBC-3.9* RBC-3.42* Hgb-8.9* Hct-26.9*
MCV-79* MCH-26.0 MCHC-33.1 RDW-13.3 RDWSD-37.8 Plt Ct-10*
___ 09:49PM BLOOD Neuts-39 Bands-7* ___ Monos-2*
Eos-0 Baso-0 Atyps-2* Metas-3* Myelos-1* Other-16* AbsNeut-1.79
AbsLymp-1.25 AbsMono-0.08* AbsEos-0.00* AbsBaso-0.00*
___ 09:49PM BLOOD Hypochr-1+* Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-NORMAL Microcy-2+* Polychr-NORMAL
Ovalocy-OCCASIONAL
___ 11:39PM BLOOD ___ PTT-30.5 ___
___ 11:39PM BLOOD ___ 09:49PM BLOOD Glucose-101* UreaN-16 Creat-0.9 Na-142
K-4.5 Cl-101 HCO3-27 AnGap-14
___ 06:15AM BLOOD ALT-35 AST-19 LD(LDH)-387* AlkPhos-66
TotBili-0.3
___ 09:22PM BLOOD Calcium-9.7 Phos-6.4* Mg-1.9 UricAcd-7.8*
___ 09:49PM BLOOD calTIBC-330 Ferritn-716* TRF-254
___ 11:00AM BLOOD IgG-401* IgA-36* IgM-23*
___ 06:15AM BLOOD HBsAg-NEG HBsAb-NEG HBcAb-NEG
IMAGING:
___ CT HEAD
There is no evidence of acute large territorial
infarction,hemorrhage,edema, or mass. Periventricular and
subcortical white matter hypodensities are nonspecific but
likely sequelae of chronic small vessel ischemic disease. The
ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. The visualized portion of the
paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
The visualized portion of the orbits are unremarkable.
IMPRESSION: No evidence of an acute intracranial abnormality.
___ SPLEEN US
1. Moderate splenomegaly, measuring up to 18 cm. No focal
splenic lesions are identified.
2. Normal Doppler evaluation of the splenic artery and vein.
___ TTE
The left atrium is normal in size. The left ventricle is not
well seen. Due to suboptimal technical quality, a focal wall
motion abnormality cannot be fully excluded. Overall left
ventricular systolic function is normal (LVEF>55%). Doppler
parameters are most consistent with Grade I (mild) left
ventricular diastolic dysfunction. Right ventricular chamber
size and free wall motion are normal. The number of aortic valve
leaflets cannot be determined. There is no aortic valve
stenosis. No aortic regurgitation is seen. The mitral valve
leaflets are structurally normal. There is no mitral valve
prolapse. Trivial mitral regurgitation is seen. The pulmonary
artery systolic pressure could not be determined. There is a
trivial/physiologic pericardial effusion.
IMPRESSION: Very suboptimal image quality, despite myocardial
contrast use. Grossly normal biventricular systolic function.
Grade I diastolic dysfunction. No significant valvular heart
disease identified.
___ CT CHEST W/ CONTRAST
Small mediastinal lymph nodes. These are not enlarged by size
criteria.
Splenomegaly. Please refer to dedicated report on abdomen which
has been
dictated separately.
___ CT ABD/PELVIS
1. No intra abdominal or pelvic lymphadenopathy or solid organ
masses
identified.
2. Left ovarian cyst measures 4.9 cm and is simple in
appearance. Follow-up ultrasound in ___ year is recommended.
RECOMMENDATION(S): Follow-up pelvic ultrasound in ___ year is
recommended to document stability and/or resolution of left
ovarian cyst.
___ CT HEAD W/O CONTRAST: There is no evidence of acute
intracranial process or hemorrhage
___ CT BONE MARROW BIOPSY: Technically successful CT-guided
right iliac bone marrow biopsy and aspiration.
MICRO:
__________________________________________________________
___ 11:51 am BLOOD CULTURE Source: Line-CVL #1.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
DISCHARGE LABS:
=====================
___ 12:00AM BLOOD WBC-3.4* RBC-3.09* Hgb-8.7* Hct-26.9*
MCV-87 MCH-28.2 MCHC-32.3 RDW-20.0* RDWSD-58.3* Plt ___
___ 12:00AM BLOOD Neuts-75* Bands-1 ___ Monos-0 Eos-1
Baso-0 ___ Metas-1* Myelos-0 NRBC-1* AbsNeut-2.58
AbsLymp-0.75* AbsMono-0.00* AbsEos-0.03* AbsBaso-0.00*
___ 12:00AM BLOOD ___ PTT-23.1* ___
___ 12:00AM BLOOD Glucose-233* UreaN-18 Creat-0.7 Na-138
K-4.4 Cl-97 HCO3-26 AnGap-15
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tolterodine 4 mg PO QHS
2. Omeprazole 20 mg PO DAILY
3. Metoprolol Succinate XL 50 mg PO DAILY
4. Sertraline 100 mg PO QAM
5. Sertraline 50 mg PO QPM
6. Sulfameth/Trimethoprim DS 1 TAB PO BID
7. Aspirin 81 mg PO BID
Discharge Medications:
1. Acyclovir 400 mg PO Q12H
RX *acyclovir 400 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*60 Tablet Refills:*0
2. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth Daily Disp #*30
Tablet Refills:*0
3. DASatinib 70 mg PO Q12H )
( )
RX *dasatinib [Sprycel] 70 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*60 Tablet Refills:*2
4. PredniSONE 10 mg PO DAILY Duration: 11 Doses
Take 30 mg (3 pills) ___.
Take 20 mg (2 pills) ___.
Take 10 mg (1 pill) ___.
RX *prednisone 10 mg 1 tablet(s) by mouth Daily Disp #*11 Tablet
Refills:*0
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
RX *sulfamethoxazole-trimethoprim 400 mg-80 mg 1 tablet(s) by
mouth Daily Disp #*30 Tablet Refills:*0
6. Metoprolol Succinate XL 50 mg PO DAILY
7. Sertraline 100 mg PO QAM
8. Sertraline 50 mg PO QPM
9. HELD- Aspirin 81 mg PO BID This medication was held. Do not
restart Aspirin until you have discussed with your PCP.
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Ph+ ALL
Pancytopenia
Secondary diagnoses:
Anxiety
Depression
Hypertension
Discharge Condition:
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Mental Status: Clear and coherent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with thrombocytopenia and headache.
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Sequenced Acquisition 8.0 s, 8.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
401.4 mGy-cm.
Total DLP (Head) = 1,204 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of acute large territorial infarction,hemorrhage,edema,
or mass. Periventricular and subcortical white matter hypodensities are
nonspecific but likely sequelae of chronic small vessel ischemic disease.
The ventricles and sulci are normal in size and configuration.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
No evidence of an acute intracranial abnormality.
Radiology Report
EXAMINATION: Chest radiographs
INDICATION: ___ with pancytopenia and bandemia.
TECHNIQUE: Frontal and lateral views of the chest
COMPARISON: None
FINDINGS:
Lungs are fully expanded and clear. No pleural abnormalities. Heart size is
normal. Cardiomediastinal and hilar silhouettes are normal.
IMPRESSION:
No evidence of an acute cardiopulmonary abnormality.
Radiology Report
EXAMINATION: SPLEEN ULTRASOUND
INDICATION: ___ year old woman with severe thrombocytopenia// Eval for
abnormalities that can cause thrombycytopenia
TECHNIQUE: Grey scale and color Doppler ultrasound images of the spleen were
obtained.
COMPARISON: None.
FINDINGS:
The spleen demonstrates normal echogenicity, measuring up to 18 cm. No
evidence of focal splenic lesions. Doppler ultrasound images of the splenic
artery and vein are within normal limits.
IMPRESSION:
1. Moderate splenomegaly, measuring up to 18 cm. No focal splenic lesions are
identified.
2. Normal Doppler evaluation of the splenic artery and vein.
Radiology Report
EXAMINATION: CT-guided bone marrow biopsy and aspiration.
INDICATION: ___ year old woman with concern for acute leukemia// ___ guided
bone marrow biopsy
COMPARISON: None.
PROCEDURE: CT-guided bone marrow biopsy and aspiration of the right iliac.
OPERATORS: Dr. ___ fellow and Dr. ___
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a prone position on the CT scan table. Limited
preprocedure CTscan of the intended biopsy area was performed. Based on the
CT findings an appropriate position for the biopsy was chosen. The site was
marked.
The site was prepped and draped in the usual sterile fashion. 1% lidocaine
were administered to the subcutaneous and deep tissues for local anesthetic
effect. Under CT guidance, an 11 gauge TRAP system needle was introduced into
the right iliac bone. 5 aspirations of less than 1 cc each were obtained, 3
placed and purple top tubes and 2 placed in green top tubes. Finally, the
needle was used to obtain 1 core biopsy specimen placed in B-fix. All of the
specimen were provided to the Hematology/Oncology fellow, ___ MD.
The procedure was tolerated well and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.2 s, 16.7 cm; CTDIvol = 23.6 mGy (Body) DLP = 400.4
mGy-cm.
2) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
3) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
4) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
5) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
6) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
7) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
8) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
9) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
10) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
11) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
12) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
13) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
14) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
15) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
16) Spiral Acquisition 1.9 s, 10.2 cm; CTDIvol = 24.2 mGy (Body) DLP = 253.6
mGy-cm.
Total DLP (Body) = 713 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of 3
mg Versed and 150 mcg fentanyl throughout the total intra-service time of 35
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
1. Subcutaneous fat stranding and edema is noted in the posterior soft tissues
overlying the left iliac as well as the midline which is consistent with
nonspecific dependent edema and possible trace amount of hemorrhage possibly
due to prior bone marrow aspiration attempt.
2. There is a cystic appearing left adnexal lesion measuring up 4.9 x 4.0 cm
which is incompletely visualized.
3. Slight abnormal contour of the left lateral portion of the uterus may
represent a fibroid.
4. Subsequent images demonstrate biopsy needle within the right iliac. No
definite evidence of hematoma on postprocedure images.
IMPRESSION:
1. Technically successful CT-guided right iliac bone marrow biopsy and
aspiration.
2. Left adnexal cystic lesion is incompletely visualized on this exam. Non
urgent pelvic ultrasound is recommended for further evaluation.
3. Possible uterine fibroid can be further evaluated on recommended pelvic
ultrasound.
RECOMMENDATION(S): Non-urgent pelvic ultrasound.
NOTIFICATION: The findings were discussed with ___ M.D. by
___, M.D. on the telephone on ___ at 5:00 pm, 15 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with right PICC// Right PICC 49cm, ___
Contact name: ___: ___
IMPRESSION:
In comparison with study of ___, there has been placement of right
subclavian PICC line, which extends to the mid SVC.
Remainder the study is unchanged and there is no evidence of acute
cardiopulmonary disease.
Radiology Report
EXAMINATION: CT abdomen pelvis with contrast
INDICATION: ___ female with past medical history of
depression,anxiety, IBS-C, scleroderma, hypogammaglobulinemia andhypertension
presents as a transfer for concern of acuteleukemia. vs. high grade
lymphoma.// Please assess for lymphadenopathy
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) = 3,990 mGy-cm.
COMPARISON: None available.
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous hypoattenuation throughout
compatible steatosis. 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 enlarged measuring up to 16 cm and demonstrates normal
attenuation throughout, without evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: There is a 4.9 x 4.3 cm right adrenal cyst. The uterus
is enlarged and contains fibroids. The right adnexa is normal in appearance.
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: Multilevel degenerative changes visualized throughout the imaged
portion of the thoracolumbar spine without worrisome osseous lesions or acute
fracture identified.
SOFT TISSUES: An umbilical hernia containing fat is noted.
IMPRESSION:
1. No intra abdominal or pelvic lymphadenopathy or solid organ masses
identified.
2. Left ovarian cyst measures 4.9 cm and is simple in appearance. Follow-up
ultrasound in ___ year is recommended.
RECOMMENDATION(S): Follow-up pelvic ultrasound in ___ year is recommended to
document stability and/or resolution of left ovarian cyst.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ female with past medical history of depression,
anxiety, IBS, scleroderma, hypogammaglobulinemia and hypertension presents as
a transfer for concern of acute leukemia.
TECHNIQUE: Multi detector CT of the chest was performed after the
administration of intravenous contrast. Axial coronal and sagittal
reconstructions were acquired. Maximum intensity projections were also
acquired
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.3 s, 28.0 cm; CTDIvol = 33.2 mGy (Body) DLP = 907.6
mGy-cm.
2) Sequenced Acquisition 0.5 s, 0.4 cm; CTDIvol = 5.7 mGy (Body) DLP = 2.3
mGy-cm.
3) Stationary Acquisition 18.8 s, 0.2 cm; CTDIvol = 320.6 mGy (Body) DLP =
64.1 mGy-cm.
4) Spiral Acquisition 10.6 s, 68.9 cm; CTDIvol = 30.0 mGy (Body) DLP =
2,049.7 mGy-cm.
5) Spiral Acquisition 4.6 s, 29.9 cm; CTDIvol = 33.0 mGy (Body) DLP = 966.0
mGy-cm.
Total DLP (Body) = 3,990 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS W AND W/O CONTRAST, ADDL SECTIONS)
COMPARISON: No priors available for comparisons
FINDINGS:
THORACIC INLET: The thyroid is unremarkable. There are no enlarged
supraclavicular lymph nodes. Right-sided PICC line projects to the SVC.
BREAST AND AXILLA : There are no enlarged axillary lymph nodes
MEDIASTINUM: There are small mediastinal lymph nodes not enlarged by size
criteria. The right paratracheal lymph node measures 8 mm. The left
paratracheal lymph nodes measure up to 7 mm. A small prevascular lymph nodes.
There are no enlarged hilar lymph nodes. The aorta and pulmonary arteries
normal in caliber. There is mild coronary artery calcification.
PLEURA: There is no pericardial effusion. There is no pleural effusion.
LUNG: Lungs are clear. No nodules or consolidations are seen.
BONES AND CHEST WALL : Review of bones shows degenerative changes involving
the thoracic spine.
UPPER ABDOMEN: Limited sections through the upper abdomen shows evidence of
hepatosplenomegaly. Please refer to dedicated report on abdomen which has
been dictated separately
IMPRESSION:
Small mediastinal lymph nodes. These are not enlarged by size criteria.
Splenomegaly. Please refer to dedicated report on abdomen which has been
dictated separately.
Radiology Report
INDICATION: ___ female with past medical history of depression,
anxiety, IBS-C, scleroderma, hypogammaglobulinemia and hypertension found to
have pro-B ___ chromosome positive ALL.// please assess placement of
picc
TECHNIQUE: Chest AP
COMPARISON: None
IMPRESSION:
Lungs are clear. Right-sided PICC line projects to the SVC.
Cardiomediastinal silhouette is stable. There is no pleural effusion. No
pneumothorax is seen.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD.
INDICATION: ___ female with past medical history of depression,
anxiety, IBS-C, scleroderma, hypogammaglobulinemia and hypertension found to
have pro-B ___ chromosome positive ALL and refractory
thrombocytopenia// Please assess for bleed.
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.
Total DLP (Head) = 940 mGy-cm.
COMPARISON: CT head from ___.
