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Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
ciprofloxacin
Attending: ___.
Chief Complaint:
abdominal pain/fever
Major Surgical or Invasive Procedure:
1. PTBD Exchange
2. Balloon Cholangioplasty / Sphincteroplasty
History of Present Illness:
___ with PMH of Roux en Y gastric bypass ___ ___, multiple
SBOs requiring resection, cholecystectomy, and ampullary
stenosis
s/p PTCD with multiple rounds of dilation recently admitted for
abdominal pain and placement of PCBD conversion of ampullary
drain who presents 3 days after discharge with progressive
abdominal pain, fevers to 101 and purulent drainage from her
cholecystostomy site.
Note, patient just had ___ Guided placement of internal/external
ampullary drain on ___
___ the ED, initial vitals:
98.9 78 125/71 18 100% RA
Exam notable for non-toxic-appearing
Labs were significant for normal WBC count, alk phos 121, BUN/Cr
___
CT A/P:
1. Interval development of small subcapsular fluid collection
(1.2 x 2.2 x 2.4cm) along the PTBD as it exits the liver
anteriorly, likely representing biloma though cannot exclude
abscess.
2. Small volume ascites.
___ the ED, she received IV cipro/flagyl, morphine, dilaudid and
2L NS IV.
Currently, she reports pain/edema and red/pruritic rash over
left wrist when she received ciprofloxacin ___ the ED. ROS
positive for nausea, no emesis. OK PO intake, although pain is
worse with eating. Her R-sided abdominal pain and epigastric
pain both radiate to eh back. No cough, dyspnea, chest pain,
although she feels like she can't take a deep breath due to
pain.
ROS:
As per HPI. Remaining 10-point ROS negative.
Past Medical History:
# ampullary stenosis
-___: ERCP (___)
-___: PTBD (___)
-___: Upsize of internal hepatobiliary catheter and balloon
sphicteroplasty (___)
# Papillary thyroid cancer - s/p total thyroidectomy & radiation
___
# RNY Gastric bypass - ___, lost 130 pounds (___)
# SBR for SBO/intussusception - ___ ___
# Cervical cancer s/p partial hysterectomy ___, total
hysterectomy & BSO ___
# Pre-cancerous colonic polypectomy ___
# Lumpectomy of left breast - ___
# Cholecystectomy ___, removed for polyps, surgical path
reportedly normal
# Umbilical Hernia
# Seizures - occurred 3 times ___ ___ after large caffeine
ingestion, no seizures since
# Vasovagal syncope, on fludrocortisone
# Asthma
# Spinal fusion L3-S1 - ___ c/b epidural hematoma vs.
thrombosis
# Neuropathy ___ left lower leg and foot (s/p spinal fusion)
# Fibromyalgia vs. Complex Regional Pain Syndrome
# MRSA infection of ankle (___)
Social History:
___
Family History:
Mother - ___ strokes, first ___ ___
Father - MI ___ ___
Brother - died of lung cancer (smoker)
Grandparents - colon cancer, prostate cancer
Aunt - breast cancer
Physical Exam:
>> ADMISSION PHYSICAL EXAM:
VS: 98.4 72 149/72 17 98RA
GEN: Alert, lying ___ bed, appears uncomfortable
HEENT: Moist MM, anicteric sclerae, no conjunctival pallor
NECK: Supple without LAD
PULM: Generally CTA b/l without wheeze or rhonchi
COR: RRR (+)S1/S2 no m/r/g
ABD: Soft, non-distended. PTBD site ___ epigastrium
erythematous/indurated & exquisitely tender to palpation with
purulent material on gauze. Bag with bilious fluid. Abdomen very
tender over epigastrium and RUQ. Unable to elicit peritoneal
signs due to sensitivity. Mild TTP over R CVA
EXTREM: Warm, well-perfused, no edema
NEURO: CN II-XII grossly intact, motor function grossly normal
.
>> DISCHARGE PHYSICAL EXAM:
Vitals: T 98.2 135 / 63 69 18 99 RA
General: Alert, oriented x 3, comfortable.
HEENT: MMM, anicteric sclera, no conjunctival pallor.
Neck: No cervical LAD.
Lungs: CTAB/L, no adventitial sounds heard.
Cardiac: RRR, S1, S2, no extra sounds.
Abdomen: Soft, PTBD ___ the epigastrum, dressing intact. Improved
erythema at drainage site, with minimal surrounding drainage
around site. Tenderness improved ___ the RUQ, and the epigastric.
No CVA tenderness.
Extremities: Warm, no ___ edema bilaterally.
NEURO: CN II-XII grossly intact, motor function grossly normal
Pertinent Results:
>> ADMISSION LABS:
___ 12:45PM BLOOD WBC-7.1 RBC-4.19 Hgb-12.1 Hct-39.3 MCV-94
MCH-28.9 MCHC-30.8* RDW-14.8 RDWSD-50.4* Plt ___
___ 12:45PM BLOOD Glucose-85 UreaN-7 Creat-0.7 Na-140 K-4.6
Cl-102 HCO3-30 AnGap-13
___ 12:45PM BLOOD ALT-27 AST-28 AlkPhos-121* TotBili-0.4
DirBili-0.2 IndBili-0.2
___ 12:45PM BLOOD Albumin-3.5 Calcium-8.6 Phos-4.4 Mg-2.0
___ 12:50PM BLOOD Lactate-1.7
.
>> DISCHARGE LABS:
___ 06:15AM BLOOD WBC-6.3 RBC-4.12 Hgb-11.9 Hct-38.5 MCV-93
MCH-28.9 MCHC-30.9* RDW-14.7 RDWSD-50.0* Plt ___
___ 06:15AM BLOOD Neuts-47.7 ___ Monos-7.2 Eos-5.4
Baso-1.0 Im ___ AbsNeut-2.99 AbsLymp-2.41 AbsMono-0.45
AbsEos-0.34 AbsBaso-0.06
___ 06:15AM BLOOD ALT-19 AST-27 AlkPhos-99 TotBili-0.1
___ 06:15AM BLOOD Calcium-8.1* Phos-4.1 Mg-1.9
___ 06:15AM BLOOD Glucose-74 UreaN-10 Creat-0.7 Na-140
K-4.0 Cl-107 HCO3-22 AnGap-15
.
>> MICROBIOLOGY:
__________________________________________________________
___ 8:40 pm BILE
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS.
FLUID CULTURE (Preliminary):
GRAM POSITIVE COCCUS(COCCI). SPARSE GROWTH.
ANAEROBIC CULTURE (Preliminary): NO ANAEROBES ISOLATED.
__________________________________________________________
___ 12:45 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 6:09 am URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
__________________________________________________________
___ 5:55 am BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
__________________________________________________________
___ 11:50 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
.
>> PERTINENT REPORTS:
___ ABD & PELVIS WITH CO:
1. Interval development of small subcapsular fluid collection
(1.2 x 2.2 x 2.4
cm) along the PTBD as it exits the liver anteriorly, likely
representing
biloma though cannot exclude abscess.
2. Small volume ascites.
.
___ CATH REPLACE:
FINDINGS:
.
1. Preprocedure ultrasound demonstrating 2.3 x 2.0 x 0.7 cm
subcapsular
collection surrounding the hepatic entry site of the existing
catheter.
2. Initial cholangiograms demonstrating narrowing at the level
of the ampulla
with poor antegrade flow of contrast.
3. 12 mm balloon sphincteroplasty (prolonged inflation for 5
min) with a waist
initially noted at the level of the ampulla, with improved flow
on
post-sphinteroplasty cholangiogram.
4. Ultrasound and fluoroscopy guided aspiration subcapsular
collection with
minimum amount of fluid returned. No significant fluid was
identified ___ this
location at the completion of procedure.
5. Successful exchange of 12 ___ PTBD catheter with a new 12
___ PTBD
catheter.
.
IMPRESSION:
.
1. Successful exchange of existing 12 ___ PTBD catheter with
a new 12
___ PTBD catheter.
2. Successful performance of 12 mm balloon
cholangioplasty/sphincteroplasty
3. Percutaneous aspiration of 2 cm perihepatic collection
surrounding the
liver entry site of the existing catheter, with minimal fluid
aspirated.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q4H
2. Citalopram 20 mg PO BID
3. Docusate Sodium 100 mg PO BID:PRN constipation
4. Fludrocortisone Acetate 0.1 mg PO DAILY
5. Fludrocortisone Acetate 0.05 mg PO QHS
6. Gabapentin 800 mg PO QHS
7. Levothyroxine Sodium 137 mcg PO DAILY
8. Multivitamins 1 TAB PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Polyethylene Glycol 17 g PO DAILY
11. Vitamin D 3000 UNIT PO DAILY
12. Cal-Citrate (calcium citrate-vitamin D2) ___ mg oral TID
13. Cyanocobalamin 100 mcg PO DAILY
14. grape seed oil (bulk) 100 mg PO DAILY
15. Melatin (melatonin) 10 mg oral QHS
16. Bisacodyl ___AILY
17. Senna 8.6 mg PO BID
18. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN pain
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H
2. Bisacodyl ___AILY
3. Citalopram 20 mg PO BID
4. Cyanocobalamin 100 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID:PRN constipation
6. Fludrocortisone Acetate 0.1 mg PO DAILY
7. Fludrocortisone Acetate 0.05 mg PO QHS
8. Gabapentin 800 mg PO QHS
9. Levothyroxine Sodium 137 mcg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Polyethylene Glycol 17 g PO DAILY
12. Senna 8.6 mg PO BID
13. Vitamin D 3000 UNIT PO DAILY
14. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every ___ hours Disp
#*30 Tablet Refills:*0
15. Sulfameth/Trimethoprim DS 1 TAB PO BID Duration: 5 Days
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth twice daily Disp #*6 Tablet Refills:*0
16. Cal-Citrate (calcium citrate-vitamin D2) ___ mg oral TID
17. grape seed oil (bulk) 100 mg PO DAILY
18. Melatin (melatonin) 10 mg oral QHS
19. Multivitamins 1 TAB PO DAILY
20. Medipore H (adhesive tape) 3 X 10 topical DAILY
Please dispense 1 Roll
RX *adhesive tape 1" X ___ yard Apply dressing daily Disp #*1
Package Refills:*2
21. Gauze Pad (gauze bandage) 4 X 4 topical DAILY
RX *gauze bandage 4" X 4" Apply dressing daily Disp #*2 Package
Refills:*2
22. Tech
Split Drain Sponge
ICD 10: 87.51 Duration: Ongoing
Please dispense split-drain sponge, 1 Box to apply daily
Refill: 2
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS: 1. Ampullary Stricture with PTBD Drain
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 recent biliary drain exchange, increased ABD pain,
fever, purulent drainage from skin puncture site, palpable SQ collection
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique. No oral contrast was administered. Coronal and
sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 610 mGy-cm.
COMPARISON: Prior exam from ___.
FINDINGS:
LOWER CHEST: Mild scarring is seen anteriorly at the right lung base. There
is mild dependent atelectasis. The imaged portion of the heart is
unremarkable.
ABDOMEN:
HEPATOBILIARY: Pneumobilia again noted with a PTBD in place. The tip of the
biliary drain resides within the duodenum. New from prior exam, is a
peripherally enhancing subcapsular fluid collection abutting the left hepatic
lobe anteriorly best seen on series 602b, image 36 measuring 1.2 x 2.2 x 2.4
cm. The biliary drain courses through this collection. There is a similar
mild prominence of the intrahepatic biliary tree. Main portal vein is patent.
Gallbladder is surgically absent.
PANCREAS: Pancreas appears normal.
SPLEEN: The spleen is normal.
ADRENALS: Adrenals are normal.
URINARY: Kidneys enhance symmetrically and excrete shin of contrast is prompt
and equal. No signs of hydronephrosis, pyelonephritis or worrisome renal
lesion. No perinephric abnormality.
GASTROINTESTINAL: Patient has undergone a prior Roux-en-Y a gastric bypass
with no signs of anastomotic obstruction. The excluded stomach is mostly
decompressed. Suture material involving distal loops of small bowel are also
noted without evidence of complication. Is not definitively visualized though
there are no secondary signs of appendicitis. Loops of large bowel contain
mild fecal load without wall thickening or signs of acute inflammation. There
is a small volume of free fluid in the abdomen and pelvis. No free air.
PELVIS: Ureters appear normal. The urinary bladder is moderately distended
appearing normal. Uterus is surgically absent. No adnexal mass 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 to moderate
atherosclerotic disease is noted.
BONES: No worrisome lesion. Laminectomy infusion is seen in the lower lumbar
spine.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Interval development of small subcapsular fluid collection (1.2 x 2.2 x 2.4
cm) along the PTBD as it exits the liver anteriorly, likely representing
biloma though cannot exclude abscess.
2. Small volume ascites.
Radiology Report
INDICATION: ___ year old woman with left PTBD with subcapsular collection //
PTBD check/change, collection aspiration
COMPARISON: CT abdomen pelvis of ___.
TECHNIQUE: OPERATORS: Dr. ___, Interventional Radiology Fellow and Dr.
___, attending radiologist performed the procedure. Dr. ___
___ personally supervised the trainee during the key components of the
procedure and has reviewed and agrees with the trainee's findings.
ANESTHESIA: Sedation was administered by the anesthesiology department. The
patient's hemodynamic parameters were continuously monitored by an independent
trained radiology nurse.
MEDICATIONS: 1 g ceftriaxone.
CONTRAST: 40 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 13.0 min, 14 mGy
PROCEDURE:
1. Limited preprocedure right upper quadrant ultrasound.
2. Tube cholangiogram.
3. Over the wire sheath cholangiogram.
4. 12 mm balloon dilatation of the ampulla (prolonged inflation).
5. Post balloon dilatation cholangiogram.
6. Ultrasound and fluoroscopy guided aspiration of subcapsular collection
using a combination of a 7 ___ sheath, 5 ___ pigtail catheter, and ___
needle.
7. Exchange of prior 12 ___ PTBD catheter with a new 12 ___ PTBD
catheter.
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 mid abdomen was prepped and draped in the usual sterile fashion.
A limited preprocedure ultrasound demonstrated 2.3 x 2.0 x 0.7 cm subcapsular
hypoechoic area surrounding the hepatic entry site of the existing catheter.
Initial scout images showed biliary drain in the appropriate position. A
cholangiogram was performed of the existing tube, demonstrating distal tube
occlusion. The hub of the catheter was cut and ___ wire was advanced
through the catheter into the small bowel. The catheter was removed. The
___ wire was exchanged using a Kumpe catheter for an Amplatz wire.
A 7 ___ sheath was advanced over the wire into the small bowel. Pull-back
cholangiogram and antegrade cholangiogram were performed to delineate the
level of stenosis and assess antegrade biliary drainage, findings below.
Based on the results of the cholangiogram, decision was made to perform
balloon dilatation of the sphincter. A 12 mm balloon was advanced over the
wire through the sheath to the level of the ampulla. Multiple overlapping
serial balloon dilatations were performed of the ampulla and distal CBD. A
waist was noted at the level of the ampulla. The 12 mm balloon was used to
perform a prolonged inflation for 5 min at the level of the ampulla. The waist
was noted to fully reduce. The balloon was withdrawn. Post balloon dilatation
cholangiogram was performed, demonstrating improved flow through the ampulla.
Next, the sheath was slowly withdrawn to the level of subcapsular collection.
Using a combination of ultrasound and fluoroscopy to confirm position within
the subcapsular collection, aspiration was performed, with a minimum amount of
fluid returned. A 5 ___ pigtail catheter was advanced into the collection
through the sheath and formed. This was confirmed under US. US images were
stored. This was also then used to perform aspiration of the subcapsular
collection. No significant fluid was aspirated. ___ needle was
advanced percutaneously under ultrasound guidance into the collection.
Sonographic image of the needle within the hypoechoic area were archived.
Aspiration was attempted, without significant fluid return.
All needles and catheters were withdrawn. A 12 ___ PTBD catheter was
advanced into the duodenum. Side holes were positioned above and below the
level of obstruction to facilitate internal drainage. The wire and inner
stiffener were removed, the catheter was flushed, the loop was formed, the
catheter was attached to a bag and sterile dressings were applied.
The patient tolerated the procedure well and there were no immediate
post-procedure complications.
FINDINGS:
1. Preprocedure ultrasound demonstrating 2.3 x 2.0 x 0.7 cm subcapsular
collection surrounding the hepatic entry site of the existing catheter.
2. Initial cholangiograms demonstrating narrowing at the level of the ampulla
with poor antegrade flow of contrast.
3. 12 mm balloon sphincteroplasty (prolonged inflation for 5 min) with a waist
initially noted at the level of the ampulla, with improved flow on
post-sphinteroplasty cholangiogram.
4. Ultrasound and fluoroscopy guided aspiration subcapsular collection with
minimum amount of fluid returned. No significant fluid was identified in this
location at the completion of procedure.
5. Successful exchange of 12 ___ PTBD catheter with a new 12 ___ PTBD
catheter.
IMPRESSION:
1. Successful exchange of existing 12 ___ PTBD catheter with a new 12
___ PTBD catheter.
2. Successful performance of 12 mm balloon cholangioplasty/sphincteroplasty
3. Percutaneous aspiration of 2 cm perihepatic collection surrounding the
liver entry site of the existing catheter, with minimal fluid aspirated.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, Wound eval
Diagnosed with Unspecified abdominal pain
temperature: 98.9
heartrate: 78.0
resprate: 18.0
o2sat: 100.0
sbp: 125.0
dbp: 71.0
level of pain: 10
level of acuity: 3.0 | Ms. ___ is a ___ year old female, with past history of
Roux-en-Y Gastric Bypass ___ ___, Multiple SBOs requiring
cholecystectomy, and ampullary stenosis s/p PTCD with multiple
rounds of dilation recently admitted for abdominal pain and
placement of PCBD conversion of ampullary drain who presents
with progressive abdominal pain, fevers to 101 and purulent
drainage from her cholecystostomy site 3 days after returning
from the hospital.
.
>> ACTIVE ISSUES:
# Possible recurrent biliary obstruction
abdominal wall cellulitis at site of biliary drain
Upon admission, given concern for prior PTBD manipulation,
patient underwent CT Abdomen scan which was remarkable for a
subcapsular fluid collection along the PTBD as it exited the
liver anteriorly, concerning for a biloma but could not exclude
abscess. Patient also was found to have small volume ascites.
Given this, patient underwent immediate uncapping of her PTBD
drain, and then underwent procedure on ___: Exchange of the
exisiting PTBD catheter with a new catheter, and performance of
dilation with cholangioplasty / sphincteroplasty. Patient also
had percutaneous aspiration of perihepatic collection with
minimal fluid aspirated. Cultures returned negative ___ blood.
Patient's abdominal pain improved with tube replacement, and
felt that ampulla had been stenosed, and that repeated dilation
has been only moderately successful. Patient underwent
successful capping trial on ___, and given stability,
patient stable for discharge. Pain regimen was converted from IV
Dilaudid to oxycodone, and was dispensed #30 tablets after
verification with PMP. Furthermore, patient was found to have
redness at drainage site concerning for abdominal wall
cellulitis, and therefore initially treated with broad spectrum
antibiotics, narrowed to TMP-SMX to complete course. Wound care
supplies were given to patient, along with prescriptions for
refills.
.
>> CHRONIC ISSUES:
# Constipation: Given increased narcotic load for abdominal
pain, patient placed on aggressive regimen and had several bowel
movements during hospital stay prior to discharge.
.
# Depression: Patient was continued on home citalopram.
.
# Vasovagal Syncope: Patient was continued on home
fludrocortisone. Patient did not have any hemodynamic
instability during hospital stay.
.
# Chronic Pain / Fibromyalgia: Patient was continued on home
gabapentin.
.
# Papillary Thyroid Cancer s/p Resection: Patient continued on
home levothyroxine supplement.
.
>> TRANSITIONAL ISSUES:
# Cellulitis: Please complete TMP-SMX antibiotic course until
___
# PTBD: Please continue to maintain PTBD drain site, and check
CBC, Chem-7, and LFTs upon discharge follow-up.
# Pain Regimen: Patient was given oxycodone, and bowel regimen
upon discharge for maintenance of pain. PMP checked prior to
prescription.
# Pending Labs: Please f/u blood culture obtained ___ (No
growth upon discharge).
# CODE STATUS: Full
# CONTACT: HCP ___ ___ |
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, rash, fevers
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old female with a history of morbid obesity, superficial
thrombophlebitis (on enoxaparin until stopped ___, LTBI
(completed 9 months of isonizaid), Hep C (neg VL ___,
previous IVDU (last use ___ years ago), PTSD, presenting with 1
day of increased abdominal redness swelling and warmth as well
as arm shaking chills and fever to 101. Pt states was in usual
state of health until day prior to admission. In ___ had sudden
onset chills, subjective fevers, and noticed increasing redness
in lower abdomen. Sensation of fevers and chills lasted
approximately one hour, but resolved without intervention. On
the day of admission, patient awoke in the morning with another
episode of chills, headache and diffuse body aches and measured
temperature to be 101.3. At this time she presented to the
emergency department. Apart from these two episodes, the
patient denies any other recent symptoms. No cough, shortness of
breath, n/v/d, or urinary symptoms recently. The patient notes
that she has not used IV drugs for over ___ years, and that she
is no longer taking subcutaneous lovenox since her prescription
ran out in ___. She denies back pain, flank pain, weakness
numbness or tingling.
The patient was most recently admitted to the OB/GYN service in
___ where she had a C-section complicated by pain control
and incisional cellulitis. The cellulitis was treated with PO
Bactrim and she was discharged on ___ with improvement in
symptoms. During this admission, the patient was noted to have
an abdominal rash concerning for cellulitis. She self injects
enoxaparin into her abdomen, and has been on this therapy since
___ for superficial thrombophlebitis, though has never been
diagnosed with a DVT. She was started on Vancomycin for this,
however she had US of the area which was not consistent with an
underlying abscess, and later had an ___ guided aspiration, which
was found to be a hematoma, which was sent for culture and had
no growth and antibiotics were stopped.
Initial vital signs were notable for:
T:97.8 HR:76 BP:121/68 O2:96% RA
No exam documented in the ED.
Labs were notable for:
7.1 > 10.5/33.0 < ___ / 12
--------------< 85
8.9 / ___ / 0.8
K:5.2
Lactate:1.3
Studies performed include:
CT Abd & Pelvis With Contrast
1. 3.6 x 5.5 cm right upper abdominal subcutaneous fluid
collection appears similar in appearance to prior ultrasound
dated ___. Previously demonstrated left lower
quadrant fluid collection is no longer visualized. No evidence
of a new fluid collection in the subcutaneous tissues of the
left lower quadrant.
2. Cellulitis involving the lower abdominal wall.
3. Mild positioned IUD. Further evaluation with pelvic
ultrasound may be considered.
4. Moderately enlarged spleen measuring up to 17 cm.
Patient was given:
IV CefTRIAXone 1g
PO/NG Gabapentin 800 mg
Buprenorphine-Naloxone (8mg-2mg) 1 TAB
PO/NG Acetaminophen 1000 mg
PO Ibuprofen 800 mg
Consults: None
Vitals on transfer:
T: 100.4 HR: 83 BP: 151/97 RR: 16 O2: 93% RA
Upon arrival to the floor, the patient complains of continued
abdominal pain around the site of redness, without the sensation
of fevers and chills at this time.
Review of Systems:
Complete ROS obtained and is otherwise negative.
Past Medical History:
Depression
Anxiety
PTSD
Bipolar w Major Depressive Disorder (Psych Admission for
excessive ETOH/Suicidal Ideation at ___ in ___
Alcohol abuse
Superficial thrombophlebitis (diagnosed ___, was on Lovenox
60mg daily, followed by Dr. ___ Heme/Onc, no longer on SQ
lovenox since ___ when prescription ran out)
Asthma
Morbid obesity (___ 68)
H/o Latent TB (finished 9 months of Isoniazid)
Hep C
HIV exposure via HIV seropositive partner ___ (was on
PrEP, but HIV negative ___ and no longer with exposure)
Gastric bypass ___
Social History:
___
Family History:
Patient is ___ and ___ in
descent. Family history of alcoholism.
Physical Exam:
Admission Physical Exam:
========================
VITALS: 99.0PO 119 / 67 79 19 96 Ra
GENERAL: Alert and interactive. In no acute distress, lying
comfortably in bed.
HEENT: Normocephalic, atraumatic. Pupils equal, round, and
reactive bilaterally, extraocular muscles intact. Sclera
anicteric and without injection. Moist mucous membranes, good
dentition. Tongue and lip piercings. Oropharynx is clear.
NECK: No cervical lymphadenopathy. Exam for JVD limited by body
habitus.
CARDIAC: Regular rhythm, normal rate. Audible S1 and S2. No
murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally w/appropriate breath
sounds appreciated in all fields. No wheezes, rhonchi or rales.
No increased work of breathing.
BACK: No spinous process tenderness. No CVA tenderness.
ABDOMEN: Normal bowels sounds, obese abdomen. Non-tender in all
quadrants, though tenderness over area of erythema (described
below)
SKIN: 5cm by 10cm area of confluent, well demarcated and
slightly elevated erythema across central pannus. No scaling.
2cm by 2cm indurated, raised area in ___ erythema. Tender
to palpation and warm to touch. No crepitus.
NEUROLOGIC: CN2-12 intact. ___ strength throughout. Normal
sensation.
Discharge Physical Exam:
========================
PHYSICAL EXAM:
Vitals: T98.2 BP136/90 P70 R20 O2 95 Ra
GENERAL: Alert and interactive. NAD, sitting comfortably in bed.
HEENT: EOMI PERRL MMM Tongue and lip piercings
CARDIAC: Regular rhythm, normal rate. No murmurs/rubs/gallops.
LUNGS: Clear to auscultation bilaterally, sounds appreciated in
all fields.
ABDOMEN: Normal bowels sounds, obese abdomen. Firm small lump in
R-side of abdomen. Non-tender in all quadrants
SKIN: improving erythematous area with decreasing confluence
(has improved each of the last 3 days), 5cm by 10cm area of
confluent, well demarcated across central pannus. Improvement in
tenderness to palpation under indurated area. Same temperature
as surrounding skin.
NEUROLOGIC: CN2-12 intact. A&Ox3. No focal deficits.
Pertinent Results:
INITIAL LABS:
===============
___ 11:15AM WBC-7.1 RBC-3.89* HGB-10.5* HCT-33.0* MCV-85
MCH-27.0 MCHC-31.8* RDW-17.2* RDWSD-53.5*
___ 11:15AM NEUTS-73.4* LYMPHS-17.7* MONOS-7.9 EOS-0.3*
BASOS-0.4 IM ___ AbsNeut-5.24 AbsLymp-1.26 AbsMono-0.56
AbsEos-0.02* AbsBaso-0.03
___ 11:15AM GLUCOSE-85 UREA N-12 CREAT-0.8 SODIUM-130*
POTASSIUM-8.9* CHLORIDE-104 TOTAL CO2-24 ANION GAP-2*
___ 11:45AM LACTATE-1.3 K+-5.2*
DISCHARGE LABS:
===============
___ 06:20AM BLOOD WBC-4.5 RBC-4.09 Hgb-10.9* Hct-35.3
MCV-86 MCH-26.7 MCHC-30.9* RDW-16.5* RDWSD-53.0* Plt ___
___:20AM BLOOD Glucose-92 UreaN-17 Creat-0.6 Na-143
K-4.7 Cl-105 HCO3-26 AnGap-12
IMAGING:
===============
CT A/P w/ contrast (___)
IMPRESSION:
1. 3.6 x 5.5 cm right upper abdominal subcutaneous fluid
collection appears similar in appearance to prior ultrasound
dated ___. Previously demonstrated left lower
quadrant fluid collection is no longer visualized. No evidence
of a new fluid collection in the subcutaneous tissues of the
left lower quadrant.
2. Cellulitis involving the lower abdominal wall.
3. Mild positioned IUD. Further evaluation with pelvic
ultrasound may be considered.
4. Moderately enlarged spleen measuring up to 17 cm.
MICROBIOLOGY:
=================
___ BLOOD CULTURES X 2 NO GROWTH FINAL
___ URINE CULTURE NO GROWTH FINAL
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB/wheeze
3. BuPROPion XL (Once Daily) 300 mg PO DAILY
4. Cyanocobalamin 100 mcg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Fluticasone Propionate 110mcg 1 PUFF IH BID
7. Gabapentin 800 mg PO TID
8. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
9. LamoTRIgine 25 mg PO DAILY
10. Latuda (lurasidone) 40 mg oral DAILY
11. Pyridoxine 50 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. Chantix (varenicline) 1 mg oral BID
14. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL TID
15. ChlorproMAZINE 50 mg PO QAM
16. ChlorproMAZINE 100 mg PO QPM
17. DiphenhydrAMINE 50 mg PO QHS:PRN insomnia
Discharge Medications:
1. Cephalexin 500 mg PO Q6H
RX *cephalexin 500 mg 1 tablet(s) by mouth every 6 hours Disp
#*25 Tablet Refills:*0
2. Clotrimazole Cream 1 Appl TP BID:PRN rash
RX *clotrimazole 1 % one application under breasts and abdominal
skin twice daily as needed for fungal skin rash Disp #*30 Gram
Gram Refills:*0
3. Miconazole Powder 2% 1 Appl TP TID:PRN rash under breasts
and pannus
4. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
5. Albuterol Inhaler ___ PUFF IH Q4H:PRN SOB/wheeze
6. Buprenorphine-Naloxone (8mg-2mg) 1 TAB SL TID
7. BuPROPion XL (Once Daily) 300 mg PO DAILY
8. Chantix (varenicline) 1 mg oral BID
9. ChlorproMAZINE 50 mg PO QAM
10. ChlorproMAZINE 100 mg PO QPM
11. Cyanocobalamin 100 mcg PO DAILY
12. DiphenhydrAMINE 50 mg PO QHS:PRN insomnia
13. Docusate Sodium 100 mg PO BID
14. Fluticasone Propionate 110mcg 1 PUFF IH BID
15. Gabapentin 800 mg PO TID
16. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Patient is NPO or unable to
tolerate PO
17. LamoTRIgine 25 mg PO DAILY
18. Latuda (lurasidone) 40 mg oral DAILY
19. Pyridoxine 50 mg PO DAILY
20. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis: Erysipelas
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 rigors, redness over left lower quadrant. Assess for
subcutaneous abscess.
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) Spiral Acquisition 6.5 s, 51.1 cm; CTDIvol = 27.7 mGy (Body) DLP =
1,412.8 mGy-cm.
Total DLP (Body) = 1,413 mGy-cm.
COMPARISON: Comparison is made to abdominal ultrasound performed ___.
FINDINGS:
LOWER CHEST: Visualized lung fields are within normal limits. There is no
evidence of pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen is moderately enlarged measuring up to 17 cm (601:44) but
demonstrates normal attenuation throughout, without evidence of focal lesions.
ADRENALS: The right adrenal gland is normal in shape and size. The left
adrenal gland mildly thickened, which is nonspecific.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of hydronephrosis. Small bilateral hypodense renal
cortical lesions likely reflect simple renal cysts. A 1.5 x 1.9 cm left lower
pole renal cyst measures 26 Hounsfield units (02:37), likely a simple renal
cyst. There is no perinephric abnormality.
GASTROINTESTINAL: Small hiatal hernia. Patient is status post Roux-en-Y
gastric bypass surgery with anastomotic suture material visualized in mid
abdomen (601:26). Otherwise, the 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: Malpositioned IUD appears within the uterine endometrium
with the cross bars directed more inferiorly than expected (2:67). No
evidence of adnexal abnormality.
RETROPERITONEUM AND MESENTERY: There is no retroperitoneal or mesenteric
lymphadenopathy. There is no pelvic or inguinal lymphadenopathy. There is no
abdominal aortic aneurysm. Mild atherosclerotic disease is noted. The
mesenteric vessels appear patent.
BONES: There is mild to moderate degenerative changes of thoracolumbar spine
with grade 1 retrolisthesis of L5 on S1. There is no evidence of worrisome
osseous lesions or acute fracture.
SOFT TISSUES: A 3.6 x 5.5 cm subcutaneous fluid collection within the right
upper quadrant has a fat fluid level (02:38). This appears similar in
appearance to prior ultrasound performed ___. A previously seen
left-sided abdominal fluid collection on prior ultrasound is not seen on
current exam. Lower abdomen skin thickening and fat stranding likely reflects
cellulitis (2:87).
IMPRESSION:
1. 3.6 x 5.5 cm right upper abdominal subcutaneous fluid collection appears
similar in appearance to prior ultrasound dated ___. Previously
demonstrated left lower quadrant fluid collection is no longer visualized. No
evidence of a new fluid collection in the subcutaneous tissues of the left
lower quadrant.
2. Cellulitis involving the lower abdominal wall.
3. Mild positioned IUD. Further evaluation with pelvic ultrasound may be
considered.
4. Moderately enlarged spleen measuring up to 17 cm.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Fever
Diagnosed with Cellulitis of abdominal wall
temperature: 97.8
heartrate: 76.0
resprate: nan
o2sat: 96.0
sbp: 121.0
dbp: 68.0
level of pain: 4
level of acuity: 3.0 | ___ year old female with a history of morbid obesity, superficial
thrombophlebitis (on enoxaparin until stopped ___, LTBI
(completed 9 months of isonizaid), Hep C (neg VL ___,
previous IVDU (last use ___ years ago), PTSD, presenting increased
abdominal redness swelling and warmth found to have erysipelas. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Latex / Penicillins / Codeine / Demerol / Iodine-Iodine
Containing / Aminophylline / lisinopril / shellfish derived
Attending: ___.
Chief Complaint:
Vaginal bleeding
Major Surgical or Invasive Procedure:
___: ___ placement of 10 ___ pelvic drain
___: Removal of withdrawn ___ pigtail catheter and
successful CT-guided placement of a ___ pigtail catheter
into the collection.
History of Present Illness:
___ is a ___ yo F with history of significant for
atrial fibrillation (currently on lovenox with plans to resume
coumadin), rheumatoid arthritis (on prednisone), perforated
diverticulitis s/p Hartmanns procedure (___) complicated by
pelvic hematoma (without drainage) and ostomy revision (___)
who now presents with concern for significant rectal bleeding
and associated hemodynamic instability. ACS is consulted for
urgent management.
The patient was originally admitted for perforated
diverticulitis ___ s/p Hartmanns procedure (___). Her
initial hospitalization was complicated by a pelvic hematoma
associated with anemia. She was eventually discharged to home on
___. She was readmitted to the hospital ___ after stomal skin
disruption and returned to the OR for ostomy stoma revision on
___. She was discharged on therapeutic lovenox (70mg BID) with
plan to transition to Coumadin. She presented to the ED this AM
after noting large column bright red blood per rectum. Patient
reported that she had an episode of coughing around 10am this
morning and subsequently felt that she was bleeding from her
rectum. Her husband then checked on her and found a large pool
of blood underneath her bottom. He then brought her directly to
the Emergency Department for evaluation.
At the time of presentation, she was initially normocardic but
soon became tachycardic to 150s. Her blood pressure remained in
the 120-130s systolic, and she was mentating appropriately
throughout. 2 peripheral IVs and a foley were placed. Upon
evaluation, she reported lower abdominal pain, intermittent
nausea, shortness of breath, and lightheadedness. On exam, her
abdomen was soft, non-distended, non-tender. Her ostomy was pink
with stool in the bag. Anoscopy exam did not reveal any active
bleeding from her rectum. Shortly thereafter, she was found to
be sitting in a small pool of blood, and repeat exam revealed
bleeding from her vagina. Gynecology was consulted. She received
1L LR, 1u pRBCs, and 1u FFP with improved heart rate to the
110s. Of note, patient has had a hysterectomy in the 1990s. She
last ate at 8am this morning, and her last dose of lovenox was
at 9am this morning.