FINDINGS:
Gray-white matter differentiation is maintained. There is no evidence of
acute intracranial hemorrhage,edema,or mass. The ventricles appear normal in
size and configuration for the patient's age, the sulci are slightly prominent
towards the frontal convexity suggesting minimal cortical volume loss,
unchanged since the prior exam.
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. There is no evidence of acute intracranial process or hemorrhage
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with ALL, PICC out 2 cm from previous
position.// Location of PICC? Location of PICC?
IMPRESSION:
Compared to chest radiographs ___ one and ___.
Right PIC line ends at the origin of the SVC. Heart size normal. Lungs
clear. No pleural abnormality.
Radiology Report
INDICATION: ___ year old woman with PICC, question of migration. Need to check
placement.// Is PICC in correct position?
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of the right PICC line again projects over the upper SVC. There is no
focal consolidation, pleural effusion or pneumothorax identified. The size of
the cardiac silhouette is within normal limits.
IMPRESSION:
No significant interval change since the prior chest radiograph. The tip of
the right PICC line projects over the upper SVC, unchanged.
Radiology Report
EXAMINATION: CT bone marrow biopsy and aspiration
INDICATION: ___ year old woman with Ph+ ALL on Dasatinib/Prednisone. She had
___ BM bx previously during admission and needs repeat BM bx and LP on
___, as part of treatment regimen.// Repeat BM bx, LP
COMPARISON: CT fluoroscopic images from prior bone marrow biopsy/aspiration
dated ___.
PROCEDURE: CT-guided right iliac bone marrow biopsy and aspiration biopsy.
OPERATORS: Dr. ___ fellow and Dr. ___ radiologist. Dr.
___ supervised the trainee during the key components of the
procedure and reviewed and agrees with the trainee's findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a prone position on the CT scan table. Limited
preprocedure CTscan of the intended biopsy area was performed. Based on the
CT findings an appropriate position for the biopsy was chosen. The site was
marked.
The site was prepped and draped in the usual sterile fashion. 1% lidocaine
were administered to the subcutaneous and deep tissues for local anesthetic
effect. Under CT guidance, an 11 gauge trap system needle was introduced into
the right iliac bone. Initial aspiration tab was dry. A core sample was
taken at the first location. A second site in the right iliac bone more
superior was then accessed. Then, approximately 6 cc of aspirate was obtained
and placed in purple and green topped tubes. Then, the needle was advanced
into the right iliac bone to obtain a core biopsy specimen which was placed in
B-Fix. After the procedure, a peripheral blood sample was obtained. All of
the samples were delivered to hematopathology.
The procedure was tolerated well and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.0 s, 15.7 cm; CTDIvol = 21.1 mGy (Body) DLP = 337.4
mGy-cm.
2) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
3) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
4) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
5) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
6) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
7) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
8) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
9) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
10) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
11) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
12) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
13) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
14) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
15) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
16) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
17) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
18) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
19) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
20) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
21) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
22) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
23) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
24) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
25) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
26) Free Acquisition 0.5 s, 1.2 cm; CTDIvol = 3.5 mGy (Body) DLP = 4.2
mGy-cm.
Total DLP (Body) = 442 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of 4
mg Versed and 200 mcg fentanyl throughout the total intra-service time of 25
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
1. The visualized osseous structures are unremarkable.
2. Subsequent images demonstrate needle tip position within the right iliac
bone.
3. Again noted is a left adnexal cystic lesion that is partially visualized
measuring at least 4.6 cm, for which a nonemergent pelvic ultrasound had been
previously recommended.
IMPRESSION:
Technically successful CT-guided right iliac bone marrow biopsy and
aspiration.
Radiology Report
EXAMINATION: LUMBAR PUNCTURE (W/ FLUORO) N8 RF SPINE
INDICATION: ___ year old woman with Ph+ ALL, currently being treated with
Dasatinib and prednisone. She needs LP on ___ (D22 of Dasatinib).// Please
perform LP on ___ as part of treatment of ALL.
TECHNIQUE: After informed consent was obtained from the patient explaining
the risks, benefits, and alternatives to the procedure, the patient was laid
in prone position on the fluoroscopic table. A pre-procedure time-out was
performed confirming the patient's identity, relevant history, procedure to be
performed and labs.
Puncture was performed at L4-5.
Approximately 5 cc of 1% lidocaine was administered for local anesthesia.
Under fluoroscopic guidance, a 20 gauge, 6 inch spinal needle was inserted
into the thecal sac. There was good return of clear CSF. 15 mls of CSF were
collected in 3 tubes and sent for requested analysis.
COMPARISON: None.
FINDINGS:
15 mls of CSF were collected in 3 tubes.
IMPRESSION:
1. Lumbar puncture at L4-5 without complication.
I, Dr. ___ supervised the trainee during the key components of
the above procedure and I reviewed and agree with the trainee's findings and
dictation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea on exertion, Headache
Diagnosed with Headache
temperature: 98.3
heartrate: 88.0
resprate: 18.0
o2sat: 95.0
sbp: 152.0
dbp: 70.0
level of pain: 4
level of acuity: 2.0 | Ms. ___ is a ___ female with PMH depression,
anxiety, IBS-C, scleroderma, hypogammaglobulinemia and HTN who
presented as a transfer and was found to have Pro-B Ph+ ALL.
# Pro-B Ph+ ALL:
On acmiddion patient had pancytopenia concerning for marrow
infiltrative process with circulating cells concerning for
blasts. Flow and cytogenetics were consistent with Pro-B
___ chromosome positive ALL (pos CD34, CD19, CD10,
C79a, and Tdt and 9;22 translocation). Patient was started on
prednisone 60 mg BID and Dasatinib 140 mg daily. Patient was
changed to Dasatinib 70 mg PO q12h. On Day ___, patient
had repeat bone marrow biopsy and LP with intrathecal
methotrexate. Per Dasatinib protocol, prednisone was tapered
starting on day 24 and will continue until day 32 (___). She
required platelet and pRBC transfusions during admission.
Patient received ciprofloxacin, Bactrim, micafungin and
acyclovir during her stay. Ciprofloxacin was discontinued when
neutropenia resolved. Micafungin was discontinued on day of
discharge. Patient will follow-up with Dr. ___ as an
outpatient.
# Thrombocytopenia:
Patient developed thrombocytopenia which did not improve despite
multiple platelet transfusions. She received aminocaproic acid
while thrombocytopenic until platelets improved greater than
50K. HLA PRA was 73% and required HLA-matched platelets during
admission. Her last platelet transfusion was on ___.
# Folliculitis:
Prior to admission, patient had ___ days of inflamed groin
nodule and was started on Bactrim. There was concern for abscess
v. leukemia cutis on admission. Dermatology evaluated the nodule
and determined it was folliculitis. Patient was started on
Bactroban with subsequent improvement in nodule.
# HTN:
Home metoprolol succinate was held on admission. Patient will
re-start home metoprolol succinate 12.5 mg on discharge.
# Anxiety/Depression
Patient had anxiety regarding diagnosis during admission. She
received PRN Ativan for anxiety. She continued home sertraline.
# Hyperglycemia:
Patient has known history of prediabetes and has never taken
medication. She had serum glucose ~250 and was started on an
insulin sliding scale. Her hyperglycemia was thought to be due
to prednisone. Prednisone will be tapered and discontinued on
___.
=======================
TRANSITIONAL ISSUES:
=======================
[ ] ___ CT Abdomen/Pelvis w/ & w/o contrast demonstrated
left ovarian cyst measuring 4.9 cm and is simple in appearance.
Please do follow-up ultrasound in one year.
[ ] Fingerstick blood sugars elevated during admission with
patient requiring insulin sliding scale. She will have
prednisone tapered and stopped on ___. She should have ___
checked as an outpatient after she has been off prednisone for
greater than 90 days. She has history of prediabetes.
[ ] Aspirin was held upon admission given pancytopenia. Consider
restarting once counts recover. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
Compazine / seafood / Wellbutrin
Attending: ___.
Chief Complaint:
sepsis
Major Surgical or Invasive Procedure:
plasmapheresis
History of Present Illness:
___ with a history of essential thrombocytosis, myasthenia
___ (on prednisone, last crisis ___ and recent admission
for perforated diverticulitis s/p ___ drainage placement on ___
who presents with somnolence, emesis and respiratory distress.
The patient presented last week after one week of abdominal
pain,
found to have perforated diverticulitis with pelvic abscess. She
underwent trans-rectal drain placement with clinical improvement
and was discharged on ___ on PO Bactrim and flagyl
(aminoglycosides and fluoroquinolones are contraindicated in
MG).
The patient developed nausea and had multiple episodes of emesis
this afternoon after taking PO antibiotics. When her respiratory
status worsened and she became somnolent, her husband brought
her
to ___ for evaluation.
At ___, she was noted to have a WBC of 43, thrombocytosis
and
imaging that showed persistent inflammation of the bowel but
improvement in the abscess cavity. She was transferred to ___
for further evaluation. In the ED, she was somnolent and had
poor
inspiratory effort, with ptosis and NIF -10. She denied
abdominal
pain prior to intubation.
Of note, she was hospitalized last fall with a myasthenic crisis
in setting of UTI, with prolonged intubation, PLEX and
cardiogenic shock.
Past Medical History:
Myasthenia ___ (follows with Dr. ___, never
history of crisis, not on steroids but was previously frequent
UTIs
Social History:
___
Family History:
Unknown
Physical Exam:
ADMISSION Physical Exam:
Vitals: T100 HR138 BP121/71 Intubated.
GEN: chronically ill appearing, cachectic, appears older than
stated age
HEENT: No scleral icterus, mucus membranes dry
CV: tachycardic, regular rhythm
PULM: decreased breath sounds bilaterally
ABD: Soft, distended, ___ drain in place with feculent output,
exiting transrectal
Ext: No ___ edema, extremities cold and pale
Neurologic:
****EXAM AFTER INTUBATION WITH ROCURONIUM AND STILL ON MIDAZOLAM
AND FENTANYL DRIPS*****
-Mental Status: intubated and sedated
-Cranial Nerves:
Pupils 2 mm and nonreactive. Eyes midline. No blink to threat.
No
corneal reflex. No cough. Face appears symmetric.
-Motor/Sensory: Decreased bulk, increased tone throughout.
RUE: does not withdraw from noxious
RLE: does not withdraw from noxious
LUE: does not withdraw from noxious
LLE: does not withdraw from noxious
-DTRs: absent reflexes, toes mute
-Coordination: Unable to assess
-Gait: Unable to assess
DISCHARGE PHYSICAL EXAM
Pertinent Results:
ADMISSION LABS
___ 08:20PM BLOOD WBC: 43.1* RBC: 3.45* Hgb: 11.4 Hct: 34.2
MCV: 99* MCH: 33.0* MCHC: 33.3 RDW: 12.2 RDWSD: 44.___*
___ 08:20PM BLOOD Plt Ct: 1302*
___ 08:20PM BLOOD Glucose: 166* UreaN: 10 Creat: 0.7 Na:
143
K: 3.3* Cl: 111* HCO3: 18* AnGap: 14
___ 08:20PM BLOOD Lipase: 229*
___ 08:20PM BLOOD cTropnT: 0.05*
___ 08:20PM BLOOD Albumin: 3.3* Calcium: 8.7 Phos: 4.5 Mg:
1.4*
___ 08:29PM BLOOD Type: ___ pO2: 74* pCO2: 52* pH: 7.20*
calTCO2: 21 Base XS: -7
___ 10:26PM BLOOD Lactate: 0.4*
___ CT ABD PEL
1. Interval decrease in size of the known pelvic collection
located anterior to the tip of right gluteal approach pigtail
drainage catheter in rectouterine space abutting the posterior
aspect of uterus. The collection measures up to 2.6 cm and
appears more organized than on prior imaging. No evidence of
fistulous formation.
2. Interval decrease in extent of inflammatory stranding
associated with
diverticulitis.
3. Stable compression fracture deformity of the superior
endplate of L5.
___ CT
1. Interval decrease in extent of inflammatory stranding related
to
diverticulitis.
2. Interval removal of pelvic drainage catheter with persistent
2.1 x 4.4 cm posterior pelvis collection.
3. New small right and trace left pleural effusions with
associated
atelectasis.
___ CT
Successful CT-guided placement of an ___ pigtail catheter
into the
collection. Samples were sent for microbiology evaluation.
___ CT abd/pelvis
1. Administered rectal contrast is seen within the perirectal
collection
surrounding the pigtail catheter, consistent with an ongoing
leak.
2. New 4.2 x 1.7 cm right gluteal intramuscular collection,
likely an abscess that has developed as a result of tracking
along the pigtail catheter.
3. Small bilateral pleural effusions.
___ ___
1. Successful CT-guided exchange of an ___ pigtail
catheter for a 10
___ pigtail catheter into the perirectal collection, which
has largely
collapsed.
2. Successful CT-guided aspiration of a right gluteal
intramuscular abscess (patient declined drainage catheter
placement into this collection).
DISCHARGE LABS
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. MetroNIDAZOLE 500 mg PO TID
2. Aspirin 81 mg PO DAILY
3. PredniSONE 10 mg PO DAILY
4. Pyridostigmine Bromide 15 mg PO Q4H
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. OLANZapine (Disintegrating Tablet) 2.5 mg PO QID: PRN
anxiety, agitation
RX *olanzapine 2.5 mg 1 tablet(s) by mouth QID:PRN Disp #*20
Tablet Refills:*0
3. Piperacillin-Tazobactam 4.5 g IV Q8H
RX *piperacillin-tazobactam 4.5 gram 4.5 g IV every eight (8)
hours Disp #*63 Vial Refills:*0
4. PredniSONE 30 mg PO DAILY
See instructions on discharge worksheet, taper by 5mg weekly
with plan to maintain on 10mg daily
Tapered dose - DOWN
RX *prednisone 5 mg 6 tablet(s) by mouth once a day Disp #*80
Tablet Refills:*1
5. Pyridostigmine Bromide 15 mg PO Q8H:PRN myasthenic sx
6. Aspirin 81 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
#Myasthenic crisis
#Diverticulitis
#Pelvic abscess s/p ___ drain replacement ___
#R gluteal abscess
#Leukocytosis
#Diarrhea
#Hypokalemia
#Hypomagnesemia
#Hypophosphatemia
#Hypernatremia
#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: CHEST (PORTABLE AP)
INDICATION: ___ with new ett placement// History: ___ with new ett placement
COMPARISON: Prior from 2 hours earlier
FINDINGS:
AP portable upright view of the chest. Interval placement of an endotracheal
tube which is seen terminating 2.6 cm above the carina. An OG tube extends
into the left upper abdomen though its tip is not included within the imaged
field. Lungs remain clear without significant change from prior.
IMPRESSION:
ET and OG tubes positioned appropriately.
Radiology Report
EXAMINATION: DX CHEST PORT LINE/TUBE PLCMT 1 EXAM
INDICATION: History: ___ with CVL// line placement
TECHNIQUE: Portable AP
COMPARISON: Multiple chest radiographs from ___ through ___ at 20:53 and 18:05 p.m.
FINDINGS:
Interval placement of a right internal jugular catheter terminates in the mid
SVC. The endotracheal tube has been retracted and now terminates in standard
position within the trachea. OG tube is incompletely imaged but the side port
projects over the mid left abdomen.
Nodular opacities in the right lung base are progressively more conspicuous
since earlier today. Retrocardiac subsegmental atelectasis new since ___ at 18:05. Small right pleural effusion. Biapical scarring is
unchanged.
Cardiomediastinal silhouette is unchanged. No pneumothorax.
IMPRESSION:
1. Progressive development of nodular opacities in the right lower lung and
retrocardiac subsegmental atelectasis as well as small right pleural effusion
is concerning for pneumonia.
2. Newly placed right internal jugular catheter terminates in the mid SVC.
3. Interval retraction of the endotracheal tube, now in standard position.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman intubated s/p myastenic crisis// Interval
change
IMPRESSION:
In comparison with the study of ___, the monitoring and support
devices are stable. The right base opacification has decreased. On the left
there is pleural fluid with volume loss in the lower lobe. No evidence of
acute focal consolidation. Set
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ year old woman with MG, sepsis// LIJ HD catheter placement
Contact name: ___, ___: ___
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___ from earlier in the day
FINDINGS:
A left pleural effusion and associated atelectasis are unchanged. There is
continued decreased conspicuity of a right lower lung opacity there is no
pneumothorax identified. The size and appearance of the cardiomediastinal
silhouette is unchanged. The tip of a new left internal jugular central
venous catheter projects over the distal SVC, as does the tip of a right
internal jugular central venous catheter. The endotracheal tube and gastric
tube have been removed.
IMPRESSION:
The tip of a new left internal jugular central venous catheter projects over
the distal SVC. No pneumothorax.
Continued decreased conspicuity of a right lower lung opacity.
Radiology Report
EXAMINATION: CT PELVIS W/CONTRAST
INDICATION: ___ year old woman with ___ w/ essential thrombocytosis,
myasthenia ___ crisis s/p discharge form hospital on ___ for perforated
diverticulitis s/p ___ drainage placement on ___ now with resolved septic
shock, ?regarding d/c drain// ?d/c drain, assessment of drain position
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.8 s, 36.7 cm; CTDIvol = 6.8 mGy (Body) DLP = 249.1
mGy-cm.
Total DLP (Body) = 249 mGy-cm.
COMPARISON: Multiple CT abdomen and pelvis examinations most recent dated ___.
FINDINGS:
PELVIS: The degree of inflammatory stranding and appearance of the collection
have improved over multiple recent CT abdomen pelvis examinations. There is a
right upper gluteal approach pigtail drainage catheter in place with the tip
in posterior rectouterine space. The previously seen abscess in the posterior
mid pelvis in rectouterine space has decreased in size with a small residual
fluid collection anterior to the tip of drainage pigtail catheter noted
measuring 2.1 x 2.3 x 2.6 cm (series 2, image 43). The pigtail catheter
appears to be at least partially within the posterior aspect of the
collection. The collection appears more well-organized and no longer contains
gas within it. Additionally, it abuts the posterior aspect of uterus however
no definite air seen in the uterus or vagina to suggest fistula. No other
collection is seen. Again noted is diffuse diverticulosis of the sigmoid
colon.
The included liver, gall bladder, right kidney and pancreas are unremarkable.
The left kidney is normal except for punctate low-density lesions.
REPRODUCTIVE ORGANS: The visualized reproductive organs are unremarkable.
LYMPH NODES: There is no pelvic or inguinal lymphadenopathy.
VASCULAR: Moderate atherosclerotic disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Superior endplate compression fracture deformity of L5 is unchanged.
SOFT TISSUES: Small fat containing umbilical hernia is noted.
IMPRESSION:
1. Interval decrease in size of the known pelvic collection located anterior
to the tip of right gluteal approach pigtail drainage catheter in rectouterine
space abutting the posterior aspect of uterus. The collection measures up to
2.6 cm and appears more organized than on prior imaging. No evidence of
fistulous formation.
2. Interval decrease in extent of inflammatory stranding associated with
diverticulitis.
3. Stable compression fracture deformity of the superior endplate of L5.
Radiology Report
EXAMINATION: Chest radiograph, portable AP upright view.
INDICATION: Myasthenia ___. Worsening flare.
COMPARISON: ___.
FINDINGS:
Left internal jugular central venous catheter terminates in the lower superior
vena cava. Right internal jugular catheter was removed. Cardiac, mediastinal
and hilar contours appear stable. Heart is again borderline in size. Aside
from some shifting in distribution, left basilar opacification including a
small left-sided pleural effusion shows no substantial change. Similar slight
medial right basilar opacity. Lungs remain otherwise clear. No pneumothorax.
No pleural effusion on the right.
IMPRESSION:
Persistent mild left basilar opacification including a small pleural effusion.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old woman with myasthenia ___ p/w myasthenic crisis
following diverticulitis/pelvic abscess.// Evaluate for recurrent 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 3.5 s, 45.7 cm; CTDIvol = 4.7 mGy (Body) DLP = 212.9
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
3) Stationary Acquisition 6.6 s, 0.5 cm; CTDIvol = 33.5 mGy (Body) DLP =
16.8 mGy-cm.
Total DLP (Body) = 231 mGy-cm.
COMPARISON: Multiple prior CT abdomen and pelvis examinations most recent
dated ___.
FINDINGS:
LOWER CHEST: There are new small right and trace left pleural effusions with
associated 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: Punctate low-density lesions in both kidneys are unchanged and too
small to characterize. The kidneys are of normal and symmetric size with
normal nephrogram. There is no evidence of focal renal lesions or
hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout.
The degree of inflammatory stranding surrounding the sigmoid colon and rectum
has decreased compared to prior exam. The previously seen drainage catheter
terminating at the mid posterior pelvis collection is no longer present.
There is residual mid-posterior pelvic collection seen measuring 2.1 x 4.4 cm
(series 2, image 64) containing air and a small amount of flui. Extensive
sigmoid diverticulosis is again seen
PELVIS: The urinary bladder and distal ureters are unremarkable.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are grossly within
normal limits. No evidence of air is seen in uterus to suggest fistulous
formation.
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: Superior endplate compression fracture deformity of L5, unchanged.
SOFT TISSUES: An umbilical hernia containing fat is noted.
IMPRESSION:
1. Interval decrease in extent of inflammatory stranding related to
diverticulitis.
2. Interval removal of pelvic drainage catheter with persistent 2.1 x 4.4 cm
posterior pelvis collection.
3. New small right and trace left pleural effusions with associated
atelectasis.
Radiology Report
INDICATION: ___ year old woman with myasthenia, rising leukocytosis, CT guided
___ drain for pelvis abscess, (was initially placed ___, pulled out ___, per
ACS this should be performed urgently, CT AP has been ordered, surgery thinks
drain should be placed before imaging is done// replace pelvic abscess drain
COMPARISON: Prior CT abdomen pelvis done ___ at 10:48
PROCEDURE: CT-guided drainage of pelvic collection.
OPERATORS: Dr. ___, radiology fellow and Dr. ___
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a prone position on the CT scan table. Limited
preprocedure CT scan was performed to localize the collection. Based on the
CT findings an appropriate skin entry site for the drain placement was chosen.
The site was marked. Local anesthesia was administered with 1% Lidocaine
solution.
Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was
inserted into the collection. A sample of fluid was aspirated, confirming
needle position within the collection. 0.038 ___ wire was placed through
the needle and needle was removed. This was followed by placement of ___
Exodus pigtail catheter into the collection. The plastic stiffener and the
wire were removed. The pigtail was deployed. The position of the pigtail was
confirmed within the collection via CT fluoroscopy.
Approximately 1 cc of brown purulent fluid was aspirated with a sample sent
for microbiology evaluation. The catheter was secured by a StatLock. The
catheter was attached to suction bulb. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence:
1) Spiral Acquisition 6.9 s, 21.2 cm; CTDIvol = 5.8 mGy (Body) DLP = 115.6
mGy-cm.
2) Stationary Acquisition 7.9 s, 1.4 cm; CTDIvol = 82.8 mGy (Body) DLP =
119.2 mGy-cm.
Total DLP (Body) = 243 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of 0
mg Versed and 125 mcg fentanyl throughout the total intra-service time of 15
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
1 cc of purulent fluid was aspirated; catheter subsequently attached to bulb
suction. Sample was sent for microbiology.
IMPRESSION:
Successful CT-guided placement of an ___ pigtail catheter into the
collection. Samples were sent for microbiology evaluation.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with new PICC- 1 cm out of vein// 40 cm R
basilic SL PICC- ___ ___ Contact name: ___: ___ cm R
basilic SL PICC- ___ ___
COMPARISON: Chest x-ray ___
FINDINGS:
There has been interval removal of the left internal jugular central venous
catheter. Interval placement of right PICC line with the distal tip at the
caval atrial junction. Cardiomediastinal silhouette is stable. There are
linear retrocardiac opacities probably representing atelectasis. Small left
pleural effusion.
IMPRESSION:
Small left pleural effusion.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old woman with diverticulitis, abscess s/p drain
placement by ___// with IV AND RECTAL contrast to evaluate drain, fistula, and
abscess
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence: 1) Spiral Acquisition 3.6 s, 47.2 cm; CTDIvol =
5.9 mGy (Body) DLP = 276.6 mGy-cm. 2) Stationary Acquisition 0.6 s, 0.5 cm;
CTDIvol = 3.0 mGy (Body) DLP = 1.5 mGy-cm. 3) Stationary Acquisition 0.6 s,
0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5 mGy-cm. Total DLP (Body) = 280
mGy-cm.
COMPARISON: CT abdomen and pelvis ___
FINDINGS:
LOWER CHEST: There are small bilateral pleural effusions with adjacent
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.
There is a subcentimeter hypodensity in the upper pole of the right kidney
that is too small to characterize, but likely represents a cyst (02:20).
There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The previously
placed pelvic drain is in unchanged position. The collection around the drain
has largely collapsed. However, there is a small amount of the administered
rectal contrast that extends into the perirectal collection surrounding the
pigtail catheter, consistent with ongoing leak (2:62, 2:61). There is no
pneumoperitoneum or ascites.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus and bilateral adnexae are within normal
limits.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Extensive atherosclerotic
disease is noted.
BONES: Unchanged mild compression fracture at L5.
SOFT TISSUES: There is a mildly rim enhancing fluid collection containing tiny
locules of gas in the right gluteus muscles that measures approximately 4.2 x
1.7 cm (2:65). This has newly developed since ___, and the medial
aspect of this collection appears to be in contiguity with the catheter tract,
suspicious for tracking along the catheter resulting in intramuscular abscess.
There is mild generalized body wall edema.
IMPRESSION:
1. Administered rectal contrast is seen within the perirectal collection
surrounding the pigtail catheter, consistent with an ongoing leak.
2. New 4.2 x 1.7 cm right gluteal intramuscular collection, likely an abscess
that has developed as a result of tracking along the pigtail catheter.
3. Small bilateral pleural effusions.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 5:00 pm, 5 minutes after discovery
of the findings.
Radiology Report
EXAMINATION: CT-GUIDED CATHETER EXCHANGE; CT-GUIDED ABSCESS ASPIRATION
INDICATION: ___ year old woman with diverticulitis, perirectal abscess s/p
drain and new R gluteal abscess on CT abd/pelvis// drainage of new R gluteal
abscess and upsizing of current drain, per ACS request.
COMPARISON: CT abdomen and pelvis ___.
PROCEDURE: 1. CT-guided exchange of the catheter in a perirectal collection.
2. CT-guided aspiration of a right gluteal intramuscular abscess.
OPERATORS: Dr. ___, radiology trainee and Dr. ___, attending
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a prone position on the CT scan table. Limited
preprocedure CT scan was performed to localize the collections.
PERIRECTAL COLLECTION:
After the pre-existing pigtail catheter was cut, a 0.038 ___ wire was
placed through the catheter and the catheter was subsequent removed. This was
followed by placement of a new ___ Exodus pigtail catheter into the
collection. The plastic stiffener and the wire were removed. The pigtail was
deployed. The position of the pigtail was confirmed within the collection via
CT fluoroscopy. The catheter was secured by a StatLock. The catheter was
attached to suction bulb. Sterile dressing was applied.
RIGHT GLUTEAL INTRAMUSCULAR ABSCESS:
Based on the initial CT findings an appropriate skin entry site for the
aspiration was chosen. The site was marked. Local anesthesia was
administered with 1% Lidocaine solution.
Using intermittent CT fluoroscopic guidance, an 18-G ___ needle was
inserted into the collection. Approximately 10 cc of thick purulent fluid was
aspirated, and a sample was sent for microbiology evaluation.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: Acquisition sequence:
1) Spiral Acquisition 10.0 s, 30.6 cm; CTDIvol = 7.8 mGy (Body) DLP = 227.9
mGy-cm.
2) Stationary Acquisition 8.3 s, 1.4 cm; CTDIvol = 86.6 mGy (Body) DLP =
124.6 mGy-cm.
Total DLP (Body) = 361 mGy-cm.
SEDATION: Sedation was provided by administering a total 100 mcg fentanyl
throughout the total intra-service time of 25 minutes during which patient's
hemodynamic parameters were continuously monitored by an independent trained
radiology nurse.
FINDINGS:
1. Limited preprocedure CT of the pelvis shows a pigtail catheter
appropriately positioned within a pre-existing perirectal collection, which
has largely collapsed. No significant fluid is seen on imaging.
2. Heterogeneous collection within the right gluteus muscles containing a
tiny locule of air, which measures approximately 4.2 x 1.9 cm.
3. Extensive diverticulosis throughout the colon.
4. Diffuse body wall edema.
IMPRESSION:
1. Successful CT-guided exchange of an ___ pigtail catheter for a 10
___ pigtail catheter into the perirectal collection, which has largely
collapsed.
2. Successful CT-guided aspiration of a right gluteal intramuscular abscess
(patient declined drainage catheter placement into this collection).
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Diverticulitis, Tachycardia, Transfer
Diagnosed with Peritoneal abscess, Myasthenia gravis with (acute) exacerbation, Tachycardia, unspecified, Essential (hemorrhagic) thrombocythemia
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: Critical
level of acuity: 1.0 | TSICU COURSE
=============
She was admitted to the TSICU after being intubated in the ED
for respiratory failure, and was put on vancomycin and Zosyn.
She initially required pressor support which was thought to be
mainly driven by propofol sedation and was quickly weaned as
propofol was weaned as well.
On hospital day 2 she was extubated and was being to room air.
Neurology service was consulted who recommended hydrocortisone
50 mg every 6 hours and started plasma exchange while she was in
the TSICU. CT scan done on ___ showed that the abscess
has now organized more and is smaller in size with less fat
stranding and is now located anterior to the tip of the pigtail
catheter.
From a GI standpoint she was kept n.p.o. due to failing the
bedside speech and swallow which was thought to be in the
setting of myasthenic crisis initially.
Infectious disease service was consulted and recommended
discontinuing vancomycin which was done and continuing Zosyn,
with consideration of long-term ertapenem as outpatient.