Past Medical History:
Past Medical History:
- Atrial fibrillation (on Coumadin)
- Rheumatoid arthritis (on MTX/pred) c/b chronic bronchiectasis
(on inhalers)
- HTN/HLD
- IDDM
- Iron deficiency anemia
- OSA
Past Surgical History:
- s/p hysterectomy
- s/p C-section ___
- s/p laparoscopic ovarian cyst excision
- s/p R THR
Social History:
___
Family History:
Family History:
Father - ___
Mother (died at ___) - CVA, HTN
Physical Exam:
Physical Exam on Admission: ___
Vitals: T 100.7, HR 154, BP 129/83, RR 18, SpO2 95% RA
General: awake, alert, AAOx3, in moderate distress
CV: sinus tachycardia
Pulm: normal respiratory effort
GI: abdomen soft, non-distended, non-tender, ostomy with air and
stool in the bag, wound vac intact
Physical Exam on Discharge:
Vitals: 97.7, 102/66, 111, 18, 98% on Ra
GEN: A&Ox3, NAD.
CV: RRR
PULM: non-labored
ABD: soft, non tender, non distended. ostomy pink and productive
of loose brown stool.
SKIN: warm, dry, midline abd incision with wound vac in place,
changed prior to discharge.
EXT: PPP, no lower ext edema bilat.
Pertinent Results:
ADMISSION LABS:
___ 05:45AM BLOOD WBC-11.3* RBC-3.04* Hgb-10.2* Hct-33.0*
MCV-109* MCH-33.6* MCHC-30.9* RDW-17.1* RDWSD-65.9* Plt ___
___ 01:02PM BLOOD Neuts-77.4* Lymphs-7.1* Monos-10.3
Eos-0.1* Baso-0.5 NRBC-0.6* Im ___ AbsNeut-13.53*
AbsLymp-1.25 AbsMono-1.80* AbsEos-0.02* AbsBaso-0.09*
___ 05:45AM BLOOD ___ PTT-29.0 ___
___ 05:45AM BLOOD Glucose-207* UreaN-12 Creat-0.7 Na-139
K-5.0 Cl-94* HCO3-30 AnGap-15
___ 05:45AM BLOOD Calcium-9.8 Phos-3.3 Mg-2.1
DISCHARGE LABS:
___ 06:21AM BLOOD WBC-5.2 RBC-3.34* Hgb-10.9* Hct-33.0*
MCV-99* MCH-32.6* MCHC-33.0 RDW-15.7* RDWSD-56.8* Plt ___
___ 07:14AM BLOOD WBC-5.5 RBC-3.09* Hgb-10.1* Hct-31.0*
MCV-100* MCH-32.7* MCHC-32.6 RDW-15.7* RDWSD-57.1* Plt ___
___ 06:21AM BLOOD ___
___ 07:14AM BLOOD ___
___ 07:14AM BLOOD Glucose-118* UreaN-8 Creat-0.6 Na-142
K-3.9 Cl-101 HCO3-26 AnGap-15
___ 07:30AM BLOOD Glucose-133* UreaN-10 Creat-0.6 Na-137
K-3.7 Cl-99 HCO3-26 AnGap-12
___ 07:14AM BLOOD Calcium-9.5 Phos-3.3 Mg-1.8
___ 07:30AM BLOOD Calcium-8.7 Phos-2.1* Mg-2.0
IMAGING:
CTA A/P: ___
Rim enhancing pelvic hematoma is slightly decreased in size as
well as density compared to prior imaging. No evidence for
active extravasation of contrast. The patient is status post
___ pouch and redo left lower quadrant colostomy. No
new/acute intra-abdominal or pelvic pathology. Unchanged
pancreatic hypodensities which most likely represent side branch
IPMNs ranging up to 21 mm.
CT ABD & PELVIS WITH CONTRAST: ___
1. Interval decrease in size and density of pelvic fluid
collection status
post drain placement. There is persistent fluid and air bubbles
within the collection.
2. No evidence of new intra-abdominal or pelvic pathology.
3. The patient is status post ___ pouch and redo of left
lower quadrant colostomy with adjacent postsurgical changes.
4. Unchanged pancreatic hypodensities which most likely
represent side branch IPMNs measuring up to 20 mm.
5. There is a locule of air at the superior aspect of the
urinary bladder
please correlate with possible history of recent catheterization
or
urinalysis.
US BUTTOCKS, SOFT TISSUE RIGHT: ___
No superficial drainable collection in the area of clinical
concern.
CT ABD & PELVIS WITH CONTRAST: ___
1. The posterior approach percutaneous drain has been withdrawn,
now
terminating outside the rim enhancing fluid collection in the
perirectal
space.
2. The pelvic fluid collection has minimally decreased in size,
now measuring approximately 6.5 x 4.4 cm, previously 7.3 x 4.6
cm. However, the collection closely abuts the cecum along its
superior anterior margin and it is unclear if there is a
fistulous connection. If further evaluation is desired,
contrast could either be administered via the ostomy or via the
percutaneous drain once it is replaced.
3. No evidence of leak from the rectal stump.
4. Stable pancreatic hypodensities measuring to 1.9 cm in the
pancreatic head, which most likely represent side branch IPMNs.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Aspirin 81 mg PO DAILY
3. Dulera (mometasone-formoterol) 200-5 mcg/actuation inhalation
BID
4. Ezetimibe 10 mg PO DAILY
5. FoLIC Acid 1 mg PO DAILY
6. Furosemide 40 mg PO DAILY
7. Losartan Potassium 100 mg PO DAILY
8. Metoprolol Tartrate 25 mg PO TID:PRN palpitations
9. Metoprolol Succinate XL 100 mg PO QHS
10. Levalbuterol Neb 0.63 mg NEB BID:PRN shortness of breath
11. Montelukast 10 mg PO DAILY
12. Nitroglycerin SL 0.4 mg SL ASDIR chest pain
13. Omeprazole 20 mg PO BID
14. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
Reason for PRN duplicate override: Discontinuing IV zofran
15. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
16. Polyethylene Glycol 17 g PO DAILY
17. PredniSONE 5 mg PO BID
This is the maintenance dose to follow the last tapered dose
18. Senna 8.6 mg PO BID:PRN Constipation - First Line
19. Ciprofloxacin HCl 500 mg PO Q12H
20. Docusate Sodium 100 mg PO BID
21. MetroNIDAZOLE 500 mg PO Q8H
22. Milk of Magnesia 30 mL PO Q8H:PRN Constipation - First Line
23. Zoledronic Acid (Reclast) (zoledronic acid-mannitol-water) 5
mg/100 mL injection ANNUALLY
24. GlipiZIDE 10 mg PO BID
25. riTUXimab 1000 mg IV EVERY 3 MONTHS
26. Tiotropium Bromide 1 CAP IH AT BEDTIME
27. Warfarin 2.5 mg PO 5X/WEEK (___)
28. Warfarin 3.75 mg PO 2X/WEEK (MO,TH)
Discharge Medications:
1. Glargine 18 Units Breakfast
Novolog 2 Units Breakfast
Novolog 2 Units Lunch
Novolog 2 Units Dinner
Insulin SC Sliding Scale using Novolog Insulin
2. Lidocaine 5% Patch 1 PTCH TD QAM
3. Spiriva Respimat (tiotropium bromide) 2.5 mcg/actuation
inhalation 2 puffs daily
4. PredniSONE 5 mg PO DAILY
5. ___ MD to order daily dose PO DAILY16
6. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
7. Aspirin 81 mg PO DAILY
8. Docusate Sodium 100 mg PO BID
9. Dulera (mometasone-formoterol) 200-5 mcg/actuation
inhalation BID
10. Ezetimibe 10 mg PO DAILY
11. FoLIC Acid 1 mg PO DAILY
12. Furosemide 40 mg PO DAILY
13. Levalbuterol Neb 0.63 mg NEB BID:PRN shortness of breath
14. Losartan Potassium 100 mg PO DAILY
15. Metoprolol Succinate XL 100 mg PO QHS
16. Metoprolol Tartrate 25 mg PO TID:PRN palpitations
17. Milk of Magnesia 30 mL PO Q8H:PRN Constipation - First Line
18. Montelukast 10 mg PO DAILY
19. Nitroglycerin SL 0.4 mg SL ASDIR chest pain
20. Omeprazole 20 mg PO BID
21. Ondansetron 4 mg PO Q8H:PRN Nausea/Vomiting - First Line
Reason for PRN duplicate override: Discontinuing IV zofran
22. OxyCODONE (Immediate Release) 5 mg PO Q4H:PRN Pain -
Moderate
23. Polyethylene Glycol 17 g PO DAILY
24. riTUXimab 1000 mg IV EVERY 3 MONTHS
25. Senna 8.6 mg PO BID:PRN Constipation - First Line
26. Tiotropium Bromide 1 CAP IH AT BEDTIME
27. Zoledronic Acid (Reclast) (zoledronic acid-mannitol-water)
5 mg/100 mL injection ANNUALLY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pelvic abscess / hematoma
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: ___ year old woman remote ___ hysterectomy (___) sp hartmans (___)
and redo colostomy (___) presents with active vaginal bleeding with known
pelvic hematoma on therapeutic lovenox// ?interveanable vs active bleeding.
Please do at ___. anaphylactic reaction. 1st dose steroids 1530, 2nd dose
___
TECHNIQUE: Multiphasic contrast: MDCT axial images were acquired through the
abdomen 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 3.6 s, 56.7 cm; CTDIvol = 3.6 mGy (Body) DLP = 204.5
mGy-cm.
2) Spiral Acquisition 4.3 s, 56.7 cm; CTDIvol = 12.9 mGy (Body) DLP = 731.4
mGy-cm.
3) Spiral Acquisition 4.3 s, 56.7 cm; CTDIvol = 12.9 mGy (Body) DLP = 730.7
mGy-cm.
4) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
5) Stationary Acquisition 2.4 s, 0.5 cm; CTDIvol = 13.2 mGy (Body) DLP =
6.6 mGy-cm.
Total DLP (Body) = 1,675 mGy-cm.
COMPARISON: Prior CT abdomen done ___. Chest CT dated ___.
FINDINGS:
LOWER CHEST: Subsegmental bibasal atelectasis is improved on the left and
similar to minimally increased on the right. No pleural effusion. No
pericardial effusion. Mild to moderate coronary artery calcification. Mildly
enlarged heart.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
Suspected perfusional change in segment 4A of the liver (series 303, image
53). There is no evidence of intrahepatic or extrahepatic biliary dilatation.
The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout. Multiple pancreatic
cystic lesions measuring up to 20 mm in the pancreatic head (series 303, image
62) appear similar compared to prior imaging. The main pancreatic duct is not
dilated. 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: Bilateral renal cortical cysts appear simple, or mildly hyperdense,
but without any enhancement nodularity wall thickening or septations.
Bilateral renal cortical scarring. No hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. No features of small bowel
obstruction. The patient is status post left lower quadrant diverting
colostomy with ___ pouch. Stranding in the left lower quadrant is most
likely secondary to prior surgical intervention. There is a large rim
enhancing collection in the pelvis measuring 40 Hounsfield units in density
and 81 x 86 mm in the axial plane (previously measuring 53 Hounsfield units in
density and 90 x 90 mm in the axial plane). This collection is inseparable
from the proximal aspect of the ___ pouch and posterior cecal wall.
Decrease in previously noted hemorrhagic fluid component along the right
paracolic gutter.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy.
PELVIS: The right hemipelvis is obscured by beam hardening artifact from right
hip metallic arthroplasty prosthesis. Foley's catheter in situ with air
present in the bladder most likely secondary to instrumentation.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: Mild degenerative changes of the lumbar spine with endplate compression
fractures of the L3-L5 vertebral bodies. Minimally displaced left lateral
ninth rib fracture with blunting of the ends, unchanged. Sclerosis along the
right sacral ala suggesting prior nondisplaced fracture, unchanged. Bones
appear demineralized.
SOFT TISSUES: Postoperative changes are seen in the midline in the anterior
abdominal wall.
IMPRESSION:
Rim enhancing pelvic hematoma is slightly decreased in size as well as density
compared to prior imaging.
No evidence for active extravasation of contrast.
The patient is status post ___ pouch and redo left lower quadrant
colostomy.
No new/acute intra-abdominal or pelvic pathology.
Unchanged pancreatic hypodensities which most likely represent side branch
IPMNs ranging up to 21 mm.
RECOMMENDATION(S): Follow-up MRCP recommended in ___ months to reassess
pancreatic cystic lesions.
Radiology Report
EXAMINATION: CT interventional
INDICATION: ___ year old woman with pelvic hematoma// eval for possible
drainage (pelvic abscess)
COMPARISON: CT dated ___
PROCEDURE: CT-guided drainage of pelvic collection.
OPERATORS: Dr. ___, radiology fellow and Dr. ___,
attending radiologist. Dr. ___ 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 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 metal stiffener and the wire
were removed. The pigtail was deployed. The position of the pigtail was
confirmed within the collection via CT fluoroscopy.
Approximately 100 cc of bloody fluid was aspirated with a sample sent for
microbiology evaluation. The catheter was secured by a StatLock and a ___ silk
suture. 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 6.1 s, 18.6 cm; CTDIvol =
11.2 mGy (Body) DLP = 193.5 mGy-cm. Total DLP (Body) = 203 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of
1.5 mg Versed and 75 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. Preprocedural imaging demonstrates a 9 cm fluid collection.
2. Final images demonstrate a ___ Fr drain in the pelvic fluid collection via a
transgluteal approach.
IMPRESSION:
Successful CT-guided placement of a ___ pigtail catheter into the pelvic
collection. Samples were sent for microbiology evaluation.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ w/ afib (on lvx), RA (on prednisone), IDDM, HTN/HLD, perf
diverticulitis s/p ___ c/b pelvic hematoma c/b ostomy detachment s/p
colostomy revision, now p/w vaginal bleeding. Found to have pelvic hematoma
that was drained by ___ via CT guidance. Pt. still c/o abdominal pain, poor PO
intake. Please eval interval change in abdominal/pelvic collection.// Please
eval interval change in abdominal/pelvic collection.
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 4.2 s, 55.7 cm; CTDIvol = 12.6 mGy (Body) DLP = 703.1
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 3.3 mGy (Body) DLP = 1.7
mGy-cm.
3) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 33.4 mGy (Body) DLP =
16.7 mGy-cm.
Total DLP (Body) = 722 mGy-cm.
COMPARISON: CT abdomen pelvis dated ___ and most recent dated ___.
FINDINGS:
LOWER CHEST: Significant, interval improvement of bibasilar subsegmental
atelectasis. There is no evidence of pleural or pericardial effusion. Mild
to moderate coronary artery calcifications. Mildly enlarged heart.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout with
smooth contours. There is geographic hypoattenuation at segment IV A which
likely represents focal fat deposit. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout without pancreatic
ductal dilatation. Multiple pancreatic cystic lesions measuring up to 20 mm
at the pancreatic head, (series 601, image 23) appears similar compared to
prior imaging. 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: Multiple bilateral renal cortical cysts appear simple or mildly
hyperdense but without any nodular enhancement, unchanged over several
evaluations. Bilateral renal cortical scarring is likely sequela of prior
renal insult. No hydronephrosis. The kidneys are of normal and symmetric
size with normal nephrogram. There is no evidence of hydronephrosis. There
is no perinephric abnormality.
GASTROINTESTINAL: The patient is status post left lower quadrant diverting
colostomy with ___ pouch. There is edema adjacent to the left lower
quadrant colostomy and stranding in the left lower abdominal quadrant which is
most likely secondary to prior surgical intervention. The stomach is
unremarkable. Small bowel loops demonstrate normal caliber, wall thickness,
and enhancement throughout.
PELVIS: There has been interval placement of a percutaneous drain within a rim
enhancing hypoattenuating pelvic fluid collection with a density of 35
Hounsfield units which demonstrates few locules of air. The aforementioned
fluid collection measures 7.3 x 4.1 cm and previously measured 8.6 x 2.1 cm.
Additionally the fluid collection previously demonstrated a density of 53
Hounsfield units on most recent prior. There is a locule of gas at the
superior aspect of the urinary bladder.
REPRODUCTIVE ORGANS: Uterus is not demonstrated. The bilateral adnexa
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: The patient is status post a right total hip arthroplasty.
Redemonstrated is a linear hypodensity at the right sacral ala which may
related to an insufficiency fracture, relatively unchanged when compared to CT
abdomen and pelvis dated ___. Mild degenerative changes of the lumbar
spine with endplate compression fractures at L3 and L5 vertebral bodies.
Minimally displaced left lateral ninth rib fracture with blunting of the and
unchanged.
SOFT TISSUES: Postoperative changes are seen at the midline of the anterior
abdominal wall.
IMPRESSION:
1. Interval decrease in size and density of pelvic fluid collection status
post drain placement. There is persistent fluid and air bubbles within the
collection.
2. No evidence of new intra-abdominal or pelvic pathology.
3. The patient is status post ___ pouch and redo of left lower quadrant
colostomy with adjacent postsurgical changes.
4. Unchanged pancreatic hypodensities which most likely represent side branch
IPMNs measuring up to 20 mm.
5. There is a locule of air at the superior aspect of the urinary bladder
please correlate with possible history of recent catheterization or
urinalysis.
RECOMMENDATION(S): A follow-up MRCP in the ___ months is again recommended
to further characterize the pancreatic lesions, or can be followed on future
followup examinations.
Radiology Report
EXAMINATION: US BUTTOCKS, SOFT TISSUE RIGHT
INDICATION: ___ w/ afib (on lvx), RA (on prednisone), IDDM, HTN/HLD, perf
diverticulitis s/p ___ c/b pelvic hematoma c/b ostomy detachment s/p
colostomy revision, now p/w vaginal bleeding// Collection over ___ drain
insertion site? (R-buttock).
TECHNIQUE: Grayscale ultrasound images were obtained of the superficial
tissues of the right buttocks at the site drain insertion in area of clinical
concern as indicated by the patient.
COMPARISON: CT of the abdomen and pelvis from ___
FINDINGS:
There is heterogeneous subcutaneous edema without superficial drainable
collection in the area of clinical concern.
IMPRESSION:
No superficial drainable collection in the area of clinical concern.
Radiology Report
EXAMINATION: CT ABDOMEN AND PELVIS WITH CONTRAST
INDICATION: ___ year old woman with Hartmans with persistent fluid collection
and rising white count, concern for reversal stump leak- please use
gastrigraffin PR to assess, please do NOT use barium. Thank you!// ? Recital
stumpLeak
TECHNIQUE: Single phase contrast: MDCT axial images were acquired through the
abdomen and pelvis following intravenous contrast administration.
Rectal contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.6 s, 60.2 cm; CTDIvol = 9.9 mGy (Body) DLP = 596.5
mGy-cm.
2) Spiral Acquisition 2.6 s, 34.7 cm; CTDIvol = 10.3 mGy (Body) DLP = 356.1
mGy-cm.
Total DLP (Body) = 953 mGy-cm.
COMPARISON: CT abdomen pelvis dated ___.
FINDINGS:
LOWER CHEST: Aside from minimal bibasilar atelectasis, the visualized lung
fields are within normal limits. There is no evidence of pleural or
pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
Geographic hypoattenuation in segment ___ again likely represents focal fat
deposition. Scattered punctate calcifications within the liver likely
represent calcified granulomas. There is no evidence of suspicious 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
pancreatic ductal dilatation. Re-demonstrated are multiple pancreatic cystic
lesions measuring up to 1.9 cm in the pancreatic head (02:26), which appear
unchanged. 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.
As before, multiple bilateral renal cortical cysts appears simple or mildly
hyperdense and are unchanged. A 3.1 x 2.3 cm cystic structure in the right
mid kidney likely represents a caliceal diverticulum (02:34). There is no
evidence of hydronephrosis. There is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Similar to prior, the patient
is status post left lower quadrant diverting colostomy with a ___
pouch. Contrast was instilled via the rectum. There is no extraluminal
contrast to suggest a leak. There is similar soft tissue stranding adjacent
to the bowel loops in the left lower quadrant near the ostomy, likely
postsurgical. Small bowel loops demonstrate normal caliber, wall thickness,
and enhancement throughout.
A posterior approach percutaneous drain has been withdrawn, now with tip
terminating outside the rim enhancing fluid collection in the perirectal
space. A rim enhancing pelvic fluid collection with a few locules of air has
slightly decreased in size, now measuring 6.5 x 4.4 cm, previously 7.3 x 4.6
cm (2:76). This collection closely abuts the cecum along its anterior
superior margin (2:76, 302:78).
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The uterus is not visualized.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
The patient is status post right total hip arthroplasty. There is a chronic
fracture in the posterior-lateral left ninth rib. There are moderate to
severe degenerative changes in the thoracolumbar spine with unchanged
multilevel loss of height in the L3, L4 and L5 vertebral bodies.
SOFT TISSUES: Aside from expected postsurgical changes, the abdominal and
pelvic wall is within normal limits.
IMPRESSION:
1. The posterior approach percutaneous drain has been withdrawn, now
terminating outside the rim enhancing fluid collection in the perirectal
space.
2. The pelvic fluid collection has minimally decreased in size, now measuring
approximately 6.5 x 4.4 cm, previously 7.3 x 4.6 cm. However, the collection
closely abuts the cecum along its superior anterior margin and it is unclear
if there is a fistulous connection. If further evaluation is desired,
contrast could either be administered via the ostomy or via the percutaneous
drain once it is replaced.
3. No evidence of leak from the rectal stump.
4. Stable pancreatic hypodensities measuring to 1.9 cm in the pancreatic head,
which most likely represent side branch IPMNs.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 6:06 pm, 2 minutes
after discovery of the findings. The updated findings and recommendation were
discussed with ___ at 19:19 on ___.
Radiology Report
EXAMINATION: CT Guided Drainage
INDICATION: ___ w/ afib (on lvx), RA (on prednisone), IDDM, HTN/HLD, perf
diverticulitis s/p ___ c/b pelvic hematoma c/b ostomy detachment s/p
colostomy revision, now p/w vaginal bleeding and pelvic abscess sp drainage by
___, drain pulled back by ___ and not now in continuity with abscess, also would
appreciate possible tube study? ? cecal involvement on recent CT scan// ?
drain study, ? drain upsize and advancement
COMPARISON: CT ___
PROCEDURE: CT-guided drainage of pelvic collection.
OPERATORS: Dr. ___, radiology fellow 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 left lateral position on the CT scan table.
Limited preprocedure CT scan was performed to localize the collection and
position of existing tube. 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.
The tube was cut and ___ wire was advanced via existing tube in an
attempt to negotiate wire along the tract into the collection. Unfortunately,
this was unsuccessful and the wire was retracted along with the tube. The
same skin entry site was used. 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 10 cc of purulent fluid was aspirated 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.
DOSE: Acquisition sequence:
1) Spiral Acquisition 5.4 s, 16.5 cm; CTDIvol = 10.8 mGy (Body) DLP = 163.8
mGy-cm.
2) Stationary Acquisition 8.3 s, 0.7 cm; CTDIvol = 97.0 mGy (Body) DLP =
69.8 mGy-cm.
Total DLP (Body) = 243 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of 2
mg Versed and 100 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:
The original 10 ___ pigtail was retracted and tip was extraluminal to the
pelvic fluid collection.
IMPRESSION:
Remove of withdrawn/malpositioned ___ pigtail catheter and successful
CT-guided placement of a ___ pigtail catheter into the collection.
Samples were sent for microbiology evaluation.
RECOMMENDATION(S): Flush catheter at least q 12h
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: BRBPR
Diagnosed with Abnormal uterine and vaginal bleeding, unspecified, Other shock, Syncope and collapse, Unspecified atrial fibrillation, Long term (current) use of anticoagulants
temperature: 98.0
heartrate: 80.0
resprate: 18.0
o2sat: 98.0
sbp: 127.0
dbp: 80.0
level of pain: 0
level of acuity: 2.0 | Patient is a ___ year old female with a history of perforated
diverticulitis s/p ___ complicated by a pelvic hematoma and
later complicated by ostomy detachment s/p colostomy revision,
who presented to ___ on
___ with concern for rectal bleeding. She was found to
actually have vaginal bleeding with a small defect present at
her vaginal cuff (from her prior hysterectomy), concerning for
drainage from her known pelvic hematoma versus new active
hemorrhage. She was initially tachycardic to the 150s upon
arrival in the ED with SBP in the 130s. Her tachycardia improved
with fluid resuscitation. In this setting, she was admitted to
the trauma ICU for hemodynamic monitoring and serial
hematocrits.
The patient was kept NPO, on IV fluid resuscitation. She was
continued on cipro/flagyl (which she had been taking at home as
directed after hospital discharge). underwent pre-treatment for
a contrast allergy in preparation for a CTA. Imaging
demonstrated a rim-enhancing large pelvic hematoma with no
active extravasation. As such, her vaginal bleeding was presumed
to represent drainage of her old hematoma rather than
active/acute new hemorrhage. She remained hemodynamically stable
with stable hematocrits. She did not require any blood
transfusions after leaving the ED (where she received only 1u
pRBCs due to concern for active bleeding and hemodynamic
instability). On ___, the patient underwent CT guided placement
of ___ transgluteal drain into her pelvic hematoma. Cultures
were sent, and she was found to be growing enterococcus. Her
antibiotics were broadened to vancomycin, cipro, and flagyl
pending sensitivities. On ___, she was started on ___, her
foley was removed, and she was deemed appropriate for transfer
to the surgical floor. Her therapeutic Lovenox and remainder of
home meds were resumed on ___.
On ___ her cultures speciated with enterococcus gallinarum,
which was resistant to vancomycin. Her antibiotic therapy was
advanced to IV Linezolid while cipro/flagyl continued until the
course was completed on ___. Her vac was also changed and her
Coumadin was resumed for hx of afib. On ___ she underwent cat
scan to evaluate for interval change of pelvic collection and CT
showed persistent collection. Her drain was then manipulated by
___ team on ___ and irrigated with TPA. She was re-scanned on ___
and drain found to no longer be in communication with her fluid
collection. On ___ she had ___ drain removed and ___ drain
placed in interventional radiology with good effect. She
tolerated the procedure well. Her wound vac was changed and
antibiotic course was changed from intravenous to oral therapy.
On ___ her antibiotic therapy regimen was completed and on ___
she was cleared for discharge to home at which time she
complained of mild lightheadedness while walking. Orthostatic
blood pressures were then checked. She also reported she
believed she would benefit for home physical therapy in addition
to visiting nurses, and case management was notified and
services arranged.
At the time of discharge, the patient was doing well. She was
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 with
services and received discharge teaching. A follow-up
appointment was made and discharge instructions were reviewed
with reported understanding and agreement. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
tramadol / Ultram / codeine / Demerol / Elavil / Elavil
Attending: ___.
Chief Complaint:
R hip pain
Major Surgical or Invasive Procedure:
Right hip aspiration
History of Present Illness:
Ms. ___ is a ___ with a PMH notable for Hep C, HIV on HAART,
prior heroin use on methadone therapy, bipolar disorder, ADHD,
HTN, and asthma presents with 6 weeks atraumatic right hip pain.
The patient reports that she went to an OSH 6 weeks ago where
she had an unremarkable hip xray and then had an MRI but is
uncertain of the results. She had a followup xray taken several
weeks later which showed collapse of the right femoral head and
she was sent to ___ where she was diagnosed with AVN and
referred to outpatient clinic. She is here today because she is
continuing to have severe pain and her appointment isn't until
___. The patient has been walking with a cane since 6
weeks ago due to pain and concern that she will fall, especially
since she lives alone in a ___ floor apartment. She has been
taking oxycodone 5mg q4hrs that doesnt help, daily methadone
that helps somewhat, and ibuprofen 600mg q3-4hrs x 6 weeks that
helps somewhat. She has peripheral neuropathy at baseline.
In the ED, initial vitals: 97.8 48 104/64 14 99%
- Exam notable for no ext ernal deformaty, edema, or ROM
deficits. 1+ ___ pulses, foot warm and well-perfused
- Labs notable for:
___ ___ aspiration femoral head consistent with AVN
___ Hip aspirate Prelim-No PMN, no micro
- Imaging notable for: XR: Dysmorphic, collapsed, flattened
right femoral head, compatible with advanced AVN. Mild lateral
subluxation of the right femoral head also present.
- Pt given: All home meds with the exception that Adderall was
held
- Vitals prior to transfer: 97.9 52 111/62 18 98%RA
On arrival to the floor, pt reports right hip pain, ___.
Endorses intermittent nausea due to pain.
ROS: She denies fever, chills, headache, chest pain, abdominal
pain, diarrhea, constipation, respiratory distress. She has
baseline abdominal distension due to HIV lipodystrophy
Past Medical History:
HTN
HLD
Bipolar
ADHD
Opiate abuse
Hep C
HIV - on HAART therapy
Social History:
___
Family History:
Not contributory.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- 97.2 120/553 16 97%RA
General- Alert, oriented, no acute distress while lying in bed
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2
Abdomen- soft, non-tender, quiet bowel sounds present, no
rebound tenderness or guarding, abdomen distended
GU- no foley
Ext- warm, well perfused, no clubbing, cyanosis or edema
Neuro- EOMI, tongue midline, face symmetric, motor function
grossly normal
Right lower extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender thigh and leg
- Patient unable to actively range hip due to pain. Full PROM
intact but painful. Full, painless AROM/PROM of knee, and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
- Patient reports TN palsy with foot drop, but patient has good
dosriflexion ability
Left lower extremity:
- Skin intact
- No deformity, erythema, edema, induration or ecchymosis
- Soft, non-tender thigh and leg
- Full, painless AROM/PROM of hip, knee, and ankle
- ___ fire
- SILT SPN/DPN/TN/saphenous/sural distributions
- 1+ ___ pulses, foot warm and well-perfused
Pertinent Results:
========LABS========
___ 09:23PM BLOOD WBC-4.4 RBC-3.81* Hgb-10.8* Hct-33.9*
MCV-89 MCH-28.3 MCHC-31.9* RDW-13.7 RDWSD-44.8 Plt ___
___ 09:23PM BLOOD ___ PTT-31.8 ___
___ 09:23PM BLOOD Glucose-112* UreaN-28* Creat-0.6 Na-139
K-3.3 Cl-98 HCO3-32 AnGap-12
___ 09:23PM BLOOD ALT-11 AST-14 AlkPhos-70 TotBili-0.8
___ 09:23PM BLOOD Calcium-9.3 Phos-2.5* Mg-1.7
___ 10:10AM BLOOD CRP-1.7
=======IMAGING =========
TECHNIQUE: AP view of the pelvis, and right femur, three views.
COMPARISON: None.
FINDINGS:
The right femoral head is dysmorphic, collapse, and flattened,
compatible with
advanced AVN. Mild lateral subluxation is also identified.
Significant right
hip degenerative joint disease with near complete loss of joint
space also
noted.
Mild osteoarthritic changes of the left hip and lower lumbar
spine are
identified, with joint space narrowing and osteophytosis. There
is also mild
osteoarthritis at the right knee, with a small posterior
flabella. No knee
joint effusion identified.
IMPRESSION:
Dysmorphic, collapsed, flattened right femoral head, compatible
with advanced
AVN. Mild lateral subluxation and significant DJD also noted at
the right
hip.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 600 mg PO Q6H:PRN Pain
2. Ranitidine 150 mg PO BID
3. Albuterol Inhaler 2 PUFF IH Q6H:PRN respiratory distress
4. Metoprolol Tartrate 50 mg PO BID
5. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
6. Atazanavir 300 mg PO DAILY
7. RiTONAvir 100 mg PO DAILY
8. Calcium Carbonate 600 mg PO BID
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Fenofibrate 145 mg PO DAILY
11. ClonazePAM 1 mg PO TID
12. Divalproex (DELayed Release) 250 mg PO QAM
13. Hydrochlorothiazide 25 mg PO DAILY
14. OxycoDONE (Immediate Release) 5 mg PO Q4-6H PRN Pain
15. Escitalopram Oxalate 40 mg PO QHS
16. Methadone 170 mg PO DAILY
17. dextroamphetamine-amphetamine 20 mg oral TID
18. Gabapentin 100 mg PO TID
19. Pregabalin 50 mg PO BID
20. Divalproex (DELayed Release) 500 mg PO QPM
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN respiratory distress
2. Atazanavir 300 mg PO DAILY
3. Calcium Carbonate 600 mg PO BID
4. ClonazePAM 1 mg PO TID
5. Divalproex (DELayed Release) 250 mg PO TID
6. Emtricitabine-Tenofovir (Truvada) 1 TAB PO DAILY
7. Escitalopram Oxalate 40 mg PO QHS
8. Fenofibrate 145 mg PO DAILY
9. Methadone 170 mg PO DAILY
10. Metoprolol Tartrate 50 mg PO BID
11. Multivitamins W/minerals 1 TAB PO DAILY
12. OxycoDONE (Immediate Release) 5 mg PO Q4-6H PRN Pain
RX *oxycodone 5 mg 1 tablet(s) by mouth q4hr Disp #*50 Tablet
Refills:*0
13. Pregabalin 50 mg PO BID
14. Ranitidine 150 mg PO BID
15. RiTONAvir 100 mg PO DAILY
16. Hydrochlorothiazide 25 mg PO DAILY
17. dextroamphetamine-amphetamine 20 mg ORAL TID
18. Gabapentin 100 mg PO TID
19. Ibuprofen 600 mg PO Q6H:PRN Pain
20. Bisacodyl 10 mg PO DAILY:PRN constipation
21. Docusate Sodium 100 mg PO BID:PRN Constipation
22. Enoxaparin Sodium 40 mg SC QPM
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 40 mg/0.4 mL 40 mg sc qpm Disp #*30 Syringe
Refills:*0
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: right femoral avascular necrosis
Secondary: Hep C, HIV, HTN, HLD, bipolar disorder, panic
disorder, ADHD
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: ORIF.
TECHNIQUE: One view right hip
COMPARISON: ___
FINDINGS:
There is a right total hip arthroplasty. There is a non cemented femoral
stem. No periprosthetic fracture or lucency is identified. Air in the soft
tissues is an expected postsurgical finding.
IMPRESSION:
Expected postsurgical findings status post right total hip arthroplasty.
Radiology Report
EXAMINATION: PELVIS (AP ONLY) PORT
INDICATION: ___ year old woman with R hip AVN s/p R THA // s/p THA
COMPARISON: ___,
FINDINGS:
Compared with the prior study, the patient has undergone placement of a right
total with a prosthesis, in overall anatomic alignment on this single AP view.
No periarticular fracture is detected.
Subcutaneous emphysema, soft tissue swelling common skin staples are present,
consistent with recent surgery.
A linear density overlies soft tissues of the medial proximal right thigh. It
is not clear whether this represents a catheter or something outside of the
the patient. Clinical correlation is requested.
Incidental note is made of hydroxyapatite or an enthesophyte at the left
ischial tuberosity, unchanged.
IMPRESSION:
As above.
Radiology Report
EXAMINATION: DX PELVIS AND FEMUR
INDICATION: ___ with right hip pain, OSH images concerning for AVN. Please
eval for AVN of the hip.
TECHNIQUE: AP view of the pelvis, and right femur, three views.
COMPARISON: None.
FINDINGS:
The right femoral head is dysmorphic, collapse, and flattened, compatible with
advanced AVN. Mild lateral subluxation is also identified. Significant right
hip degenerative joint disease with near complete loss of joint space also
noted.
Mild osteoarthritic changes of the left hip and lower lumbar spine are
identified, with joint space narrowing and osteophytosis. There is also mild
osteoarthritis at the right knee, with a small posterior flabella. No knee
joint effusion identified.
IMPRESSION:
Dysmorphic, collapsed, flattened right femoral head, compatible with advanced
AVN. Mild lateral subluxation and significant DJD also noted at the right
hip.
Radiology Report
EXAMINATION: INJ/ASP MAJOR JT W/FLUORO
INDICATION: ___ year old woman with right hip pain // arthrocentesis of right
hip
COMPARISON: Pelvic and right hip radiographs on ___.
PROCEDURE: The procedure was supervised by Dr. ___,
the attending radiologist, who was present for the critical portions of the
procedure.
The risks, benefits, and alternatives were explained to the patient and
written informed consent obtained.
A pre-procedure timeout confirmed three patient identifiers.
Under fluoroscopic guidance, an appropriate spot was marked. The area was
prepared and draped in standard sterile fashion.
3 cc 1% Lidocaine was used to achieve local anesthesia. Under intermittent
fluoroscopic guidance, an 18-gauge spinal needle was advanced into the right
hip joint. Approximately 3 cc of yellow fluid was aspirated from the right
hip joint. Samples were sent for cell count, crystal analysis, culture and
Gram stain.
The needle was removed, hemostasis achieved, and a sterile bandage applied.
The patient tolerated the procedure well and left the department in stable
condition. There were no immediate complications or complaints.
FINDINGS:
Dysmorphic, collapsed and flattened right femoral head consistent with AVN and
associated secondary degenerative changes.
IMPRESSION:
1. Imaging Findings - see above.
2. Procedure - Technically successful aspiration of the right hip joint.
I Dr. ___ personally supervised the Fellow during the key
components of the above procedure and I have reviewed and agree with the
Fellow findings/dictation.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Hip pain
Diagnosed with ASEPTIC NECROSIS FEMUR, JOINT PAIN-PELVIS, ASYMPTOMATIC HIV INFECTION
temperature: 97.8
heartrate: 48.0
resprate: 14.0
o2sat: 99.0
sbp: 104.0
dbp: 64.0
level of pain: 9
level of acuity: 3.0 | ___ is a ___ year old woman with a PMH notable for Hep
C, HIV on HAART, prior heroin use on methadone therapy, bipolar
disorder, ADHD, HTN, and asthma who presented due to
uncontrolled pain from her recently diagnosed right hip
avascular necrosis.
# Right femoral AVN:
She had been recently diagnosed as an outpatient and requiring
increased support for ambulation and activities of faily living
(using a cane, etc). She lives alone and had reached the point
where she felt her pain and limited mobility were no longer
compatible with living alone in a ___ floor apartment. She was
assessed by ___, who agreed. Ortho was consulted in the ED, who
aspirated the hip and ruled out infection. Her pain was
controlled with her usual methodone, as well as PRN oxycodone.
She went to the orthopedic surgery service with plan for right
total hip arthroplasty.
#HIV: On HAART therapy, which was continued (Truvada, Reyataz,
Norvir). No signs or symptoms of infection. Creatinine was WNL,
no dose adjustments needed.
#Hepatitis C: LFTs were within normal limits. She says she was
told to avoid acetaminophen and declined to take this for pain
control.
#HTN: Continued metoprolol 50mg and HCTZ 25mg.
#HLD: Continued Tricor 145mg daily.
#Methadone maintenance: Her home dose of 170mg daily was
comfirmed by the ED and continued without event in the hospital.
#Bipolar disorder: Continue Depakote 250mg q AM and 500mg q ___.
#Panic disorder: Continued Klonopin 1mg TID.
#ADHD: Held Adderall while inpatient given it is nonformulary
and she did not have her own medications.
# Right hip THA: pain well controlled with PRN oxycodone. She is
touchdown weight bearing on the right lower extremity, with
posterior hip precautions. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Lower extremity edema, dyspnea
Major Surgical or Invasive Procedure:
Right heart cath ___
Placement of ___ coronary sinus lead ___
History of Present Illness:
Mr. ___ is an ___ man with a history of heart
failure with reduced ejection fraction (EF 35%), right
ventricular dilation with free wall hypokinesis, moderate
tricuspid regurgitation, permanent atrial fibrillation on
rivaroxaban, chronotropic incompetence while in AF status post
single-chamber pacemaker (___), severe OSA, DMII, prostate
cancer status post TURP, chronic lower back pain, depression and
history of medication nonadherence who presents with lower
extremity swelling and shortness of breath concerning for heart
failure exacerbation.
Notably, he was hospitalized in ___ for heart failure
exacerbation in the setting of not taking any diuretics as an
outpatient. He was diuresed with furosemide boluses until being
transitioned to torsemide 10 mg PO daily. He was discharged on
losartan 50mg daily, metoprolol succinate 12.5 mg daily, and
spironolactone 12.5mg daily. He had persistent lower extremity
edema, at least partially attributable to venous insufficiency,
and was not willing to wear compression stockings or use ACE
wraps.
In ED, he reports dyspnea. He also reported swelling in his
bilateral legs that they were itchy. He also reported some pain
in the left side of his chest but does not remember when it
started. He says he thinks he took his medications today but is
not sure. Per his chart. He has had frequent admissions for
heart failure exacerbations that were likely due to medication
nonadherence.
In the ED initial vitals were:
T 97.9F HR 104 BP 180/111 RR 20 O2 97% RA
EKG: AF, V paced
Labs/studies notable for:
CBC unremarkable.
Cr 1.2 BUN 20, otherwise BMP unremarkable.
BNP 1219 (last admission: 1675)
INR 1.5
CXR
1. Mild pulmonary edema, similar to prior.
2. Indistinct left hemidiaphragm with patchy left lower lobe
opacities may reflect atelectasis, although pneumonia cannot be
excluded in the proper clinical setting.
Patient was given:
IV Furosemide 40 mg with significant urine output.
On the floor, the patient endorses the above history. He
reports
that he has been feeling short of breath for several days. This
is worse when he lies down and with exertion. He reports that
he
has been taking his medications as prescribed but notes that his
daughter has been out of town so things are more difficult for
him. He also notes that his legs are much more swollen than
usual. He denies any recent infectious symptoms such as
fever/chills, URI symptoms, nausea/vomiting/diarrhea. His chest
pain that he reported in the ED is now resolved.
REVIEW OF SYSTEMS:
Positive per HPI.
Past Medical History:
Diabetes (A1c 6.7 in ___
Atrial fibrillation w/slow ventricular rate on rivaroxaban
HFPEF
Post-op afib/flutter in ___, resolved
Prostate CA (s/p RRP/pelvic lymphadenectomy ___
Severe OSA
Secondary polycythemia
Osteoarthritis
Depression
Chronic distal sensorimotor polyneuropathy per ___ EMG
Impotence
(+)PPD
s/p R S2 dermatomal herpes zoster ___
(+) RPR/late latent syphilis treated ___ (doxycycline), ___
(PCN with desensitization)
s/p H. pylori-associated gastritis ___ (treated)
s/p arthroscopic rotator cuff repair ___
s/p anterior cervical decompression and fusion C3-C4
C5-C6/anterior cervical arthrodesis/posterior cervical
laminectomy
C4-C7/posterior cervical arthrodesis C3 to ___
s/p TKR RLE ___
s/p medial meniscectomy RLE ___
s/p LIH repair ___
Social History:
___
Family History:
-Maternal h/o cardiac disease, unspecified
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: T ___ PO BP 159/80 L Lying HR 61 RR 20 ___
GENERAL: Pleasant man in no acute distress. Fully oriented.
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. No pallor or cyanosis of the oral mucosa.
No xanthelasma.
NECK: Supple. JVP elevated to midneck.
CARDIAC: Irregularly irregular. Normal S1, S2. No murmurs, rubs,
or gallops.
LUNGS: No chest wall deformities or tenderness. Respiration is
unlabored with no accessory muscle use. Bibasilar crackles
present. No wheezes or rhonchi.
ABDOMEN: Soft, non-tender, distended.
EXTREMITIES: Warm, well perfused. 4+ pitting edema to sacrum
bilaterally. No clubbing, cyanosis.
SKIN: No significant skin lesions or rashes.
PULSES: Distal pulses palpable and symmetric.
DISCHARGE PHYSICAL EXAM:
========================
GENERAL: Elderly gentleman sitting up in chair, NAD
NECK: JVP 10 at 90 degrees.
CARDIAC: Regular rate and rhythm, no murmurs.
LUNGS: Vesicular breath sounds bilaterally.
ABD: Large, mildly distended, non-tender to palpation
EXTREMITIES: improvement in bilateral lower extremity edema,
though still distended. There is significant discoloration with
skin appearing dark red/purple. The extremities are warm.
Pertinent Results:
ADMISSION LABS:
==============
___ 10:12PM BLOOD WBC-6.5 RBC-5.12 Hgb-14.2 Hct-48.2 MCV-94
MCH-27.7 MCHC-29.5* RDW-15.9* RDWSD-55.0* Plt ___
___ 10:12PM BLOOD Neuts-65.2 ___ Monos-8.3 Eos-4.8
Baso-0.8 Im ___ AbsNeut-4.23 AbsLymp-1.34 AbsMono-0.54
AbsEos-0.31 AbsBaso-0.05
___ 10:12PM BLOOD ___ PTT-33.6 ___
___ 10:12PM BLOOD Glucose-129* UreaN-20 Creat-1.2 Na-138
K-4.8 Cl-105 HCO3-24 AnGap-9*
___ 10:12PM BLOOD Calcium-9.0 Phos-2.9 Mg-2.0
___ 11:26PM BLOOD Na-142 K-3.8
DISCHARGE LABS:
===============
___ 06:36AM BLOOD WBC-6.5 RBC-5.04 Hgb-14.0 Hct-45.9 MCV-91
MCH-27.8 MCHC-30.5* RDW-15.7* RDWSD-53.0* Plt ___
___ 06:36AM BLOOD ___ PTT-38.0* ___
___ 06:36AM BLOOD Glucose-103* UreaN-42* Creat-1.3* Na-141
K-4.9 Cl-99 HCO3-25 AnGap-17
___ 06:36AM BLOOD Calcium-9.6 Phos-3.4 Mg-2.4
STUDIES:
=======
CXR - ___:
IMPRESSION:
1. Mild pulmonary edema, similar to prior.
2. Indistinct left hemidiaphragm with patchy left lower lobe
opacities may
reflect atelectasis, although pneumonia cannot be excluded in
the proper
clinical setting.
RIGHT ___ ___
IMPRESSION:
No evidence of deep venous thrombosis in the right lower
extremity veins.
ABDOMINAL ULTRASOUND ___
IMPRESSION:
1. No focal liver lesion identified. No biliary dilatation.
2. Mild splenomegaly.
3. No ascites visualized in the abdomen.
RIGHT HEART CATH ___
Label Systolic Diastolic Mean dP/dt A wave V Wave
AO 121 69 86
PA 53 19 31
PCW 15 13 27
RA 12 19 9
RV 45 1 14 432
CORONARY SINUS LEAD PLACEMENT ___
Left pectoral pocket was opened and old MDT Sensia SR was
extracted with no difficulty.
Left subclavian v. access via Seldinger:
MDT ___ LV lead to posterolateral LV. Local delay 160 msec.
New MDT ___ CRT-P implanted in same pocket.
No complications.
CHEST X-RAY ___
IMPRESSION:
Mild cardiomegaly with the left basilar and retrocardiac
opacification.
Atelectasis versus pleural effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 40 mg PO QPM
3. Escitalopram Oxalate 20 mg PO DAILY
4. Losartan Potassium 50 mg PO DAILY
5. Torsemide 10 mg PO DAILY
6. GlipiZIDE XL 2.5 mg PO DAILY
7. Metoprolol Succinate XL 12.5 mg PO DAILY
8. Rivaroxaban 15 mg PO DAILY
9. Spironolactone 12.5 mg PO DAILY
Discharge Medications:
1. Cephalexin 500 mg PO/NG Q8H Duration: 5 Days
2. Losartan Potassium 25 mg PO DAILY
3. Rivaroxaban 20 mg PO DINNER
4. Spironolactone 25 mg PO DAILY
5. Torsemide 20 mg PO DAILY
6. Aspirin 81 mg PO DAILY
7. Atorvastatin 40 mg PO QPM
8. Escitalopram Oxalate 20 mg PO DAILY
9. Metoprolol Succinate XL 12.5 mg PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY:
- Acute heart failure reduced ejection fraction from ventricular
dyssynchrony
SECONDARY:
- Atrial fibrillation
- Acute kidney injury
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ male with history of CHF who presents with signs of
volume overload, assess for evidence of heart failure
TECHNIQUE: Chest PA and lateral
COMPARISON: Multiple prior chest radiographs, most recently ___
FINDINGS:
Left-sided pacer device is again noted with lead in unchanged position within
the right ventricle. Moderate enlargement of the cardiac silhouette is
stable. Mild pulmonary edema appears overall similar to prior. Indistinct
left hemidiaphragm with patchy left lower lobe opacities, better seen on the
lateral projection, may reflect atelectasis, although pneumonia cannot be
excluded in the proper clinical setting.
Mild-to-moderate degenerative changes are again seen throughout the thoracic
spine. Cervical spinal fusion hardware is incompletely assessed, although
their is unchanged fracture through the pedicular screws of the T1 level.
IMPRESSION:
1. Mild pulmonary edema, similar to prior.
2. Indistinct left hemidiaphragm with patchy left lower lobe opacities may
reflect atelectasis, although pneumonia cannot be excluded in the proper
clinical setting.
Radiology Report
EXAMINATION: UNILAT LOWER EXT VEINS RIGHT PORT
INDICATION: ___ year old man admitted for HF exacerbation with BLE edema now
with asymmetry in color, significant pain to palpation right leg and with
right dorsiflexion. Evaluation for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: Comparison to bilateral lower extremity venous ultrasound from ___.
FINDINGS:
There is normal compressibility, color flow, and spectral doppler 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
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old man with abdominal distention and bloating and lower
extremity edema out of proportion to JVP and concern for possible intra
abdominal tumor, will start with u/s and consider CT pending results//
Evaluate for ascites
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 a small hyperechoic avascular lesion in the
left lobe of the liver which likely represents a hemangioma. No suspicious
liver lesion is visualized. The main portal vein is patent with hepatopetal
flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation.
CHD: 4 mm
GALLBLADDER: The gallbladder is partially contracted. No gallstones are
visualized.
PANCREAS: The pancreas is unremarkable but is only minimally visualized due to
overlying bowel gas.
SPLEEN: Normal echogenicity.
Spleen length: 13.1 cm
KIDNEYS: Normal cortical echogenicity and corticomedullary differentiation is
seen bilaterally. There is no evidence of masses, stones, or hydronephrosis
in the kidneys.
Right kidney: 10.5 cm
Left kidney: 9.2 cm
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. No focal liver lesion identified. No biliary dilatation.
2. Mild splenomegaly.
3. No ascites visualized in the abdomen.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with CMP ___ CRT-P upgrade// r/o pneumothorax.
TECHNIQUE: Portable chest AP.
COMPARISON: Chest radiograph from ___.
FINDINGS:
Left upper chest pacing device and leads are in similar configuration. Lung
volumes are low. Prominent central pulmonary vascular and perihilar
interstitial markings, compatible with mild to moderate pulmonary edema.
Bibasilar densities with prominent retrocardiac density largely obscuring the
left hemidiaphragm may reflect a combination of atelectasis, edema, and
pleural effusion, better seen on lateral projection in the prior study. There
is no pneumothorax. Cardiomediastinal silhouette is similarly enlarged.
There is no pneumothorax.
Cervical fusion hardware is partially imaged.
IMPRESSION:
-Similar to slightly increased mild-to-moderate pulmonary edema.
-No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man with CMP ___ CRT-P upgrade// lead position
lead position
COMPARISON: Chest x-ray ___
FINDINGS:
Left chest wall dual lead pacer and leads unchanged in positioning. The heart
remains enlarged. Right costophrenic angle is sharp. There is blunting of
the left costophrenic angle with retrocardiac opacification which could
represent atelectasis or effusion. No pneumothorax. Mild pulmonary vascular
congestion.
IMPRESSION:
Mild cardiomegaly with the left basilar and retrocardiac opacification.
Atelectasis versus pleural effusion.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea, Leg swelling
Diagnosed with Heart failure, unspecified, Dyspnea, unspecified
temperature: 97.9
heartrate: 104.0
resprate: 20.0
o2sat: 97.0
sbp: 180.0
dbp: 111.0
level of pain: 5
level of acuity: 2.0 | ___ man with a history of heart failure with newly
reduced ejection fraction (EF 35%), right ventricular dilation
with free wall hypokinesis, moderate tricuspid regurgitation,
permanent atrial fibrillation on rivaroxaban, chronotropic
incompetence while in AF status post single-chamber pacemaker
(___), and DMII presenting with lower extremity edema and
dyspnea consistent with heart failure exacerbation. He was found
to have newly reduced ejection fraction this admission, which
was attributed to dependence on single chamber pacing causing
dyssynchrony. He was taken for biventricular pacemaker placement
on ___. He was restarted on maintenance diuresis and discharged
with plan for close followup.
CORONARIES: recent negative stress test; declined cath in past
PUMP: 35%
RHYTHM: AF, V-paced |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Compazine / Sulfur / Vicodin / Morphine / Penicillins
/ Macrodantin / Iodine / Clindamycin / azithromycin / Cipro
Attending: ___.
Chief Complaint:
left lower extremity swelling for past two days
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with ___, CKD stage 4, LLE DVT ___
complicated by BRBPR now off coumadin who presents with two day
history of left lower extremity swelling noted by her daughter
who is a ___. She does not report chest pain, shortness of
breath, orthopnea, paroxysmal noctural dyspnea, long travels,
plain rides, trauma or BRBPR.
In the ED, initial VS 99.5 72 157/91 18 99% RA. Labs notable for
creatinine of 1.8 (baseline) and BNP in 6000s (better than
baseline in 9000s). LLE US showed left common femoral and
femoral vein similar to ___ and thus started on IV heparin
without bolus and admitted to medicine for further management.
On the floor, she reported no complains.
Past Medical History:
___: EF 75-80%
LLE DVT off comuadin secondary to BRBPR
Hyperlipidemia
Hyperparathyroid
Hypothyroid
PMR
CRI
venous insufficiency
hx aspiration pna
Social History:
___
Family History:
Mother deceased of stroke. Husband deceased of stroke. No other
known family hx of clot
Physical Exam:
Physical Exam on admission:
VS - 97.5 200/78 60 99%RA
GENERAL - Alert, interactive, well-appearing woman in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - Left lower extremity 2 cm bigger than right lower
extremity
NEURO - awake, A&Ox2, CNs II-XII grossly intact
Physical Exam on discharge:
VS - T 98.2 BP 176/73 P 67 RR 18 96% RA
GENERAL - Alert, interactive, well-appearing woman in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MMM, OP clear
HEART - RRR, nl S1-S2, no MRG
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored
ABDOMEN - NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - Left lower extremity 2 cm larger than right lower
extremity
NEURO - awake, A&Ox2, CNs II-XII grossly intact
Pertinent Results:
Labs on admission:
___ 10:30PM BLOOD WBC-11.8* RBC-3.30* Hgb-9.6* Hct-30.1*
MCV-91 MCH-29.0 MCHC-31.8 RDW-17.1* Plt ___
___ 10:30PM BLOOD Neuts-82.0* Lymphs-14.0* Monos-3.5
Eos-0.4 Baso-0.1
___ 10:38PM BLOOD ___ PTT-21.5* ___
___ 10:30PM BLOOD Glucose-118* UreaN-44* Creat-1.8* Na-138
K-5.0 Cl-105 HCO3-21* AnGap-17
___ 10:30PM BLOOD CK(CPK)-35
___ 10:30PM BLOOD CK-MB-4 cTropnT-0.03* proBNP-___*
___ 06:10AM BLOOD Calcium-8.8 Phos-3.6 Mg-2.4
___ 01:18PM BLOOD D-Dimer-5751*
___ 12:24PM BLOOD D-Dimer-5485*
Labs on discharge:
___ 06:10AM BLOOD WBC-10.0 RBC-3.40* Hgb-10.0* Hct-31.1*
MCV-92 MCH-29.5 MCHC-32.2 RDW-17.0* Plt ___
___ 06:10AM BLOOD Neuts-66.9 ___ Monos-4.3 Eos-2.0
Baso-0.2
___ 06:10AM BLOOD Glucose-80 UreaN-40* Creat-1.8* Na-141
K-4.3 Cl-105 HCO3-27 AnGap-13
CXR ___:
AP AND LATERAL CHEST RADIOGRAPHS: Lungs are reasonably well
expanded with persistent right lower lung opacity decreased in
conspicuity from the previous examination, which could reflect
scarring from prior pneumonia; however, recurrent pneumonia
cannot be excluded. Interstitial prominence likely reflects
chronic pulmonary disease. Cardiomegaly and dual-lead pacer are
=unchanged with extensive atherosclerotic calcification of the
aorta. Trace right effusion or pleural thickening may also be
present.
IMPRESSION: Right lower lobar opacity could reflect scarring
from prior
pneumonia, though recurrent pneumonia cannot be excluded.
___ ___:
IMPRESSION: Chronic-appearing thrombus of the left CFV and
superficial
femoral vein with incompletely assessed calf veins bilaterally.
No right
lower extremity DVT was seen.
Medications on Admission:
ACETAMINOPHEN 650 mg Q8H PRN pain
Amlodipine 2.5 mg po qhs
Ascorbic acid ___ mg po qdaily
Carvedilol 3.125 mg po qhs
Cetirizine 10 mg po qhs
Vitamin D3 1,000 unit po qdaily
Ferrous sulfate 325 mg po qdaily
Levothyroxine 88 mcg po qdaily
Lidocaine patch daily
Multivitamin po qdaily
Omeprazole 40 mg po qdaily
Miralax daily
Prednisone 15 mg po qdaily
Sennosides 8.6 mg po BID
Aloe Vesta BID
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO TID (3
times a day) as needed for pain.
2. amlodipine 2.5 mg Tablet Sig: One (1) Tablet PO HS (at
bedtime).
3. ascorbic acid ___ mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO QHS (once a
day (at bedtime)).
5. cetirizine 10 mg Tablet Sig: One (1) Tablet PO once a day.
6. cholecalciferol (vitamin D3) 1,000 unit Tablet Sig: One (1)
Tablet PO DAILY (Daily).
7. ferrous sulfate 300 mg (60 mg iron) Tablet Sig: One (1)
Tablet PO DAILY (Daily).
8. levothyroxine 88 mcg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
9. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
10. multivitamin,tx-minerals Tablet Sig: One (1) Tablet PO
DAILY (Daily).
11. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: Two (2)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
12. polyethylene glycol 3350 17 gram Powder in Packet Sig: One
(1) Powder in Packet PO DAILY (Daily).
13. prednisone 5 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
14. senna 8.6 mg Tablet Sig: One (1) Tablet PO twice a day.
15. Aloe Vesta 2 % Ointment Sig: One (1) Topical twice a day.
16. aspirin 81 mg Tablet, Delayed Release (E.C.) Sig: One (1)
Tablet, Delayed Release (E.C.) PO once a day.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Chronic Deep Venous Thrombosis
Secondary:
Hypertension
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with left leg swelling. Assess for DVT.
COMPARISONS: ___.
FINDINGS: Grayscale and color Doppler sonographic evaluation was performed of
the bilateral lower extremities. The left common femoral and superficial
femoral veins were incompletely compressible with internal echogenic material
compatible with thrombus in a similar appearance to the recent comparison,
though on the current examination no thrombus was seen in the left popliteal
vein. The right common femoral, superficial femoral and popliteal veins were
normal with normal compressibility and flow. The calf veins were incompletely
seen with a single peroneal and posterior tibial veins seen bilaterally, which
were patent.
IMPRESSION: Chronic-appearing thrombus of the left CFV and superficial
femoral vein with incompletely assessed calf veins bilaterally. No right
lower extremity DVT was seen. This was discussed with Dr. ___ by Dr. ___
at 2320 on ___ by phone.
Radiology Report
INDICATION: ___ woman with chest pain.
COMPARISONS: ___.
AP AND LATERAL CHEST RADIOGRAPHS: Lungs are reasonably well expanded with
persistent right lower lung opacity decreased in conspicuity from the previous
examination, which could reflect scarring from prior pneumonia; however,
recurrent pneumonia cannot be excluded. Interstitial prominence likely
reflects chronic pulmonary disease. Cardiomegaly and dual-lead pacer are
unchanged with extensive atherosclerotic calcification of the aorta. Trace
right effusion or pleural thickening may also be present.
IMPRESSION: Right lower lobar opacity could reflect scarring from prior
pneumonia, though recurrent pneumonia cannot be excluded.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: LT, CALF SWELLING
Diagnosed with ACUTE VENOUS EMBOLISM AND THROMBOSIS OF UNSPECIFIED DEEP VESSELS OF LOWER EXTREMITY, CHEST PAIN NOS, ATRIAL FIBRILLATION
temperature: 99.5
heartrate: 72.0
resprate: 18.0
o2sat: 99.0
sbp: 157.0
dbp: 91.0
level of pain: 5
level of acuity: 3.0 | ___ year old female with dCHF, CKD stage 4, LLE DVT ___
complicated by BRBPR s/p discontinuation of coumadin in ___
who presents with a two day history of left lower extremity
swelling, found to have persistent DVT on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
___ ERCP
___ Laparoscopic Cholecystectomy
History of Present Illness:
Mrs ___ is a pleasant ___ woman who presented to ___
___ on day of admission with complaints of nausea, NBNB
vomiting, and intermittent RUQ abd pain. She states that the
nausea was worse than the abd pain, which was moderate in
severity. Her last episode of emesis was on ___, however
the nausea has been present for the last ___ days, and the abd
pain started last night. She has had poor PO intake because of
her sxs, however is now feeling improved with the fluids and
anti-emetics that she received in the ED. No fevers, chills, no
previous history of abdominal pain. Last BM was 2 ays PTA and
was loose. She presented to the ED today because her urine was
become darker and she was concerned that she was becoming more
dehydrated.
At ___, labs were notable for: ALT: 813 AP: 596 Tbili:
4.61 Alb: 4.3 AST: 514 TProt: 7.2 ___: Lip: 1050. US showed
cholelithiasis without other sonographic evidence of acute
cholecystitis as well as dilated intra and extra hepatic bile
ducts. She was given zosyn, IVF and transferred to ___ for
ERCP.
In our ED, initial vs were 98.2 76 131/77 16 100% RA. She was
seen by surgery who recommended ERCP consult. ERCP evaluated
the pt in the ED and recommended medicine admission for ERCP in
the AM. Vitals on transfer were 98.7 70 130/83 16 97%.
On arrival to the floor, she is comfortable and has no
complains. Denies N/V/abd pain presently.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies diarrhea, constipation. No
recent change in bowel or bladder habits. No dysuria, frequency.
Denies arthralgias or myalgias. Ten point review of systems is
otherwise negative.
Past Medical History:
--HTN
--Anxiety/depression
Social History:
___
Family History:
HTN, mom with cardiac disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T:98.2 BP:137/87 P:77 R:16 O2:98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfusedno clubbing, cyanosis or edema
Skin: no rashes/lesions
Neuro: CNs ___ intact, moving all extremities
On discharge:
VS 98.6, 80, 116/70, 14, 96% on room air
Pertinent Results:
___ labs ___:
WBC 8.4
HCT 38.0
PLT 299
HCG Neg
Na 135
K 3.7
Cl 96
CO2 30
Glu 118
BUN 11
Cr 0.46
Ca ___
Mg 1.92
Alb 4.3
TP 7.2
BILI 4.6
ALP 596
ALT 813
AST 514
Lipase 1050
UA +bili, + nitrite, +leuk esterase
STUDIES:
___ RUQ US
1. CHOLELITHIASIS WITHOUT OTHER SONOGRAPHIC EVIDENCE OF ACUTE
CHOLECYSTITIS.
2. DILATED INTRA- AND EXTRAHEPATIC BILE DUCTS. PLEASE NOTE
THAT A DISTAL DUCT STONE CANNOT BE EXCLUDED. IF THERE IS
CONCERN FOR CHOLEDOCHOLITHIASIS, MRCP SHOULD BE OBTAINED.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lisinopril 10 mg PO DAILY
Please hold for SBP <100.
2. Atenolol 50 mg PO DAILY
Please hold for SBP <100 or HR <50.
3. Paroxetine 30 mg PO DAILY
Discharge Medications:
1. Atenolol 50 mg PO DAILY
2. Lisinopril 10 mg PO DAILY
3. Paroxetine 30 mg PO DAILY
4. 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
5. Docusate Sodium 100 mg PO BID
6. Acetaminophen 650 mg PO Q6H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
1. Choledocholithiasis
2. Cholelithiasis
3. Pancreatitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ woman with gallstone pancreatitis. REASON FOR THIS
EXAMINATION: Please evaluate if patient passed stone.
COMPARISON: None available
TECHNIQUE: Multiplanar T1 and T2 weighted images were acquired on a 1.5 tesla
magnet, including dynamic 3D imaging, obtained prior to, during, and after the
uneventful intravenous administration of 0.1 mmol/kg (7 cc) of Gadavist
gadolinium contrast. Patient also received 2.5 cc of Gadavist gadolinium in
75 cc of water for oral contrast.
FINDINGS:
Patient is apparently status post ERCP the morning prior to this study,
although report is not available at this time. There is persistent moderate
diffuse intrahepatic and extrahepatic biliary ductal dilatation, the common
bile duct measures 10 mm in diameter. There is diffuse peribiliary enhancement
consistent with cholangitis, including enhancement about the intrahepatic and
extrahepatic bile ducts as well as the gallbladder wall. In the more inferior
common bile duct is a small likely partially obstructing hypointense calculus
measuring 6 mm in diameter. 2 smaller filling defects are seen superior and
inferior to this lesion, these may represent additional nonobstructing
calculi. Smaller filling defects are also seen in the distalmost common bile
duct near the ampulla, with note also made of ampullary edema and hyperemia.
No evidence of abscess formation. The gallbladder is nondistended but filled
with sludge and stones with wall hyperenhancement which may represent
secondary or chronic cholecystitis. 6 mm simple appearing cyst in the left
hepatic lobe. There is minimal dilatation of the pancreatic duct measuring 4
mm. Mild fat stranding is seen surrounding the pancreatic head. The
pancreatic parenchyma appears to have preserved enhancement.
Bilateral simple appearing renal cortical cysts measuring up to 8 mm in the
right upper pole. Spleen, pancreas, bilateral adrenal glands appear
unremarkable. Normal caliber abdominal aorta. No evidence of significant
lymphadenopathy. Visualized small and large bowel appear unremarkable. No
evidence of ascites. Small fat containing umbilical hernia.
IMPRESSION:
1. Persistent moderate intrahepatic and extrahepatic biliary ductal
dilatation suggestive of distal CBD obstruction. Multiple common bile duct
stones measuring up to 6 mm in the inferior common bile duct, with small
stones seen near the ampulla, along with ampullary edema and minimal
pancreatic ductal prominence. Cannot exclude tiny stone impacted at the
ampulla. Extensive cholelithiasis.
2. Findings suggestive of associated cholangitis with secondary or chronic
cholecystitis.
Radiology Report
INDICATION: History of cholelithiasis and choledocholithiasis and gallstone
pancreatitis. Status post laparoscopic cholecystectomy.
COMPARISONS: MRCP from ___.
FINDINGS: Four fluoroscopic spot views from an intraoperative cholangiogram
are submitted for review without the presence of a radiologist. These
demonstrate opacification of the common bile duct, common hepatic duct, and
cystic duct. The common bile duct and the common hepatic duct appear dilated.
There are no filling defects. For further details, please refer to the
intraoperative note.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: DIARRHEA
Diagnosed with CHOLELITHIASIS NOS, HYPERTENSION NOS
temperature: 98.2
heartrate: 76.0
resprate: 16.0
o2sat: 100.0
sbp: 131.0
dbp: 77.0
level of pain: 0
level of acuity: 3.0 | This is a ___ woman with a past medical history
significant for HTN, anxiety, and depression, who is admitted
with cholelithiasis, choledocholithiasis, and gallstone
pancreatitis.
# CHOLELITHIASIS, CHOLEDOCHOLITHIASIS, GALLSTONE PANCREATITIS:
Mrs ___ is a pleasant ___ woman with a history of
hypertension and anxiety who is admitted with pancreatitis in
the setting of choledocholithiais. Patient initially presented
to ___ with abdominal pain and dark urine. At ___,
labs were significant for: ALT: 813 AP: 596 Tbili: 4.61 Alb: 4.3
AST: 514 TProt: 7.2 ___: Lip: 1050. US showed cholelithiasis
without other sonographic evidence of acute cholecystitis as
well as dilated intra and extra hepatic bile ducts. An MRCP
done on ___ confirmed that there were still stones in the CBD
and dilated ducts. The patient went for an MRCP on ___ which
demonstrated CBD stone. The stone was extracted, a
sphincterotomy was performed and she was transferred to surgery
for a cholecystectomy. On ___ the patient underwent a
laparoscopic cholecystectomy. She was taken to the operating
room and underwent a laparoscopic cholecystectomy. Please see
operative report for details of this procedure. She tolerated
the procedure well and was extubated upon completion. She we
subsequently taken to the PACU for recovery.
She was transferred to the surgical floor hemodynamically
stable. Her vital signs were routinely monitored and she
remained afebrile and hemodynamically stable. She was initially
given IV fluids postoperatively, which were discontinued when
she was tolerating PO's. Her diet was advanced on the morning of
___ to regular, which she tolerated without abdominal pain,
nausea, or vomiting. 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. Her pain level was routinely assessed and well
controlled at discharge with an oral regimen as needed.
# POSITIVE U/A: Patient with positive u/a at ___. She
was asymptomatic and was not treated for UTI. Microbiology
report pending.
# HTN, BENIGN: Patient was continued on atenolol and
lisinopril.
# DEPRESSION: Patient was continued on paroxetine.
On the afternoon of ___, Mrs. ___ was ambulating from the
bathroom to her bed when she became "dizzy" and fell forward on
to her knees. This was witnessed by her roommate. The patient
denied any LOC or head strike. She was assised to bed and
placed in the supine position. Her SBP was approximately 115
and her blood gluocse level was 126. She felt better once she
was settled in bed. She was given a liter of fluid for likely
orthostasis and placed on telemetry to assess for any
dysrhythmias. A complete blood count and basic metabolic panel
was obtained. Results were within normal limits.
On the morning of ___, Mrs. ___ felt much better than the
prior day. She had no further episodes of dizziness on
ambulation. Telemetry showed her in sinus rhythm and no ectopy
was observed. Nursing and the patient's husband ambulated with
the patient during the day and she did well. Mrs. ___ was
tolerating a regular diet and voiding without issue.
On the afternoon of ___, Mrs. ___ was discharged home in
the care of her husband. She was afebrile, hemodynamically
stable and in no acute distress. She was discharged home with
scheduled follow up in ___ 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:
shortness of breath, lightheadedness
Major Surgical or Invasive Procedure:
+ Aortic Valvuloplasty - ___
History of Present Illness:
___ w/h/o critical aortic stenosis, CAD, CHF, presents from
assisted living facility with SOB.