On HD5 the patient was hyperventilating in the Am and was
hypercarbic was put on Bipap, neuromuscular service recommended
restarting pyridostigmine and watch for increased airway
secretions. since the patient did not have any surgical issues
and her only remaining problems were neurological issues at that
point the neuro-ICU service was contacted who accepted the
patient.
Neuro ICU course
===========================
She was transferred to neuro ICU team ___ due to electrolyte
abnormalities, anemia, diarrhea and complex care. Electrolytes
were aggressively repleted although she often declined various
doses. Her diarrhea decreased. She received IVIG ___ with plan
for ___nd tolerated this well. For slowly drifting
anemia with Hgb 6.6->6.2 (hemodynamically stable, she received a
unit of pRBC on ___. For her perforated diverticulitis her
antibiotics were changed back from vanc/cefepime to zosyn. Plan
is for 7 day course once drain is pulled. Given stability and
improvement, she was transferred back to the general service
care on ___.
NIMU course
=======================
Ms. ___ is a ___ year old woman with myasthenia ___ (AChR+,
possibly thymoma +, not resected) initially admitted to ICU ___
for myasthenic crisis beginning within hours of discharge for
divericulitis/pelvic abscess drained ___. She received several
sessions of PLEX; however, given c/f abdominal
abscess/infection, she was then switched over to IVIG, of which
she completed a 5 day course (last day ___. Respiratory
parameters were been limited by poor effort with NIF testing
(patient refuses them often), but she was stable clinically with
good strength on neck flexion. She continued on IV zosyn for
continued management of her abdominal infection per ID recs.
Her course was complicated by diarrhea associated with mestinon
(now resolved), leukocytosis, as well as hypokalemia,
hypomagnesemia. Medicine and nephrology were consulted regarding
the electrolyte abnormalities; it was felt that her low
magnesium and diarrhea early on during her hospital stay were
contributing to her hypokalemia. They provided recommendations
regarding electrolyte repletion. Overall, her MG symptoms have
been improving with PLEX and IVIG. She also continued on
prednisone 30mg daily with plan to taper down by 5mg weekly
starting on ___.
- Continue PO potassium chloride replacement 40 mEq daily until
follow-up with her PCP.
- Continue PO magnesium oxide replacement 200mg daily until
follow-up with her PCP.
For the abdominal abscess, surgery, ___, and ID have provided
recommendations. ID recommended to continue Zosyn 4.5g IV Q8H
and once drain is removed, continue Zosyn for another week after
drain removal. ACS recommended repeat CT pelvis with rectal
contrast prior to discharge, which showed new R gluteal abscess.
ACS recommended upsizing of the existing drain and new drain
placement in the new R gluteal intramuscular abscess. Ms. ___
was in agreement with drain upsizing, but did not agree to
placement of a drain in the new abscess. Thus, she underwent ___
procedure for aspiration of the intamuscular abscess and
upsizing of diverticular abscess drain on ___.
The surgical team (attending Dr. ___ agrees with the
plan for her to be discharged on ___, with the drain in place,
continuing antibiotics and with close follow-up in the surgery
clinic.
TRANSITIONAL ISSUES
-------------------
#HypoK, #HypoMag
[]Patient has a primary care appointment on ___
-please check CBC, chem-10 to ensure that Hgb is above 7 and
check electrolyte levels, especially K, Mag. Repletion as
necessary.
___ will check electrolyte and CBC twice/week; results will be
faxed to PCP ___
#Pelvic abscess
#R gluteal abscess
[]follow up with surgery outpatient - Dr. ___ at the ___ Care
Surgery Clinic in ___ weeks. ___ Office Number: ___
___ service set up for zosyn infusion at home
[]continue Zosyn 4.5g IV Q8H and once drain is removed, continue
Zosyn for another week after drain removal
___ will check electrolyte and CBC twice/week; results will be
faxed to PCP office and PCP office has been notified of this
[]follow up with infectious disease outpatient
#Myasthenia ___
[]follow up with outpatient neurology
[]continue Prednisone 30mg daily until ___, then decrease by
5mg per week with plan to remain on Prednisone 10mg daily
ongoing or until follow-up with outpatient neurologist, Dr. ___
___ []25mg prednisone daily
___ []20mg prednisone daily
and so on until back to 10mg daily |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
lisinopril / simvastatin / hydrochlorothiazide
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
Coronary catheterization with percutaneous coronary intervention
History of Present Illness:
Pt is an ___ F w/ PMH of HFpEF, HTN, DM on insulin, and
osteoporosis p/w chest pain refractory to nitroglycerin, found
to
have 3-vessel disease on cath, now s/p stent placement x2.
Per ED: "History obtained with interpreter. Patient poor
historian. Patient states having ___ days of severe chest pain
radiating to the back with associated shortness of breath.
Denies
fevers, cough or cold, belly pain, urinary or bowel symptoms."
In the ED...
- Initial vitals:
BP 138/49 HR 79 RR 16 O2 sat 97% RA Temp 97.9
- EKG:
NSR, c/f anterior infarct. ST-elevations in V1-V3, but don't
meet
criteria for STEMI.
- Labs/studies notable for:
trop 0.29, repeat trop 0.36
BNP 12182
CK 222
BUN 26 Cr 1.2
- Patient was given: carvedilol 3.125mg, nitro 0.35-3.5
mcg/kg/min IV drip, nitro 0.4mg SL, aspirin 324mg, heparin drip
- Vitals on transfer:
BP 124/88 HR 68 RR 20 O2 sat 98% RA
Since troponins were positive and chest pain was refractory to
nitroglycerin in ED, pt was taken to cath lab, where she was
found to have 3-vessel disease and had two stents placed.
Upon arriving on the floor, further history was obtained with
the
patient's daughter as an interpreter. Phone interpreter was
offered, but denied.
The patient stated that she developed worsening back pain over
the preceding ___ days. Patient endorses above history and
additionally reports 1 week history of episodes of chest pain at
rest. The morning of presentation, she developed acute
substernal
chest pain that didn't improve. It was accompanied by shortness
of breath and nausea. She lives in alone in an elder apartment
complex. They called EMS, who brought her to ___.
On the floor, she reports a burning sensation in her chest and
significant fatigue. Of note, she reports this is a similar
sensation to a burning sensation that she's had for "a while"
after eating. She denies current chest pain, shortness of
breath,
n/v, palpitations, diaphoresis, and swelling.
Past Medical History:
- Insulin dependent diabetes
- Hypertension
- CAD
- Hyperlipidemia
- Osteoporosis
- HFpEF (EF 55%, ___
- Pulmonary hypertension
- Peripheral arterial disease
Social History:
___
Family History:
There is no family history of hypertension or diabetes mellitus
or coronary artery disease or cancer or hepatitis B.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
GENERAL: Well-developed, well-nourished. Resting comfortably in
bed.
HEENT: NCAT. Sclera anicteric.
CARDIAC: RRR, normal S1, S2. No murmurs, rubs, or gallops.
LUNGS: Normal work of breathing. LCBA.
ABDOMEN: Soft, NTND.
EXTREMITIES: No lower extremity edema.
SKIN: no rashes
DISCHARGE PHYSICAL EXAM
=======================
24 HR Data (last updated ___ @ 840)
Temp: 97.5 (Tm 98.4), BP: 163/75 (95-163/50-75), HR: 68
(59-74), RR: 18 (___), O2 sat: 92% (91-97), O2 delivery: RA
(0.5L-2L), Wt: 133.82 lb/60.7 kg
Fluid Balance (last updated ___ @ 839)
Last 8 hours Total cumulative -100ml
IN: Total 150ml, PO Amt 150ml
OUT: Total 250ml, Urine Amt 250ml
Last 24 hours Total cumulative 325ml
IN: Total 1000ml, PO Amt 1000ml
OUT: Total 675ml, Urine Amt 675ml
GENERAL: Well-developed, well-nourished. Resting comfortably in
bed.
HEENT: NCAT. Sclera anicteric. JVD elevated to mid-neck when
sitting upright.
CARDIAC: RRR, normal S1, S2. No murmurs, rubs, or gallops.
LUNGS: Normal work of breathing. Fine crackles at bases
bilaterally.
EXTREMITIES: No lower extremity edema.
Pertinent Results:
ADMISSION LAB RESULTS
=====================
___ 11:49AM BLOOD WBC-8.1 RBC-3.83* Hgb-11.4 Hct-34.3
MCV-90 MCH-29.8 MCHC-33.2 RDW-13.6 RDWSD-44.5 Plt ___
___ 11:49AM BLOOD Glucose-174* UreaN-26* Creat-1.2* Na-143
K-4.2 Cl-100 HCO3-31 AnGap-12
___ 11:49AM BLOOD CK-MB-9 MB Indx-4.1 ___
___ 11:49AM BLOOD CK-MB-9 cTropnT-0.29*
___ 11:49AM BLOOD %HbA1c-8.5* eAG-197*
___ 11:49AM BLOOD Triglyc-79 HDL-48 CHOL/HD-2.8 LDLcalc-68
DISCHARGE LAB RESULTS
=====================
___ 05:40AM BLOOD WBC-7.5 RBC-3.47* Hgb-10.3* Hct-32.2*
MCV-93 MCH-29.7 MCHC-32.0 RDW-13.7 RDWSD-46.5* Plt ___
___ 05:40AM BLOOD Glucose-109* UreaN-22* Creat-1.1 Na-145
K-4.6 Cl-104 HCO3-27 AnGap-14
___ 05:47AM BLOOD CK-MB-28* cTropnT-1.14*
IMAGING
=======
___ CTA
1. Moderate pulmonary edema. No focal consolidation. No acute
aortic
dissection or pulmonary embolism.
2. Healing right tenth and eleventh ribs.
3. Cholelithiasis without evidence of acute cholecystitis.
4. Dense calcification in the midportion of the SMA narrowing
the lumen. Due
to non angiographic technique, evaluation of the patency is
limited. No
evidence of acute bowel injury/wall thickening or decreased
perfusion.
___ Coronary angiogram
LM The left main coronary artery is without significant disease.
LAD The left anterior descending coronary artery is with 99%
mid.
Circ The circumflex coronary artery is with mid hazy 95%.
RCA The right coronary artery is with diffuse mid ___. A high
takeoff RPDA is with mild
irregularities. There is 80-90% focal mid RPL disease.
___ TTE
1) Moderate to severe regional LV systolic dysfunction c/w prior
myocardial
infarction in the LAD and possibly LCX territory. Global LV
systolic radial function (as measured
by LVEF) is moderately reduced however global longitudinal
strain is severely reduced more
consistent with extensive regional dysfunction. 2) Severe type
II pulmonary hypertension with
normal RV size/function.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. CARVedilol 6.25 mg PO BID
2. amLODIPine 2.5 mg PO DAILY
3. Simvastatin 5 mg PO QPM
4. Torsemide 20 mg PO DAILY
5. HydrALAZINE 100 mg PO TID
6. Losartan Potassium 100 mg PO DAILY
7. Aspirin 81 mg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Glargine 20 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
10. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral DAILY
11. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
2. Clopidogrel 75 mg PO DAILY
3. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
RX *nitroglycerin 0.3 mg 1 tablet(s) sublingually Every 5
minutes Disp #*10 Tablet Refills:*0
4. Aspirin 81 mg PO DAILY
5. Calcium 600 with Vitamin D3 (calcium carbonate-vitamin D3)
600 mg(1,500mg) -400 unit oral DAILY
6. CARVedilol 6.25 mg PO BID
7. Glargine 20 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
8. Isosorbide Mononitrate (Extended Release) 120 mg PO DAILY
9. Losartan Potassium 100 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
11. Torsemide 20 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. HELD- amLODIPine 2.5 mg PO DAILY This medication was held.
Do not restart amLODIPine until you are told to do so by your
primary care doctor
14. HELD- HydrALAZINE 100 mg PO TID This medication was held.
Do not restart HydrALAZINE until you are told to do so by your
primary care doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
NSTEMI
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA chest with abdomen pelvis
INDICATION: History: ___ with CP radiating to back// ?dissection, with venous
phase in 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 4.0 s, 0.5 cm; CTDIvol = 12.1 mGy (Body) DLP =
6.1 mGy-cm.
2) Spiral Acquisition 4.2 s, 33.0 cm; CTDIvol = 8.9 mGy (Body) DLP = 294.5
mGy-cm.
3) Spiral Acquisition 6.4 s, 50.1 cm; CTDIvol = 8.7 mGy (Body) DLP = 434.3
mGy-cm.
Total DLP (Body) = 735 mGy-cm.
COMPARISON: CT from ___
FINDINGS:
CHEST:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus.
The thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. The heart is mildly enlarged. No pericardial effusion
is seen. The main pulmonary artery is enlarged measuring 3.2 cm, similar to
prior exam and suggestive of pulmonary arterial hypertension. Coronary artery
calcification since are minimal. Aortic and mitral annular calcifications are
moderate.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: Small amount of bilateral pleural effusions, right greater
than left is likely related to pulmonary edema. No pneumothorax.
LUNGS/AIRWAYS: Compared to prior exam, there is extensive pulmonary septal
thickening, ground-glass opacities and peribronchial wall thickening, likely
representing pulmonary edema. No focal consolidation is seen. 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.
CHEST CAGE: Healing minimally displaced fractures of the right lateral tenth
rib and posterior eleventh rib are noted. Heterogeneous appearance of T9
vertebral body is likely related to a hemangioma.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder contains gallstones
without wall thickening or surrounding inflammation.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions. Splenic artery is heavily calcified.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is relatively collapsed. Small bowel loops
demonstrate normal caliber, wall thickness, and enhancement throughout. The
colon and rectum are within normal limits. The appendix is normal. There is
no free intraperitoneal fluid or free air.
PELVIS:
The urinary bladder and distal ureters are unremarkable. There is no free
fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is of normal size and enhancement. There is no
evidence of adnexal abnormality bilaterally.
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. Dense calcification is noted in the midportion of the SMA
narrowing the lumen (05:30, 32), which may be a chronic finding. Due to the
non angiographic technique, evaluation of the patency is limited.
BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions or
acute fracture. Multiple calcified injection granulomas are noted in the
bilateral buttock region.
IMPRESSION:
1. Moderate pulmonary edema. No focal consolidation. No acute aortic
dissection or pulmonary embolism.
2. Healing right tenth and eleventh ribs.
3. Cholelithiasis without evidence of acute cholecystitis.
4. Dense calcification in the midportion of the SMA narrowing the lumen. Due
to non angiographic technique, evaluation of the patency is limited. No
evidence of acute bowel injury/wall thickening or decreased perfusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with HFpEF, htn, T2DM, admitted for NSTEMI, s/p
PCI to LAD and LCx on ___, now with SOB.// Pulmonary congestion
TECHNIQUE: AP portable chest radiograph
COMPARISON: CT chest performed earlier today
FINDINGS:
There is mild to moderate pulmonary edema. A small right pleural effusion is
suspected. No pneumothorax. The size of the cardiac silhouette is mildly
enlarged.
IMPRESSION:
Mild to moderate pulmonary edema.
Gender: F
Race: ASIAN - CHINESE
Arrive by AMBULANCE
Chief complaint: Back pain
Diagnosed with Non-ST elevation (NSTEMI) myocardial infarction, Essential (primary) hypertension, Type 2 diabetes mellitus without complications
temperature: 97.9
heartrate: 79.0
resprate: 16.0
o2sat: 97.0
sbp: 138.0
dbp: 49.0
level of pain: 5
level of acuity: 3.0 | TRANSITIONAL ISSUES:
====================
- F/u TTE in 3 months for akinetic apex and concern for thrombus
- please monitor LFTs on atorvastatin 80mg
- Patient would benefit from improved diabetes control. Hb A1c
while inpatient is 8.5%
- Patient's hydralazine and amlodipine were discontinued due to
orthostasis. Please follow-up on antihypertensive regimen as an
outpatient. Ensure medication compliance as patient became
orthostatic when she was given home antihypertensive
medications.
- New medications on discharge: Clopidogrel 75 mg and
atorvastatin 80 mg
- Discharge Cr: 1.1, discharge weight: 133 lb, discharge
diuretic: torsemide 20 mg |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: UROLOGY
Allergies:
Bactrim DS
Attending: ___.
Chief Complaint:
hematuria
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ with ___ mechanical AVR on Coumadin
one month s/p
TURP with ___ who presented to the ED with clot retention
overnight. The patient reports intermittent hematuria since his
procedure that has been gradually improving. He denies fever,
chills, N/V, or dysuria. He held his Coumadin without bridge for
5 days perioperatively and then restarted. He reports that he
had
been holding Coumadin over the last week due to hematuria but
restarted 2 days prior to presentation. On the day prior to
admission, he noted
increasing difficulty urinating with worsening blood and clot
passage. He got to the point where he was unable to urinate so
presented to the ED. INR 1 and HCT stable since last month. A 3
way Foley was placed and CBI started. Given his INR was
subtherapeutic a heparin gtt was started in the ED.
Past Medical History:
-IgA nephropathy
-Aortic insufficiency with bicuspid aortic valve s/p aortic
valve replacement (___ mechanical valve ___
-ascending aortic aneurysm (dilated ascending aorta (5cm)
-BPH s/p laser photovaporization of prostate, PVP ___
-HTN
-CAD s/p PTCA LAD ___
-hyperlipidemia
-hernia repair
Social History:
___
Family History:
Mother: CAD, deceased from ___; no CA
Father: CAD; no CA
Physical Exam:
gen: no acute distress
resp: conversing easily
abd: soft nontender
gu: foley was clear then removed and patient passed void trial
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Warfarin 10 mg PO 2X/WEEK (___)
2. Warfarin 7.5 mg PO 5X/WEEK (___)
3. dutasteride 0.5 mg oral QPM
4. Lisinopril 40 mg PO DAILY
5. Metoprolol Tartrate 12.5 mg PO BID
6. Rosuvastatin Calcium 20 mg PO QPM
7. Aspirin 81 mg PO DAILY
8. Chlorthalidone 25 mg PO DAILY
9. Vitamin B Complex 1 CAP PO DAILY
10. Vitamin D 400 UNIT PO DAILY
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
2. Senna 17.2 mg PO QHS
3. Aspirin 81 mg PO DAILY
4. Chlorthalidone 25 mg PO DAILY
5. dutasteride 0.5 mg oral QPM
6. Lisinopril 40 mg PO DAILY
7. Metoprolol Tartrate 12.5 mg PO BID
8. Rosuvastatin Calcium 20 mg PO QPM
9. Vitamin B Complex 1 CAP PO DAILY
10. Vitamin D 400 UNIT PO DAILY
11. Warfarin 10 mg PO 2X/WEEK (___)
12. Warfarin 7.5 mg PO 5X/WEEK (___)
Discharge Disposition:
Home
Discharge Diagnosis:
Bleeding and clot retention after TURP
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: COMPLETE GU U.S. (BLADDER AND RENAL)
INDICATION: ___ year old man with ___ turp now with persistent hematuria//
evaluate bladder for clot
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: Renal ultrasound dated ___.
FINDINGS:
The right kidney measures 12.8 cm. The left kidney measures 10.9 cm. Multiple
simple cysts are seen bilaterally measuring up to 1.5 cm within the left
kidney. There is no hydronephrosis, stones, or masses bilaterally. Normal
cortical echogenicity and corticomedullary differentiation are seen
bilaterally.
A Foley is seen within a moderately distended bladder. There is a moderate
amount of echogenic avascular material surrounding the Foley catheter, which
likely represents clot. There is no bladder wall thickening.
IMPRESSION:
1. Moderate amount of echogenic avascular material surrounding the Foley
catheter in the bladder, likely representing clot. No bladder wall
thickening.
2. Simple cysts, but otherwise normal kidneys bilaterally.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Urinary retention
Diagnosed with Hematuria, unspecified
temperature: 97.6
heartrate: 109.0
resprate: 19.0
o2sat: 100.0
sbp: 158.0
dbp: 97.0
level of pain: 8
level of acuity: 3.0 | Mr. ___ was admitted to the urology service from the ED and
kept on CBI with hand irrigation as needed to remove clot. His
hematocrit was stable through his admission. By the day of
discharge, his urine had cleared and he passed a void trial. He
was discharged home with instructions to call in or return to
the ED if he was unable to urinate or had further hematuria. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___
Chief Complaint:
Fever
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with Down syndrome, recent hx of aspiration PNA presenting
from group home with fever.
Was at baseline ___ evening, then developed a fever AM of ___
while at his day program. He was brought into the ED for
further
evaluation. Patient is nonverbal at baseline, per home
attendant
there has been no cough, change in urinary frequency, or
complaints of pain.
Of note, he was admitted to CHA 1 month ago for ___ days for
aspiration PNA, treated with ABx. His diet was switched to
pureed after this hospitalization.
In the ED, initial VS were:
___ 15:07
0, 101.8F, 70, 124/82, 18, 96% RA
Exam notable for:
Non-significant
ECG: None
Labs showed:
WBC 10.7, Hgb 13.3, PLT 199
Na 140, K 4.2, Cl 100, HCO3 29, BUN 20, Cr 1.1
Lactate 1.8
Imaging showed:
___ CXR
Patchy left base opacity which could be due to atelectasis and
vascular structures, but consolidation due to pneumonia may be
present. If patient able, dedicated ___ and lateral views would
help further assess.
Consults: None
Patient received:
___ 21:19 IVF NS 1000 mL
___ 21:56 IV Levofloxacin 750 mg
___ 21:57 IV Vancomycin 1000 mg
Transfer VS were:
Yest 21:15
98.4F, 75, 97/49, 20, 95% 2L NC
On arrival to the floor, patient is nonverbal, but is awake and
not in any distress.
REVIEW OF SYSTEMS: 10 point ROS reviewed and negative except as
per HPI
Past Medical History:
Downs syndrome
Alzheimer's
Chronic constipation
Social History:
___
Family History:
Noncontributory to patient's presenting complaint
Physical Exam:
Admission
=========
24 HR Data (last updated ___ @ 230)
Temp: 99.6 (Tm 99.6), BP: 95/57, HR: 67, RR: 19, O2 sat: 91%
(91-93), O2 delivery: RA
GENERAL: NAD, nonverbal, not following commands
HEENT: AT/NC, anicteric sclera, MMM
NECK: supple, 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
PULSES: 2+ radial pulses bilaterally
NEURO: Moving all 4 extremities with purpose, face symmetric
DERM: warm and well perfused, no excoriations or lesions, no
rashes
Discharge:
==========
Vital Signs:
___ 2339 Temp: 97.5 PO BP: 120/61 L Lying HR: 41 RR: 18 O2
sat: 95% O2 delivery: Ra
GEN: Well appearing, in no acute distress
HEENT: Conjunctiva clear, PERRL, MMM
NECK: No JVD. No cervical LA.
LUNGS: CTAB
HEART: RRR, nl S1, S2. No m/r/g.
ABD: NT/ND
EXTREMITIES: No edema or cyanosis.
SKIN: No rashes.
NEURO: Nonverbal, alert and interactive. Able to high five,
shake
hand when offered.
Labs, Micro, Imaging reviewed in OMR
Pertinent Results:
Admission:
==========
___ 05:39PM BLOOD WBC-10.7* RBC-4.06* Hgb-13.3* Hct-39.7*
MCV-98 MCH-32.8* MCHC-33.5 RDW-16.4* RDWSD-58.4* Plt ___
___ 05:39PM BLOOD Neuts-90.9* Lymphs-5.7* Monos-2.6*
Eos-0.0* Baso-0.3 Im ___ AbsNeut-9.74* AbsLymp-0.61*
AbsMono-0.28 AbsEos-0.00* AbsBaso-0.03
___ 05:39PM BLOOD Glucose-107* UreaN-20 Creat-1.1 Na-140
K-4.2 Cl-100 HCO3-29 AnGap-11
___ 06:02AM BLOOD Calcium-8.3* Phos-2.8 Mg-1.7
Discharge:
===========
___ 04:40AM BLOOD WBC-5.2 RBC-3.80* Hgb-12.7* Hct-37.7*
MCV-99* MCH-33.4* MCHC-33.7 RDW-16.3* RDWSD-59.5* Plt ___
___ 12:42AM BLOOD Neuts-57.4 ___ Monos-12.8
Eos-0.5* Baso-0.8 Im ___ AbsNeut-3.59 AbsLymp-1.67
AbsMono-0.80 AbsEos-0.03* AbsBaso-0.05
___ 04:40AM BLOOD Glucose-90 UreaN-14 Creat-1.1 Na-139
K-4.6 Cl-99 HCO3-30 AnGap-10
___ 04:40AM BLOOD Calcium-8.2* Phos-4.2 Mg-2.2
Studies:
=========
___ CXR
Patchy left base opacity which could be due to atelectasis and
vascular
structures, but consolidation due to pneumonia may be present.
If patient
able, dedicated ___ and lateral views would help further assess.
___ CXR
New posterior right middle lobe consolidation, concerning for
new pneumonia
versus aspiration. Unchanged left lower lobe opacities, likely
due to
atelectasis.
___ CT Scan
1. Suspected small pulmonary emboli within subsegmental branches
of the left
lower lobe (series 301, image 126, 100).
2. Multifocal pneumonia predominantly throughout the right lower
lobe, with
additional consolidations within the right upper and left lower
lobes, with
associated small bilateral pleural effusions.
3. Enlarged right subcarinal/subhilar lymph nodes and high right
paratracheal/infraclavicular lymph node which may be reactive to
patient's
multifocal pneumonia. Consider follow-up CT chest in ___ weeks
to ensure
resolution/improvement.
___ Video Swallow
There was silent aspiration with thin consistency barium by
teaspoon. There was no penetration or aspiration with nectar
thick or pudding consistencies.
There was valecular residue with pudding, which cleared with
subsequent sips of nectar.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium 100 mg PO BID
2. PARoxetine 30 mg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Alendronate Sodium 70 mg PO 1X/WEEK (MO)
5. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral DAILY
6. Meladox (melatonin) 3 mg oral DAILY
7. Donepezil 5 mg PO QHS
8. Fluticasone Propionate NASAL 1 SPRY NU DAILY
9. Senna 17.2 mg PO QHS
10. guaiFENesin 200 mg oral DAILY
11. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
12. lactulose 20 gram oral DAILY
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN Pain - Mild
2. Alendronate Sodium 70 mg PO 1X/WEEK (MO)
3. Calcium 600 + D(3) (calcium carbonate-vitamin D3) 600 mg
calcium- 200 unit oral DAILY
4. Docusate Sodium 100 mg PO BID
5. Donepezil 5 mg PO QHS
6. Fluticasone Propionate NASAL 1 SPRY NU DAILY
7. guaiFENesin 200 mg oral DAILY
8. lactulose 20 gram oral DAILY
9. Meladox (melatonin) 3 mg oral DAILY
10. PARoxetine 30 mg PO DAILY
11. Senna 17.2 mg PO QHS
12. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Aspiration Pneumonia
Acute Hypoxemic Respiratory Failure
Hypotension
Secondary:
Alzheimer's
Downs syndrome
Constipation
Osteoporosis
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with fever// r/o acute infectious process
TECHNIQUE: Single AP upright portable view of the chest
COMPARISON: ___
FINDINGS:
No large pleural effusion or pneumothorax is seen. The cardiac and
mediastinal silhouettes are grossly stable. There is patchy left base opacity
which could be due to atelectasis and vascular structures, but consolidation
due to pneumonia may be present. If patient able, dedicated PA and lateral
views would help further assess.
IMPRESSION:
Patchy left base opacity which could be due to atelectasis and vascular
structures, but consolidation due to pneumonia may be present. If patient
able, dedicated PA and lateral views would help further assess.
Radiology Report
INDICATION: ___ year old man with PNA// ? worsening aspiration pna or
pnuemonitis
TECHNIQUE: Portable AP chest
COMPARISON: Multiple prior chest radiographs, most recent dated ___.
FINDINGS:
Unchanged low lung volumes. New posterior right middle lung consolidation,
concerning for new pneumonia versus aspiration. Unchanged left lower lobe
patchy opacities, likely related atelectasis. No pleural effusion or
pneumothorax. Cardiomediastinal silhouette is unchanged.
IMPRESSION:
New posterior right middle lobe consolidation, concerning for new pneumonia
versus aspiration. Unchanged left lower lobe opacities, likely due to
atelectasis.
RECOMMENDATION(S): Repeat chest radiograph in ___ weeks to ensure resolution
of right middle lung consolidation and exclude an underlying malignancy.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 3:45 pm, 20 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with increasing O2 requirement// pulm edema?
Other cause of hypoxia?
IMPRESSION:
In comparison with the study of ___ the, the appearance of the
opacification at the right base again is worrisome for pneumonia associated
with pleural effusion. The cardiomediastinal silhouette is stable and there
is indistinctness of pulmonary vessels suggesting some elevation in pulmonary
venous pressure. Mild atelectatic changes and possible small effusion are
seen on the left.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ year old man with PNA and increasing O2 requirement// PE?
other explanation for acute hypoxia?
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.3 s, 29.9 cm; CTDIvol = 13.3 mGy (Body) DLP = 396.6
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 4.2 s, 0.5 cm; CTDIvol = 23.2 mGy (Body) DLP =
11.6 mGy-cm.
Total DLP (Body) = 410 mGy-cm.
COMPARISON: None
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level however evaluation of subsegmental branches in the lower
lobes are limited due to respiratory motion. No pulmonary embolus identified.
The thoracic aorta is normal in caliber without evidence of dissection or
intramural hematoma. The heart, pericardium, and great vessels are unchanged
from prior study. No significant pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: There is an enlarged high right paratracheal
lymph node seen on series 301, image 30 and series 601, image 20. There are
enlarged right subcarinal/subhilar lymph nodes with the largest measuring 2.6
x 2.3 x 2.1 cm as seen on series 301, image 95 and series 601, image 28. No
additional lymphadenopathy. No mediastinal mass.
LUNGS/AIRWAYS: There is a large area of consolidation within the right lower
lobe with smaller areas of consolidation involving the right middle lobe and
left lower lobe compatible with multifocal pneumonia. The airways are patent
to the level of the segmental bronchi bilaterally.
PLEURAL SPACES: Small right pleural effusion and trace left pleural effusion.
No pneumothorax.