Yesterday she reports that she had a "weak spell" a/w nausea,
diaphoresis, and exertional dyspnea, but no chest pain. Brought
to ___ ___ "abnormal vital signs", where EKG showed mild new
lateral TWI, negative initial troponin BNP 300. Concerning for
decompensating AS vs. unstable angina. Pt's outpt cardiologist
had scheduled her for balloon valvuloplasty in ___
contacted cards at ___ regarding transfer w/ concern that
procedure may need to be scheduled more urgently.
In the ED initial vitals were: 98.7 88 112/56 18 97% RA. Labs
were significant for hg 8.7 down from baseline of 10, neg
troponin X 1, pro BNP 6143. CXR showed pulmonary edema w/ R
pleural effusion.
On floor pt is comfortable, oriented, no SOB or acute distress.
Her only complaint is poor sleep.
Review of Systems:
(+) per HPI
(-) fever, chills, night sweats, headache, vision changes,
rhinorrhea, congestion, sore throat, cough, chest pain,
abdominal pain, nausea, vomiting, diarrhea, constipation, BRBPR,
melena, hematochezia, dysuria, hematuria.
Past Medical History:
CAD s/p STEMI ___ with BMS to RCA
Hyperlipidemia
Hypertension
GERD
COPD
Hypothyroidism
h/o rheumatic fever
Severe AS s/p balloon angioplasty in ___
Social History:
___
Family History:
Brother with rheumatic heart disease, died of MI in ___ mother
with MI in ___
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals - 98.6 130-143/41-58 ___ 16 95-96RA
GENERAL: NAD, very hard of hearing, AAOx3 HEENT: AT/NC, EOMI,
anicteric sclera, pink conjunctiva, patent nares, MMM, dental
plate
NECK: supple neck, no JVD
CARDIAC: RRR, ___ SEM best heard in LUSB
LUNG: mild crackles throughout, greatest in bases, breathing
comfortably without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: trace pitting edema in ___. Moving all
extremities well. Ecchymosis and mild edema over dorsum of L
hand at site of blood draw
NEURO: no focal deficits.
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
Vitals - 98.4 108-140/40-50 ___ 18 93-98% on RA
I/O: ___ NET -600
GENERAL: AAOx3, NAD.
HEENT: MMM, dentures in place
NECK: supple neck, no JVD
CARDIAC: RRR, ___ SEM best heard in LUSB. Pulses not delayed or
soft.
LUNG: CTAB ___, no accessory muscle use
ABDOMEN: nondistended, mildly tender in RLQ, otherwise
nontender.
EXTREMITIES: no edema in ___. Moving all extremities well.
The right femoral artery access site has resolving ecchymosis,
non-tender and without induration. Distal dorsalis pedis and
posterior tibial pulses are easily palpable and 2+ bilaterally.
Feet well perfused, <1 sec cap refill.
NEURO: no focal deficits. full strength, normal sensation.
Oriented and appropriate
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
ADMISSION LABS:
___ 06:00PM BLOOD WBC-7.8 RBC-2.73* Hgb-8.7* Hct-26.5*
MCV-97 MCH-32.0 MCHC-32.9 RDW-14.3 Plt ___
___ 06:00PM BLOOD Neuts-78.4* Lymphs-12.7* Monos-7.3
Eos-1.4 Baso-0.2
___ 10:00AM BLOOD ___ PTT-53.1* ___
___ 06:00PM BLOOD Glucose-108* UreaN-25* Creat-1.0 Na-137
K-4.8 Cl-105 HCO3-23 AnGap-14
___ 06:10AM BLOOD Calcium-9.8 Phos-2.9 Mg-1.9
___ 06:00PM BLOOD CK-MB-4 proBNP-6143*
___ 06:00PM BLOOD cTropnT-<0.01
___ 10:00AM BLOOD CK-MB-3 cTropnT-<0.01
DISCHARGE LABS:
___ 09:45AM BLOOD WBC-9.6 RBC-3.82* Hgb-11.9* Hct-37.1
MCV-97 MCH-31.2 MCHC-32.2 RDW-14.9 Plt ___
___ 09:45AM BLOOD Plt ___
___ 09:45AM BLOOD Glucose-137* UreaN-36* Creat-1.2* Na-141
K-4.9 Cl-105 HCO3-23 AnGap-18
___ 09:45AM BLOOD Calcium-8.9 Phos-2.6* Mg-2.2
STUDIES:
+ CXR: Widespread bilateral interstitial opacities are new since
the prior exam and consistent with mild interstitial pulmonary
edema. A small right pleural effusion is present with bibasilar
opacities consistent with atelectasis. No focal consolidation
or pneumothorax. The heart size is mildly enlarged and there is
calcification of the aortic knob. Right rib deformities are
consistent with chronic fractures. Osseous structures are
diffusely demineralized with multiple thoracic and lumbar spine
compression deformities, of indeterminate age.
IMPRESSION:
1. Mild interstitial pulmonary edema with small right pleural
effusion.
2. Mild cardiomegaly.
3. Multiple thoracolumbar spine compression deformities of
indeterminate age.
+ EKG: NSR @ 86. Normal axis. Normal intervals. LAE, LVH.
+ Aortic Valvuloplasty: Assessment & Recommendations
1.Severe aortic stenosis
2.Successful balloon aortic valvuloplasty using a 23 mm Tyskak
II balloon
3.Medical therapy
+ ECHO:
Overall left ventricular systolic function is mildly depressed
(LVEF= 45%). Right ventricular chamber size and free wall motion
are normal. The aortic valve leaflets are severely
thickened/deformed. The aortic valve VTI = 91 cm. There is
severe aortic valve stenosis (valve area <1.0cm2). Trace aortic
regurgitation is seen. There is no pericardial effusion.
IMPRESSION: Focused study/limited views. Severe aortic stenosis.
Mildly depressed global left ventricular systolic function.
Compared with the prior study (images reviewed) of ___, the
___ has increased in size from 0.5 cm2 to 0.7 cm2 secondary to
an interval percutaneous balloon valvuloplasty. Given the
limited nature of the current study a comprehensive comparison
of all previously assessed parameters could not be made.
+ CT Abdomen:
There is a large, retroperitoneal hematoma seen originating from
the right
inguinal region in the vicinity of the patient's known right
common femoral
artery aneurysm. The retroperitoneal hematoma extends superiorly
to the level
of the anterior superior iliac spine, and measures approximately
4.4 x 4.0 x
10.6 cm (AP x TRV x CC, 3:60 and 4b:15). The urinary bladder is
grossly
unremarkable. Bilateral inguinal hernias are noted, fat
containing on the
right and bowel-containing on the left. There is no pelvic
side-wall or
inguinal lymphadenopathy by CT size criteria.
OSSEOUS STRUCTURES: Multilevel, multifactorial degenerative
changes are seen
throughout the visualized thoracolumbar spine. The patient is
status post
left hip arthroplasty, and right femoral neck ORIF. No focal
lytic or
sclerotic lesion concerning for malignancy.
IMPRESSION:
1. Large, right retroperitoneal hematoma extending from the
right inguinal
region through the iliacus muscle plane up to the anterior
superior iliac
spine.
2. Extensive colonic diverticulosis.
3. Severe atherosclerotic calcifications of the aorta and its
major branches.
4. Bilateral inguinal hernias.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Alendronate Sodium 70 mg PO QMON
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
6. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
7. Levothyroxine Sodium 75 mcg PO DAILY
8. Lisinopril 5 mg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Omeprazole 20 mg PO DAILY
11. Vitamin D 1000 UNIT PO DAILY
12. Os-Cal 500 + D3 (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral daily
13. Multivitamins 1 TAB PO DAILY
14. Acetaminophen 325-650 mg PO Q6H:PRN pain
15. Albuterol Inhaler 2 PUFF IH Q8H:PRN sob
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atorvastatin 80 mg PO DAILY
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Isosorbide Mononitrate (Extended Release) 30 mg PO DAILY
5. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES HS
6. Levothyroxine Sodium 75 mcg PO DAILY
7. Multivitamins 1 TAB PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Vitamin D 1000 UNIT PO DAILY
10. Albuterol Inhaler 2 PUFF IH Q8H:PRN sob
11. Alendronate Sodium 70 mg PO QMON
12. Os-Cal 500 + D3 (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral daily
13. Acetaminophen 325-650 mg PO Q6H:PRN pain
14. Metoprolol Succinate XL 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
PRIMARY: Aortic stenosis status post valvuloplasty
SECONDARY: Acute Kidney Injury. Retroperitoneal hematoma.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with aortic stenosis, dyspnea // acute process?
TECHNIQUE: Frontal and lateral views of the chest.
COMPARISON: Multiple prior chest radiographs, most recently of ___.
FINDINGS:
Widespread bilateral interstitial opacities are new since the prior exam and
consistent with mild interstitial pulmonary edema. A small right pleural
effusion is present with bibasilar opacities consistent with atelectasis. No
focal consolidation or pneumothorax. The heart size is mildly enlarged and
there is calcification of the aortic knob. Right rib deformities are
consistent with chronic fractures. Osseous structures are diffusely
demineralized with multiple thoracic and lumbar spine compression deformities,
of indeterminate age.
IMPRESSION:
1. Mild interstitial pulmonary edema with small right pleural effusion.
2. Mild cardiomegaly.
3. Multiple thoracolumbar spine compression deformities of indeterminate age.
Radiology Report
INDICATION: ___ year old woman got valvulplasty yesterday, now with hematoma.
// ongoing bleeding.
TECHNIQUE: Focused grayscale, color Doppler, and spectral Doppler ultrasound
over the right groin was obtained.
COMPARISON: None
FINDINGS:
The right common femoral artery and vein are patent with appropriate arterial
and venous waveforms. There is a narrow neck of arterial blood flow extending
radially outward from the common femoral artery into a moderate perivascular
hematoma.
IMPRESSION:
Thrombosed right common femoral artery pseudoaneurysm. Minimal residual blood
flow visualized in the pseudoaneurysm neck without any flow in the hematoma.
Findings discussed with Dr. ___ by Dr. ___ at 8:15 p.m. on ___
Radiology Report
EXAMINATION: NON-INVASIVE PERIPHERAL ARTERIAL STUDY
INDICATION: ___ year old woman with AS, CAD, CHF, s/p valvuloplasty (___) c/b
R psuedoaneurysm. // Pt with known R groin pseudoaneurysm with small amt of
leak on previous study. Please eval and repair if leak still present.
TECHNIQUE: Focused grayscale, color Doppler, and spectral Doppler ultrasound
over the right groin.
COMPARISON: Comparison is made to right groin Doppler ultrasound dated ___.
FINDINGS:
The right common femoral artery and vein are patent and demonstrate
appropriate arterial and venous waveforms, respectively. Redemonstrated is a
narrow neck of arterial blood flow seen extending radially outward from the
right common femoral artery. There is an unchanged 1.7 x 1.3 cm soft tissue
hematoma seen adjacent to this pseudoaneurysm, without evidence of internal
flow.
IMPRESSION:
1. Unchanged narrow neck of arterial blood flow extending radially right CFA.
2. Stable, adjacent 1.7 x 1.3 cm soft tissue hematoma without internal flow.
Radiology Report
EXAMINATION: CT ABD AND PELVIS W/O CONTRAST
INDICATION: ___ year old woman with critical AS s/p valvuloplasty now with
peritoneal signs and falling h H/leukocytosis/lower BPS // r/o abdominal
bleed/RP bleed
TECHNIQUE: MDCT images were obtained from the lung bases to the pubic
symphysis without the administration of intravenous contrast. Axial images
were interpreted in conjunction with coronal and sagittal reformats.
DLP: 420.0 mGy-cm
COMPARISON: Comparison is made to right femoral vascular ultrasound dated ___.
FINDINGS:
There are small, bilateral, nonhemorrhagic pleural effusions with adjacent
atelectasis. Extensive coronary calcifications are noted. The heart is normal
in size and there is no evidence of pericardial effusion.
ABDOMEN:
The examination is limited secondary to the lack of intravenous contrast.
Within this limitation, the non-contrast enhanced appearance of the liver,
gallbladder, pancreas, spleen, and bilateral adrenal glands are grossly
normal. The bilateral kidneys are atrophic.
The stomach, small bowel, and large bowel are unremarkable in appearance
without dilation or wall thickening. Extensive colonic diverticulosis is
noted. There is no overt retroperitoneal lymphadenopathy by CT size criteria.
There is no pneumoperitoneum. The aorta and its major branches contain
calcifications.
PELVIS:
There is a large, retroperitoneal hematoma seen originating from the right
inguinal region in the vicinity of the patient's known right common femoral
artery aneurysm. The retroperitoneal hematoma extends superiorly to the level
of the anterior superior iliac spine, and measures approximately 4.4 x 4.0 x
10.6 cm (AP x TRV x CC, 3:60 and 4b:15). The urinary bladder is grossly
unremarkable. Bilateral inguinal hernias are noted, fat containing on the
right and bowel-containing on the left. There is no pelvic side-wall or
inguinal lymphadenopathy by CT size criteria.
OSSEOUS STRUCTURES: Multilevel, multifactorial degenerative changes are seen
throughout the visualized thoracolumbar spine. The patient is status post
left hip arthroplasty, and right femoral neck ORIF. No focal lytic or
sclerotic lesion concerning for malignancy.
IMPRESSION:
1. Large, right retroperitoneal hematoma extending from the right inguinal
region through the iliacus muscle plane up to the anterior superior iliac
spine.
2. Extensive colonic diverticulosis.
3. Severe atherosclerotic calcifications of the aorta and its major branches.
4. Bilateral inguinal hernias.
NOTIFICATION: Findings were conveyed by Dr. ___ to Dr. ___ telephone
at 12:41 on ___, 1 min after discovery.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with RESPIRATORY ABNORM NEC, CAD UNSPEC VESSEL, NATIVE OR GRAFT
temperature: 98.7
heartrate: 88.0
resprate: 18.0
o2sat: 97.0
sbp: 112.0
dbp: 56.0
level of pain: 0
level of acuity: 2.0 | ___ w/h/o critical aortic stenosis, CAD, CHF, presents from
assisted living facility with symptomatic AS s/p valvuloplasty
___ c/b psuedoaneurysm in R femoral artery.
# Critical Aortic Stenosis: Pt had been scheduled for
valvuloplasty in ___, but was transferred from ___ for
earlier intervention given symptoms. Pt was hemodynamically
stable during pre-hospitalization without CP, SOB. She underwent
a successful valvuloplasty on ___ that was complicated by
formation of right femoral artery pseudoaneursym as well as a
large retroperitoneal bleed. Procedure also complicated by
development ___ likely from hypotension, blood loss anemia
and cholesterol embolization. Deferred TAVR workup (CT
angiogram of the aortic annulus and peripheral vessels) given
patient's wish to limit interventions.
# Right femoral psuedoaneurysm and retroperitoneal hematoma: Was
transfused 3uPRBCs with appropriate bump in Hct and improvement
in blood pressure. Hct nadir 23.5 and systolic blood pressures
as low as 80 (asymptomatic). She was hemodynamically stable and
Hct stable x 48 hours by time of discharge. Surgical
intervention was deferred given patient's desire to avoid
further interventions. Please recheck Hgb, Hct 48 hours after
discharge.
# ___: Acute rise overnight from 1.0 to 1.7. Concerning for
embolism, prerenal ___, or other etiology. FeNA <1% suggestive
of pre-renal etiology. Cr downtrended to 1.2 prior to discharge.
Home ACE-inhibitor was held. Please recheck electrolytes on ___
and consider restarting ACE-inhibitor if Cr has normalized back
to baseline.
#CAD: Continued BB, ASA, Imdur. Will restart Ace-I if needed for
blood pressure control.
#Hyperlipidemia: Continued atorvastatin
#Hypertension: Well controlled during hospitalization. On
metoprolol.
#GERD: Continued omeprazole
#Hypothyroidism: Continued levothyroxine.
# Discontinued lasix, monitor volume status and consider
restarting if clinically indicated (weight gain, worsening ___
edema)
# ACE-inhibitor held during this admission given renal
dysfunction. Recheck electroyltes at follow-up appointment, if
Cr normal then restart ACE-inhibitor (Cr 1.2 on discharge).
# Recheck Hgb/Hct 48 hours after discharge (___) and at
outpatient f/u given recent bleed
# Pt will follow-up with Cardiology (Dr. ___ next month
# Code: DNR/DNI
# Emergency Contact: ___
Phone number: ___
Cell phone: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
___ Midline placement at the bedside
History of Present Illness:
___ w/ampullary carcinoma, CVA with r-sided deficits, htn, afib
on coumadin, h/o basal ganglial hemorrhage, and urinary
retention who presents with fevers and AMS. Patient recently
treated for ESBL E. coli UTI on ___ with Marcrobid and since
that time has had increasing confusion. Spiked a temperature to
105.7 at his facility today and was given some Tylenol and sent
to ___.
On evaluation, patient unable to participate in interview due to
delerium.
Past Medical History:
Hypertension
Dyslipidemia
Atrial fibrillation, on Coumadin
Prostatic hypertrophy
Hip replacement ___
Ampullary adenocarcinoma, s/p palliative XRT only
GERD
Depression
Urinary retention
Dysphagia
CVA w/R hemiparesis
Recurrent UTI
Social History:
___
Family History:
Mother: HTN
Physical ___:
ADMISSION PHYSICAL EXAM:
Vitals: T:97.6 BP:120/59 P:70 R:18 O2:97%ra
PAIN: unable to assess, appears comfortable
General: nad
Lungs: clear anteriorly
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd
Ext: no e/c/c
Skin: +sacral decubitus ulcer
GU: foley in place
Neuro: asleep, arrousable, not oriented. states location as
church and year as 1224, R hemiparesis
.
DISCHARGE PHYSICAL EXAM:
VS: AVSS
Pain: ___
Gen: NAD
CV: RRR, no murmurs
Lungs: CTAB/L ant lung fields
Abd: soft, NT, ND, NABS, no CVAT
Ext: no edema
Neuro: AAOx1 only. Fluent speech.
Psych: appropriate
Pertinent Results:
ADMISSION LABS:
===================
___ 11:30PM BLOOD WBC-11.4* RBC-3.61* Hgb-9.6* Hct-30.7*
MCV-85 MCH-26.6* MCHC-31.2 RDW-15.0 Plt ___
___ 11:30PM BLOOD ___ PTT-38.7* ___
___ 11:30PM BLOOD Glucose-154* UreaN-24* Creat-0.7 Na-140
K-3.6 Cl-103 HCO3-24 AnGap-17
___ 11:30PM BLOOD ALT-13 AST-13 AlkPhos-209* TotBili-0.4
___ 11:43PM BLOOD Lactate-2.5*
.
URINE STUDIES:
==================
___ 02:02AM URINE Color-Yellow Appear-Clear Sp ___
___ 02:02AM URINE Blood-NEG Nitrite-NEG Protein-TR
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-LG
___ 02:02AM URINE RBC-4* WBC-28* Bacteri-FEW Yeast-NONE
Epi-0
.
PERTINENT LABS:
===================
___ 07:45AM BLOOD WBC-5.0 RBC-3.33* Hgb-8.6* Hct-29.1*
MCV-88 MCH-25.9* MCHC-29.6* RDW-15.4 Plt ___
___ 06:25AM BLOOD Albumin-2.7* Calcium-8.3* Iron-12*
___ 06:25AM BLOOD calTIBC-118* VitB12-644 Ferritn-943*
TRF-91*
.
INR TREND:
==============
___ 11:30PM BLOOD ___ PTT-38.7* ___
___ 04:58PM BLOOD ___
___ 06:55AM BLOOD ___ PTT-45.6* ___
___ 07:45AM BLOOD ___
___ 06:40AM BLOOD ___
.
MICROBIOLOGY:
=================
___ Blood culture x 1: NGTD, final PENDING
___ Urine culture
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. 10,000-100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 2 S
CEFTAZIDIME----------- 2 S
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
.
IMAGING:
============
___ CT HEAD
IMPRESSION:
No acute hemorrhage and no evidence of other acute intracranial
abnormalities.
.
___ PA/LAT CXR
IMPRESSION: No focal consolidation.
.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. cranberry 405 mg oral daily
2. Vitamin D 50,000 UNIT PO QMONTH
3. Tamsulosin 0.4 mg PO BID
4. Potassium Chloride 10 mEq PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. Multivitamins 1 TAB PO DAILY
7. Mirtazapine 7.5 mg PO HS
8. Metoprolol Tartrate 25 mg PO BID
9. Magnesium Oxide 400 mg PO DAILY
10. Levothyroxine Sodium 88 mcg PO DAILY
11. Finasteride 5 mg PO DAILY
12. Docusate Sodium 100 mg PO TID
13. CloniDINE 0.3 mg PO BID
14. BuPROPion 75 mg PO HS
15. Bethanechol 25 mg PO TID
16. Ascorbic Acid ___ mg PO DAILY
17. Amlodipine 7.5 mg PO DAILY
18. Acetaminophen 650 mg PO TID
19. Polyethylene Glycol 17 g PO DAILY
20. Senna 17.2 mg PO HS
21. Bisacodyl ___VERY 3 DAYS
22. ___ MD to order daily dose PO DAILY16
Discharge Medications:
1. Finasteride 5 mg PO DAILY
2. Tamsulosin 0.4 mg PO BID
3. Bethanechol 25 mg PO TID
4. Acetaminophen 650 mg PO TID
5. Docusate Sodium 100 mg PO TID
6. Senna 17.2 mg PO HS
7. Potassium Chloride 10 mEq PO DAILY
8. Levothyroxine Sodium 88 mcg PO DAILY
9. Ascorbic Acid ___ mg PO DAILY
10. cranberry 405 mg oral daily
11. Magnesium Oxide 400 mg PO DAILY
12. CloniDINE 0.3 mg PO BID
13. Metoprolol Tartrate 25 mg PO BID
14. Mirtazapine 7.5 mg PO HS
15. Pantoprazole 40 mg PO Q24H
16. BuPROPion 75 mg PO HS
17. Amlodipine 7.5 mg PO DAILY
18. Bisacodyl ___VERY 3 DAYS
19. Polyethylene Glycol 17 g PO DAILY
20. Multivitamins 1 TAB PO DAILY
21. Vitamin D 50,000 UNIT PO QMONTH
22. Warfarin 4 mg PO DAILY16 Duration: 3 Days
Needs INR check on ___ to determine dosing
23. ertapenem 1 gram injection every 24 hours Duration: 7 Days
RX *ertapenem [Invanz] 1 gram 1 gram iv every 24 hours Disp #*7
Vial Refills:*0
24. Collagenase Ointment 1 Appl TP DAILY
25. Heparin Flush (10 units/ml) 2 mL IV DAILY and PRN, line
flush
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
ESBL E. coli UTI
Anemia, likely anemia of chronic disease
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with history of basal ganglia hemorrhage in setting
of elevated INR, now presenting with altered mental status and INR of 5.1.
Evaluate for hemorrhage.
TECHNIQUE: Axial helical MDCT images were obtained through the brain without
administration of IV contrast. Multiplanar reformatted images in coronal and
sagittal axes and thin section bone algorithm reconstructed images were
acquired.
DOSE: DLP: 892 mGy-cm
COMPARISON: Nonenhanced head CT dated ___
FINDINGS:
There is no evidence of acute intracranial hemorrhage, edema, mass effect or
acute large vascular territory infarction. There is stable encephalomalacia
along the lateral margin of the left lentiform nucleus at the site of prior
basal ganglia hemorrhage. Periventricular white matter hypodensities are
nonspecific but likely represent sequela of chronic small vessel ischemic
disease. The ventricles and sulci are normal in size for age. The basal
cisterns appear patent. Calcification of the vertebral and internal carotid
arteries is noted.
No fracture is identified. There is mild mucosal thickening within the
visualized portion of the right maxillary sinus. The remaining visualized
paranasal sinuses, mastoid air cells and middle ear cavities are clear. Soft
tissue density in bilateral external auditory canals is compatible with
cerumen.
IMPRESSION:
No acute hemorrhage and no evidence of other acute intracranial abnormalities.
Radiology Report
INDICATION: Fever and altered mental status. Evaluate for pneumonia.
COMPARISON: ___.
FINDINGS: Frontal and lateral radiographs of the chest demonstrate stable top
normal heart size with mild tortuosity of the thoracic aorta. No focal
consolidation, pleural effusion or pneumothorax is present.
IMPRESSION: No focal consolidation.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, Altered mental status
Diagnosed with URIN TRACT INFECTION NOS
temperature: 99.2
heartrate: 98.0
resprate: 16.0
o2sat: 97.0
sbp: 149.0
dbp: 73.0
level of pain: 0
level of acuity: 2.0 | ___ w/ampullary carcinoma, CVA, afib on coumadin, basal ganglial
hemorrhage, and urinary retention who presents with fevers and
AMS with known ESBL E. coli UTI.
.
#Fever / #Delerium / #UTI:
On presentation, patient had known ESBL E.coli UTI that was
treated as an outpatient with Macrobid. On admission, Head CT
was unremarkable, but UA continued to show evidence of
infection. He initially received broad-spectrum coverage with
IV Zosyn and IV gentamicin, however, once sensitivities of his
ESBL E.coli were reviewed, he was placed on Meropenem. On IV
antibiotics, his mental status cleared quickly and he returned
to his baseline, confirmed by his brother / HCP ___. Repeat
UCx interestingly grew Pseudomonas, but pan-sensitive, so
Meropenem was continued. A midline was placed for access for
prolonged IV antibiotic course. The plan is to treat him with
Ertapenem as an outpatient, to complete a total of a 10 day
course ___ - ___ of appropriate IV antibiotics for his
complicated UTI. However, for his Pseudomonas, he will need
additional PO ciprofloxacin to complete a treatment course. He
could be covered with frequent Zosyn or Meropenem to cover both
organisms, however, his facility cannot due Q6 or Q8 hour dosing
of IV antibiotics. During hospitalization he initially did have
a Foley catheter placed, however, this was discontinued and he
has resumed intermittent straight cath as previous.
.
#Afib:
His appears to have paroxysmal afib, although on day of
discharge, he was in atrial fibrillation with irregularly
irregular rhythmn on physical exam. His HR is well-controlled
with beta-blockade. He p/w supratherapeutic INR to 6, but did
not have any evidence of bleeding. The elevated INR was likely
due to combination of poor PO intake recently as well as oral
antibiotics as an outpatient. Coumadin was initially held and
he was given Vitamin K 5mg x 1 to reverse his INR so a midline
could be safely placed. Given that his CHADS2 score is 2 (as
documented by outpatient Cardiology notes, and presumably his
CVA is not included as it was a hemorrhagic event on Coumadin),
briding therapy was not felt to be indicated. He was given
Coumadin 4mg on ___ with INR of 2.4. INR on day of discharge
was 1.5. He should continued on Coumadin 4mg daily for the next
3 days with repeat INR on ___ with further Coumadin dosing
TBD pending INR results.
.
#Anemia, likely of chronic disease: Patient noted to have lower
than baseline Hct of high 20's vs baseline of low 30's. He did
not have any evidence of active bleeding. Vitamin B12 level was
adequate. Iron panel suggests anemia of chronic disease. This
can be further worked-up as an outpatient.
.
#HTN: Continued home meds of clonidine, metoprolol and
amlodipine. BP in good range.
#GERD: Continued home PPI.
#BPH: Continued home Proscar, Flomax and bethanechol. He had
Foley catheter placed briefly during hospitalization but it has
since been discontinued. He should resume intermittent straight
catheterization 4x daily.
#Hypothyroidism: Continued home Synthroid dose.
#ACCESS: midline
#CODE STATUS: FULL CODE. Confirmed with HCP (Brother ___
___. Previous documentation at nursing home had
documented to attempt resuscitation but do not intubate, however
this is often not possible, so further d/w HCP to clarify was
done.
#CONTACT: HCP, brother ___ ___
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain, vomiting
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ male with a PMH notable for
metastatic rectal cancer status post laparoscopic
abdominoperineal resection and colostomy, chemotherapy, and
radiation along with right lower lobe segmentectomy for lung
metastases who presents with acute onset of abdominal pain,
nausea, and vomiting.
Patient recently had a complicated hospitalization from ___
to
___ at ___ after being transferred from ___ due to
concerns for SBO. During the hospitalization, she was treated
for acute L5-S1 osteomyelitis which was thought to be due to
MSSA
bacteremia from a likely left foot ulcer source. Patient was
also initially conservatively managed for intermittent SBO but
ultimately on ___ he was taken to the OR for exploratory
laparoscopy, lysis of adhesion, and incision and resection of
small bowel. During this admission, he also was started on TPN,
which he continued as an outpatient.
The patient reports feeling relatively well since discharge and
improving. After he follow-up with Dr. ___ started
advancing his diet to a non-residual diet. However, he felt
that
he may have pushed too far, having a cheeseburger and fries
yesterday prior, which soon led to nausea and vomiting. The
vomiting continued through the night and into this morning, and
he subsequently presented to the ___ ED. He reports that his
last BM in his colostomy bag was yesterday morning. He has not
had any fevers or chills.
In the ED his initial vitals were notable for a temp of 99.2,
heart rate 105, BP 116/85, oxygen saturation 98% on room air.
See exam was notable for a soft abdomen that was descended with
a
small amount of green soft stool in the ostomy and diffuse
tenderness. His lab was notable for an elevated white count of
14.8, H&H of 10.7 and 34.0, normal LFTs, creatinine of 0.9, BUN
of 31, and a lactate of 2.8. He had a CT abdomen and pelvis
with
contrast which showed a small bowel obstruction with a
transition
point in the right lower quadrant, proximal to the small bowel
anastomosis with no bowel wall thickening, pneumatosis, or
pneumoperitoneum. Blood cultures were taken. He received 2 L
of
normal saline, esomeprazole 40 mg IV every 12, Zofran as needed,
and Dilaudid 1 mg ×1. Colorectal surgery was consulted, and
after reviewing the case, no surgical option were available
given
the extent of the patient's disease and recommendation was made
for admission to home in with conservative management of SBO.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
ONCOLOGICAL HISTORY (per ___ records):
___- first screening colonoscopy (pt with new anemia Hg
12.4) showed a large, ulcerated, three fourths circumferential
mass highly suspicious for malignancy in the mid to lower
rectum;
2 other small polyps were seen-biopsy showed 2 tubular adenomas
and moderately differentiated invasive adenocarcinoma, low-grade
in rectal biopsy
___: CT C/A/P showed rectal wall thickening, several
perirectal lymph nodes, small pulmonary nodules, possible small
pericardial cyst versus 10 mm lung nodule
___: pelvic MRI showed large near circumferential low
rectal
tumor, with extramural extension contacting the mesorectal
fascia, anal sphincter involvement, and multiple mesorectal
nodal
involvement, imaging stage T3N1MX.
___: concurrent chemoradiotherapy with continuous
infusion ___
___- cycle ___ FOLFOX
___- RLL nodule resected (Dr. ___ and showed adenocarcinoma
c/w colon primary
___- cycle ___ FOLFOX; CT chest showed new lung nodules
___- cycle ___ FOLFOX
___- cycle ___ FOLFOX
___ ___ FOLFOX
___- chest CT showed stable RML nodule; 2 add'l nodules
detected on last CT not definitely appreciated; no new nodules
___- cycle ___ FOLFOX
___- cycle ___ FOLFOX
___- cycle ___ FOLFOX
___- Cycle ___ FOLFOX
___- CT C/A/P with stable pulmonary nodules, slight decrease
in rectal mass
___- Dr. ___ APR, coccygectomy, and placement
of
fiducials with flap closure of perineum; final pathology showed
adenocarcinoma of rectum, low grade, measuring 10.1 x 6.0 x 1.2
cm with tumor perforation. The tumor was staged as yT4bpN0 with
total of 14 nodes evaluated (___). The tumor extended to the
circumferential margin at orange ink but was negative; adjacent
tissue "coccyx" was negative for margins as well (by 21 mm);
+LVI; MMR IHC showed intact expression of MLH1, MSH2, MSH6, and
PMS2
___- completed cyberknife therapy to rectal region (Dr.
___
___- CT chest with RLL opacity- inflammation vs recurrence;
reviewed with radiology- favor inflammation/scar tissue
___- CT C/A/P showed possible liver lesion- liver MRI
ordered
___ MRI showed ring-enhancing lesions in segment
4A
of the liver and a smaller one in segment 3 of the liver
concerning for metastatic lesion; spleen was slightly enlarged
___ her biopsy showed a single focus with atypical
appearing ductal epithelium, seen in association with abundant
chronic inflammation, predominantly passed cells; no diagnostic
evidence of malignancy
___- start FOLFIRI- received 1 cycle
___- had multiple hospitalizations at ___ then
transferred to ___- initially had diabetic foot
infection (resulting in high grade MSSA bacteremia), then
intermittent SBO; then had back pain and dx'd with presumed
osteomyelitis (despite negative biopsy); eventually went to OR
and found to have diffuse peritoneal carcinomatosis; d/c'd
___ he is DNR/DNI
PAST MEDICAL/SURGICAL HISTORY:
- Type 2 diabetes mellitus
- Hypertension
- Hypercholesterolemia
- Erectile dysfunction
- Stasis dermatitis
Social History:
___
Family History:
No first degree relative with colon cancer. Other relatives with
lung cancer.
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
Patient declined a full physical examination.
VITALS: T 98.1, BP 149/88, HR 103, RR 20, O2 Sat 93% 2L NC
GENERAL: Alert and in no apparent distress, slightly somnolent
appearing
EYES: Anicteric
ENT: Ears and nose without visible erythema, masses, or trauma
CV: Patient declined
RESP: Patient declined
GI: Abdomen moderately distended and tympanic, diffusely tender
and most prominent in the RLQ. Bowel sounds present. Gas is
present in the colostomy bag.
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs
SKIN: No rashes or ulcerations noted
NEURO: Alert, oriented, face symmetric, gaze conjugate with
EOMI,
speech fluent, moves all limbs
PSYCH: Appeared irritated and did not wish to converse for a
long
period
DISCHARGE PHYSICAL EXAMINATION:
VITALS: 98.0 PO 132 / 72 86 18 99 RA
GENERAL: Alert and in no apparent distress
EYES: Anicteric, PERRLA, pink conjunctiva, MMM, oropharynx clear
Neck: supple
CV: RRR, normal S1, S2, no murmurs, rubs, or gallops
RESP: CTAB, no wheezes, rales, or ronchi
GI: Abdomen soft, nontender, nondistended. Normoactive bowel
sounds. Draining stool and gas in colostomy bag. Area
surrounding
colostomy clean and dry, no erythema or tenderness. No guarding
or rebound.
Ext: Warm and well perfused, no clubbing, cyanosis, or edema.
Pertinent Results:
ADMISSION LABORATORY STUDIES
========================================
___ 01:00PM BLOOD WBC-14.8*# RBC-4.08* Hgb-10.7* Hct-34.0*
MCV-83 MCH-26.2 MCHC-31.5* RDW-17.7* RDWSD-51.6* Plt ___
___ 01:00PM BLOOD Neuts-85.7* Lymphs-2.3* Monos-10.9
Eos-0.1* Baso-0.3 Im ___ AbsNeut-12.68*# AbsLymp-0.34*
AbsMono-1.61* AbsEos-0.01* AbsBaso-0.04
___ 01:00PM BLOOD ___ PTT-28.1 ___
___ 01:00PM BLOOD Glucose-209* UreaN-31* Creat-0.9 Na-139
K-4.2 Cl-95* HCO3-27 AnGap-17*
___ 01:00PM BLOOD Albumin-4.1 Calcium-9.5 Phos-4.0 Mg-2.0
___ 01:15PM BLOOD Lactate-2.8*
___ 07:28AM BLOOD freeCa-1.09*
DISCHARGE LABORATORY STUDIES
========================================
___ 05:30AM BLOOD WBC-5.1 RBC-3.16* Hgb-8.4* Hct-26.3*
MCV-83 MCH-26.6 MCHC-31.9* RDW-17.1* RDWSD-52.2* Plt ___
___ 05:30AM BLOOD Plt ___
___ 05:30AM BLOOD Glucose-100 UreaN-19 Creat-0.6 Na-138
K-4.0 Cl-103 HCO3-21* AnGap-14
___ 05:30AM BLOOD Calcium-8.1* Phos-3.7 Mg-2.0
___ 06:30AM BLOOD Triglyc-41
MICROBIOLOGY
========================================
BLOOD CULTURES: Pending
IMAGING/REPORTS
========================================
CT ABD/PELVIS:
1. Small-bowel obstruction with a transition point in the right
lower
quadrant, proximal to the small bowel anastomosis. No bowel
wall thickening, pneumatosis, or pneumoperitoneum.