BASE OF NECK: Visualized portions of the base of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES: Stable degenerative change without acute fracture or suspicious osseous
lesion.
IMPRESSION:
1. Suspected small pulmonary emboli within subsegmental branches of the left
lower lobe (series 301, image 126, 100).
2. Multifocal pneumonia predominantly throughout the right lower lobe, with
additional consolidations within the right upper and left lower lobes, with
associated small bilateral pleural effusions.
3. Enlarged right subcarinal/subhilar lymph nodes and high right
paratracheal/infraclavicular lymph node which may be reactive to patient's
multifocal pneumonia. Consider follow-up CT chest in ___ weeks to ensure
resolution/improvement.
RECOMMENDATION(S): Follow-up chest CT examination in ___ weeks for
re-evaluation of the left pulmonary arteries and mediastinal nodes.
Radiology Report
EXAMINATION: AP portable chest radiograph
INDICATION: ___ year old man with aspiration PNA and worsening hypoxia// pulm
edema? Other etiology of hypoxia?
TECHNIQUE: AP portable chest radiograph
COMPARISON: Chest CT dated ___ as well as multiple prior chest
radiographs dating back to ___.
FINDINGS:
In comparison to the prior chest radiograph dated ___ there is
worsening opacification at the right lung base concerning for pneumonia with
associated pleural effusion. Lung volumes are somewhat low, however the
cardiomediastinal silhouette remains somewhat enlarged and there is a
suggestion of pulmonary vascular engorgement. Atelectatic changes and
possible small effusion is seen at the left base.
IMPRESSION:
Increased opacification and pleural effusion at the right lung base raises
concern for worsening pneumonia.
Radiology Report
EXAMINATION: Video oropharyngeal swallow
INDICATION: ___ year old man with Downs with recurrent aspiration// Per s/s,
evaluate for 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: 3:09 min.
COMPARISON: None.
FINDINGS:
There was silent aspiration with thin consistency barium by teaspoon. There
was no penetration or aspiration with nectar thick or pudding consistencies.
There was valecular residue with pudding, which cleared with subsequent sips
of nectar.
IMPRESSION:
Gross aspiration of thin consistency barium by teaspoon.
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).
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with PNA, with CTA showing subsegmental PE// Any
DVT that could have caused PE seen on CTA
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
No evidence of deep venous thrombosis in the right or left lower extremity
veins.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever
Diagnosed with Fever, unspecified
temperature: 101.8
heartrate: 70.0
resprate: 18.0
o2sat: 96.0
sbp: 124.0
dbp: 82.0
level of pain: 0
level of acuity: 3.0 | Mr ___ is a ___ with PMH of Down Syndrome (complicated by
progressive Alzheimer's dementia) and history of recurrent
aspiration PNA, presenting with fever and pulmonary infiltrate
consistent with
recurrent aspiration PNA. The patient completed a 5 day course
of cefepime and
metronidazole with improvement in leukocytosis, fever, and
oxygen requirement. His hospitalization was complicated by
frequent nighttime oxygen desaturations. Goals of care
discussions were initiated with the family, and while it was
ultimately deemed appropriate that the patient be discharged
back to the group home that he is currently living at, hospice
applications were placed for additional support there. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Cellulitis/osteomyelitis/septic right knee joint and UTI
Major Surgical or Invasive Procedure:
___ I&D, washout, and liner exchange of the right knee
History of Present Illness:
Ms. ___ is an ___ year-old woman with DM, HTN, HLD, CKD who
had a chair break from under her one week ago now presenting
with RLE swelling and erythmea. Patient reports that she landed
on her bottom and felt well initially however ___ the days that
followed she had stiffer back and neck and sore right leg,
athough she was able to walk. She then noticed RLE swelling two
day prior to presentation with redness of her RLE prompting
presentation to the ED.
Initial vitals ___ the ED were 98.7 106 148/74 18 97% RA. On
evaluation ___ the ED her BLE was noted to be swollen with
pronounced erythema consistent with cellulitis on the right leg
from ankle to thigh on the posterior side. Labs ___ the ED were
notable for lactate of 2.8, WBC 22.4 with 92.4% PMNs and UA c/w
UTI. She was given 1g vancomycin IV and 500mg levofloxacin IV
and was planned to be admitted to the medicine service.
Subsequently she was noted to have an episode of SVT with HR to
the 160s for which she received 20mg IV and 30mg of PO diltiazem
and the decision was made to admit her to the MICU for further
care. Vitals on transfer were 110 153/43 22 99% RA.
On the floor she appears comfortable and denies numbness,
tingling, weakness, or incontinence.
Past Medical History:
Type II diabetes,
hypertension, high cholesterol,
obesity,
mild renal insufficiency, and a
previous history of asthma.
problems with balance and has swelling of her foot.
right knee replacement surgery ___ and left knee replacement ___
___. colonoscopy and had a small polyp removed ___ ___ that
was
an adenoma no repeat given age and weight have offered repeat
colonoscopy.
Bone density study ___ WNL.
Social History:
___
Family History:
Her father had a ruptured gallbladder and cardiovascular
disease. Her mother died at the age of ___.
Physical Exam:
Admission exam (per ortho):
General: Morbidly obese, Alert, oriented x 3, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, pupils 4mm-2mm
___
Neck: plethoric neck, supple, no LAD
Lungs: Distant lung sounds ___, summetric breath shounds, no
wheezes, rales, rhonchi
CV: Regular rate and rhythm, no murmurs, rubs, gallops
Abdomen: Obese abodmen, soft, non-tender, nomal bowel sounds
present, no rebound tenderness or guarding, no organomegaly
Ext: ___ ___ Edema with lichenification and venous stasis changes.
Erythema of RLE from ankle to thigh. Skin breakdown on the back
of the right calf with minimal drainage noted.
On transfer to Medicine:
VS: T: 97.8; BP: 106/53 (83-120/38-65); HR: 83 (83-95) ; RR: 16
99% 2L
LOS: + 4256cc
GA: Obese women, lying flat, very pleasant, A&Ox3
HEENT: EOMI, MMM. no lymphadenopathy. neck supple. JVD difficult
to assess
Cards: RRR S1/S2 heard. no murmurs rubs or gallops
Pulm: Patient was unable to turn ___ pain of right knee so
difficult to assess, but lung sounds present with no audible
rales
Abd: soft, NT ND, +BS. Organomegaly difficult to assess
Extremities: RLE wrapped with JP drain ___ place. LLE with
chronic skin changes, minimal pitting edema
Skin: warm and moist
Neuro/Psych: CNs II-XII intact.
Discharge Exam:
VS: 98.2, 122/58, 84, 16, 94%RA ___ 100s-200s
___: 360/8hr, Out 1000 (foley)
GA: Obese women, lying flat, sleeping, comfortable, pleasant,
A&Ox3
HEENT: MMM. no lymphadenopathy. JVD difficult to assess
Cards: distant, RRR S1/S2 heard. no murmurs rubs or gallops
Pulm: CTAB. no wheezes, rales or rhonchi, good inspiratory
effort.
Abd: obese, soft, NT ND, +BS. Organomegaly difficult to assess.
Extremities: RLE wrapped, knee with stapled incision looking
clean ___ intact and healing well. Right foot with 2+ edema. LLE
with chronic skin changes, minimal pitting edema, right hand
with mild erythema around the base of the thumb stable from
yesterday.
Skin: warm and moist
Neuro/Psych: less confused this morning, A&Ox3. CNs II-XII
intact. Moving all extremities.
Pertinent Results:
Admission Labs:
___ 11:30AM BLOOD WBC-22.4*# RBC-4.12* Hgb-13.3 Hct-41.5
MCV-101* MCH-32.2* MCHC-31.9 RDW-13.0 Plt ___
___ 11:30AM BLOOD Neuts-92.6* Lymphs-4.4* Monos-2.3 Eos-0.4
Baso-0.2
___ 12:33PM BLOOD ___ PTT-29.7 ___
___ 11:30AM BLOOD Glucose-274* UreaN-38* Creat-1.4* Na-133
K-4.6 Cl-97 HCO3-20* AnGap-21*
___ 11:37AM BLOOD Lactate-2.8*
.
JOINT FLUID ANALYSIS WBC RBC Polys Lymphs Monos
___ 10:50 ___ 100* 0 0
.
Inflammatory markers:
___ 07:00AM BLOOD ESR-127*
___ 07:00AM BLOOD CRP-142.8*
Discharge Labs:
___ 07:35AM BLOOD WBC-8.9 RBC-3.25* Hgb-10.3* Hct-31.7*
MCV-98 MCH-31.7 MCHC-32.5 RDW-13.1 Plt ___
___ 07:35AM BLOOD Calcium-9.0 Phos-4.0 Mg-2.0
___ 07:35AM BLOOD Glucose-104* UreaN-24* Creat-1.1 Na-136
K-4.4 Cl-103 HCO3-26 AnGap-11
Urine Analysis:
___ 11:40AM URINE Color-AMBER Appear-CLOUDY Sp ___
___ 11:40AM URINE Blood-MOD Nitrite-NEG Protein-30
Glucose-150 Ketone-10 Bilirub-NEG Urobiln-2* pH-5.0 Leuks-LG
___ 11:40AM URINE RBC-44* WBC->182* Bacteri-MANY Yeast-NONE
Epi-0
Repeat after antibiotics:
___ 01:03PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 01:03PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-2* pH-5.0 Leuks-SM
___ 01:03PM URINE RBC-4* WBC-6* Bacteri-NONE Yeast-NONE
Epi-0
Microbiology:
___ blood culture: BETA STREPTOCOCCUS GROUP G.
___ bottle), ___ blood culture NGTD
___ urine culture negative
___ MRSA screen negative
___ jount fluid:GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ AND CHAINS.
Reported to and read back by TO ___ @1345
___.
FLUID CULTURE (Final ___:
BETA STREPTOCOCCUS GROUP G. MODERATE GROWTH.
SENSITIVITIES PER ___ ___ ___ ___.
Sensitivity testing performed by Sensititre.
SENSITIVE TO CLINDAMYCIN MIC <=0.12 MCG/ML.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
BETA STREPTOCOCCUS GROUP G
|
CLINDAMYCIN----------- S
ERYTHROMYCIN----------<=0.25 S
PENICILLIN G----------<=0.06 S
VANCOMYCIN------------ <=1 S
___ tissue: TISSUE BONE RIGHT KNEE.
GRAM STAIN (Final ___:
Reported to and read back by ___ @ 2211 ON ___
- CC7D.
2+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
3+ ___ per 1000X FIELD): GRAM POSITIVE COCCI.
___ AND SHORT CHAIN.
TISSUE (Final ___:
BETA STREPTOCOCCUS GROUP G. MODERATE GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
Imaging:
___ ECG: rate 100, Sinus tachycardia. Atrial ectopy. Left
bundle-branch block.
___ ECG: rate 169, Lead V1 is missing. Regular wide
complex tachycardia which is most likely a supraventericular
tachycardia with inverted P waves noted ___ the inferior leads.
Compared to the previous tracing of the same date
supraventricular tachycardia is new.
___ LENIs: No evidence of deep vein thrombosis ___ the right
lower extremity.
___ CT c-spine: 1. No acute fractures. Severe multilevel
degenerative changes. 2. Chronic bilateral maxillary sinus
disease.
___: CXR: no pneumonia
___ Right wrist: No acute fracture or dislocation.
Moderate-to-severe
osteoarthritis of the first CMC and triscaphe joints.
___ right hip: No fracture or dislocation.
___ lumbosacral spine xray: No definite fracture or
subluxation.
___ ECG: rate 97, Artifact is present. Probable sinus
rhythmn with atrial eactopy. The P-R interval is 180
milliseconds. Left bundle-branch block. Compared to the previous
tracing of ___ supraventricular tachycardia is no longer
present.
___ right knee xray: Limited examination due to body
habitus. Probable joint effusion. However this is difficult to
evaluate. Prior total knee arthroplasty. The hardware appears
intact. No definite ___ lucency. No definite fracture
identified, however no true AP and lateral views were provided.
No definite dislocation.
IMPRESSION: Limited examination as above. No definite acute
abnormality.
___ right wrist xray: As compared to the prior study, there
is no substantial change with diffuse demineralization of the
osseous structures that were imaged. There is no evidence of
fracture or dislocation seen.
Severe degenerative changes of the first carpometacarpal joint
and triscaphe joint are noted with joint space narrowing,
subchondral sclerosis, and osteophyte formation, unchanged since
the prior study. No interval development of soft tissue
swelling, or subcutaneous or periarticular" gas is noted.
___ Echo: The left atrium is mildly dilated. The estimated
right atrial pressure is ___ mmHg. Left ventricular wall
thicknesses and cavity size are normal. Due to suboptimal
technical quality, a focal wall motion abnormality cannot be
fully excluded. Overall left ventricular systolic function is
low normal (LVEF 50-55%). The aortic valve leaflets (?#) appear
grossly normal with good leaflet excursion. There is no aortic
valve stenosis. No aortic regurgitation is seen. The mitral
valve appears grossly structurally normal with trivial mitral
regurgitation. The pulmonary artery systolic pressure could not
be determined. There is no pericardial effusion. IMPRESSION:
Very suboptimal image quality. No definite vallvular pathology
or pathologic valvular flow identified. Normal left ventricular
cavity size with low normal global systolic function. Compared
with the report of the prior study (images unavailable for
review) of ___, the severity of mtiral regurgitation is
now reduced.
___ TEE: Overall left ventricular systolic function is
normal (LVEF>55%). There are simple atheroma ___ the aortic arch.
There are simple atheroma ___ the descending thoracic aorta.
There are three aortic valve leaflets. No masses or vegetations
are seen on the aortic valve. No mass or vegetation is seen on
the mitral valve. Trivial mitral regurgitation is seen. There is
no pericardial effusion. IMPRESSION: No evidence of
endocarditis.
Medications on Admission:
Glimepiride 4mg BID
Metformin 250 mg BID
Lisiniprol 20 mg
Simvastatin 40
aspirin 81 mg
Januvia 100 mg
Levemir Insulin 55 units daily
Discharge Medications:
1. glimepiride 4 mg Tablet Sig: One (1) Tablet PO twice a day.
2. metformin 500 mg Tablet Sig: 0.5 Tablet PO twice a day.
3. simvastatin 40 mg Tablet Sig: One (1) Tablet PO once a day.
4. aspirin 81 mg Tablet, Chewable Sig: One (1) Tablet, Chewable
PO DAILY (Daily).
5. Januvia 100 mg Tablet Sig: One (1) Tablet PO once a day.
6. Levemir 100 unit/mL Solution Sig: ___ (55) units
Subcutaneous once a day.
7. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
Disp:*60 Tablet(s)* Refills:*2*
8. polyethylene glycol 3350 17 gram/dose Powder Sig: One (1)
packet PO DAILY (Daily).
Disp:*30 packet* Refills:*2*
9. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
Disp:*60 Capsule(s)* Refills:*2*
10. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H
(every 6 hours) as needed for pain: Do not exceed 4gm a day.
Disp:*100 Tablet(s)* Refills:*0*
11. oxycodone 5 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Disp:*80 Tablet(s)* Refills:*0*
12. ceftriaxone ___ dextrose,iso-os 2 gram/50 mL Piggyback Sig:
Two (2) grams Intravenous Q24H (every 24 hours): Continue until
the Infectious Disease specialists tell you to stop.
Disp:*84 grams* Refills:*0*
13. heparin, porcine (PF) 10 unit/mL Syringe Sig: One (1) ML
Intravenous PRN (as needed) as needed for line flush.
Disp:*20 syringes* Refills:*1*
14. enoxaparin 30 mg/0.3 mL Syringe Sig: Thirty (30) mg
Subcutaneous Q12H (every 12 hours) for 2 weeks.
Disp:*28 syringes* Refills:*0*
15. Outpatient Lab Work
Weekly labs while on Ceftriaxone: Please draw CBC with
differential, Basic Metabolic Panel, Liver Function Tests, ESR,
CRP and fax results to Infectious Disease at ___.
16. lisinopril 10 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: Septic knee
Secondary Diagnosis: Type II diabetes, hypertension, high
cholesterol, obesity, mild renal insufficiency, and a previous
history of asthma.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
INDICATION: Recent fall from chair and 2 days of swelling and redness in the
right lower extremity. Evaluate for DVT.
TECHNIQUE: Gray-scale, color, and pulse-wave Doppler of the right lower
extremity.
COMPARISONS: None.
FINDINGS: The bilateral common femoral veins demonstrate a normal respiratory
flow pattern. There is normal compressibility, flow, and augmentation of the
right common femoral, superficial femoral, and popliteal veins. There is
normal compressibility and flow in the right posterior tibial and peroneal
veins.
IMPRESSION: No evidence of deep vein thrombosis in the right lower extremity.
Radiology Report
INDICATION: Fall and leukocytosis.
COMPARISON: Chest radiograph ___.
SUPINE AP VIEW OF THE CHEST: Cardiac silhouette size is top normal. Aorta is
mildly tortuous with vascular calcifications again noted. Hilar contours are
within normal limits. There is no pulmonary vascular congestion, focal
consolidation, pleural effusion or pneumothorax. Rounded ossific densities
are seen about the left shoulder joint, which could represent loose bodies.
Degenerative changes of the acromioclavicular joints and glenohumeral joints
are noted bilaterally, with severe narrowing of the right acromiohumeral
interval indicative of underlying rotator cuff disease.
IMPRESSION: No radiographic evidence for pneumonia.
Radiology Report
INDICATION: ___ female with fall from chair two days ago, now with
neck discomfort.
No prior examinations for comparison.
TECHNIQUE: Helical MDCT images were acquired through the cervical spine
without intravenous contrast. 2.5-mm axial images were reconstructed in soft
tissue and bone kernels. 2-mm coronal and sagittal multiplanar reformats were
also generated.
FINDINGS: There are no acute fractures or dislocations. Mutltilevel
degenerative changes are noted at all levels, especially C6-7. There is
moderate loss of disc space, endplate sclerosis, anterior osteophytes,
posterior disc-osteophyte complexes, and marked uncovertebral and facet joint
hypertrophy, resulting in mild canal and moderate foraminal stenoses at all
levels.
Intracranial structures are significant for global atrophy and dense
calcifications in the cavernous carotid arteries. There is moderate mucosal
thickening in the bilateral maxillary sinuses, with dense surrounding
sclerosis indicative of chronic disease. Air-fluid level is noted on the
left, and the right sinus is completely opacified. Mastoid air cells and
middle ear cavities are clear.
Cervical lymph nodes are not pathologically enlarged. The thyroid gland is
normal. Lung apices are unremarkable. Dense calcifications are noted in the
aortic arch and branch vessels.
IMPRESSION:
1. No acute fractures. Severe multilevel degenerative changes.
2. Chronic bilateral maxillary sinus disease.
Radiology Report
INDICATION: Fall and leukocytosis.
COMPARISON: CT abdomen and pelvis from ___.
TWO VIEWS OF THE LUMBAR SPINE: No acute fracture or subluxation is
visualized. There are multilevel degenerative changes with anterior
osteophyte formation most pronounced at L3/4 and L4/5. There are degenerative
changes of the sacroiliac joints without evidence of diastasis. Evaluation of
the sacrum is limited due to overlying bowel gas. Vascular calcifications
present.
IMPRESSION: No definite fracture or subluxation.
Radiology Report
INDICATION: Fall with leukocytosis.
COMPARISON: None.
AP VIEW OF THE PELVIS, TWO VIEWS OF THE RIGHT HIP: There is diffuse
demineralization of the osseous structures, which limits evaluation for the
detection of subtle fractures. No fracture or dislocation is visualized.
There is mild joint space narrowing of both hips, with degenerative changes of
the sacroiliac joints noted. No diastasis of pubic symphysis is present. The
sacrum appears intact, though evaluation is somewhat limited by overlying
bowel gas.
IMPRESSION: No fracture or dislocation.
Radiology Report
INDICATION: Fall with right thumb and hand pain.
COMPARISON: None.
RIGHT HAND, FOUR VIEWS: Diffuse demineralization of the osseous structures is
noted. No fracture or dislocation is present. Degenerative changes of the
first CMC and triscaphe joints are moderate-to-severe with joint space
narrowing, subchondral sclerosis, and osteophyte formation. No radiopaque
foreign bodies are present. A few scattered vascular calcifications are noted
within the distal right forearm. No suspicious lytic or sclerotic osseous
abnormalities are present.
IMPRESSION: No acute fracture or dislocation. Moderate-to-severe
osteoarthritis of the first CMC and triscaphe joints.
Radiology Report
AP CHEST 7:01 P.M. ON ___
HISTORY: ___ woman with a fever, suspect pneumonia.
IMPRESSION: AP chest compared to ___, 3:04 p.m.:
Lung volumes are lower and there is a suggestion of small areas of new
opacification at both lung bases, either of which could be early pneumonia or
atelectasis or even a result of recent aspiration. Followup advised. There
is no pulmonary vascular engorgement. Heart size is normal. Ascending
thoracic aorta is tortuous or dilated. No pneumothorax or appreciable pleural
effusion.
Radiology Report
STUDY: Two views of the right knee ___.
COMPARISON: None.
INDICATION: Fall. Question fracture.
FINDINGS: Limited examination due to body habitus. Probable joint effusion.
However this is difficult to evaluate. Prior total knee arthroplasty. The
hardware appears intact. No definite ___ lucency. No definite
fracture identified, however no true AP and lateral views were provided. No
definite dislocation.
IMPRESSION: Limited examination as above. No definite acute abnormality.
Radiology Report
REASON FOR EXAMINATION: Septic knee, now base of the thumb pain and swelling,
to exclude trauma or fluid accumulation.
COMPARISON: ___.
As compared to the prior study, there is no substantial change with diffuse
demineralization of the osseous structures that were imaged. There is no
evidence of fracture or dislocation seen.
Severe degenerative changes of the first carpometacarpal joint and triscaphe
joint are noted with joint space narrowing, subchondral sclerosis, and
osteophyte formation, unchanged since the prior study. No interval
development of soft tissue swelling, or subcutaneous or periarticular gas is
noted.
Radiology Report
CHEST RADIOGRAPH
INDICATION: New PICC line.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the patient has received a
left PICC line. The line is malpositioned in the left jugular vein and must
be re-positioned. There is no evidence of pneumothorax.
At the time of dictation, 2:23 p.m. on ___ the responsible nurse
___ was called by telephone under ___ for notification.
Otherwise there is no relevant change. Borderline size of the cardiac
silhouette without pulmonary edema. No pleural effusions. No evidence of
pneumonia.
Radiology Report
HISTORY: ___ female with repositioning of a left PICC.
STUDY: Portable AP semi-upright chest radiograph.
___ at 1336.
FINDINGS/IMPRESSION: There continues to be a left PICC that courses
superiorly up the left jugular vein. Otherwise, the cardiopulmonary
appearance is unchanged. Findings were discussed with IV nurse over the phone
at 17:03 on ___ by ___.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: S/P FALL
Diagnosed with DIAB W MANIF NEC ADULT, CELLULITIS OF LEG, URIN TRACT INFECTION NOS
temperature: 98.7
heartrate: 106.0
resprate: 18.0
o2sat: 97.0
sbp: 148.0
dbp: 74.0
level of pain: 2
level of acuity: 3.0 | ___ year-old woman with DMII, HTN, HLD, obesity and CKD presented
one week after a mechanical fall with right knee Group G strep
cellulitis, septic joint, and evidence of osteomyelitis of the
surrounding bones, as well as a UTI.
.
# Septic Joint/Osteomyelitis: Joint tap of the right knee showed
impressive septic joint, growing group G strep. Patient was
admitted to the unit after a run of SVT. Orthopedic surgery took
the patient to the OR and performed a right knee washout with
replacement of the plastic liner on ___. A JP drain was
placed for several day which drained serosanginous fluid. Tissue
and bone samples also growing Group G strep, pansensitive.
Patient was inititially started on vancomycin and levofloxacin
___ the ED, but was broadened to Vanc/Zosyn ___ the unit, and then
switched to ceftriaxone once the cultures returned on ___. ESR
(127), CRP (142.8), suggestive of osteomyelitis as well. Bone
sample also growing Group G strep. Midline catheter was placed
(there was difficulty advancing the PICC further). Infectious
disease was consulted and recommended at least 6 weeks of
ceftriaxone and weekly blood monitoring. Patient will have OPAT
monitoring ___ the outpatient setting (___). TTE study was
suboptimal but did not show vegetations on the valves. TEE did
not show any valvular vegetations. JP drain was removed 2 days
prior to discharge to rehab. Joint was bandaged with dry sterile
dressings during admission. Pain was managed initially with
dilaudid and transitioned to oxycodone.
.
#. Point tenderness and erythema over right wrist: Erythema and
tenderness is surrounding a previous IV site, which suggests
previous infilration by the IV. Xray more consistent with
osteoarthritis. Appearance is somewhat suggestive of a
cellulitis, however it has been improving since administration
of ceftriazone. It has also been treated with warm compresses.
.
#. UTI: Patient had a grossly positive UA with WBC greater than
assay and many bacteria. Initial urine culture was mixed flora
and second culture, after antibiotic administration, was
negative. Patient remained asymptomatic. Continued ceftriaxone
should adequately treat the infection.
.
#. Hypoxemia: Upon transfer from the MICU, patient was 5L above
her normal weight with an oxygen requirement. She was lying flat
and breathing comfortably on 2L nasal cannula. Patient was
given lasix 20mg IV and put out 4L of urine. Soon after, patient
was weaned off supplemental oxygen and breathing comfortably on
room air. Echo shows EF>55%.
.
#. SVT: Patient had a single observed run of SVT to 160s ___ the
ED likely secondary to infection. No repeat episode has been
observed. Patient was monitored ___ the MICU and transferred to
the floor, shortly after without any further events. During her
hospitalization, she remained on diltiazem. It was discontinued
several days prior to discharge without any further events.
.
#. DMII: Held oral diabetic medications while inpatient.
Continued home lantus therapy and covered with an ISS. Finger
sticks remained ___ the mid ___ - mid ___.
.
#. HTN: Initially held lisinopril for concern of low blood
pressure and recurrence of SVT, but we were able to restart it
without any issues. Patient was also ___ diltiazem initially on
admission. Just prior to discharge, lisinopril with discontinued
for a rising creatinine (1.2) and K+ (5.2). Blood pressures were
monitored and systolics were below 140.
.
#. HLD: Continued statin therapy.
.
#. CKD: Initially held lisinopril for low blood pressure. It was
restarted prior to discharge, but again discontinued for rising
K+ and Creatinine. Urine Lytes were unrevealing and her
creatinine improved on ___.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROSURGERY
Allergies:
Compazine / Reglan / Zomig
Attending: ___.
Chief Complaint:
BLE weakness and paresthesias; non-epileptic pseudoseizures
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with history of chronic back pain s/p spinal
cord stimulator placement in ___ and revision in ___ who was
admitted to ___ for several weeks after fall
down stairs 2 weeks ago with head strike after losing feeling in
her left leg, unclear if related to baseline left foot drop. She
initially presented there after seizure at home, was also
diagnosed with concussion and intracerebral hemorrhage. She
underwent EEG and was noted to have multiple epiosdes of
seizure; neurology at ___ recommended an MRI which was could not
be performed due to spinal cord stimulator. Seizure medication
was
adjusted and she was discharged home.
She presents today for evaluation of seizures while inpatient at
OSH; she had a seizure in triage. NCHCT was negative for
hemorrhage.
Past Medical History:
Low back pain s/p SCS lead replacement ___, IPG replacement
___
Left L5 Re-exploration laminotomy and microdiscectomy ___
SCS placement ___
L5-S1 RE-EXPLORATION & FORAMINOTOMY unknown date
Chronic low back pain
Lumbar radiculopathy
s/p R bunionectomy
Social History:
___
Family History:
Non contributory
Physical Exam:
-------------
On admission:
-------------
O: T: 97.2 BP: 131/89 HR: 76 RR: 17 O2Sats: 100% RA
Gen: WD/WN, comfortable, NAD.
HEENT: Pupils: 3-2mm bilaterally. EOMs intact throughout
Extrem: Warm and well-perfused.
Neuro:
Mental status: Awake and alert, cooperative with exam, normal
affect.
Orientation: Oriented to person, place, and date.
Language: Speech fluent with good comprehension and repetition.
Naming intact. No dysarthria or paraphasic errors.
Cranial Nerves:
I: Not tested.
II: Pupils equally round and reactive to light, 3mm to
2mm bilaterally.
III, IV, VI: Extraocular movements intact bilaterally without
nystagmus.
V, VII: Facial strength and sensation intact and symmetric.
VIII: Hearing intact to voice.
IX, X: Palatal elevation symmetrical.
XI: Sternocleidomastoid and trapezius normal bilaterally.
XII: Tongue midline without fasciculations.
Motor: Normal bulk and tone bilaterally. No abnormal movements,
tremors. Strength full power ___ throughout the bilateral upper
extremities. No pronator drift.
RLE- IP ___, H ___, Q 4+/5, ___ ___, Gastroc ___, AT ___
LLE- IP ___, H 4+/5, Q ___, ___ ___, Gastroc ___, AT ___
Sensation: Intact to light touch in the bilateral upper
extremities. Endorses paresthesias of the bilateral lower
extremities.