2. Small rim enhancing fluid collection within the presacral
surgical bed,
measuring up to 4.8 cm, significantly decreased in size compared
to ___.
3. Increased fat stranding surrounding a moderate-sized
periumbilical fat
containing hernia, incarcerated fat not excluded.
CTA CHEST
1) No evidence of pulmonary embolism or acute pulmonary
parenchymal process.
2) Gastric pneumatosis. Extensive portal venous gas in the
liver, as well as gas within the splenic and gastroepiploic
veins. Findings could reflect emphysematous gastritis or
underlying ischemic small bowel given the recent history of
small bowel obstruction.
3) 4 mm nodule in the right middle lobe, unchanged compared to
outside CT of the chest from ___.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Atorvastatin 40 mg PO QPM
2. Tamsulosin 0.4 mg PO QHS
3. Acetaminophen 1000 mg PO Q8H:PRN Pain - Moderate
4. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
5. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate
6. Prochlorperazine 10 mg PO Q6H:PRN nausea
7. Nystatin Oral Suspension 15 mL PO QID
8. LORazepam 1 mg PO Q6H:PRN nausea, anxiety
9. Glargine 18 Units Bedtime
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Moderate
2. Atorvastatin 40 mg PO QPM
3. Ibuprofen 600 mg PO Q8H:PRN Pain - Moderate
4. Glargine 18 Units Bedtime
5. LORazepam 1 mg PO Q6H:PRN nausea, anxiety
6. Nystatin Oral Suspension 15 mL PO QID
7. OxyCODONE (Immediate Release) ___ mg PO Q6H:PRN Pain -
Severe
8. Prochlorperazine 10 mg PO Q6H:PRN nausea
9. Tamsulosin 0.4 mg PO QHS
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
- recurrent small bowel obstruction
SECONDARY
- metastatic rectal cancer
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 IV contrast.
INDICATION: ___ with rectal cancer and colostomy here with SBO symptoms.
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) = 1,031 mGy-cm.
COMPARISON: CT abdomen and pelvis dated ___.
FINDINGS:
LOWER CHEST: Dependent atelectasis. No focal consolidations. Trace
pericardial fluid. No pleural effusion. A venous catheter is seen
terminating at the superior cavoatrial junction.
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. A small splenule is seen anteriorly.
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. There are multiple dilated
fluid-filled loops of small bowel with air-fluid levels. There is a
transition point within the right lower quadrant (series 2, image 72), which
is proximal to a small bowel anastomosis, also in the right lower quadrant.
There is no thickening of the small bowel wall, pneumatosis, or
pneumoperitoneum. The colon is normal in appearance with a left lower
quadrant colostomy. The appendix is normal. Patient is status post
proctectomy. Within the presacral surgical bed, there is a small rim
enhancing fluid collection measuring 4.8 x 3.3 cm (series 2, image 83), which
has significantly decreased in size compared to the CT dated ___.
PELVIS: The urinary bladder and distal ureters are unremarkable.
LYMPH NODES AND PERITONEUM: 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: Degenerative changes throughout the lumbar spine a Schmorl's node
involving the superior endplate of L3, which is unchanged compared to prior.
SOFT TISSUES: A left lower quadrant colostomy is normal in appearance. There
is a moderate-sized periumbilical hernia containing fat with surrounding fat
stranding, which has slightly increased compared to prior.
IMPRESSION:
1. Small-bowel obstruction with a transition point in the right lower
quadrant, proximal to the small bowel anastomosis. No bowel wall thickening,
pneumatosis, or pneumoperitoneum.
2. Small rim enhancing fluid collection within the presacral surgical bed,
measuring up to 4.8 cm, significantly decreased in size compared to ___.
3. Increased fat stranding surrounding a moderate-sized periumbilical fat
containing hernia, incarcerated fat not excluded.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with PICC in place, not flushing easily// ?PICC
placement
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Right-sided PICC terminates in the low SVC/cavoatrial junction, without
evidence of pneumothorax. Linear left base atelectasis is seen without focal
consolidation. No pleural effusion or pneumothorax is seen. Cardiac
silhouette size is borderline to mildly enlarged. Mediastinal contours are
unremarkable. No pulmonary edema is seen.
IMPRESSION:
Right-sided PICC terminates in the low SVC/cavoatrial junction without
evidence of pneumothorax.
Mild left base atelectasis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, N/V
Diagnosed with Unspecified intestinal obstruction
temperature: 99.2
heartrate: 105.0
resprate: 18.0
o2sat: 98.0
sbp: 116.0
dbp: 85.0
level of pain: 10
level of acuity: 2.0 | BRIEF SUMMARY
=============
___ w/ metastatic rectal CA (s/p rsxn, colostomy, on FOLFIRI
C1D1 ___ w/ lung mets s/p RLL segmentectomy), DM, recent
admission for SBO (s/p lyses of adhesions & partial rsxn c/b
MSSA bacteremia and L5-S1 osteomyelitis), admitted w/ recurrent
partial SBO that was managed conservatively with improvement.
ACTIVE ISSUES
=============
#) PARTIAL SMALL BOWEL OBSTRUCTION
Pt presented with acute onset of abdominal pain, nausea and
vomiting. Imaging was notable for small bowel obstruction with
a transitional point in the right lower quadrant, proximal to
the small bowel anastomosis. Colorectal surgery was consulted
and recommended conservative management and no acute surgical
intervention. Patient was made NPO and given IVF. The
following day, patient began to have output from the colostomy
and was advanced to a clear liquid diet, which he tolerated
well. TPN was continued. Patient discharged on a clear liquid
diet with a plan to advance diet over the next several days.
#) SUSPECTED UPPER GI BLEED
Pt initially with reported coffee ground emesis but had no
further evidence of bleeding during admission and did not
require a transfusion. Managed with IV PPI during admission,
which was discontinued on discharge given low suspicion for GI
bleed.
CHRONIC ISSUES
==============
#) METASTATIC RECTAL CANCER: patient scheduled for follow up
with Dr. ___ further management
#) ANEMIA: remained at baseline and did not require transfusion
#) DIABETES: managed with glargine and insulin sliding scale
while inpatient
#) HYPERLIPIDEMIA: continued home atorvastatin
#) BPH: continued home tamsulosin
TRANSITIONAL ISSUES
=======================================
#) Discharge diet: clear liquids, advance slowly
#) Patient scheduled for follow up with Dr. ___
# Contacts/HCP/Surrogate and Communication: ___
(HCP, mother, ___, cell ___ ___
(alternate, brother, cell ___, home ___
# Code Status/ACP: DNR/DNI |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea, vomiting and diffuse abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ woman with no significant PMH but
a few prior epiodes of abdominal pain who presents with a 2-day
history of nausea/vomiting and diffuse abdominal pain. Symptoms
started with nausea/vomiting without any clear inciting cause 2
days ago; she denies any recent travel outside of the ___
___, denies sick contacts, denies consumption of any new or
unusual foods, and denies any recent antibiotic use.
She has been having watery emesis approximately every 2 hours,
non-bloody and non-bilious, although her last emesis was
approximately 7 hours prior to time of ACS evaluation. She
states that she continues to pass flatus but has not had a bowel
movement in 2 days. Her pain is sharp but diffusely distributed
and comes in waves. Percocet left over from previous dental
procedure provided moderate relief. She denies fevers/chills,
denies other symptoms.
She states that she has had 3 episodes like this before, all of
which spontaneously resolved after 1 day. The first episode was
___ years ago and she has had 2 more over the past ___ years, all
characterized by nausea/vomiting and abdominal pain. She has
not
needed to seek treatment for these episodes until now. Pain is
sharp, constant, worsening, diffuse in abdomen but centered
mid-abdomen. No appetite. Denies chest pain, dyspnea.
Family history is significant for a brother with GI problems
never formally diagnosed. Patient has never had a colonoscopy.
ACS was consulted for evaluation and management while in ED.
ED Course (labs, imaging, interventions, consults):
In the ED, patient had an episode of coffee ground emesis. Per
report, she admitted drinking baileys everyday in her coffee for
the past ___ years. Also admits to using MJ occasionally. She has
had this pain for days and has taken some percocet from an old
prescription
- Initial Vitals/Trigger: T 98.7 HR 85 BP 163/88 O2Sat 100%RA.
- EKG: SR @95, NANI, no STE, TW flattening inferior and lateral
- Meds: For her nausea she received Zofran 4mg. She also
received Ativan and morphine for pain. HAD 1L of fluid in total.
Concerned for infection given ileitis (see below), she was
started on cipro flagyl per ACS recs
- Labs: No leukocytosis, lactate 1.3, nml lytes, neg tropx1, nml
coags, neg tox screen
- urine: UA and UCx were sent. Few bacteria, moderate blood,
trace leukocytes, nitrites positive
- CT abd/pelvis: Terminal ileitis. Proximal to the inflamed
ileus, the small bowel is dilated and fluid-filled with multiple
air-fluid levels conssistent with some degree of SBO or ileus
SURGERY RECS: Seen in ED
No evidence of indication for acute surgical intervention.
Recommend admit to Medicine and ultimately endoscopy. Surgery
will follow for present.
___ ___
ROS:
No fevers, chills, night sweats, or weight changes. No changes
in vision or hearing, no changes in balance. No cough, no
shortness of breath, no dyspnea on exertion. No chest pain or
palpitations. No diarrhea or constipation. No dysuria or
hematuria. No hematochezia, no melena. No numbness or weakness,
no focal deficits.
Past Medical History:
Denies any PMHx
Social History:
___
Family History:
CAD in multiple family members
Brother with GI problems NOS
Physical Exam:
Physical exam on admission
Vitals- T 98.5 HR 82 BP 120/66 RR 16 O2Sat 98%RA
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, dry mucous menbrane, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, diffusely tender to palpation but 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
Physical exam at discharge
VS- Tm 100.1 Tc 99.3 60-70s 110-140s/60-70s 18 >96 on RA
General- Alert, oriented, no acute distress
HEENT- Sclerae anicteric, MMM, oropharynx clear
Neck- supple, JVP not elevated, no LAD
Lungs- CTAB no wheezes, rales, rhonchi
CV- RRR, Nl S1, S2, No MRG
Abdomen- soft, NT/ND, bowel sounds present, no rebound
tenderness, no guarding, no organomegaly
GU- no foley
Ext- warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro- Pupils equal. Rest of neuro exam non-focal
Pertinent Results:
Labs on admission
-------------------
___ 07:44AM LACTATE-1.3
___ 06:48AM URINE COLOR-Straw APPEAR-Clear SP ___
___ 06:48AM URINE BLOOD-MOD NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-TR
___ 06:48AM URINE RBC-15* WBC-4 BACTERIA-FEW YEAST-NONE
EPI-1
___ 06:48AM URINE MUCOUS-RARE
___ 01:53AM cTropnT-<0.01
___ 01:46AM GLUCOSE-199* UREA N-26* CREAT-0.8 SODIUM-138
POTASSIUM-5.0 CHLORIDE-97 TOTAL CO2-24 ANION GAP-22*
___ 01:46AM ALT(SGPT)-12 AST(SGOT)-26 ALK PHOS-90 TOT
BILI-0.5
___ 01:46AM LIPASE-12
___ 01:46AM ALBUMIN-4.1
___ 01:46AM CRP-136.7*
___ 01:46AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 01:46AM WBC-9.9 RBC-4.87 HGB-15.7 HCT-48.4* MCV-99*
MCH-32.2* MCHC-32.4 RDW-12.6
___ 01:46AM NEUTS-73* BANDS-10* LYMPHS-12* MONOS-5 EOS-0
BASOS-0 ___ MYELOS-0
___ 01:46AM HYPOCHROM-NORMAL ANISOCYT-NORMAL
POIKILOCY-NORMAL MACROCYT-NORMAL MICROCYT-NORMAL
POLYCHROM-NORMAL
___ 01:46AM PLT SMR-HIGH PLT COUNT-446*
___ 01:46AM ___ PTT-27.1 ___
___ 01:46AM SED RATE-16
Labs at discharge
------------------
___ 05:50AM BLOOD WBC-6.3# RBC-4.20 Hgb-13.5 Hct-41.9
MCV-100* MCH-32.3* MCHC-32.3 RDW-12.6 Plt ___
___ 05:50AM BLOOD Plt ___
___ 05:50AM BLOOD ___ PTT-29.6 ___
___ 05:50AM BLOOD
___ 05:50AM BLOOD Glucose-102* UreaN-3* Creat-0.7 Na-141
K-3.5 Cl-103 HCO3-29 AnGap-13
___ 05:50AM BLOOD Calcium-8.6 Phos-2.3* Mg-2.1
Images
----------
CT ABD&Pelvis with contrast
1. Narrowed segment of terminal ileum with wall edema, mucosal
hyperemia and prominence of the Vasa recta consistent with
terminal ileitis. This could be due to inflammatory bowel
disease, infectious or ischemic causes.
2. Just proximal to the inflamed loop of bowel there is a focal
narrowing
which could reflect peristalsis; however, an underlying
stricture is possible.
3. Proximal to the inflamed ileum, the small bowel is dilated
and fluid-filled with multiple air-fluid levels consistent with
some degree of obstruction or ileus.
Microbiology:
___ 7:30 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
ANAEROBIC GRAM POSITIVE ROD(S). UNABLE TO IDENTIFY
FURTHER.
Isolated from only one set in the previous five days.
Anaerobic Bottle Gram Stain (Final ___:
Reported to and read back by ___. ___ ON ___ AT
0555.
GRAM POSITIVE ROD(S).
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: NO_PO contrast; History: ___ with 4d worsening abdominal
painNO_PO contrast // eval for intra-abdominal infection
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis
following intravenous administration of 130cc of Omnipaque. Coronal and
sagittal reformations were performed.
DOSE: DLP: 286 mGy-cm.
COMPARISON: None.
FINDINGS:
CHEST:
The bases of clear. Visualized heart and pericardium are unremarkable
ABDOMEN:
The liver enhances homogeneously without focal lesion or intrahepatic biliary
dilatation. The gallbladder is unremarkable and the portal vein is patent. The
pancreas, spleen and adrenal glands are unremarkable. There are multiple
hypodensities within the bilateral kidneys, the largest on the right measuring
1.3 cm consistent with a simple cyst. Others are too small to characterize but
likely also represent cysts. The kidneys present symmetric nephrograms and
excretion of contrast with no focal lesions, stones or hydronephrosis.
The small bowel is dilated measuring up to 3.7 cm, fluid-filled and has
multiple air-fluid levels. A transition point is noted in the mid pelvis with
a focal area of narrowing (2:66). Just distal to this there is a long segment
of narrowed terminal ileum with extensive wall edema, mucosal hyper
enhancement and prominence of the Vasa recta consistent with terminal ileitis.
The ileocecal valve demonstrates fatty deposition within the wall. The
appendix is not visualized; however, there is no evidence of appendicitis.
There is scattered sigmoid diverticulosis without evidence of diverticulitis.
There is no retroperitoneal or mesenteric lymphadenopathy by CT size criteria.
There is a small amount of free fluid tracking along the right pericolic
gutter. No free air is identified. The anterior abdominal vasculature
demonstrates scattered atherosclerotic calcifications.
PELVIS:
The urinary bladder is unremarkable. There is no evidence of pelvic or
inguinal lymphadenopathy. There is no free fluid in the pelvis.
BONES AND SOFT TISSUES:
No lytic or sclerotic lesion suspicious for malignancy is present.
IMPRESSION:
1. Narrowed segment of terminal ileum with wall edema, mucosal hyperemia and
prominence of the Vasa recta consistent with terminal ileitis. This could be
due to inflammatory bowel disease, infectious or ischemic causes.
2. Just proximal to the inflamed loop of bowel there is a focal narrowing
which could reflect peristalsis; however, an underlying stricture is possible.
3. Proximal to the inflamed ileum, the small bowel is dilated and fluid-filled
with multiple air-fluid levels consistent with some degree of obstruction or
ileus.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with REG ENTERITIS, SM INTEST
temperature: 98.0
heartrate: 118.0
resprate: 24.0
o2sat: 96.0
sbp: 162.0
dbp: 100.0
level of pain: 10
level of acuity: 3.0 | ___ with no known PMHx but possibly significant EtOH use p/w
2-day hx n/v/ diffuse abd pain found to have normal creatinine
and lipase, no leukocytosis, LFTs/amylase/lipase normal and CT
abd/pelvis with evidence of terminal ileitis admitted for
further management.
#N/V/diffuse abdominal pain: She presented with a 2-day history
of nausea,vomiting and diffuse abd pain found to have normal
creatinine and lipase, no leukocytosis, LFTs/amylase/lipase
normal, elevated CRP and CT with evidence of terminal ileitis.
She was then admitted to the medicine floor for further
management. Upon arrival on the floor, she was also dry on exam
and was hydrated with IVF bolus and maintenance NS which was
then switched to LR given given continuous nausea and vomiting.
Family history significant for brother with GI problems never
formally diagnosed concerning for inflammatory/ autoimmune
process. Patient has had previous self-limited similar episodes
in past ___ years, possible IBD given history of constipation
with breakthrough diarrhea. Data suporting an inflammatory
process substantial elevation of CRP to 136.7. ESR 16. Physical
exam was pertinent for diffuse abdominal pain but normal bowel
sound and no concern for acute abdomen. Hemeoccult negative in
ED. No hx of colonoscopy. Other etiology include partial SBO in
the setting dilated and fluid-filled with multiple air-fluid
levels supported by her chronic constipation at presentation. We
also considered viral gastroenteritis, but strange to be so
limited to terminal ileum. Given her CT finding and concern for
IBD, she was started on ciprofloxacin and flagyl in the
emergency room which was continued upon admission. She was
switched to Unasyn on ___ when her blood culture grew GPRs but
d/c'ed on ___ w/ low suspicion for bacteremia. She initially
could not tolerate PO due to worsening abdominal pain so she was
maintained NPO and diet was advance when she was clinically
improved. Her pain was well controlled with IV morphine as
needed and her nausea with zofran. Her symptoms significantly
improved by day-4 of stay and she was able to tolerate a regular
diet without pain or nausea. She was transitioned successfully
to PO oxycodone and d/c'ed on it for pain control. We consulted
the GI service who recommended steroid if symptoms do not
resolve and follow-up colonoscopy as outpatient. This will help
to narrow the differential and possibly arrive at a final
diagnosis. At discharge, she was tolerating regular diet without
worsening abdominal pain or nausea, ambulating with benign
abdominal exam. Per GI recommendation, we sent for TPMT enzyme
assay, hep B serology and placed a PPD in preparation should she
need to be started on Azathioprine in the future, pending
further outpatient work-up. She is also to start Entocort 9mg
qAM after discharge. She is set to follow-up with Dr. ___ ___
in 2 weeks and a colonoscopy in 4 weeks. PPD to be read on
___ as an outpatient.
# + blood cx: Blood culture with anaerob GPRx1, thought to be
most likely P. acne. Covered on unasyn starting on ___, but we
feel contaminant, so we d/c'ed uansyn prior to discharge. Final
cultures pending at time of discharge.
#B12 deficiency: B12 level of 234 consistent with mild B12
deficiency. Possible cause include decrease absorption i/s/o
terminal GI disease (most likely) vs decrease intake i/s/o
chronic n/v. Started on PO Cyanocobalamin 2000mcg/day on ___.
# FEN: Pt had low Mg, K, and P which were repleted prn/ regular
diet at discharge
TRANSITIONAL ISSUES
# After discharge, patient second BCx botle grew GNRs. Although
it seems most likely to be a contaminant as it has been 5 days
since culture was sent. Please see WebOMR note on ___ with
details on communication with patient regarding these results
and further management.
#Concern for IBD. No colonoscopy in the past. Pt follow-up with
GI as outpatient as well as a colonoscopy 2 weeks and 4 weeks
from now, respectively
# CODE STATUS: Full (confirmed)
# Emergency Contact: Friend ___ ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
___ Complaint:
Diverticular abscess
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ recently diagnosed with sigmoid diverticultis w/ phlegmon
extending to left adnexa in ___ after she presented with
LLQ pain. She as admitted for 3 days, and completed a course of
augmentin for 10days. Her symptoms improved, until ___, she
began having copius vaginal dischage. She went to the ER, a
repeat CTAP was done and showed mild improvement. She was
discharged with 10day course of levaquin and flagyl.
She presents today with LLQ pain that started this afternoon.
Denies fevers, chills , nausea, emesis, changes to bowel habits.
The pain has since improved since being in the ED.
Last colonosocpy ___ that showed pandiverticulosis.
Past Medical History:
PMH:
Peptic Ulcer s/p Billroth II ___ w Dr. ___
Acute necrotizing esophagus, "black esophagus"
Diverticulosis
GERD
Anemia of chronic disease
Hyperlipidemia
Essential hypertension
Gastroesophageal reflux disease
PSH
Billroth II ___ w Dr. ___
Colonoscopy ___ multiple diverticuli
Remote ex-lap LOA for endometriosis
Social History:
___
Family History:
Significant family hx of breast cancer: sister died of breast
cancer and ___ nieces with ___ diagnoses, however, patient
negative for mutation; dad with peptic ulcers; and no hx of
colon cancer.
Physical Exam:
--ADMISSION--
Vitals: 98 78 125/67 18 99RA
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,
incisons CDI withut hernia
Ext: No ___ edema, ___ warm and well perfused
--DISCHARGE--
VS: 99.1, 82, 149/88, 21, 100% RA
Gen: well-appearing, NAD, A&O
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
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
--LABS--
___ 05:20PM BLOOD WBC-9.5 RBC-3.96*# Hgb-11.9*# Hct-35.4*#
MCV-90 MCH-30.2 MCHC-33.7 RDW-13.3 Plt ___
___ 07:00AM BLOOD WBC-8.7 RBC-3.59* Hgb-10.6* Hct-31.2*
MCV-87 MCH-29.6 MCHC-33.9 RDW-13.2 Plt ___
___ 05:20PM BLOOD Glucose-156* UreaN-10 Creat-0.8 Na-136
K-4.0 Cl-100 HCO3-26 AnGap-14
___ 07:00AM BLOOD Glucose-97 UreaN-8 Creat-0.8 Na-135 K-4.2
Cl-100 HCO3-26 AnGap-13
___ 07:00AM BLOOD Calcium-9.2 Phos-3.3 Mg-1.7
--IMAGING/STUDIES--
CT ABD/PELV ___
1. Wall thickening and mild surrounding fat stranding of the
mid sigmoid
colon compatible with known diverticulitis with associated 3.1 x
2.0 x 1.6 cm pericolonic abscess. No intraperitoneal free air.
Extensive pan colonic diverticulosis.
2. Multi lobulated lesion at the left adnexa containing small
hypodensities measuring up to 1.2 cm. It is unclear whether
this is reactive inflammation from surrounding diverticulitis or
involvement of the ovaries/fallopian tubes. Continued followup
is recommended following treatment.
3. Compression deformities of the L1 and L2 lumbar vertebral
bodies, worse in the L2 level without CT findings to suggest
acuity however are of unknown chronicity. Correlate with focal
tenderness.
4. Moderate hiatal hernia.
Medications on Admission:
protonix 40 bid, calcitriol 0.5mcg daily, vitamin D 50,
000U/week, lisinopril 5mg daily, ca, simvistatin 10daily, reglan
10 qhs
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
RX *amoxicillin-pot clavulanate 1,000 mg-62.5 mg 1 tablet(s) by
mouth twice a day Disp #*42 Tablet Refills:*0
2. Lisinopril 5 mg PO DAILY
3. Calcitriol 0.5 mcg PO DAILY
4. Calcium Carbonate 500 mg PO TID
5. Metoclopramide 10 mg PO QHS
6. Pantoprazole 40 mg PO Q12H
7. Simvastatin 10 mg PO QPM
Discharge Disposition:
Home
Discharge Diagnosis:
Diverticulitis with pericolonic abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with recurrent diverticulitis now w/ LLQ pain intermittent,
pyuria. Evaluate for diverticulitis
TECHNIQUE: Axial helical MDCT scan of the abdomen and pelvis following the
intravenous administration of 130 cc of Omnipaque . Coronal and sagittal
reformatted images were also generated for review.
DOSE: 448 mGy-cm
COMPARISON: CT chest from ___
FINDINGS:
LOWER CHEST: The lung bases are clear. Atherosclerotic calcifications are
seen in the coronary arteries. There is no pericardial or pleural effusion.
LIVER: The liver enhances homogeneously, with no focal lesions or
intrahepatic biliary duct dilatation. The gallbladder is unremarkable and the
portal vein is patent.
PANCREAS: The pancreas does not demonstrate focal lesions or peripancreatic
stranding or fluid collection.
SPLEEN The spleen is homogeneous and normal in size.
ADRENALS: The adrenal glands are unremarkable.
KIDNEYS: The kidneys do not show solid or cystic lesions and demonstrate
symmetric nephrograms and excretion of contrast. No pelvicaliceal dilatation
or perinephric abnormalities are present.
GI TRACT: There is a moderate hiatal hernia with suture material and surgical
clips posterior to the crura of the right hemidiaphragm and the lesser
curvature of the stomach, unchanged since prior study. The duodenum and
remaining small bowel are within normal limits, without evidence of wall
thickening or obstruction. There is wall thickening and mild surrounding fat
stranding of the mid sigmoid colon compatible with known diverticulitis.
There is a associated 3.1 x 2.0 x 1.6 cm pericolonic abscess (02:59). There
is also extensive diverticulosis throughout the entire colon. The appendix is
visualized and normal.
VASCULAR: The aorta contains moderate atherosclerotic calcifications but is
normal in caliber without aneurysmal dilatation. The origins of the celiac
axis, SMA, bilateral renal arteries, and ___ are patent.
RETROPERITONEUM AND ABDOMEN: There is no retroperitoneal or mesenteric lymph
node enlargement. No ascites, free air, or abdominal wall hernias are noted.
PELVIC CT: The urinary bladder and distal ureters are unremarkable. No
pelvic wall or inguinal lymph node enlargement is seen. There is no pelvic
free fluid. There is a multilobuated lesion in the left adnexa with several
hypodensities measuring up 1.2 cm. There is no fat plane between the
pericolonic abscess and this left adnexal structure.
OSSEOUS STRUCTURES: No blastic or lytic lesions suspicious for malignancy is
present. There is moderate to severe compression deformity of the L2
vertebral body with associated 4 mm retropulsion into the spinal canal of
indeterminate chronicity. There is also mild compression deformity of the
superior endplate of L1. Moderate degenerative changes are seen throughout
the lower thoracic and lumbar spine.
IMPRESSION:
1. Wall thickening and mild surrounding fat stranding of the mid sigmoid
colon compatible with known diverticulitis with associated 3.1 x 2.0 x 1.6 cm
pericolonic abscess. No intraperitoneal free air. Extensive pan colonic
diverticulosis.
2. Multi lobulated lesion at the left adnexa containing small hypodensities
measuring up to 1.2 cm. It is unclear whether this is reactive inflammation
from surrounding diverticulitis or involvement of the ovaries/fallopian tubes.
Continued followup is recommended following treatment.
3. Compression deformities of the L1 and L2 lumbar vertebral bodies, worse in
the L2 level without CT findings to suggest acuity however are of unknown
chronicity. Correlate with focal tenderness.
4. Moderate hiatal hernia.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with ABDOMINAL PAIN LLQ, INTESTINAL ABSCESS
temperature: 99.5
heartrate: 80.0
resprate: 18.0
o2sat: 99.0
sbp: 137.0
dbp: 73.0
level of pain: 0
level of acuity: 3.0 | After undergoing a CT that showed a diverticular abscess, Ms.
___ was admitted to the Colorectal Surgery from the ER for
further management. She was started on IV antibiotics
(ciprofloxacin & Flagyl). By HD2, her LLQ pain had largely
resolved. She was advanced to a regular diet and tolerated it
well. Her antibiotics were transitioned to PO. She was afebrile
and hemodynamically appopriate. She was discharged home on a
3-week course of oral antibiotics (Augmentin), after which she
will have repeat imaging to re-assess her diverticular abscess
and have subsequent follow up with Dr. ___ to discuss surgical
management. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Headache, blurry vision
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ old right-handed man with a history of
asthma, prior smoking history, and family history of stroke who
presents with acute-onset, persistent symptoms of unsteadiness
lasting all day as well as progressive headache, blurry vision,
and intermittent sensory loss.
He was last in his normal state of health at 7AM this morning as
he was getting ready for work. He had the acute onset of
dizziness, which he describes as "lightheadedness" but seems to
be more instability rather than near syncope. He had difficulty
donning his uniform, and nearly fell into a chair while trying
to do so. Sitting down he felt somewhat better, though not back
to
normal. However, he was able to go to work. However, around 1330
___ he began to develop headache and worsening instability. At
___ he started to notice blurry vision. It initially improved
but then returned with worsening headache. At 1630 he felt
numbness and tingling in his left leg below the knee. He talked
to his daughter and told her he wanted to go home, but they
encouraged him to go to the emergency department. When they met
him here, they noticed that he was walking and holding on to the
walls, which is not typical for him.
Upon presentation to the ED, his initial NIHSS was 0. He was
given fluids and a CT/CTA was ordered. This scan showed a new R
PCA infarct, largely in the medial occipital lobe; as well as
occlusion of the right carotid artery.
Regarding his headache, these are quite unusual for him as he
does not usually get headches. Otherwise, he denies diplopia,
dysarthria, dysphagia, vertigo, tinnitus or hearing difficulty.
Denies difficulties producing or comprehending speech. Denies
focal weakness, numbness, paresthesias. No bowel or bladder
incontinence or retention.
On general review of systems, the pt denies recent fever or
chills. Jehad a severe cold about a month ago which has
resolved. No night sweats or recent weight loss or gain. Denies
cough,
shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation
or abdominal pain. No recent change in bowel or bladder habits.
No dysuria. Denies arthralgias or myalgias. Denies rash.
Past Medical History:
-Asthma
-Conjunctivitis
-Bladder stones
-s/p TURP
Social History:
___
Family History:
Mother died at age ___ of catastrophic stroke. Two maternal aunts
with obesity and stroke. No family history of headache, heart
disease.
Physical Exam:
General: Overweight man, sitting up in bed, joking in NAD.
HEENT: NC/AT, no scleral icterus, mucus membranes are moist.
Supraorbital pulses palpable bilaterally, could not determine
whether there was reversal of flow.
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: Normal work of breathing. Vesicular breath sounds
bilaterally, no wheezes or crackles appreciated.
Cardiac: S1/S2 appreciated, RRR, no M/R/G.
Abdomen: Obese, soft, nontender, nondistended.
Extremities: No lower extremity edema
Skin: Rash on right thumb. No other rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Speaks ___ fluently and
some ___. Jocular, able to relate history without difficulty
but somewhat vague. Language is fluent and intact to
repetition,
naming of high and low frequency objects, comprehension or
cross-body commands. Normal prosody. Pt. was able to register
3 objects and recall ___ at 5 minutes. There was no evidence of
apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm, both directly and consensually; brisk
bilaterally. Left homonymous hemianopsia.
III, IV, VI: EOMI without nystagmus. There are hypometric
saccades most prominent on leftward gaze.
V: Facial sensation intact to light touch, pinprick in all
distributions.
VII: No facial droop, facial musculature symmetric and ___
strength in upper and lower distributions, bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline, and is equal ___ strength
bilaterally as evidenced by tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No asterixis noted.
Delt Bic Tri WrE WrFl FFl FE IO IP Quad Ham TA ___
L ___ 4+ 4+ ___ ___ 5 5 5 5
R ___ ___ ___ ___ 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 3 2
R 2 2 2 3 2
- Plantar response was flexor bilaterally.
-Sensory: No deficits to light touch, pinprick in upper and
lower extremities. Proprioception intact in great toes
bilaterally. No extinction to DSS.
-Coordination: Subtle left intention tremor, no
dysdiadochokinesia noted. Dysmetria on L FNF and HKS, normal on
right.
-Gait: Good initiation. Slightly wide-based, normal stride and
arm swing. Could not walk in tandem. Romberg absent.
###DISCHARGE EXAM###
Patient continues to have L sided dysmetria and L homymous
hemianopsia. His gait was stable and independent.
Pertinent Results:
___ 02:50PM BLOOD cTropnT-<0.01
___ 02:50PM BLOOD Triglyc-116 HDL-51 CHOL/HD-2.8 LDLcalc-68
___ 02:50PM BLOOD %HbA1c-5.8 eAG-120
___ 02:50PM BLOOD CRP-6.5*
___ 02:50PM BLOOD TSH-1.5
___ Head CTA
1. Focal hypodensity with loss of gray-white differentiation in
the right
posterior cerebral artery distribution involving the right
occipital lobe,
right inferior medial temporal lobe, compatible with an evolving
acute
infarct.
2. Hypodensity of the right thalamus is identified, which may
represent
prominent perivascular space versus sequela of lacunar infarct.
3. Complete occlusion of the right common carotid artery just
distal to the
bifurcation with a tapering configuration, potentially secondary
to
dissection.
4. Otherwise, unremarkable CTA of the head and neck.
___ Brain MRI/A
1. Study is moderately degraded by motion.
2. Redemonstration of known right PCA distribution infarcts with
evidence of
hemorrhagic transformation, as described.
3. Redemonstration of complete occlusion of right common and
cervical internal
carotid arteries, with flow noted within right supraclinoid
internal carotid
artery and distal branches.
4. Within limits of study, no definite focal dissection
identified of right
common or cervical internal carotid artery.
5. Paranasal sinus disease as described.
___ NCHCT
1. Hemorrhagic transformation of right temporal occipital
infarct wild new
since the CT of ___ is unchanged from the MRI of ___. The
area of infarct appears stable in size.
___ Echo
The left atrium is normal in size. No atrial septal defect or
patent foramen ovale is seen by 2D, color Doppler or saline
contrast with maneuvers. Left ventricular wall thickness, cavity
size, and global systolic function are normal (LVEF = 70%).
Right ventricular chamber size and free wall motion are normal.
The aortic root is mildly dilated at the sinus level. The aortic
valve leaflets (3) are mildly thickened but aortic stenosis is
not present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
The estimated pulmonary artery systolic pressure is normal.
There is no pericardial effusion.
___ CXR
1. Bilateral lower lung interstitial abnormality is of
indeterminate
chronicity, but new since ___. If the patient has
clinical evidence
pointing to a specific pulmonary problem, consider chest CT for
further
evaluation.
2. No focal consolidation concerning for pneumonia.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fluticasone Propionate NASAL 2 SPRY NU DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*3
2. Fluticasone Propionate NASAL 2 SPRY NU DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
-Right PCA territory stroke
-R ICA occluded from common carotid to intracranial portion
where it reconstitutes - unknown chronocity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK PQ147 CT HEADNECK
INDICATION: History: ___ with HA, lightheadedness, L eye visual changes // ?
stroke or other abnormality
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of 70 mL of Omnipaque intravenous contrast material.
Three-dimensional angiographic volume rendered, curved reformatted and
segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 6.4 s, 16.0 cm; CTDIvol = 56.1 mGy (Head) DLP =
897.1 mGy-cm.
2) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 43.6 mGy (Head) DLP =
21.8 mGy-cm.
3) Spiral Acquisition 5.0 s, 39.4 cm; CTDIvol = 31.9 mGy (Head) DLP =
1,258.3 mGy-cm.
Total DLP (Head) = 2,177 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is a focal hypodensity in the right occipital lobe extending into the
inferior right temporal lobe on image 4: ___ with loss of gray-white
differentiation in keeping with an evolving acute infarct in the right
posterior cerebral artery distribution. Also seen is a focal hypodensity in
the right thalamus on image 4:16.
There is no evidence of no evidence of hemorrhage, edema, or mass. The
ventricles and sulci are normal in size and configuration.
There is mild mucosal thickening in the floor of bilateral maxillary sinuses.
The remaining visualized paranasal sinuses and mastoid air cells are clear. .
The visualized portion of the orbits are unremarkable.
There are multiple periapical lucencies surrounding the maxillary and
mandibular teeth with a large lucency in the anterior hard palate surrounding
the right maxillary incisors.
CTA HEAD:
There is absence of contrast opacification of the right internal carotid
artery along its entire course up to the level of carotid terminus where there
is contrast opacification likely secondary to retrograde flow from the
anterior communicating artery and ophthalmic artery.
The remaining vessels of the circle of ___ and their principal intracranial
branches appear normal without stenosis, occlusion, or aneurysm formation.
The dural venous sinuses are patent.
Incidentally seen is hypoplastic right vertebral artery terminating into
posterior inferior cerebellar artery. Also seen is hypoplastic left posterior
communicating artery.
CTA NECK:
There is a 3 vessel aortic arch. There is complete occlusion of the right
common carotid artery just distal to the bifurcation with a tapering
configuration. There is absence of contrast opacification of the right common
and internal carotid artery along its entire course up to the carotid
terminus.
The left carotid artery demonstrates minimal atherosclerotic calcification at
its bifurcation without any stenosis by NASCET criteria. Bilateral vertebral
arteries appear unremarkable.
OTHER:
There is dependent atelectasis in bilateral upper also seen is minimal
paraseptal emphysema in right lung apex and mild centrilobular emphysema in
visualized lung parenchyma. The visualized portion of the thyroid gland is
within normal limits. There is no lymphadenopathy by CT size criteria.
IMPRESSION:
1. Focal hypodensity with loss of gray-white differentiation in the right
posterior cerebral artery distribution involving the right occipital lobe,
right inferior medial temporal lobe, compatible with an evolving acute
infarct.
2. Hypodensity of the right thalamus is identified, which may represent
prominent perivascular space versus sequela of lacunar infarct.
3. Complete occlusion of the right common carotid artery just distal to the
bifurcation with a tapering configuration, potentially secondary to
dissection.
4. Otherwise, unremarkable CTA of the head and neck.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with stroke. Evaluate for acute cardiopulmonary process.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiographs of ___ and ___.
FINDINGS:
Compared with the prior radiograph, lung volumes remain low with
bronchovascular crowding. New bilateral lower lung interstitial abnormality
is equivocal and of indeterminate chronicity. There is no focal consolidation
or pneumothorax.
IMPRESSION:
1. Bilateral lower lung interstitial abnormality is of indeterminate
chronicity, but new since ___. If the patient has clinical evidence
pointing to a specific pulmonary problem, consider chest CT for further
evaluation.
2. No focal consolidation concerning for pneumonia.
RECOMMENDATION(S): If the patient has clinical evidence pointing to a
specific pulmonary problem, consider chest CT for further evaluation.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with history of asthma, prior smoker, family
history of stroke, with stroke and right ICA occlusion and right PCA
distribution acute to subacute infarcts. Evaluate extent of infarct and for
right carotid artery dissection.
TECHNIQUE: Three dimensional time of flight MR arteriography was performed
through the brain with maximum intensity projection reconstructions.
Dynamic MRA of the neck was performed during administration of 16 mL of
Multihance intravenous contrast.
Brain imaging was performed with sagittal T1 and axial FLAIR, T2, gradient
echo and diffusion technique.
Three dimensional maximum intensity projection and segmented images were
generated. This report is based on interpretation of all of these images. The
examination was performed using a 1.5T MRI.
COMPARISON: ___ head and neck CTA.
FINDINGS:
Study is moderately degraded by motion.
MRI BRAIN:
Areas of slow diffusion are identified in the right posterior medial temporal
and right occipital lobe, as well as right thalamus. There are matched FLAIR
hyperintensities and areas of increased susceptibility.
There is no evidence of masses or midline shift. The ventricles and sulci
are normal in caliber and configuration.
Bilateral maxillary sinus and ethmoid air cell mucosal thickening is present.
MRA BRAIN:
Complete occlusion of right common carotid artery from the origin up to the
level of carotid terminus is again demonstrated. The right ophthalmic artery
remains patent. The remaining anterior and posterior circulation are patent.
A patent right posterior communicating artery is noted. Left PCOM origin
probable infundibulum is again noted (see 4 01:10, 4: 77 on current study and
651:11 on the prior exam). The left vertebral artery is dominant.
MRA NECK:
Hypoplastic right vertebral artery terminates into posterior inferior
cerebellar artery. Left posterior communicating artery is hypoplastic. The
left common, internal and external carotid arteries appear normal. There is
no evidence of left internal carotid artery stenosis by NASCET criteria. The
origins of bilateral vertebral, the left common carotid, and subclavian
arteries are grossly patent. Again is noted complete occlusion of the left
common carotid and cervical internal carotid artery. The right common carotid
artery origin is not visualized. Within limits of examination, no definite
dissection is identified.
IMPRESSION:
1. Study is moderately degraded by motion.
2. Redemonstration of known right PCA distribution infarcts with evidence of
hemorrhagic transformation, as described.
3. Redemonstration of complete occlusion of right common and cervical internal
carotid arteries, with flow noted within right supraclinoid internal carotid
artery and distal branches.
4. Within limits of study, no definite focal dissection identified of right
common or cervical internal carotid artery.
5. Paranasal sinus disease as described.
NOTIFICATION: The impression ___ were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 6:00 ___, 2 hrs after discovery
of the findings.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with stroke, hemorrhagic conversion // assess
size of bleed for stability
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.8 s, 16.2 cm; CTDIvol = 52.2 mGy (Head) DLP =
848.0 mGy-cm.
Total DLP (Head) = 848 mGy-cm.
COMPARISON: ___ contrast head MR
___ head and neck CTA
FINDINGS:
There is area of increased density (03:18) in the posterior right temporal
and right occipital region compared to before, consistent with hemorrhagic
transformation which is unchanged from the previous MRI of ___.
Surrounding area of hypodensity appear stable in size and consistent with
infarct. Right thalamic infarct is also stable.
The ventricles and sulci are stable 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:
1. Hemorrhagic transformation of right temporal occipital infarct wild new
since the CT of ___ is unchanged from the MRI of ___. The
area of infarct appears stable in size.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with large PCA infarct with hemorrhagic
conversion who now has a fever // infiltrate? infiltrate?
IMPRESSION:
Comparison to ___. The lung volumes have increased, likely
reflecting improved ventilation. Minimal left basilar atelectasis. Mild
elongation of the descending aorta. No pneumonia, no pulmonary edema, no
pleural effusions.
Gender: M
Race: HISPANIC/LATINO - CUBAN
Arrive by WALK IN
Chief complaint: Headache, Visual changes, Presyncope
Diagnosed with Headache
temperature: 99.0
heartrate: 87.0
resprate: 16.0
o2sat: 100.0
sbp: 161.0
dbp: 95.0
level of pain: 3
level of acuity: 1.0 | ___ is a ___ old right-handed man with a prior
smoking history and family history of stroke who presented with
sudden onset of lightheadedness and stepwise worsening of
symptoms of blurry vision, double vision, lightheadedness and
headache throughout the day. On initial examination in the ED,
he has a left homonymous hemianopsia, hypometric saccades on
leftward gaze, left appendicular ataxia and inability to walk in
tandem.
CT/CTA shows a right PCA territory stroke with patent posterior
circulation as well as a R ICA which is occluded from the common
carotid to the intracranial portion where it reconstitutes. MRI
revealed right PCA distribution infarcts with evidence of
hemorrhagic transformation. Repeat NCHCT 24 hours after
demonstration of hemorrhagic confirmation showed stability
without increased hemorrhage.
The patient was started on Aspirin 81mg Daily for stroke
prevention. LDL 68. A1C 5.8. TSH normal. Echocardiogram did not
reveal intracardiac thrombus, EF 70%. He was monitored on
telemetry without arrhythmia. He will be discharged to home with
___ of Hearts monitor.
The etiology of his stroke was not clear. He does have complete
occlusion with reconstitution of the R common carotid with no
evidence of dissection (but fat sat sequence not obtained) and
does have extensive collaterals. Though dissection is on the
differential, given his bleed he would not be an immediate
candidate for dual antiplatelet therapy or anticoagulation, so
further imaging was not pursued to classify this during
admission.
It is possible, though rare, that he could have a dissection
near the origin of the common carotid; however, he has no prior
traumatic history to support this. Collagen vascular disease is
another consideration, but he has no hypermobile joints,
hyperextensible skin or valve abnormalities to support this.
Given a stroke of unknown etiology, he will be discharged with a
heart monitor to observe for any evidence of a. fib and undergo
carotid US in ___ weeks as an outpatient. If not revealing, a
TEE may be considered at that time. Additionally, a
hypercoaguable work-up was initiated -- with protein C/S,
antithrombin, beta-2-glycoprotein, cardiolipin ab, and
antiphosphlipid Ab were pending at the time of discharge. He
will have prothrombin and factor V Leiden sequencing tested as
an outpatient. D-dimer pending at the time of discharge which
will be followed, and if significantly elevated a CT Torso will
be pursued to evaluate for malignancy.
He was evaluated by OT who felt his balance was appropriate and
stable for home. However, given his visual field deficit, he
cannot drive.
Of note, his CXR did reveal a lower lung interstitial
abnormality, and a chest CT can be considered as an outpatient
by PCP. He had a low grade fever to Tmax 100.5, with repeat UA
negative, blood culture no growth to date, and CXR negative for
consolidation. |
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:
___ aspiration of perirectal abscess
History of Present Illness:
___ woman with crohn's disease with recent
hospitalization for SBO with perforation, complicated by
intraabdominal abscesses requiring drainage procedures and
placement of wound VAC and post-operative pulmonary embolism,
who presents with a abdominal pain. She notes the pain started
six days ago and is associated with nausea/vomiting. Pain is in
LUQ, is ___. She has been unable to keep fluids food or
fluids down as a result. She notes that her emesis has appeared
to look like food content with associated fever and chills. She
denies blood in her stool or melena. She has had increased
watery consistency of ostomy output. Denies slowing of output
concerning for obstruction. She notes that her symptoms are most
consistent with prior episodes of c. diff colitis.
___ has had multiple hospitalizations over the fall. With one
hospitalization over a month long that was complicated by SBO
with perforation requiring ex-lap, SBR, revision of ileostomy,
then drainage of intraabdominal abscess. Course complicated by
pulmonary embolism and has been on anticoagulation since. Her
course was also complicated by bacteremia with need for
antibiotics.
In the ED, initial vital signs were:
Temp 97.7, HR 108, BP 95/72, RR 18, 100% RA
- Labs were notable for: WBC 11.3, Hg 7.9, platelets 818. Na
136, K 3.8, Cl 99, bicarb 21, BUN 5 Cr, 1.0, lipase 222 with
normal lactate.
Past Medical History:
Crohn's disease c/b rectovaginal fistula
erythema nodosum
pyoderma gangrenosum
LLE fracture
H. pylori
C. diff.
DVT associated with surgery (completed 6 month of coumadin)
depression
PSH:
- Lap diverting ileostomy (___)
- Excision of fistulous track and primary repair of vaginal
canal (___)
- Lap left hemicolectomy, proctectomy and excision of anus w/
end-colostomy, takedown of ileostomy
- Completion colectomy w/ end ileostomy (___)
- Revision ileostomy ___
- Revision of ileostomy and debridement and drainage of abscess
cavity (___)
- Exploratory laparotomy, end ileostomy revision (___)
- LLE fixation of fracture
- Transvaginal revision of levatorplasty (release of mid vaginal
band) (___)
- Exploratory laparoscopy and resection and revision of end
ileostomy (___)
- Exploratory laparotomy, revision of ileostomy with
extraperitonealization of the ileostomy (___)
Social History:
___
Family History:
Mother and cousin with Crohn's disease. No family history of
colorectal cancer. Mother with hypertension. Father with heart
disease.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS - 98.1, 104/65, 73, 18, 100RA
GENERAL - chronically ill appearing young woman, uncomfortable,
dry heaving
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, dry MM
NECK - supple
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, tender in LUQ,
non-distended, ostomy in RLQ, pink color, liquid stool. Wound
vac in place. No erythema or purulence noted.
EXTREMITIES - warm, well-perfused, no cyanosis, clubbing or
edema
SKIN - without rash
NEUROLOGIC - A&Ox3, CN II-XII grossly normal, gross motor
function intact
PSYCHIATRIC - listen & responds to questions appropriately,
pleasant
PHYSICAL EXAM on DISCHARGE:
Vitals: T 99.2/98.2 BP 94-117/58-82 HR ___ RR 18 SatO2
>98%/RA
General: Appears to be uncomfortable, in NAD.
HEENT: PERLA, moist mucous membranes
CV: RRR, normal S1 + S2, m/r/g.
Lungs: CTAB
Abdomen: Healing midline scar consistent with laparotomy
incision, has two sites of exudative drainage on morning of
discharge. Ostomy draining loose dark green stool without frank
blood. Remains tender to palpation in the LUQ/left flank. Today
complains of mild tenderness to palpation in the right abdomen
as well. Soft, non-distended. No rebound or guarding.
GU: Deferred.
Ext: Warm, well-perfused. No clubbing, cyanosis, edema.
Skin: No rashes, lesions, or cyanosis.
Pertinent Results:
LABS on ADMISSION:
___ 12:15PM BLOOD WBC-11.3* RBC-3.42* Hgb-7.9* Hct-26.0*
MCV-76* MCH-23.1* MCHC-30.4* RDW-18.2* RDWSD-50.0* Plt ___
___ 12:15PM BLOOD Neuts-83.6* Lymphs-8.1* Monos-7.0
Eos-0.4* Baso-0.5 Im ___ AbsNeut-9.46* AbsLymp-0.92*
AbsMono-0.79 AbsEos-0.04 AbsBaso-0.06
___ 12:15PM BLOOD ___ PTT-48.8* ___
___ 12:15PM BLOOD Plt ___
___ 12:15PM BLOOD Glucose-93 UreaN-5* Creat-1.0 Na-136
K-3.8 Cl-99 HCO3-21* AnGap-20
___ 12:15PM BLOOD ALT-12 AST-19 AlkPhos-127* TotBili-0.2
___ 12:15PM BLOOD Lipase-222*
___ 12:15PM BLOOD Albumin-3.6
___ 06:51AM BLOOD Calcium-9.4 Phos-5.3*# Mg-1.5*
___ 12:15PM BLOOD HCG-<5
___ 12:15PM BLOOD CRP-113.9*
___ 12:24PM BLOOD Lactate-1.2
LABS on DISCHARGE:
___ 06:50AM BLOOD WBC-7.3 RBC-3.61* Hgb-8.2* Hct-27.6*
MCV-77* MCH-22.7* MCHC-29.7* RDW-17.3* RDWSD-48.6* Plt ___
___ 06:50AM BLOOD Plt ___
___ 06:50AM BLOOD ___ PTT-43.5* ___
___ 06:50AM BLOOD Glucose-84 UreaN-3* Creat-0.8 Na-135
K-3.8 Cl-95* HCO3-30 AnGap-14
___ 06:50AM BLOOD ALT-7 AST-18 AlkPhos-108* TotBili-0.2
___ 06:50AM BLOOD Calcium-9.2 Phos-4.5 Mg-1.6
PERTINENT STUDIES/IMAGING:
- CT abd with contrast (___):
1. Enhancing perirectal fluid collection appears minimally
increased in size from the prior examination in ___ and
shows adjacent fat stranding.
2. Overall size of perihepatic, and perisplenic fluid
collections are decreased from ___. Mild small bowel mucosal
hyper enhancement as well asenhancement within the mesentery and
omentum also appears minimally decreasedfrom the prior
examination.
3. No free air in the abdomen or pelvis.
- KUB (___):
No evidence of free air. Several dilated small bowel loops, may
represent obstruction or focal ileus. CT can be performed for
further evaluation if clinically indicated.
- CXR (___):
No acute cardiopulmonary abnormalities
- PELVIS U.S., TRANSVAGINAL (___):
Pelvic fluid collection consistent with abscess. No evidence of
ovarian torsion.
- CT interventional procedure (___):
Limited preprocedure images demonstrate a presacral collection,
as seen on recent CT. Successful CT-guided aspiration the
presacral collection. Samples was sent for microbiology
evaluation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Citalopram 40 mg PO DAILY
3. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
4. Lactobacillus acidophilus ___ colonies ORAL DAILY
5. Ondansetron 4 mg PO Q8H:PRN nausea
6. OxycoDONE (Immediate Release) ___ mg PO Q4-6H PRN pain
7. Pantoprazole 40 mg PO Q24H
8. Promethazine 12.5 mg PO Q6H:PRN nausea
9. Warfarin 3 mg PO 3X/WEEK (___)
10. Warfarin 2 mg PO 4X/WEEK (___)
11. Xeljanz (tofacitinib) 5 mg oral DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Pantoprazole 40 mg PO Q24H
3. Xeljanz (tofacitinib) 5 mg oral DAILY
4. Citalopram 40 mg PO DAILY
5. Calcium 500 + D (D3) (calcium carbonate-vitamin D3) 500
mg(1,250mg) -125 unit oral DAILY
6. Lactobacillus acidophilus ___ colonies ORAL DAILY
7. Ondansetron 4 mg PO Q8H:PRN nausea
8. OxycoDONE (Immediate Release) ___ mg PO Q4-6H PRN pain
9. Promethazine 12.5 mg PO Q6H:PRN nausea
10. Warfarin 3 mg PO 3X/WEEK (___)
11. Warfarin 2 mg PO 4X/WEEK (___)
12. Outpatient Lab Work
___ (DOB ___ ICD Code ___.40
Please draw INR on ___ and fax results to ___, MD
to ___
13. OxycoDONE (Immediate Release) ___ mg PO Q4-6H:PRN pain
RX *oxycodone 10 mg ___ tablet(s) by mouth Q4-6H:PRN Disp #*21
Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Pancreatitis
Perirectal abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT abdomen and pelvis
INDICATION: ___ with abd pain+PO contrast // hernia, infection, sbo?
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 26.5 mGy (Body) DLP =
13.2 mGy-cm.
2) Spiral Acquisition 4.8 s, 52.5 cm; CTDIvol = 7.7 mGy (Body) DLP = 404.6
mGy-cm.
Total DLP (Body) = 418 mGy-cm.
COMPARISON: ___ CT
FINDINGS:
LOWER CHEST: There is minimal atelectasis at the lung bases. The visualized
heart and pericardium is within normal limits.
HEPATOBILIARY: The liver is normal in size and attenuation. There is no
biliary ductal dilatation. The portal vein is patent. At 1.5 cm hypodensity
in segment 4A is unchanged from the prior exam (02:20). The gallbladder is
within normal limits
SPLEEN: The spleen is normal in size and enhancement.
PANCREAS: The pancreas shows normal enhancement. There is no pancreatic duct
dilatation or peripancreatic fat stranding.
ADRENALS: The adrenal glands are unremarkable bilaterally.
URINARY: The kidneys display symmetric nephrograms with no evidence of
hydronephrosis or mass lesion in either kidney. The ureters are symmetrical
in their course to the bladder.
GASTROINTESTINAL: The stomach is within normal limits. The patient is status
post colectomy and right lower quadrant ileostomy. Similar to prior exams,
there is mild mucosal hyper enhancement and subtle wall thickening of the
small bowel, which appears minimally decreased from the prior examination on
___. The small bowel is normal in caliber and there is no evidence of
small bowel obstruction.
A right perihepatic collection measures approximately 3.8 x 0.7 cm and is
decreased in size from the prior examination when it measured approximately
4.6 x 0.8 cm (___:12). A small subhepatic rim enhancing fluid collection is
essentially resolved with only minimal residual soft tissue density remaining.
A small perisplenic collection is also minimally decreased from the prior
examination (02:27). A 3.8 x 3.0 cm deep pelvic fluid collection appears
increased from the prior examination when it measured 3.5 x 2.8 cm. There is
adjacent fat stranding surrounding this collection. Mild inflammation of the
mesentery and omentum persists but appears slightly decreased from the prior
examination in ___. There is no free air in the abdomen or pelvis.
LYMPH NODES: Scattered prominent but not pathologically enlarged mesenteric
lymph nodes are re- demonstrated. There is no pelvic or inguinal adenopathy.
VASCULAR: The abdominal aorta is normal in caliber without evidence of
aneurysmal dilatation or atherosclerotic disease.
PELVIS: The bladder is within normal limits. The reproductive organs are
within normal limits.
BONES AND SOFT TISSUES: A right lower quadrant ileostomy is demonstrated. A
13 mm hypodense collection at the level of the umbilicus may represent a small
postoperative seroma, consistent with recent procedure. No suspicious osseous
lesions are identified.
IMPRESSION:
1. Enhancing pelvic fluid collection appears minimally increased in size from
the prior examination in ___ and shows adjacent fat stranding.
2. Overall size of perihepatic, and perisplenic fluid collections are
decreased from ___. Mild small bowel mucosal hyper enhancement as well as
enhancement within the mesentery and omentum also appears minimally decreased
from the prior examination.
3. No free air in the abdomen or pelvis.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ yo woman with chronic Crohn's disease s/p multiple
intra-abdominal surgeries, recurrent hospitalizations for obstructions and
ostomy revisions, DVT (on Coumadin), and cdiff. She is now p/w 1 week of
nausea, vomiting, LUQ pain, and PO intolerance. We are investigating potential
infectious etiologies with Cdiff assay (now returned negative), stool
cultures, norovirus, rotavirus, and CXR. // Is there radiologic evidence of
acute intrathoraic processs suggestion of infection?
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
Cardiomediastinal contours are normal. The lungs are clear. There is no
pneumothorax or pleural effusion. S-shaped scoliosis is again noted.
IMPRESSION:
No acute cardiopulmonary abnormalities
Radiology Report
INDICATION: ___ woman with Crohn's disease with recent
hospitalization for SBO with perforation, complicated by intraabdominal
abscesses requiring drainage procedures and placement of wound VAC and
post-operative pulmonary embolism, who presents with a abdominal pain. //
assess for perforation, obstruction
TECHNIQUE: Supine and upright views of the abdomen.
COMPARISON: CT abdomen pelvis on ___.
FINDINGS:
No evidence of free intraperitoneal air. Patient is status post colectomy.
There are several loops of dilated small bowel in the abdomen. No air-fluid
levels.
IMPRESSION:
No evidence of free air. Several dilated small bowel loops, may represent
obstruction or focal ileus. CT can be performed for further evaluation if
clinically indicated.
Radiology Report
EXAMINATION: PELVIS, NON-OBSTETRIC
INDICATION: ___ woman with Crohn's disease with recent
hospitalization for SBO with perforation, complicated by intraabdominal
abscesses requiring drainage procedures and placement of wound VAC and
post-operative pulmonary embolism, who presents with a abdominal pain. // New
onset RLQ/Right pelvic pain; patient has no appendix; eval ovarian
cyst/torsion
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: CT ___
FINDINGS:
The uterus is normal and measures 3.7 x 2.5 x 8.0 cm cm. The endometrium is
homogenous and measures 2 mm.
The ovaries are normal with a dominant follicle seen in the right ovary which
measures 2.9 x 1.9 x 2.7 cm. The left ovary measures 2.1 x 1.3 x 1.8 cm.
Both ovaries show normal arterial and venous flow patterns.
A complex fluid collection is seen in the left hemipelvis corresponding to the
known abscess as demonstrated on recent CT scan.
IMPRESSION:
Pelvic fluid collection consistent with abscess. No evidence of ovarian
torsion. .
Radiology Report
INDICATION: ___ year old woman with Crohn's and recent SBO with perf, now with
recurrent abdominal pain and a slowly enlarging pelvic collection. // request
for aspiration of collection and culture.
COMPARISON: CT abdomen pelvis ___.
PROCEDURE: CT-guided drainage of presacral collection.
OPERATORS: Dr. ___ resident and Dr. ___
radiologist. Dr. ___ supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a 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 aspiration was chosen. The
site was marked. Local anesthesia was administered with 1% Lidocaine solution.
Using intermittent CT fluoroscopic guidance, an 5 ___ ___ 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 more fluid was then aspirated.
Approximately 9 cc of purulent fluid was aspirated with a sample sent for
microbiology evaluation. Limited postprocedure fluoroscopic images shows
interval decrease in size of fluid collection.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: DLP: 179 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of 2
mg Versed and 75 mcg fentanyl throughout the total intra-service time of 20
minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
Limited preprocedure images demonstrate a presacral collection, as seen on
recent CT.
IMPRESSION:
Successful CT-guided aspiration the presacral collection. Samples was sent for
microbiology evaluation.
Gender: F
Race: WHITE
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Chief complaint: Abd pain, N/V
Diagnosed with Unspecified abdominal pain
temperature: 97.7
heartrate: 108.0
resprate: 18.0
o2sat: 100.0
sbp: 95.0
dbp: 72.0
level of pain: 6
level of acuity: 2.0 | ___ woman with Crohn's disease with recent
hospitalization for SBO with perforation, complicated by
intraabdominal abscesses requiring drainage procedures and
placement of wound VAC and post-operative pulmonary embolism,
who presents with a abdominal pain consistent with acute
pancreatitis, found to have a perirectal abscess s/p aspiration.
In summary, the patient presented with a several-day history of
LUQ worsening pain, nausea/vomiting, and poor PO intake, and
decreased ostomy output. CT abdomen and KUB did not reveal any
perforation. However, CT abdomen/pelvis revealed a perirectal
fluid collection, and per colorectal surgery recommendation, it
was aspirated by ___ (fluid culture pending). The patient was
norovirus and C diff negative. ___ procedure, the patient
spiked a fever to 101.8, which could be due to the abscess site,
and she was placed on IV cefepime and flagyl. There was lower
concern for an infection, and flagyl and cefepime were
discontinued. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Glucocorticoids,Systemic
Classifier / Leukine / Prochlorperazine
Attending: ___.
Chief Complaint:
Neurologic changes over past week
Major Surgical or Invasive Procedure:
Stereotactic biopsy of the left frontal lesion ___
History of Present Illness:
Mr ___ is a ___ year old male with metastatic melanoma to the
lungs, brain, and left lower extremity who recently initiated
PD-1 (nivolumab, ipilimumab) 12 weeks ago presenting with 1 week
of neurologic changes.
His wife notes over the past week he has been increasingly
confused, with increasing anxiety and depressive symptoms; he
has been weak and fatigued. No lateralized motor deficits, but
he has overall had difficulties with balance. He was scheduled
to get an MRI brain in a few weeks as part of the study, however
the MRI was moved up several days on account of these worsening
neurologic symptoms. On the MRI he was found to have an
increasing left frontal lobe lesion (5 mm -> 3 cm) associated
with brain edema, along with an increase in the 2 right frontal
lobe lesions also associated with edema.
Of note, per his family, although he has had prior brain
metastases, he has never been on significant stretches of
steroids for edema. This is his first episode of brain edema
according to his wife. He has also never had seizures; 2 days
prior to this admission, his wife did notice that he had some
tremors that lasted a few minutes but no loss of consciousness.
He also has had improvement in his leg pain (site of melanoma
metastases) since initiating PD-1 12 weeks ago. He's attempted
to decrease his pain medications given this improvement (does
continue on a 100 mcg fentanyl patch changed every 72 hours) but
quit dilaudid 3 days ago (was taking ___ pills per day) cold
___.
Following the brain MRI today, he developed nausea and one
episode of emesis. Usually, he experiences nausea during/after
an MRI and takes lorazepam to mitigate these symptoms.
Review of systems is negative for chest pain, chest pressure,
shortness of breath, abdominal pain, diarrhea, dysuria. He is
frequently constipated secondary to his pain medications; he is
chronically taking stool softeners.
He is admitted given his worsening brain lesions, edema, and
likely consequent neurologic symptoms.
In the ED, he received 10 mg of decadron and zofran.
Past Medical History:
ONCOLOGIC HISTORY: Mr. ___ underwent an excisional biopsy of
a 6.2 mm thick, ___ Level IV, broadly ulcerated melanoma on
his right shoulder in ___. Wide local excision showed tumor
within 0.1 mm of the edge, a satellite nodule, and 25 mitoses
per
HPF. Sentinel node biopsy showed evidence of melanoma in 1 of 2
lymph nodes. He underwent complete node dissection with
residual melanoma being identified in the soft tissue of the
axilla, but no melanoma was found in 15 lymph nodes.
-- ___ to ___, received adjuvant interferon,
and then stopped due to fatigue. He was then noted to have a
right axillary mass, FNA confirmed recurrent melanoma. CT scan
revealed 2 nodules in the right axilla, but no clear evidence of
distant metastases. There was uptake in the right glenoid, most
consistent with a rotator cuff injury.
-- ___ had excision of the right axillary nodules:
Pathology showed 3 soft tissue deposits of melanoma within the
dermis, resected with clean margins. He had postoperative
radiation therapy, 5100 cGy in 17 fractions over 3 weeks in
Western ___.
-- in ___ started on adjuvant GM-CSF. After 4 doses, he
developed erythema & leg swelling.
-- in ___ PET-CT showed a lung nodule. Brain MRI then showed
a metastatic lesion in the left parietal lobe s/p SRS ___.
-- in ___ received ___ cycle of high dose IL-2; course was
c/b shock, toxic encephalopathy, & myocarditis. During his ___
cycle of ___, he developed tongue swelling after the ___
day of the ___ week. Given concern for airway compromise, he did
not receive any additional doses.
-- in ___, 4 week scans showed stability of lung nodules.
Scans done again in ___ showed stable lung disease, no
new
brain lesions. He seen in our clinic in ___ and last
in
___ at which time scans were again stable.
- ___, MRI revealed a tiny 3 x 3 lesion in the right frontal
lobe adjacent to the surface of the brain, which was new.
- ___ underwent stereotactic radiation with Dr.
___.
He states that after the radiation, he had a significant frontal
headache, which has improved, but recurs with any coughing.
- ___ MRI head was unchanged right frontal 4 x 4 mm
enhancing
lesion, consistent with a stable metastasis. No new lesions.
-- ___, he had significantly worsening headaches
and
MRI findings concerning for recurrent leptomeningeal disease.
At
that time, he underwent lumbar puncture with negative cytology.
Of note, opening pressure was 14 cm of water. However, despite
negative cytology, given his severe symptoms, we discussed
starting ___ and contacted his primary oncologist, Dr.
___. However symptoms resolved and ___ not started.
-- ___: There was a concern for
leptomeningeal disease given his pressure dependent headaches;
however, these have resolved and followup imaging was stable
enough to support him pursuing wedge resection of the nodule
that
was growing in his left lower lobe. This was performed by Dr.
___ on ___ by laparoscopic thoracotomy. This was
performed near home and we have not received the pathology
report, though it is highly likely melanoma.
-- ___ - resection of recurrent disease in the LLL, RUL
and mediastinum
-- internal fixation of the left femur on ___, and
-- completion of external beam radiotherapy at ___ as of ___,
-- status post CyberKnife radiosurgery to left frontal (2mm) and
right parietal (2mm) metastases both to ___ cGy at 76%
isodose line
-- ___ : Signed consent for ___ ___, sequential protocol
of ipilimumab and PD-1 antibody, started on ___.
Social History:
___
Family History:
Mother: brain tumor
Sister died in ___ from pancreatitis
Physical Exam:
On Admission
VS: 97.9, 130/80, 80, 18, 99% RA
Gen: Caucasian male, latent speech, confused, but cooperative
to exam
Neurologic: No gross motor or sensory deficits.
Cerebellar testing WNL. Cognitively impaired, with latent,
inappropriate responses. No lateralized sensory or motor signs.
Cardiac: Nl s1/s2 no appreciable murmurs
Pulm: clear bilaterally
Abd: soft and nontender; small hematoma noted in left lower
quadrant (biopsy site from ___ years ago, still unhealed);
melanoma associated lesion in left upper quadrant, nodular, 5 cm
in diameter, erythematous and ragged
Ext: no edema or rashes noted
On Discharge
Gen: Very pleasant, lying in bed, in NAD, latent speech, but
cooperative to exam
Neurologic: Oriented to self, place, and date. No gross motor or
sensory deficits. No lateralized sensory or motor signs.
Cardiac: Nl s1/s2 no appreciable murmurs
Pulm: clear bilaterally
Abd: soft and nontender; small hematoma noted in left lower
quadrant (biopsy site from ___ years ago, still unhealed);
Ext: No edema or rashes noted
Pertinent Results:
ADMISSION LABS
___ 03:00PM GLUCOSE-102* UREA N-9 CREAT-0.6 SODIUM-141
POTASSIUM-3.8 CHLORIDE-107 TOTAL CO2-23 ANION GAP-15
___ 03:00PM ALT(SGPT)-7 AST(SGOT)-15 ALK PHOS-135* TOT
BILI-0.3
___ 03:00PM WBC-9.3 RBC-5.28 HGB-14.6 HCT-43.6 MCV-83
MCH-27.7 MCHC-33.6 RDW-15.0
___ 03:04PM ___ PTT-27.9 ___
DISCHARGE LABS
___ 07:30AM BLOOD WBC-12.9* RBC-5.49 Hgb-15.4 Hct-45.7
MCV-83 MCH-28.0 MCHC-33.7 RDW-15.7* Plt ___
___ 08:25AM BLOOD Neuts-90.2* Lymphs-5.4* Monos-3.9 Eos-0.6
Baso-0.1
___ 07:30AM BLOOD Glucose-97 UreaN-15 Creat-0.7 Na-137
K-4.0 Cl-100 HCO3-28 AnGap-13
___ 07:30AM BLOOD Calcium-8.3* Phos-3.8 Mg-2.3
MRI with contrast ___
IMPRESSION: Considerable increase in size in the left frontal
lobe
subcortical lesion measuring now 3 cm compared to 5 mm on the
previous study with a thick rim of enhancement and intrinsic
restricted diffusion likely secondary to melanin pigments or
blood products. The previously seen two right frontal lobe
lesions also now have increased in size and measure
approximately 6 mm compared to punctate enhancement on the
previous study with mild surrounding edema. No midline shift is
seen, and there is no hydrocephalus. Findings were added to the
critical communication dashboard for communication with the
referring physician.
CT Torso with contrast ___
1. Progression of retroperitoneal lymphadenopathy.
2. New metastases in the ileocecal valve and left diaphragmatic
crura are suspacted .
3. Enlarging subcutaneous metastases. Please see concurrent CT
chest report regarding supradiaphragmatic metastasis.