-------------
On discharge:
-------------
Opens eyes: [x]spontaneous [ ]to voice [ ]to noxious
Orientation: [x]Person [x]Place [x]Time
Follows commands: [ ]Simple [x]Complex [ ]None
Pupils: PERRL ___
EOM: [x]Full [ ]Restricted
Face Symmetric: [x]Yes [ ]NoTongue Midline: [x]Yes [ ]No
Pronator Drift [ ]Yes [x]No Speech Fluent: [x]Yes [ ]No
Comprehension intact [x]Yes [ ]No
Motor:
Deltoid BicepTricepGrip
Right 5 5 5 5
Left 5 4 4 4
IP Quad Ham AT ___ ___
Right5------------> 3 3 3
Left5------------> 1 1 3
[x]Clonus negative
[x]Sensation intact to light touch
Pertinent Results:
Please see OMR for pertinent results
Medications on Admission:
Keppra 1,000 mg tablet oral 1 tablet(s) Twice Daily
Topamax 25 mg tablet oral 1 tablet(s) Twice Daily
Fioricet 50 mg-300 mg-40 mg capsule oral 1 capsule(s) Every ___
hrs, as needed
lidocaine 5 % topical patch topical 1 adhesive
patch,medicated(s)
Once Daily
oxycodone 30 mg tablet oral 1 tablet(s) Every ___ hrs, as needed
Roxicodone 30 mg tablet oral 1 tablet(s) Every ___ hrs, as
needed
OxyContin 60 mg tablet,crush resistant,extended release oral
1 tablet,oral only,ext.rel.12 hr(s) Three times daily, as needed
Miralax 17 gram/dose oral powder oral 1 powder(s) Once Daily
Mirapex -- Unknown Strength Unknown sig
Discharge Medications:
1. Acetaminophen-Caff-Butalbital ___ TAB PO Q6H:PRN Headache
2. Bisacodyl 10 mg PO DAILY:PRN Constipation
3. Docusate Sodium 100 mg PO BID
4. Ibuprofen 600 mg PO Q8H:PRN Pain - Mild
5. Meclizine 25 mg PO TID
6. Senna 17.2 mg PO BID:PRN Constipation
7. Diazepam 10 mg PO Q8H:PRN muscle spasm
8. LevETIRAcetam 1000 mg PO BID
9. Lidocaine 5% Patch 1 PTCH TD DAILY:PRN local back pain
10. OxyCODONE (Immediate Release) 30 mg PO Q4H:PRN BREAKTHROUGH
PAIN
11. OxyCODONE SR (OxyconTIN) 60 mg PO Q8H
12. Topiramate (Topamax) 25 mg PO BID
13. TraMADol 25 mg PO Q6H:PRN Pain - Moderate
14.Walker with attachment and with wheels
Walker with attachment and with wheels
Customer ID # ___
15.Wheelchair standard with no attachment
Wheelchair standard with no attachment
Customer ID # ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Non-epileptic seizures
Pseudoseizure
Chronic progressive distal myopathy
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: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ with ? seizure, left facial droop and arm numbness// assess
for ICH
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.6 cm; CTDIvol = 48.5 mGy (Head) DLP =
802.7 mGy-cm.
Total DLP (Head) = 803 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of infarction,hemorrhage,edema,or mass effect. The
ventricles and sulci are normal in size and configuration.
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. If there is continued concern for acute
infarction, MRI is suggested.
Radiology Report
EXAMINATION: MYELOGRAM 2 OR MORE REGIONS W/LUMBAR INJECTION ___ N57 XA
SPINE
INDICATION: ___ year old woman with left leg numbness// assess for cord
compression, T/L spine
TECHNIQUE: After informed consent was obtained from the patient explaining
the risks, benefits, and alternatives to the procedure, the patient was laid
in prone position on the fluoroscopic table. A pre-procedure time-out was
performed confirming the patient's identity, relevant history, procedure to be
performed and labs.
Puncture was performed at L4-5.
Approximately 3 cc of 1% lidocaine was administered for local anesthesia.
Under fluoroscopic guidance, a 22 gauge spinal needle was inserted into the
thecal sac. There was good return of clear CSF.
10 mls of Isovue 300 contrast was administered intrathecally. Myelographic
images were obtained.
Following performance of the myelogram, the patient was transported to CT. CT
images of the lumbar spine were then obtained.
COMPARISON: CT myelogram ___
FINDINGS:
Following the injection of intrathecal contrast material, there is good
opacification of the lumbar spinal canal. The patient was subsequently tilted
head down with additional imaging obtained overlying the thoracic and cervical
spine.
For description of the intrathecal contents, please see the separate dedicated
CT total spine myelogram reported separately.
IMPRESSION:
1. Technically successful fluoroscopic guided lumbar puncture with
installation of intrathecal contrast material. Please see the subsequent CT
total spine myelogram for further details.
I, Dr. ___ supervised the trainee during the key components
of the above procedure and I reviewed and agree with the trainee's findings
and dictation.
Radiology Report
EXAMINATION: CT C/T/L SPINE W/ CONTRAST PQ316 CT SPINE
INDICATION: ___ year old woman with SCS and new BLE weakness/parathesias//
TOTAL SPINE CT MYELOGRAM
TECHNIQUE: CT spine of the cervical, thoracic and lumbar spine was obtained
following contrast administration within the thecal sac for myelography.
DOSE: Acquisition sequence:
1) Spiral Acquisition 10.9 s, 86.1 cm; CTDIvol = 25.8 mGy (Body) DLP =
2,224.6 mGy-cm.
Total DLP (Body) = 2,225 mGy-cm.
COMPARISON: Lumbar spine study was compared with ___.
FINDINGS:
Cervical spine:
There is no deformity of the contrast column identified. There is no
significant disc bulge or disc herniation seen. There is no spinal stenosis.
There is no foraminal narrowing.
Thoracic spine:
A spinal cord stimulator is identified projected over the posterior portion of
the thecal sac at T7-8 level. There is no deformity of the spinal cord
identified at this level. There is no local contrast extravasation seen.
There is no spinal stenosis noted. Small perineural cysts are seen
bilaterally at T8-9 level (2:120). The spinal cord stimulator lead extends to
the soft tissues through the intraspinous region at T8-9 level.
Lumbar spine:
There is endplate sclerosis at L5-S1 level. Mild ventral thecal sac
indentation by disc bulging is seen at L3-4 and L4-5 levels as before. There
is no spinal stenosis or high-grade foraminal narrowing..
IMPRESSION:
1. Spinal cord stimulator is identified at T7-8 level with its lead extending
to the posterior soft-tissues through the interspinous region of T8-9 level.
There is no deformity of the spinal cord seen adjacent to the stimulator.
2. Disc degenerative changes and vacuum at L5-S1 level and mild indentation by
disc bulging at L3-4 and L4-5 levels as on the previous CT myelographic study
of ___.
3. No evidence of spinal stenosis or high-grade foraminal narrowing in
cervical, thoracic or lumbar region.
Radiology Report
EXAMINATION: US NECK, SOFT TISSUE
INDICATION: ___ year old woman with BLE weakness/paresthesias; seizure// right
neck swelling following self removal of right IJ central line
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the right lower neck.
COMPARISON: None
FINDINGS:
Transverse and sagittal images were obtained of the superficial tissues of the
right lower neck. The right IJ vein and common carotid artery are patent.
There is no adjacent mass or abnormal fluid collection concerning for
hematoma. No central line is identified.
IMPRESSION:
Focused images of the right lower neck demonstrate patent right IJ vein and
common carotid artery without adjacent mass or abnormal fluid collection
concerning for hematoma.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T9112 MR HEAD.
INDICATION: ___ year old woman with thoracic spinal cord stimulator who
presents with leg weakness and seizures// evaluate for causes of left arm,
left leg weakness and seizures.
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of intravenous contrast, axial imaging was performed with
gradient echo, FLAIR, diffusion, and T1 technique. Sagittal MPRAGE imaging was
performed and re-formatted in axial and coronal orientations.
COMPARISON: None.
FINDINGS:
There is no evidence of intracranial hemorrhage, mass, mass effect or shifting
of the normally midline structures. The ventricles and sulci are normal in
size and configuration for patient's age. No diffusion abnormalities are
detected, there is no evidence of abnormal enhancement after contrast
administration. 2 x 2 mm focus of T2 and FLAIR hyperintensity in the right
frontal white matter (06:17) is nonspecific, similar findings can be seen in
patients with chronic migraines. Major intracranial arteries and dural venous
sinuses are patent. Paranasal sinuses are clear. There is minimal nasal
septum deviation towards the left. Bilateral orbits are unremarkable. The
visualized aspect of the upper cervical spinal craniocervical junction are
normal.
IMPRESSION:
1. There is no evidence of acute intracranial process or hemorrhage. There is
no evidence of abnormal enhancement after contrast administration.
2. 2 x 2 mm focus of T2 and FLAIR hyperintensity in the right frontal white
matter (06:17) is nonspecific, similar findings can be seen in patients with
chronic migraines.
Gender: F
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Seizure
Diagnosed with Epilepsy, unsp, not intractable, without status epilepticus
temperature: 97.2
heartrate: 76.0
resprate: 17.0
o2sat: 100.0
sbp: 131.0
dbp: 89.0
level of pain: 7
level of acuity: 2.0 | ___ year old female with bilateral lower extremity weakness and
pseudoseizures.
#Bilateral Lower Extremity Weakness and Pseudoseizures
Pt presented to ED with c/o bilateral lower extremity weakness
s/p fall. CT of the head was obtained for question of seizures
and showed no evidence of acute intracranial process. CT
myelogram was ordered due to the patient being status post
spinal cord stimulator placement. The patient initially refused
CT myelogram when she found out it would not be done under
anesthesia. She was admitted to the floor, and CT myelogram was
ordered with anesthesia. On ___, patient had multiple
seizure-like episodes which consisted of thrashing in the bed,
no loss of consciousness, oxygen saturations remain stable and
there was no post-ictal state.
CT myelogram was completed on ___ and showed no evidence of
spinal cord compression.
24 hour video EEG was ordered, which was negative for epileptic
seizures. Neurology was consulted for their recommendations
related to the patient's bilateral lower extremity weakness and
pseudoseizures and recommended a MRI of the brain to rule out
any acute intracranial process. MRI of the brain showed no
evidence of acute intracranial process and a small area in the
right frontal lobe with possible migranous changes. Neurology
work-up was negative and they believe that the patient's
seizure-like episodes are consistent with pseudoseizures.
Neurology recommended outpatient follow-up with the neurologist
at ___ who had seen the patient during her
previous admissions there. Neurology recommends maintaining the
patient's current antiepileptic drug regimen as her medical
history is unclear and we have not yet received the medical
records from ___. The antiepileptic drug regimen
may be addressed and revised as needed during outpatient
follow-up with the Neurologist at ___.
Psychiatry was consulted for recommendations related to
pseudoseizures. Their differential dx includes conversion
disorder (functional neurological symptom
disorder), which may co-exist with primary seizure disorder, and
complex migraines. Per ___, pt continues to have functional
impairments that would benefit from ongoing rehabilitation.
Treatment for conversion disorder includes ___ to address
functional needs and individual psychotherapy. Pt should follow
up outpatient with her psychiatry team in home town of
___.
On ___, the patient was neurologically stable with the
patient actually reporting some subjective improvement in her
symptoms. She was afebrile, tolerating a diet, ambulating with
assistance, voiding without difficulty, and her pain was well
controlled on her home pain medication regimen.
#Disposition
Physical Therapy and Occupational Therapy were consulted for
disposition planning and both recommended discharge to rehab.
Psychiatry recommends treatment for conversion disorder includes
___ to address functional needs and individual psychotherapy.
Her insurance denied both acute rehab and skilled nursing
facility. ___ worked with her during the continued stay, and she
was able to develop enough strength to be able to go home in a
wheelchair, with visiting home ___. Her boyfriend
arrived with the wheelchair, and she was discharged home without
complication. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Major Surgical or Invasive Procedure:
Coronary angiogram
PCI w/ DES placed in mid-RCA
attach
Pertinent Results:
ADMISSION LABS
==============
___ 12:30PM BLOOD WBC-9.9 RBC-5.64 Hgb-16.6 Hct-47.1 MCV-84
MCH-29.4 MCHC-35.2 RDW-12.0 RDWSD-36.4 Plt ___
___ 12:30PM BLOOD Neuts-69.1 ___ Monos-9.0 Eos-0.9*
Baso-0.4 Im ___ AbsNeut-6.85* AbsLymp-2.02 AbsMono-0.89*
AbsEos-0.09 AbsBaso-0.04
___ 12:30PM BLOOD Glucose-102* UreaN-12 Creat-0.9 Na-139
K-4.9 Cl-104 HCO3-22 AnGap-13
PERTINENT LABS
==============
CARDIAC:
___ 12:30PM BLOOD cTropnT-0.11*
___ 04:47PM BLOOD CK-MB-26* cTropnT-0.23*
___ 06:50AM BLOOD cTropnT-0.45*
___ 02:45PM BLOOD CK-MB-10 MB Indx-5.0 cTropnT-0.30*
___ 02:45PM BLOOD CK(CPK)-202
OTHER:
___ 07:29AM BLOOD %HbA1c-5.5 eAG-111
PERTINENT RESULTS
=================
___ Cardiac cath
95% stenosis of RCA, 80% stenosis of RPDA
Findings
Single vessel coronary artery disease.
Successful PTCA/stent of the mid RCA using drug-eluting stent.
Recommendations
ASA 81mg per day indefinitely.
Prasugrel 10mg QD for minimum 12 months.
Secondary prevention of CAD and further management as per
primary cardiology team.
___ TTE
LVEF 50-55%
IMPRESSION: Moderate left ventricular hypertrophy with normal
cavity size and mild regional systolic dysfunction c/w CAD in a
PDA distribution. Mild right ventricular cavity dilation with
focal hypokinesis of the basal and mid right ventricular free
wall. No valvular pathology or pathologic flow identified.
Indeterminate pulmonary artery systolic pressure. Mild thoracic
aortic enlargement.
DISCHARGE LABS
==============
___ 07:00AM BLOOD WBC-8.5 RBC-5.42 Hgb-15.8 Hct-47.2 MCV-87
MCH-29.2 MCHC-33.5 RDW-12.3 RDWSD-38.9 Plt ___
___ 07:00AM BLOOD Glucose-106* UreaN-12 Creat-0.9 Na-141
K-4.4 Cl-103 HCO3-24 AnGap-14
___ 07:00AM BLOOD Calcium-10.7* Phos-3.0 Mg-2.3
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Atorvastatin 80 mg PO QPM
RX *atorvastatin 80 mg 1 tablet(s) by mouth once daily at night
Disp #*30 Tablet Refills:*0
3. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Metoprolol Succinate XL 50 mg PO DAILY
RX *metoprolol succinate 50 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
5. Prasugrel 10 mg PO DAILY
RX *prasugrel 10 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS
=================
NSTEMI
HLD
HTN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with chest pain or shortness of breath // Rule out
CHF
TECHNIQUE: Chest PA and lateral
COMPARISON: None
FINDINGS:
The lungs are clear. The heart and mediastinal structures are unremarkable.
The bony thorax is grossly intact.
IMPRESSION:
No active disease.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with Non-ST elevation (NSTEMI) myocardial infarction
temperature: 97.2
heartrate: 70.0
resprate: 16.0
o2sat: 99.0
sbp: 142.0
dbp: 89.0
level of pain: 1
level of acuity: 2.0 | =====================
TRANSITIONAL ISSUES
=====================
[] New NSTEMI discharged on aspirin, prasugrel, atorvastatin,
metoprolol, lisinopril
[] Should be on ASA 81 indefinitely, prasugrel 10 QD for at
least 12 months
[] Uptitrate metoprolol and lisinopril as tolerated
[] Recommend lipid panel in 1 month to assess adequacy of high
intensity statin therapy, consider adding ezetimibe or PCSK-9
inhibitor if with continued dyslipidemia
[] A1c 5.5% on ___
===================== |