4. Nonspecific trace pelvic free fluid.
___ EEG
This is an abnormal EEG due to the presence of a variable and
disorganized background with bursts of generalized slowing. This
pattern is consistent with a mild to moderate encephalopathy of
toxic, metabolic, or anoxic etiology. No evidence of ongoing or
potential seizure activity was seen during this recording.
Date of Procedure: ___
SURGICAL PATHOLOGY REPORT - Final
PATHOLOGIC DIAGNOSIS:
1. Brain, core biopsy:
Reactive brain and necrotic tissue, see note
There is no evidence of malignancy.
2. Brain core biopsy:
Reactive brain and necrotic tissue.
There is no evidence of malignancy.
3. Brain core biopsy:
Reactive brain and necrotic tissue.
There is no evidence of malignancy.
Note: No evidence of malignant melanoma. Cells interspersed
in
necrotic debris are positive for LCA and CD68 and negative for
Melan-A
and HMB4S. S100 labels surrounding gliotic brain tissue.
Medications on Admission:
amitriptyline 20 mg qhs
fentanyl [Duragesic] 100 mcg/hr Transderm Patch q72 hrs
Dilaudid 2 mg tablet q4 hrs PRN pain
lorazepam 0.5 mg tablet PRN
sulindac 150 mg tablet q12 hrs
aspirin 81 mg chewable tablet daily
docusate sodium 100 mg capsule ___ capsules daily
One-A-Day Men's 0.4 mg-600 mcg tablet 1 Tablet(s) by mouth once
a day
Metamucil Oral Powder TID
Senokot 8.6 mg tablet BID
Discharge Medications:
1. Amitriptyline 10 mg PO HS
2. Docusate Sodium 100 mg PO BID
3. Fentanyl Patch 100 mcg/h TP Q72H
4. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Post-Op pain
5. Multivitamins W/minerals 1 TAB PO DAILY
6. Senna 2 TAB PO HS:PRN constipation
7. Aspirin 81 mg PO DAILY
8. One-A-Day Mens (multivit with min-FA-lycopene) 0.4-600 mg-mcg
Oral daily
9. Psyllium 1 PKT PO TID
10. Sulindac 150 mg PO BID
11. Famotidine 20 mg PO BID:PRN epigastric pain
RX *famotidine [___] 20 mg 1 tablet(s) by mouth
twice daily Disp #*60 Tablet Refills:*0
12. Calcium Carbonate 500 mg PO TID
RX *calcium carbonate [Calcium 500] 500 mg calcium (1,250 mg) 1
tablet(s) by mouth three times daily Disp #*90 Tablet Refills:*0
13. LeVETiracetam 500 mg PO BID
RX *levetiracetam 500 mg 1 tablet(s) by mouth twice daily Disp
#*60 Tablet Refills:*0
14. Vitamin D 800 UNIT PO DAILY
RX *ergocalciferol (vitamin D2) 400 unit 2 tablet(s) by mouth
daily Disp #*60 Tablet Refills:*0
15. Dexamethasone 4 mg PO Q8H
Tapered dose - DOWN
RX *dexamethasone 4 mg 1 tablet(s) by mouth three times daily
Disp #*60 Tablet Refills:*0
16. Omeprazole 40 mg PO DAILY
RX *omeprazole 40 mg 1 capsule,delayed ___ by
mouth daily Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Metastatic melanoma
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: MRI of the brain.
CLINICAL INFORMATION: Patient with metastatic melanoma, for re-evaluation of
CNS disease prior to therapy.
TECHNIQUE: T1 sagittal, axial and FLAIR T2 susceptibility and diffusion axial
images were obtained before gadolinium. T1 axial and MP-RAGE sagittal images
acquired following the administration of gadolinium. Comparison was made with
the previous MRI of ___.
FINDINGS: The previously seen small lesion in the left frontal lobe has
considerably increased in size. It now demonstrates significantly increased
surrounding edema and a thick rim of enhancement and now measures
approximately 3 cm in size compared to 5 mm on the previous study. There is
now restricted diffusion seen within this rim-enhancing lesion with T1
hyperintensity which could be secondary to melanin pigments or secondary to
blood products. The previously noted lesions in the right frontal lobe also
have increased in size and now measure approximately 6 mm in size compared
with a punctate enhancement seen on the previous study. Mild increase in
surrounding edema to these lesions is also seen. There is no other definite
area of abnormal enhancement seen within the supra- or infratentorial brain.
There is no midline shift or hydrocephalus identified.
IMPRESSION: Considerable increase in size in the left frontal lobe
subcortical lesion measuring now 3 cm compared to 5 mm on the previous study
with a thick rim of enhancement and intrinsic restricted diffusion likely
secondary to melanin pigments or blood products. The previously seen two
right frontal lobe lesions also now have increased in size and measure
approximately 6 mm compared to punctate enhancement on the previous study with
mild surrounding edema. No midline shift is seen, and there is no
hydrocephalus. Findings were added to the critical communication dashboard
for communication with the referring physician.
Radiology Report
HISTORY: Melanoma with lung and brain metastases, pre-operative.
FINDINGS: In comparison with the study of ___, there are several suggested
nodular opacifications on the left, both of which overlie ribs, which could
possibly represent areas of metastatic disease. No evidence of acute focal
pneumonia or vascular congestion. There is blunting of the left costophrenic
angle. Mild atelectatic changes are seen in the retrocardiac region.
Radiology Report
HISTORY: A ___ male with left frontal lesion
TECHNIQUE: Contiguous axial multi detector images were obtained after
administration of intravenous contrast. Bone algorithm reconstructed images
were acquired. DLP 958 mGy-cm. CTDI 58mGy.
COMPARISON: MR head with and without contrast ___.
FINDINGS:
Re- demonstration of a left frontal ring-enhancing well-defined lesion with
associated vasogenic edema and mild compression of the left lateral ventricle.
No shift of normally midline structures. Cisterns are patent. No evidence of
new hemorrhage or infarction.
The bones are unremarkable. The paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. Visualized vessels are patent.
IMPRESSION:
No interval change in the appearance of the left frontal lesion demonstrated
on MR 3 days ago. No evidence of new lesions, hemorrhage, or infarction.
Radiology Report
HISTORY: ___ male with brain mass status post stereotactic biopsy.
COMPARISON: Contrast enhanced head CT 4 hr prior to current study.
Technique :
TECHNIQUE: Contiguous axial multi detector images were obtained through the
brain without administration of intravenous contrast. DLP 891 mGy-cm. CTDI
53 mGy.
FINDINGS:
Re- demonstration of left frontal lesion with surrounding stable appearing
vasogenic edema. The patient is status post left frontal craniotomy without
evidence of pneumocephalus. No hemorrhage or new infarction identified.
Stable mild effacement of adjacent sulci without shift of midline structures.
Post surgical craniotomy site noted. The remainder of the bones are
unremarkable. The paranasal sinuses, mastoid air cells, middle ear cavities
remain clear.
IMPRESSION:
No interval change status post left frontal craniotomy and biopsy. No
hemorrhage identified.
Radiology Report
INDICATION: Metastatic melanoma. New chest and abdominal cutaneous nodules.
Evaluation for disease progression.
TECHNIQUE: MDCT images were obtained of the abdomen and pelvis in conjunction
with the chest. Coronal and sagittal reformations were prepared.
DLP: ___ mGy-cm. Three-minute delayed images of the abdomen were also
acquired.
COMPARISON: ___.
CT ABDOMEN: There is a new 4.5 x 2.2 cm mass in the crura of the left
hemidiaphragm (2:60). Enlarging subcutaneous masses including those adjacent
to the left pectoral muscle and between the right sixth and seventh ribs are
described in a separate report. Focal hypodensity along the falciform
ligament is likely fatty deposition. The liver otherwise enhances
homogeneously. The hepatic and portal veins are patent. The gallbladder,
pancreas, spleen, and adrenals are normal. The kidneys enhance symmetrically
and excrete contrast without evidence of hydronephrosis or mass. The stomach
is normal. Retroperitoneal lymphadenopathy has progressed considerably from
___ (300B:30). There is no portacaval or mesenteric lymphadenopathy.
Small amount of free fluid is noted in the rectovesicular space (2:117).
There is no free intraperitoneal air.
CT PELVIS: Focal nodularity of one of the lips of the ileocecal valve is not
seen on prior CT and suspicious for metastasis, measuring 2.8 x 2.7 cm
(2:106). The sigmoid colon is redundant, but there is no evidence of
volvulus. The rectum is normal. The urinary bladder is distended but
otherwise unremarkable. The seminal vesicles and prostate are normal. There
is no pelvic lymphadenopathy. Subcutaneous nodule in the left lower quadrant
now measures 2.6 x 2.5 cm, previously 1.6 x 1.5 cm (2:100). 50 mm right
inguinal lymph node is not present on prior CT and is suspicious for
metastasis (2:126).
OSSEOUS STRUCTURES: There is no lytic or blastic lesion suspicious for
metastasis. The intramedullary rod is noted in the left proximal femur.
IMPRESSION:
1. Progression of retroperitoneal lymphadenopathy.
2. New metastases in the ileocecal valve and left diaphragmatic crura are
suspacted .
3. Enlarging subcutaneous metastases. Please see concurrent CT chest report
regarding supradiaphragmatic metastasis.
4. Nonspecific trace pelvic free fluid.
Radiology Report
INDICATION: Metastatic melanoma. Evaluation of tumor burden prior to next
cycle of chemotherapy.
TECHNIQUE: MDCT images of the chest were obtained in conjunction with imaging
of the abdomen and pelvis after administration of oral and intravenous
contrast. Coronal and sagittal reformations as well as axial MIPs were
prepared.
COMPARISON: ___.
FINDINGS: Numerous pulmonary nodules have developed since ___. The largest
is in the left upper lobe and measures 15 x 11 mm (2:24). Numerous other
nodules are all worrisome for metastasis (2:9, 13, 18, 20, 24, 32, 34, 37,
41). A large left axillary, hilar lymph node is also new, measuring 3.9 x 2.7
cm (2:13). Several chest wall metastases, the left mass adjacent to the
inferior margin of the left pectoralis major has enlarged to 3.2 x 2.7 cm,
previously 11 mm (2:43). More inferiorly the mass between the anterior sixth
and seventh ribs now measures 4.5 x 3.4 cm, previously 2.4 x 2.3 cm (2:52).
More superiorly in the chest wall is a new 7-mm nodule (2:14). The 11-mm
nodule between the right posterior ninth and tenth ribs is enlarged, and seen
retrospectively (2:49).
Post-surgical changes from prior right upper lobe wedge resection are noted.
There is no focal consolidation or pleural effusion. The airways are patent
to the subsegmental level. The heart and great vessels are normal. There are
no pathologically enlarged mediastinal or hilar lymph nodes by size criteria.
OSSEOUS STRUCTURES: There is no lytic or blastic lesion worrisome for
metastasis.
IMPRESSION:
1. Diffuse pulmonary and chest wall metastases as described above,
representing marked progression from ___.
2. Please correlate with report of CT abdomen and pelvis regarding
subdiaphragmatic metastases.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: VOMITING,NAUSEA
Diagnosed with NAUSEA WITH VOMITING, SEC MAL NEO BRAIN/SPINE
temperature: 98.0
heartrate: 72.0
resprate: 16.0
o2sat: 99.0
sbp: 125.0
dbp: 71.0
level of pain: 0
level of acuity: 3.0 | Mr ___ is a ___ year old male with metastatic melanoma to the
lungs, brain, and left lower extremity who recently initiated
PD-1 (nivolumab, ipilimumab) 12 weeks ago presenting with 1 week
of neurologic changes.
# Neurologic decline: His neurologic decline was thought to be
due to increase in metastatic focus in brain with surrounding
edema, and with question of possible underlying seizure
activity. He underwent stereotactic brain biopsy of the lesion,
and pathology showed changes consistent with cerebral edema and
necrosis in response to PD-1, rather than progressive metastatic
disease. He was started on decadron and keppra on admission,
but his mental status continued to be A&O x 2 daily. He
continued to be confused, and confabulated, and was tearful and
emotional at times but unable to verbalize his thoughts clearly.
20-minute EEG showed findings consistent with mild/moderate
encephalopathy with no evidence of ongoing or potential seizure.
His neurologic exam was otherwise nonfocal and he had no other
deficits that were noted during hospital course. He was cleared
for home with home ___.
# Melanoma - Patient was on PD-1 as outpatient, and had recently
completed week 9, dose 5. He had known mets to his lungs, brain
and left leg, but on admission was also found to have new
fungating lesion on his left chest wall, as well as a
subcutaneous pigmented lesion on his left abdomen along with
growth in his brain met. CT torso showed progression of his
disease; decision per outpatient oncology team was to stop PD-1
therapy. He will instead start treatment with a BRAF inhibitor,
which will arrive in the mail.
# Hemochromatosis - Patient has history of hemachromatosis - not
currently being treated.
# Leukocytosis - Noted to have leukocytosis on starting
dexamethasone without fevers, localizing symptoms or signs of
infection. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
slurred speech and facial droop
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is an ___ yo man with CAD, DM2, sCHF (EF <40%),
afib, and CKD, recently found to have a cerebellar mass (likely
metastatic lung primary), s/p VP shunt placement on ___ and
undergoing WBXRT, who presents today with worsening slurred
speech over the last one week and a left sided facial droop. Per
report, the patient's sons have reported that he has been less
attentive and less ambulatory over the last one week, with
increasingly slurred speech and gradually worsening facial
drooping.
.
He was initially diagnosed with the cerebellar mass on ___,
when he presented to ___ with several weeks of
unsteady gait. Brain CT there showed the right cerebellar mass,
and CXR showed a left lingular mass and left hilar fullness. CT
Torso showed peripheral LUL mass with left hilar and mediastinal
LAD. He was transferred to ___, and brain MRI ___ showed
the right cerebellar mass with surrouding edema. He was started
on steroids. The neurosurgery service did not recommend surgical
intervention. Lung bx ___ showed poorly differentiated
carcinoma. Since that time, he has had issues with gait
unsteadiness. On ___ he underwent elective VP shunt
placement, with an uncomplicated OR course, and post-op head CT
stable without new hemorrhage. Exam was intact, and the pt was
discarged on ___. His Coumadin had been on hold due to
bleeding risk, while he continued in atrial fibrillation.
In the ___, he was called as a code stroke upon presentation with
an NIHSS of 9, for a gaze preference (left, although able to
fully ___ sclera on the right), right sided facial droop,
right pronator drift and subtle weakness in an upper motor
neuron pattern, right leg drift, limb ataxia, and dysarthria.
Additional findings include his overall inattentiveness, apathy,
paucity of speech, and perseveration. Labs were unremarkable
except BUN 56 and Cr 1.6, and positive UA (22 WBCs, few
bacteria). Neurology felt that a new acute stroke was unlikely,
and that his symptoms were more likely due to increasing edema
around the right cerebellar mass. Seizure and GBS were thought
unlikely. On head CT there appeared to be a slight increase in
the size of his ventricles, so a shunt study was performed and
Neurosurgery was made aware, with a plan to evaluate the
integrity of the shunt and adjust as necessary.
ROS: Unable to be adequately assess as pt is inattentive with
poor communication. Denies all other symptoms.
Past Medical History:
PAST ONCOLOGIC HISTORY:
___ Ataxia
___ Brain CT showed right cerebellar mass
___ Chest x ray showed a left lingular mass
___ CT Torso showed left upper lobe mass
___ Brain MRI showed right cerebellar mass
___ Lung biopsy preliminary report shows poorly
differentiated carcinoma
OTHER PAST MEDICAL HISTORY:
- Coronary artery disease
- Diabetes mellitus with peripheral neuropathy, no retinopathy
- Atrial fibrillation (off coumadin due to high bleeding risk)
- Nonischemic cardiomyopathy w/ sCHF EF <40%
- Hypertension
- Peripheral vascular disease
- Osteomyelitis of right foot
- Right great toe amputation
- Cataracts
- Chronic kidney disease, stage IV
- Asbestosis
Social History:
___
Family History:
No known oncologic disease.
Physical Exam:
Physical Exam on Admission:
VS: Temp 96.8F, BP 120/66, HR 69, R 20, SaO2 100% RA
General: elderly man in NAD, lying comfortably in bed
HEENT: PERRL/EOMI, sclerae anicteric, MMM, OP clear
Neck: supple, no LAD or JVD, no nuchal rigidity
Lungs: CTA bilat, no r/rh/wh
Heart: RRR, nl S1-S2, no MRG
Abdomen: +BS, soft/NT/ND, no HSM
Extrem: WWP, no c/c/e
Skin: no rashes or lesions
.
Physical Exam on Discharge:
VS: Tm/c 98.8 BP 130/68 HR 85 R 20 SaO2 94% RA
General: elderly man in NAD, lying comfortably in bed, somewhat
sleepy but easily arousable
HEENT: PERRL/EOMI, sclerae anicteric, MM dry, OP clear
Neck: supple, no LAD or JVD, no nuchal rigidity
Lungs: CTA bilat, no r/rh/wh
Heart: RRR, nl S1-S2, no MRG
Abdomen: +BS, soft/NT/ND, no HSM
Extrem: WWP, no c/c/e, cogwheel rigidity on R>L
Skin: no rashes or lesions
Neuro:
-oriented to self, place, birthdate when prompted with 3
choices, not date, perseverates
-CN: EOMI, PERRL, some neglect on left, V intact, left sided
facial droop sparing the forehead, SCM intact ___, tongue
protrudes midline
-Motor: ___ in ___
-finger to nose intact
-sensation grossly intact throughout
Pertinent Results:
Labs on Admission:
.
___ 12:10PM WBC-10.3 RBC-4.17* HGB-12.7* HCT-36.7* MCV-88
MCH-30.4 MCHC-34.6 RDW-13.9
___ 12:10PM PLT COUNT-176
___ 12:10PM ___ PTT-26.7 ___
___ 12:26PM GLUCOSE-155* NA+-137 K+-4.5 CL--100 TCO2-26
___ 12:10PM UREA N-56*
___ 12:10PM CREAT-1.6*
___ 04:30PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-100 KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.0
LEUK-SM
___ 04:30PM URINE RBC-3* WBC-22* BACTERIA-FEW YEAST-MOD
EPI-1
.
Imaging
.
Head CT (12:17pm): Again seen is a 2.3 x 2.0 cm cystic lesion in
the right cerebellar peduncle with mass effect on the adjacent
fourth ventricle and surrounding edema, unchanged from the prior
exam from today. Ventricles continued to be moderately dilated
with prominent temporal horns and a right frontal approach
ventriculostomy catheter terminating in the frontal horn. There
is no area of hemorrhage identified or new mass lesion.
IMPRESSION: Unchanged exam compared to the study performed
earlier today at 8:54 a.m. No evidence of hemorrhage.
.
Head CT (8:54am): Again a cystic lesion identified in the right
middle cerebellar peduncle with mass effect on the adjacent
fourth ventricle. The lesion measures approximately 2.5 cm
compared to 2.2 cm on the previous study. The surrounding edema
and the mass effect is not significantly changed. The ventricles
are moderately dilated with prominent temporal horns, not
significantly changed. Shunt catheter is seen from the right
frontal region extending to the anterior horn, unchanged.
IMPRESSION: Unchanged appearance of the ventricular size.
Although the cystic lesion in the right middle cerebellar
peduncle appears slightly larger, the surrounding edema and the
associated mass effect is not significantly changed. No
hemorrhage seen.
.
Shunt Study: The course of the ventriculoperitoneal shunt
arising from the right side of the brain and coursing along the
right neck, chest, and epigastric region appears intact. Its tip
terminates along the left lateral mid abdomen. There is again a
large lung nodule projecting over the left lower lung. Calcified
pleural plaques are present. There are moderate degenerative
changes of the thoracolumbar spine. Bony demineralization is
suspected.
IMPRESSION: Intact course of ventriculoperitoneal shunt.
.
Reports
.
EEG ___:
This is an abnormal EEG because of diffuse background
slowing and bursts of generalized slowing. These findings are
indicative
of a mild to moderate diffuse encephalopathy, which is
etiologically non
specific. There were no epileptiform features. Of note, the
cardiac
rhythm strip demonstrated an irregularly irregular rhythm with
occasional wide complex ectopic beats.
.
Labs on Discharge:
___ 09:00AM BLOOD WBC-7.1 RBC-4.33* Hgb-12.9* Hct-39.3*
MCV-91 MCH-29.8 MCHC-32.8 RDW-14.2 Plt ___
___ 09:00AM BLOOD Neuts-82.7* Lymphs-11.9* Monos-5.2
Eos-0.2 Baso-0.1
___ 07:05AM BLOOD ___ PTT-26.8 ___
___ 09:00AM BLOOD Glucose-310* UreaN-56* Creat-1.5* Na-142
K-4.7 Cl-104 HCO3-29 AnGap-14
___ 07:05AM BLOOD ALT-23 AST-14 AlkPhos-121 TotBili-0.6
___ 09:00AM BLOOD Calcium-9.1 Phos-3.4 Mg-2.2
Medications on Admission:
- famotidine 20mg PO BID
- docusate 100mg PO BID
- senna 8.6mg PO BID
- oxycodone-acetaminophen ___ tabs PO Q6hrs PRN pain
- acetaminophen 325-650mg PO Q6hrs PRN pain
- atorvastatin 80mg daily
- digoxin 125mcg PO daily
- carvedilol 3.125mg PO BID
- dexamethasone 4mg PO Q8hrs
- 70/30 insulin
Discharge Medications:
1. famotidine 20 mg Tablet Sig: One (1) Tablet PO twice a day.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day).
3. senna 8.6 mg Tablet Sig: One (1) Tablet PO BID (2 times a
day).
4. oxycodone-acetaminophen ___ mg Tablet Sig: ___ Tablets PO
Q6H (every 6 hours) as needed for pain.
5. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain, fever: Do not exceed 4000mg
acetaminophen over any 24-hour period.
.
6. atorvastatin 80 mg Tablet Sig: One (1) Tablet PO once a day.
7. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
8. carvedilol 3.125 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
9. levetiracetam 500 mg Tablet Sig: One (1) Tablet PO BID (2
times a day).
10. cefpodoxime 100 mg Tablet Sig: Two (2) Tablet PO Q24H (every
24 hours) for 2 days: last day is ___.
11. dexamethasone 6 mg Tablet Sig: One (1) Tablet PO twice a
day.
12. insulin aspart 100 unit/mL Solution Sig: per sliding scale
units Subcutaneous QACHS: Please give insulin per sliding scale
depending on fingerstick blood glucose readings.
13. insulin glargine 100 unit/mL Solution Sig: Ten (10) units
Subcutaneous QAM.
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary:
Cerebellar mass
Carcinoma of the lung
Urinary tract infection
.
Secondary:
Diabetes
Hypertension
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAM: CT head.
CLINICAL INFORMATION: Patient with VP shunt, for further evaluation to assess
interval change.
TECHNIQUE: Axial images of the head were obtained without contrast.
Comparison was made with the CT of ___ and MRI of ___.
FINDINGS: Again a cystic lesion identified in the right middle cerebellar
peduncle with mass effect on the adjacent fourth ventricle. The lesion
measures approximately 2.5 cm compared to 2.2 cm on the previous study. The
surrounding edema and the mass effect is not significantly changed. The
ventricles are moderately dilated with prominent temporal horns, not
significantly changed. Shunt catheter is seen from the right frontal region
extending to the anterior horn, unchanged.
IMPRESSION: Unchanged appearance of the ventricular size. Although the
cystic lesion in the right middle cerebellar peduncle appears slightly larger,
the surrounding edema and the associated mass effect is not significantly
changed. No hemorrhage seen.
Radiology Report
CLINICAL HISTORY: ___ man with left facial droop and right-sided
weakness. Evaluate for CVA.
COMPARISON: Multiple priors, most recently from ___,
approximately 4 hours prior to this exam.
TECHNIQUE: Non-contrast head CT.
FINDINGS: Again seen is a 2.3 x 2.0 cm cystic lesion in the right cerebellar
peduncle with mass effect on the adjacent fourth ventricle and surrounding
edema, unchanged from the prior exam from today. Ventricles continued to be
moderately dilated with prominent temporal horns and a right frontal approach
ventriculostomy catheter terminating in the frontal horn. There is no area of
hemorrhage identified or new mass lesion.
IMPRESSION: Unchanged exam compared to the study performed earlier today at
8:54 a.m. No evidence of hemorrhage.
Radiology Report
SHUNT SERIES
HISTORY: Ventriculoperitoneal shunt.
COMPARISONS: None aside from CT interventional procedure-related imaging from
___. This provides a comparison for a portion of the chest based on the
scout film.
TECHNIQUE: Shunt series.
FINDINGS: The course of the ventriculoperitoneal shunt arising from the right
side of the brain and coursing along the right neck, chest, and epigastric
region appears intact. Its tip terminates along the left lateral mid abdomen.
There is again a large lung nodule projecting over the left lower lung.
Calcified pleural plaques are present. There are moderate degenerative
changes of the thoracolumbar spine. Bony demineralization is suspected.
IMPRESSION: Intact course of ventriculoperitoneal shunt.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R/O CVA
Diagnosed with BRAIN CONDITION NOS, FACIAL WEAKNESS, VENTRICULAR SHUNT STATUS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: 1.0 | Mr ___ is an ___ man with CAD, DM2, sCHF (EF <40%), afib,
and CKD, recently found to have a cerebellar mass (likely
metastatic lung primary), s/p VP shunt placement on ___ and
undergoing WBXRT, who presents today with worsening neurologic
symptoms over the last week.
.
# Progressive neurologic symptoms: Per family, Mr. ___ has
had intermittent facial droop, slurred speech, confusion since
the VP shunt was placed. These progressive symptoms are most
likely secondary to increased edema surrounding the right
cerebellar mass. He was evaluated by neurology in the ___, and
other etiologies such as stroke, seizure, and GBS were thought
to be much less likely. Additionally, shunt series revealed the
VP shunt to be intact. In the ER, he received 6mg IV decadron
and was started on standing dose on the floor. EEG was obtained
which showed diffuse slowing but no epileptiform activity. On
discharge, he will taper to Dexamethasone 6mg PO bid. In the
setting of high dose steroids, he should continue Famotidine for
prophylaxis and blood glucose should be monitored with
fingersticks and insulin sliding scale. He was also started on
Keppra 500mg PO bid for seizure prophylaxis. Whole brain xrt was
continued during the admission. On discharge, Mr. ___ will
f/u with Dr. ___ neuro-oncologist.
.
# UTI: Positive UA in ___, culture with contamination. Given
recent UTI and possible contribution of infection to confusion,
treated with anbitiobics. Will complete 7 day course of
cefpodoxime 200mg PO qd on ___.
.
# DM II: maintained on an unknown dose of 70/30 insulin at home.
Blood sugars likely to elevate in setting of Decadron use.
Patient was on Lantus 10 U qam and humalog ISS in house.
.
# Afib: Not anticoagulated due to recent cranial surgery.
Continued home digoxin, carvedilol.
.
# sCHF: non-ischemic, EF <40%: Continued home digoxin,
carvedilol.
.
# CAD: Continued home statin and carvedilol.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Losartan
Attending: ___.
Chief Complaint:
ACUTE LEUKEMIA
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with no PMH apart from h/o acute leukemia diagnosed in the
past week, now admitted for chemotherapy.
.
She has experienced 1 month of nightsweats and fatigue plus dry
cough x 1 week (cough now resolved). No fever, no N/V/C.
Describes poor appetite and 6 lb weight loss over several weeks.
At initial eval, PCP found leukopenia on screening labs.
Referred to hematologist who performed BM bx ___ - preliminary
BM bx results showed acute leukemia concerning for AML.
.
Patient presented to the ___ ED for admission to the ___
service.
.
In the ED, initial VS T99.6 HR 136 BP123/67 RR18 99/RA. While in
the ED she triggered for tachycardia, which improved to HR ___
greatly after 2L NS IVF. Labs remarkable for WBC 0.7, HCT 33.1,
platelets 174, 19% PMNs, 77% lymphs, 2% monos, 1% eosinophils.
.
On the floor, she feels well except for 1 month mouth dryness
and bilateral eye redness/swelling. Tried eyedrops per
ophthalmology recommendation (beta blocker eyedrops,
prescription unknown) without no improvement.
.
ROS: As per HPI. Full 12-system ROS negative including GI/GU
issues, CP, palpitations, SOB, abd pain.
Past Medical History:
HTN
Social History:
___
Family History:
2 children, ___ and ___. One brother died ___ age ___. Father
DM and CAD, mother CVA.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS 96.3 106/64 92 18 98/RA
GENERAL - well developed younger than stated ago, NAD AOX3
HEENT - MM dry no oral lesions no cervical LAD PERRL EOMI
injected conjunctiva/sclera, and periorbital erythema and
swelling
CARDIAC - RRR nl S1 S2 no murmur
PULM - CTAB no r/r/w
___ - soft nt nd +BS no organomegaly
EXTREM - no edema
PSYCH - mood and affect appropriate
HEME/LYMPH - no LAD
SKIN - minimally raised red rash >1 cm diameter lesions, on back
and posterior L leg, non-pruritic
.
Discharge PE:
VS 99 122/72 101 (80s-100s) 97%RA
GENERAL - NAD, very well appearing
HEENT - MMM, no oral lesions no LAD
CARDIAC - RRR nl S1 S2 no murmur
PULM - CTAB no r/r/w
___ - soft nt nd +BS no organomegaly
EXTREM - RUE without edema, but with continued palpable clot
medial upper arm
PSYCH - mood and affect appropriate
HEME/LYMPH - no LAD, few bruises but no bleeding.
SKIN - b/l thigh plaques are much improved
ACCESS: Peripheral, intact.
Pertinent Results:
ADMISSION LABS
___ 10:45AM BLOOD WBC-0.7* RBC-3.50* Hgb-10.9* Hct-33.1*
MCV-95 MCH-31.1 MCHC-32.9 RDW-13.5 Plt Ct-74*
___ 10:45AM BLOOD Neuts-19* Bands-0 Lymphs-77* Monos-2
Eos-1 Baso-0 ___ Metas-1* Myelos-0
___ 12:08PM BLOOD ___ PTT-26.0 ___
___ 12:08PM BLOOD ___
___ 10:45AM BLOOD Glucose-165* UreaN-23* Creat-1.1 Na-135
K-4.3 Cl-100 HCO3-23 AnGap-16
___ 10:45AM BLOOD ALT-25 AST-25 LD(LDH)-238 AlkPhos-42
TotBili-0.7
___ 10:45AM BLOOD Albumin-3.2* Calcium-8.9 Phos-2.2*
UricAcd-3.7
___ 11:16AM BLOOD Lactate-3.1*
.
.
PATHOLOGY
.
OSH thigh punch biopsy: 1.Perivascular and predominantly
superficial dermal neutrophilic infiltrate with leukocytoclasis
and red blood extravasation consistent with acute neutrophilic
vasculitis (see comment).
2.Atypical dermal mononuclear cell infiltrate
.
___ KARYOTYPE: 46,XX[20]
INTERPRETATION:
No cytogenetic aberrations were identified in 20
metaphases analyzed from this unstimulated specimen.
This normal result does not exclude a neoplastic
proliferation.
.
___ BM BIOPSY
PRELIM: Poorly differentiated acute myelogenous leukemia
.
IMAGING
.
___ CXR
FINDINGS: PA and lateral views of the chest. The cardiac,
mediastinal, and hilar contours are normal. The lungs are clear.
Heart size is top normal. Pleural surfaces are normal. No
evidence of pneumonia. No pleural effusions or pneumothorax. No
evidence of pulmonary edema.
IMPRESSION: No evidence of pneumonia. No acute cardiopulmonary
process.
.
DISCHARGE LABS
Micro: Blood cultures negative ___ x2
.
___ 05:33AM BLOOD WBC-0.9* RBC-2.83* Hgb-8.6* Hct-24.0*
MCV-85 MCH-30.4 MCHC-35.9* RDW-15.0 Plt Ct-34*
___ 05:33AM BLOOD Neuts-22.2* Bands-0 Lymphs-68.8*
Monos-7.2 Eos-1.2 Baso-0.5
___ 05:33AM BLOOD ___ PTT-26.8 ___
___ 05:41AM BLOOD ___ 05:33AM BLOOD Glucose-116* UreaN-16 Creat-0.7 Na-135
K-4.2 Cl-101 HCO3-29 AnGap-9
___ 05:33AM BLOOD ALT-18 AST-13 LD(LDH)-143 AlkPhos-57
TotBili-0.7
___ 05:33AM BLOOD Calcium-9.4 Phos-3.3 Mg-2.2
Medications on Admission:
Lisinopril (dose unknown)
Discharge Medications:
1. acyclovir 400 mg Tablet Sig: One (1) Tablet PO Q8H (every 8
hours).
Disp:*90 Tablet(s)* Refills:*0*
2. levofloxacin 500 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*0*
3. fluconazole 200 mg Tablet Sig: One (1) Tablet PO Q24H (every
24 hours).
Disp:*30 Tablet(s)* Refills:*0*
Discharge Disposition:
Home
Discharge Diagnosis:
acute myeloid leukemia
left upper extremity deep vein thrombosis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Acute leukemia. Question of pneumonia.
COMPARISON: None available.
FINDINGS: PA and lateral views of the chest. The cardiac, mediastinal, and
hilar contours are normal. The lungs are clear. Heart size is top normal.
Pleural surfaces are normal. No evidence of pneumonia. No pleural effusions
or pneumothorax. No evidence of pulmonary edema.
IMPRESSION: No evidence of pneumonia. No acute cardiopulmonary process.
Radiology Report
INDICATION: New PICC line placement.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the patient has received a
right-sided PICC line. The course of the line is unremarkable, the tip of the
line projects over the mid SVC. There is no evidence of complications,
notably no pneumothorax. Otherwise, the radiograph is unchanged, except for a
newly appeared atelectatic opacity at the level of the left hilus, that should
receive attention at subsequent followups.
Radiology Report
CLINICAL HISTORY: ___ woman with AML and right upper extremity PICC,
now with right arm swelling.
COMPARISON: None.
FINDINGS: The right subclavian shows some decrease in phasicity of flow. A
right PICC is seen within the basilic vein and through the subclavian vein.
Around the PICC, there is hypoechoic material without compressibility
representing clot; flow is not seen in most of the basilic vein indicating the
clot is occlusive. The clot also extends into the axillary vein, where it is
also occlusive, and into the medial brachial vein, which has some flow within
it and is not occlusive. There may be thrombus around the PICC within the
right subclavian vein but there is clear flow in the right subclavian vein
with good variability inidcating no occlusion here or more centrally.
IMPRESSION:
1. Occlusive thrombis in the right basicilic and axillary veins, surrounding
the PICC. Non-occlusive thrombus within the medial brachial vein.Possible
thrombus extending into the right subclavian vein around the PICC, which would
be non-occlusive if present.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: WEAKNESS, NEW LEUKEMIA SENT FOR ADMIT
Diagnosed with OTHER MALAISE AND FATIGUE, ACUTE LEUKEMIA OF UNSPECIFIED CELL TYPE, WITHOUT MENTION OF HAVING ACHIEVED REMISSION
temperature: 99.6
heartrate: 136.0
resprate: 18.0
o2sat: 99.0
sbp: 123.0
dbp: 67.0
level of pain: 3
level of acuity: 1.0 | Summary: Ms. ___ is a ___ yo woman with newly diagnosed AML,
treated with 10d course of decitabine, course c/b PICC DVT and
transaminitis.
.
#New AML: NPM1 mutation postive. Her counts increased
substantially on the day of discharge. Acyclolvir, fluconazole,
levofloxacin were started for prophylaxis.
.
# Transaminitis: Stopped fluconazole, enoxaparin, and
levofloxacin and LFTs improved. However, most likely that
increase was due to the chemotherapy. Levo was restarted, and
LFTs did not increase over several days. Fluconazole was started
just prior to discharge. LFTs should be monitored as an
outpatient.
.
# R upper extremity DVT: Associated with PICC, which was
discontinued on ___, and enoxaparin was stopped on ___ after
the patient became thrombocytopenic.
.
#HYPERTENSION: Held lisinopril
.
# Thigh Plaques: Neutrophilic vasculitis according to derm
biopsy. Likely in setting of losartan. Improved markedly this
admission.
.
==== |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Confusion
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ hx of glaucoma, ? dementia, COPD, Rheumatoid arthritis,
DVT/PE, who presents after being confused about his PCP
___. Pt reports that yesterday AM, he was notified that
he had an appointment for the next day. He took a nap, woke up
in the afternoon, but thought it was the next morning, and
proceeded to go to ___ for his PCP ___. At ___, given that
he was confused, he was told to go to the ED. He was then
admitted for concern for poor self care.
A community nurse helps patient fills his medication box. He
lives alone as his wife is currently sick and is at nursing
home. He walks with a cane. Reports having good appetite.
Per previous note with community resource nurse: Pt takes the
bus or a taxi to ___ ___ and/or social activities:
such as visiting his wife in the nursing home. He does not have
a lifeline. He says if he does not feel well, he knocks on his
neighbor's door and asks for help. Pt was asked what he would
do if he was alone, not able to get OOB to ask for help. ___ did
not know.
Past Medical History:
Seropositive rheumatoid arthritis
Latent TB
Hepatitis B, continues on lamivudine
Diabetes
COPD continues the inhaler therapy
Medication compliance issues
Social History:
___
Family History:
No h/o autoimmune disease, denies family history of DVT/PE
Physical Exam:
ADMISSION PHYSICAL EXAM
==========================
Vital Signs: 98.1 142/71 61 18 98% RA
General: Alert, oriented, no acute distress
HEENT: Erythematous sclera. EOMI. Clear oropharynx.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait
deferred.
DISCHARGE PHYSICAL EXAM
============================
Vital Signs: 98.9 120-137/57-71 59-68 ___ 93-98% RA
General: Alert, oriented, no acute distress
HEENT: Erythematous sclera. EOMI. No tonsillar exudates.
Neck: No cervical lymphadenopathy
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding. Umblilical hernia,
non-tender, reducible.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, gait deferred.
Pertinent Results:
ADMISSION LABS
===================
___ 01:22AM BLOOD WBC-5.9 RBC-4.23* Hgb-11.8* Hct-38.1*
MCV-90 MCH-27.9 MCHC-31.0* RDW-13.8 RDWSD-44.9 Plt ___
___ 01:22AM BLOOD Neuts-60.4 ___ Monos-7.4 Eos-2.4
Baso-0.8 Im ___ AbsNeut-3.59 AbsLymp-1.69 AbsMono-0.44
AbsEos-0.14 AbsBaso-0.05
___ 01:22AM BLOOD Glucose-123* UreaN-13 Creat-1.0 Na-139
K-5.0 Cl-96 HCO3-31 AnGap-17
___ 01:22AM BLOOD ALT-7 AST-14 AlkPhos-70 TotBili-0.4
___ 01:22AM BLOOD Albumin-3.9
___ 01:22AM BLOOD VitB12-230* Folate->20
___ 01:22AM BLOOD ___
METHYLMALONIC ACID (___): 543 H Normal range: 87-318 nmol/L
**FINAL REPORT ___
RAPID PLASMA REAGIN TEST (Final ___:
REACTIVE.
Reference Range: Non-Reactive.
QUANTITATIVE RPR (Final ___:
REACTIVE AT A TITER OF 1:4.
DISCHARGE LABS
==================
___ 12:51PM BLOOD WBC-5.8 RBC-4.46* Hgb-12.6* Hct-40.5
MCV-91 MCH-28.3 MCHC-31.1* RDW-13.9 RDWSD-45.8 Plt ___
___ 12:51PM BLOOD Neuts-61.7 ___ Monos-9.1 Eos-3.1
Baso-0.9 Im ___ AbsNeut-3.59 AbsLymp-1.44 AbsMono-0.53
AbsEos-0.18 AbsBaso-0.05
___ 12:51PM BLOOD Glucose-91 UreaN-14 Creat-1.0 Na-137
K-4.9 Cl-99 HCO3-29 AnGap-14
___ 12:51PM BLOOD Calcium-9.1 Phos-4.2 Mg-2.2
MICRO:
R/O Beta Strep Group A (Pending) ___:
URINE culture (___): No growth
CXR (___)
Mild interstitial edema. Left basilar opacity may reflect
atelectasis though infection can be considered in the
appropriate clinical setting.
Radiology Report
INDICATION: ___ male with confusion. Evaluate for infectious
process.
TECHNIQUE: PA and lateral chest radiographs were obtained.
COMPARISON: Chest radiograph from ___.
FINDINGS:
There is mild interstitial edema, and the heart is normal in size. A left
basilar opacity may reflect atelectasis versus pneumonia. There is no pleural
effusion or pneumothorax.
IMPRESSION:
Mild interstitial edema. Left basilar opacity may reflect atelectasis though
infection can be considered in the appropriate clinical setting.
Gender: M
Race: BLACK/CARIBBEAN ISLAND
Arrive by UNKNOWN
Chief complaint: Confusion, Eye redness
Diagnosed with Altered mental status, unspecified
temperature: 99.7
heartrate: 78.0
resprate: 18.0
o2sat: 99.0
sbp: 155.0
dbp: 78.0
level of pain: 3
level of acuity: 3.0 | Mr. ___ is an ___ y/o ___ speaking man
presenting after mistakenly going to the hospital for an
unscheduled appointment. TSH within normal limits, RPR with
stable titer in the setting of known latent syphilis. Patient
was found to be B12 deficiency with elevated methylmalonic acid.
Supplementation with vitamin B12 was started. Physical therapy,
occupational therapy evaluated patient and recommended initially
that he be discharged to a rehabilitation facility, subsequently
revised their suggestion to home with ___ supervision. It was
determined that safest discharge would be to with his sister
with services, to which both he and she were agreeable.
#Self care:
Patient lives alone. In light of gait instability observed by ___
and concern by OT that he sometimes forgets to turn off the
stove, ___ supervision was advised. Much has been done in the
past to try to assist the patient. He has frequent follow-up
with his PCP, ___ extensive resources through HCA.
Following extensive discussion with case management, it was
determined that he did not qualify for ___
rehabilitation, and other placement options were financially
prohibitive. Following extensive discussion with his PCP and
case management, it was determined that safest discharge would
be to live with his sister, to which both the patient and his
sister were agreeable. A multidisciplinary family meeting,
including both inpatient and outpatient providers, was held on
the day of discharge, with emphasis to the patient and his
sister on the importance of his new living arrangements for his
optimal safety.
#Confusion/dementia
Patient appears back at baseline. TSH within normal limits. RPR
titer stable; in discussion with his ID provider, Dr. ___,
___ stable titer, recent rule-out for neurosyphilis, and
recent treatment for latent syphilis, no further work-up or
treatment needed at this time. Patient may be b12 deficient as
discussed below.
#B12 deficiency
Patient with low B12 level with elevated methylmalonic acid. ___
be secondary to PPI use and poor absorption. Started B12
supplementation with 1000mcg daily.
#Glaucoma:
Continues to have bilateral eye pain and erythematous sclerae.
Patient has appt with ophthalmologist on ___. Per
ophthalmology, his glaucoma has been difficult to control. His
conjunctival hyperemia is secondary to his eye drops which helps
to control his pressures. Continued home eye drops:
dorzolamide/timolol.
#Sore throat
___ be viral pharyngitis. Centor score of 1, therefore unlikely
strep pharyngitis. Was given lozenges for symptomatic relief.
Patient continued to have persistent sore throat. Swab for strep
pharyngitis pending at discharge and subsequently returned
negative.
#Weight loss: Outpatient PCP performing occult malignancy
work-up. Weight appears back up at 200lb on this admission.
Continue outpatient workup. Patient was seen eating well while
hospitalized. ___ be due to poor access to food.
#Pulmonary Embolism
Continued xarelto for 6 months of treatment (last dose ___.
#History of hepatitis B.
Continued lamivudine.
#Seropositive rheumatoid arthritis.
Continued prednisone 5 mg daily and methotrexate 25 weekly
#COPD
Continued home tiotroprium, and albuterol prn
#Gerd:
Continued omeprazole 20mg BID.
# Chronic Back Pain:
Continued home tramadol
***TRANSITIONAL ISSUES***
- Pt has chronic glaucoma, pain in eye, and conjunctival
hyperemia. Has an appointment with ophthalmologist on ___.
- Patient with B12 deficiency, persistent sore throat, weight
loss, consider workup of possible malignancy, as has been
ongoing in the outpatient setting.
- Consider further work-up of etiology of vitamin B12
deficiency, including IF Ab and EGD.
- Continue to monitor vitamin B12 level and MMA; oral
supplementation was chosen for patient convenience, but may
consider IM injections if deficiency does not improve with oral
supplementation or concern for malabsorption.
New medications: Vitamin B12 1000mcg
# CODE: full
# CONTACT:
Name of health care proxy: ___
___: sister
Phone number: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: ORTHOPAEDICS
Allergies:
Penicillins
Attending: ___
___ Complaint:
Left leg and ankle pain
Major Surgical or Invasive Procedure:
Left tibia external fixator
History of Present Illness:
The patient is a ___ male who slipped on wet rocks and
fell, worked up at OSH and found to have left ankle fracture,
then transferred to ___. He was in his usual state of health,
was walking, slipped on some wet gravel with inversion injury
and then fell over with immediate pain and inability to
ambulate. He was found to have comminuted distal tibia/fibula
fracture with intra-articular extension. He was admitted to the
orthopaedic team and treated with external fixator on ___.
Past Medical History:
HTN
GERD
Social History:
___
Family History:
NC
Physical Exam:
DISCHARGE PHYSICAL EXAM
General: Alert and oriented, NAD, AVSS
Cardio: RRR
Resp: breathing unlabored
Left lower extremity:
External fixator in place, pin sites wrapped in dry gauze with
mild staining, wiggles toes, SILT superficial peroneal, deep
peroneal, saphenous, tibial, sural distributions, ___ pulses,
foot warm and well-perfused
Radiology Report
INDICATION: ___ with pilon L ankle fracture, status post reduction.
COMPARISON: Prior exam performed earlier today from outside hospital.
FINDINGS:
AP, lateral, oblique views of the left ankle were provided. There has been
interval reduction attempt with no significant change in alignment. Comminuted
fractures through the distal tibia and fibula are unchanged. Overlying plaster
splint is in place.
IMPRESSION:
Distal tibia and fibula fractures in unchanged overall alignment.
Radiology Report
INDICATION: Status post trauma with distal tibia and fibular fractures.
Evaluate preoperatively.
TECHNIQUE: MDCT images were obtained through the left ankle without the
administration of IV contrast. Sagittal and coronal reformatted images were
obtained and reviewed.
DOSE: Total DLP: 440.44 mGy-cm.
COMPARISON: Ankle radiographs from ___.
FINDINGS:
There is a markedly comminuted oblique fracture of the distal tibia with
intra-articular extension. The dominant distal fracture fragment is displaced
anteromedially. The fragments are overriding by approximately 1 cm. The
intra-articular portion of the fracture has two major components. First, there
is a nondisplaced fracture through the posterior portion of the joint. Second,
there is an anteromedial fragment that is displaced anteriorly by 1.2 cm. This
is creating a small focal articular surface gap.
There are two tiny bone fragments adjacent to the medial malleolus, suggesting
an avulsion injury. The remainder of the medial malleolus is intact.
There is also a markedly comminuted fracture of the distal fibula with
intra-articular extension. There is one fracture above the syndesmosis with
the distal fragments displaced anteromedially, similar to the tibial fracture.
Below the syndesmosis, the lateral malleolus is split into two dominant
fracture fragments. There is an anterior fragment and a posterior fragment
which are distracted by approximately 1.4 cm. Additionally, there are several
smaller bone fragments, including an elongated horizontally oriented fracture
fragment at the level of the distal fibula which extends to within 4 mm of the
skin (400 be, 92). Additionally, there is a small 9 mm fragment in between the
dominant anterior and posterior fragments of the lateral malleolus at the
level of the tibio-talar joint.
No other fracture is identified.
No evidence of entrapment of the extensor, peroneal, or flexor tendons.
There is edema in the surrounding soft tissues, most marked along the lateral
aspect of the joint. There is no subcutaneous gas or evidence of a foreign
body. There is no large focal fluid collection or hematoma.
IMPRESSION:
Markedly comminuted displaced intra-articular fractures of the distal tibia
and fibula, as described above.
Radiology Report
EXAMINATION: TIB/FIB (AP AND LAT) LEFT
INDICATION: LEFT TIB FX.ORIF
IMPRESSION:
Multiple images from the operating room shows placement of extensive fixation
device about the comminuted fracture of the distal tibia. Further information
can be gathered from the operative report.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Ankle pain, FX
Diagnosed with FX TIBIA W FIBULA NOS-CL, UNSPECIFIED FALL
temperature: 97.5
heartrate: 56.0
resprate: 14.0
o2sat: 100.0
sbp: 135.0
dbp: 70.0
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 comminuted distal tibia/fibula fracture with
intra-articular extension and was admitted to the orthopedic
surgery service. The patient was taken to the operating room on
___ for placement of external fixator, 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
patient's home medications were continued throughout this
hospitalization. The orthopaedic team determined that discharge
to home was appropriate with follow up with a surgeon closer to
the patient's home in ___. 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 with ex-fix, and will be discharged on lovenox
for DVT prophylaxis. The patient will follow up with an
orthopaedic surgeon closer to his home in ___. A thorough
discussion was had with the patient regarding the diagnosis and
expected post-discharge course, and all questions were answered
prior to discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Ace Inhibitors / Aspirin / Avandia / spironolactone / amiodarone
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with heart failure w/ preserved ejection fraction, PAH,
AF, DM, hypothyroidism, p/w ___ year old female with chief
complaint of dyspnea and hypoxemia. 2L o2 at home, sats 92% at
baseline presenting with dyspnea and hypoxia.
Reportedly, over the past 10 days, she has had worsening
dyspnea, hypoxemia (down to 85%). She uses O2 at home. She
reports shortness of breath, even with small activities and
bending over to look down at her feet. She was seen on ___ and
was noted to have an unchanged weight with mild R-sided chest
pain, baseline O2 sat at rest, but with sats that dropped to the
___ when she was taken off her O2 (usually she is in the ___ off
O2). No lightheadedness, headache, f/c, n/v/d, myalgias.
Although medication compliance has been an issue in the past,
she reports taking her torsemide every day.
In the ED, initial vitals were: 96.8 F, BP 150/70s, HR ___, RR
20, 96% on 2 L NC.
Past Medical History:
Type 2 Diabetes
HTN
Hyperlipidemia
Sick sinus syndrome s/p atrial pacemaker implantation
Paroxysmal atrial fibrillation
Iron deficiency anemia
Chronic diastolic heart failure with home O2 requirement
Osteoporosis
GERD w/ paraesophageal hernia
Osteoarthritis/Back Pain
OSA supposed to be on CPAP
s/p CCY
Social History:
___
Family History:
Says her mother and father had 'heart problems', unclear on
specifics. Denies h/o cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vital Signs: not yet taken on the floor
General: Alert, oriented, no acute distress, on 2 L O2
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. Unable to appreciate JVP. no LAD
CV: Regular rate and rhythm. Normal S1+S2, soft systolic murmur
at the RUSB
Lungs: Decreased breath sounds with crackles b/l
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, 1+ pitting edema to the
mid shins
Neuro: ___ strength upper/lower extremities, grossly normal
sensation, normal gait
DISHCARGE PHYSICAL EXAM
Vitals: 98.3 92-127/52-71 69-70 95% 3L NC
I/O= 300/650 (8hr's) 1240/1650 (24hrs)
Weight: 71.4 <- 71.2 kg <- 70.8 <-71.3 kg
Weight on admission: 71.3 kg
Weight in ___ - 164 lb - 74.4kg
Telemetry: unremarkable.
General: Chronically ill appearing female in NAD
HEENT: MM dry, face symmetrical
Lungs: scattered crackles
CV: Regular rate and rhythm. Normal S1+S2, soft systolic murmur
at the RUSB. JVP 6-8 cm
Abdomen: soft nd nt
Ext: wwp no peripheral edema
Pertinent Results:
ADMISSION LABS
-------------
___ 08:00PM WBC-9.7 RBC-4.16 HGB-12.0 HCT-37.9 MCV-91
MCH-28.8 MCHC-31.7* RDW-14.6 RDWSD-48.7*
___ 08:00PM proBNP-3154*
___ 08:00PM cTropnT-<0.01
___ 07:30AM ALT(SGPT)-12 AST(SGOT)-12 LD(LDH)-188 ALK
PHOS-141* TOT BILI-0.5
IMPORTANT STUDIES:
--------------------
CT CHEST W/O ___
1. Diffuse ground-glass pulmonary opacities with smooth
interlobular septal
thickening likely represents pulmonary edema in the setting of
cardiomegaly.
Although less likely, this could alternatively be related to
infectious or
inflammatory process.
2. Stable large hiatal hernia.
3. Increase in number of mediastinal lymph nodes. These are not
enlarged by
CT size criteria and demonstrate ___ years of stability, and may
represent a low
grade lymphoproliferative process.
4. Interval increase in size of cystic lesion within the
pancreatic body
measuring up to 2.5 cm. Further evaluation with MRI may be
helpful if
desired.
5. No significant change in right adrenal adenoma and left
adrenal
myelolipoma.
6. A 15 x 30 mm left thyroid nodule, for which further
evaluation with
nonemergent thyroid ultrasound is recommended.
TTE ___
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>60%). Tissue Doppler
imaging suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Doppler parameters are most consistent with Grade
II (moderate) left ventricular diastolic dysfunction. There is
no ventricular septal defect. Right ventricular chamber size is
normal with mild global free wall hypokinesis. The aortic valve
leaflets (3) are mildly thickened but aortic stenosis is not
present. No aortic regurgitation is seen. The mitral valve
appears structurally normal with trivial mitral regurgitation.
There is no mitral valve prolapse. Moderate to severe [3+]
tricuspid regurgitation is seen accounting for shadowing from
the right ventricular pacer lead. There is at least moderate
pulmonary artery systolic hypertension. [In the setting of at
least moderate to severe tricuspid regurgitation, the estimated
pulmonary artery systolic pressure may be underestimated due to
a very high right atrial pressure.] There is no pericardial
effusion.
IMPRESSION: Hypertensive heart disease. Increased PCWP. Mildly
hypokinetic right ventricle with moderate to severe tricuspid
regurgitation (intrinsic RV function will be decreased) and at
least moderate pulmonary hypertension.
Compared with the prior study (images reviewed) of ___
the findings are similar.
DISCHARGE LABS
-------------
___ 05:10AM BLOOD WBC-8.2 RBC-3.73* Hgb-10.8* Hct-34.1
MCV-91 MCH-29.0 MCHC-31.7* RDW-13.9 RDWSD-46.5* Plt ___
___ 05:10AM BLOOD Glucose-201* UreaN-66* Creat-1.6* Na-138
K-4.2 Cl-98 HCO3-30 AnGap-14
___ 05:10AM BLOOD Calcium-9.0 Phos-4.2 Mg-2.1
___ 08:00PM BLOOD TSH-4.8*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. diclofenac sodium 1 % topical DAILY PRN
2. Torsemide 60 mg PO DAILY
3. Levothyroxine Sodium 25 mcg PO DAILY
4. Apixaban 2.5 mg PO BID
5. Losartan Potassium 25 mg PO BID
6. Sertraline 50 mg PO DAILY
7. Pravastatin 40 mg PO QPM
8. Ketoconazole Shampoo 1 Appl TP ASDIR
9. Januvia (SITagliptin) 25 mg oral DAILY
10. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
11. GlipiZIDE XL 5 mg PO DAILY
12. Omeprazole 20 mg PO DAILY
13. Metoprolol Succinate XL 150 mg PO BID
14. Felodipine 5 mg PO DAILY
15. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
16. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
17. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
18. nystatin 100,000 unit/gram topical DAILY:PRN
19. Acetaminophen 1000 mg PO Q8H
20. Vitamin D ___ UNIT PO DAILY
21. lutein 20 mg oral BID
22. Magnesium Oxide 400 mg PO QPM
23. Fluticasone Propionate NASAL 2 SPRY NU DAILY
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*3
2. Metoprolol Succinate XL 100 mg PO DAILY
RX *metoprolol succinate 100 mg 1 tablet(s) by mouth daily Disp
#*30 Tablet Refills:*3
3. Acetaminophen 1000 mg PO Q8H
4. Apixaban 2.5 mg PO BID
5. diclofenac sodium 1 ? topical DAILY PRN pain
6. Fluticasone Propionate NASAL 2 SPRY NU DAILY
7. GlipiZIDE XL 5 mg PO DAILY
8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
9. Januvia (SITagliptin) 25 mg oral DAILY
10. Ketoconazole Shampoo 1 Appl TP ASDIR
11. Levothyroxine Sodium 25 mcg PO DAILY
12. lutein 20 mg oral BID
13. Magnesium Oxide 400 mg PO QPM
14. nystatin 100,000 unit/gram topical DAILY:PRN
15. Omeprazole 20 mg PO DAILY
16. Pravastatin 40 mg PO QPM
17. Sertraline 50 mg PO DAILY
18. Torsemide 60 mg PO DAILY
RX *torsemide 20 mg 3 tablet(s) by mouth daily Disp #*90 Tablet
Refills:*3
19. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
20. Vitamin D ___ UNIT PO DAILY
21. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
22.Home oxygen
ICD-10 code: ___.0 Pulmonary Hypertension
Home Oxygen: 4L Nasal Cannula with rest and exercise
SpO2 with ambulation on 3L: 88%
SpO2 seated on 3L NC: 95%
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
===========
Acute Diastolic heart failure exacerbation
Acute on chronic hypoxemic respiratory failure
Severe pulmonary hypertension
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CT chest without contrast.
INDICATION: ___ year old woman with worsening shortness of breath of unclear
etiology, new findings on CXR// e/o aspiration or restrictive lung disease
TECHNIQUE: Contiguous axial images were obtained through the chest without
intravenous contrast. Coronal and sagittal reformats were obtained.
COMPARISON: Chest radiograph from ___, CT chest from ___ CT
chest from ___.
FINDINGS:
HEART AND VASCULATURE: A left-sided pacer device is present with leads in the
right atrium and right ventricle. The thoracic aorta is normal in caliber.
The heart is enlarged. No pericardial effusion. The great vessels are within
normal limits based on an unenhanced scan. No pericardial effusion is seen. A
15 x 30 mm hypoattenuating nodule is present in the left thyroid lobe.
AXILLA, HILA, AND MEDIASTINUM: No axillary lymphadenopathy. There are
prominent right upper paratracheal lymph nodes, although not enlarged by CT
size criteria, these have increased in number in comparison to the prior CT
from ___.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: There are diffuse ground-glass opacities with smooth
interlobular septal thickening, which likely represent edema or less likely
infection. This is similar in appearance to the prior CT chest from ___. 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 demonstrates a 2.8
x 1.3 mass in the medial limb of the right adrenal gland with an internal
attenuation of 2 ___ (2:42) and is compatible with adrenal adenoma. The left
adrenal gland shows a 4.5 x 3.2 cm heterogeneous mass with macroscopic fat
component compatible with myelolipoma, unchanged from ___. Large hiatal
hernia is present. Partially visualized cystic lesion within the pancreatic
body measuring 2.2 x 2.6 cm, slightly increased in size in comparison to ___.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
Moderate to severe multilevel degenerative changes of the visualized spine,
including persistent severe thoracic kyphosis.
IMPRESSION:
1. Diffuse ground-glass pulmonary opacities with smooth interlobular septal
thickening likely represents pulmonary edema in the setting of cardiomegaly.
Although less likely, this could alternatively be related to infectious or
inflammatory process.
2. Stable large hiatal hernia.
3. Increase in number of mediastinal lymph nodes. These are not enlarged by
CT size criteria and demonstrate ___ years of stability, and may represent a low
grade lymphoproliferative process.
4. Interval increase in size of cystic lesion within the pancreatic body
measuring up to 2.5 cm. Further evaluation with MRI may be helpful if
desired.
5. No significant change in right adrenal adenoma and left adrenal
myelolipoma.
6. A 15 x 30 mm left thyroid nodule, for which further evaluation with
nonemergent thyroid ultrasound is recommended.
Gender: F
Race: WHITE - RUSSIAN
Arrive by AMBULANCE
Chief complaint: Dyspnea, Hypoxia
Diagnosed with Dyspnea, unspecified
temperature: 96.8
heartrate: 70.0
resprate: 20.0
o2sat: 96.0
sbp: 157.0
dbp: 78.0
level of pain: 0
level of acuity: 3.0 | ___ with known heart failure and AF p/w increasing dyspnea over
___ days, +bibasilar crackles, found to have elevated BNP and
CXR with evidence of fluid overload concerning for HF
exacerbation.
# Acute HFpEF exacerbation (severe pHTN, moderate severe TR):
Patient came in with elevated BNP and e/o pulmonary edema on CXR
and CT chest. Despite this patient weight on admission 71.3 kg
was below her previous dry weight of 74.4kg from ___.
This was after she was diuresed with 120 IV Lasix in the ED with
good output and some resolution of her symptoms. She was given
further IV diuresis with BID bolus of 120-160 IV Lasix without
much change in her weight, but some evidence of being
hypovolemic by labs (bicarb of 30). Ultimately patient was felt
to be euvolemic at discharge and declined further invasive
testing such as a RHC and/or coronary angiography to evaluate
further for etiology of her worsening symptoms. TTE was done as
an inpatient and was largely unchanged. Etiology of exacerbation
determined to be under diuresis taking 40 mg torsemide instead
of 60 mg that was prescribed by Dr. ___ of a desire
to decrease frequency of urination. Will have close follow up in
the CDAC.
# Acute on chronic hypoxemic respiratory failure: likely ___
patients pHTN. Patient O2 rq increased form home 2 L to 4 L at
the hospital with desaturation with exertion even on this. At
home she was intermittently compliant with her O2. O2 titration
study revealed patient needed to be on 4L O2 by NC at home.
# HTN - patient was noted to be hypotensive with ambulation down
to SBP into the 60's. There were concerns about whether patient
was taking her prescribed BP regimen at home given hypotension
observed in the hospital. Medications were significantly
changed: taken off of felodipine was stopped, losartan was
stopped, metoprolol was decreased from 150 mg BID of succinate
to 100 mg daily.
# Afib: DDD pacemaker. Paced rhythm while in house. Metoprolol
decreased as above. Continued on Eliquis. No ASA
# DM2: Given ISS in house
# GERD:
- continued home PPI
# hypothyroidism:
- checked TSH, was on the high at 4.8 but dose of synthroid was
not adjusted. Should be adjusted by PCP as an outpatient
- continue home levothyroxine
# depression:
- continue sertraline
# insomnia:
- continue Zolpidem
# OA - continued home tramadol
# OSA - patient refused CPAP while in house.
TRANSITIONAL ISSUES
- checked TSH, was on the high at 4.8 but dose of synthroid was
not adjusted. Should be adjusted by PCP as an outpatient
-Interval increase in size of cystic lesion within the
pancreatic body
measuring up to 2.5 cm. Further evaluation with MRI may be
helpful if desired.
- A 15 x 30 mm left thyroid nodule, for which further evaluation
with
non-emergent thyroid ultrasound is recommended.
- Please monitor patients weight. Call her cardiologist to
change torsemide dose if weight increases by 3 lb or more.
___
- Patient should be on 4 L of O2 at home.
- Patient enrolled in PACT program.
- Discharge Creatinine: 1.6
- Discharge weight: 71.4 kg |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Shellfish
Attending: ___.
Major Surgical or Invasive Procedure:
None
attach
Pertinent Results:
===============
Admission labs
===============
___ 06:20PM BLOOD WBC-5.2 RBC-3.69* Hgb-10.4* Hct-33.3*
MCV-90 MCH-28.2 MCHC-31.2* RDW-14.7 RDWSD-48.5* Plt ___
___ 06:20PM BLOOD Neuts-69.0 Lymphs-16.2* Monos-11.5
Eos-2.1 Baso-0.8 Im ___ AbsNeut-3.59 AbsLymp-0.84*
AbsMono-0.60 AbsEos-0.11 AbsBaso-0.04
___ 06:20PM BLOOD ___ PTT-31.1 ___
___ 06:20PM BLOOD Glucose-93 UreaN-18 Creat-1.0 Na-141
K-4.5 Cl-104 HCO3-28 AnGap-9*
___ 06:20PM BLOOD Calcium-8.6 Phos-3.8 Mg-2.2
===============
Pertinent labs
===============
___ 06:30AM BLOOD TSH-3.1
___ 06:30AM BLOOD Cortsol-16.3
___ 06:20PM BLOOD cTropnT-<0.01
___ 06:20PM BLOOD CK(CPK)-232
===============
Discharge labs
===============
___ 05:40AM BLOOD WBC-6.1 RBC-4.10* Hgb-11.7* Hct-36.4*
MCV-89 MCH-28.5 MCHC-32.1 RDW-14.9 RDWSD-48.3* Plt ___
___ 05:40AM BLOOD Glucose-90 UreaN-18 Creat-0.8 Na-138
K-5.0 Cl-99 HCO3-24 AnGap-15
___ 05:40AM BLOOD Calcium-8.8 Phos-3.5 Mg-2.4
===============
Studies
===============
Carotid US ___: IMPRESSION: Right ICA <40% stenosis. Left
ICA <40% stenosis.
TTE ___: CONCLUSION: The left atrial volume index is
normal. The right atrium is mildly enlarged. There is no
evidence for an atrial septal defect by 2D/color Doppler. The
inferior vena cava diameter is normal. There is mild symmetric
left ventricular hypertrophy with a normal cavity size. There is
a small area of regional left ventricular systolic dysfunction
with severe hypokinesis/akinesis/dyskinesis of the distal
ventricle/apex. The baasal inferior wall is hypokinetic (see
schematic) and preserved/normal contractility of the remaining
segments. No thrombus or mass is seen in the left ventricle. The
visually estimated left ventricular ejection fraction is 45%.
Left ventricular cardiac index is low normal (2.0-2.5 L/min/m2).
There is no left ventricular outflow tract gradient at rest or
with Valsalva. No ventricular septal defect is seen. Normal
right ventricular cavity size with normal free wall motion. The
aortic sinus diameter is normal for gender with a normal
ascending aorta diameter for gender. There is no evidence for an
aortic arch coarctation. The aortic valve leaflets (3) are
mildly thickened. There is no aortic valve stenosis. There is
mild [1+] aortic regurgitation. The mitral valve leaflets appear
structurally normal with no mitral valve prolapse. There is mild
[1+] mitral regurgitation. The pulmonic valve leaflets are
normal. The tricuspid valve leaflets appear structurally normal.
There is trivial tricuspid regurgitation. The estimated
pulmonary artery systolic pressure is normal. There is no
pericardial effusion. IMPRESSION: Mild symmetric left
ventricular hypertrophy with mild regional systolic dysfunction
most consistent with coronary artery disease (LAD and ? RCA
distribution). Compared with the prior TTE (images reviewed) of
___ , global left ventricular systolic function slightly
less vigorous. Basal inferior wall now hypokinetic.
CT head w/o contrast ___: IMPRESSION: 1. No significant
change in the subarachnoid hemorrhage involving the
perimesencephalic cisterns, superior cerebellar sulci and left
sylvian fissure, as above. No new or expanding intracranial
hemorrhage.
CTA head/neck ___: IMPRESSION: 1. Patent circle of ___
without evidence of stenosis,occlusion,or aneurysm. 2. Patent
bilateral cervical carotid and vertebral arteries without
evidence of stenosis, occlusion, or dissection. 3. Unchanged
acute nondisplaced fracture of the left transverse process of
T1. RECOMMENDATION(S): Thyroid nodule. No follow up recommended.
Absent suspicious imaging features, unless there is additional
clinical concern, ___ College of Radiology guidelines do
not recommend further evaluation for incidental thyroid nodules
less than 1.0 cm in patients under age ___ or less than 1.5 cm in
patients age ___ or ___.
ECG ___: Sinus rhythm. 1st degree AV block. Old anterior
infarct.
CT torso w/ contrast ___: IMPRESSION: 1. Acute,
nondisplaced fracture of the left transverse process of the T1
vertebra. 2. Type 3 left AC joint separation, better evaluated
on the same day radiograph. 3. Mild interstitial pulmonary
edema.
CT head w/o contrast ___: 1. Small volume subarachnoid
hemorrhage as described most conspicuous in the quadrigeminal
cistern. 2. No acute fracture.
CT c-spine w/o contrast ___: IMPRESSION: 1. No acute cervical
spine fracture or change in alignment. 2. Acute nondisplaced
fracture involving the left transverse process of T1. 3.
Multilevel degenerative changes appear similar to prior.
CXR ___: IMPRESSION: 1. Interstitial pulmonary edema. 2.
Probable type 3 left AC joint separation. Please refer to report
from same day left shoulder radiograph for further details.
Shoulder x-ray ___: Findings are concerning for type 3 left
AC joint separation. Soft tissue swelling overlying the left AC
joint.
===============
Microbiology
===============
URINE CULTURE (Final ___: < 10,000 CFU/mL.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Pantoprazole 20 mg PO Q12H
2. Metoprolol Succinate XL 100 mg PO DAILY
3. Gabapentin 600 mg PO QHS
4. rOPINIRole 8 mg PO BID
5. Clopidogrel 75 mg PO DAILY
6. Carbidopa-Levodopa (___) 1 TAB PO 5X/DAY
7. Carbidopa-Levodopa CR (___) 1 TAB PO QHS
8. FLUoxetine 20 mg PO DAILY
9. Atorvastatin 80 mg PO QPM
10. isradipine 2.5 mg oral DAILY
11. Aspirin 81 mg PO DAILY
12. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN Chest pain
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild/Fever
2. Lidocaine 5% Patch 1 PTCH TD QAM pain
RX *lidocaine [Lidoderm] 5 % 1 patch qAM Disp #*14 Patch
Refills:*0
3. Carbidopa-Levodopa (___) 1.5 TAB PO 5X/DAY
4. Carbidopa-Levodopa CR (___) 1 TAB PO DAILY
5. Pantoprazole 40 mg PO Q24H
6. rOPINIRole 4 mg PO BID
7. Aspirin 81 mg PO DAILY
8. Atorvastatin 80 mg PO QPM
9. FLUoxetine 20 mg PO DAILY
10. HELD- Clopidogrel 75 mg PO DAILY This medication was held.
Do not restart Clopidogrel until ___
and then restart this medication
11. HELD- Gabapentin 600 mg PO QHS This medication was held. Do
not restart Gabapentin until you see your primary care doctor
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Subarachnoid hemorrhage
Type 3 left AC joint separation
Nondisplaced left transverse process of the T1 vertebra
Severe orthostatic hypotension
Syncope
Recurrent falls
___ disease
Discharge Condition:
***Left upper extremity in sling, weight-bearing as
tolerated.***
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with PD w/ syncopal episode, fell down stairs w/ HS
and LOC, found to have SAH, T1 process fx and L AC joint dislocation //
Please evaluate vasculature
TECHNIQUE: Helically acquired rapid axial imaging was performed from the
aortic arch through the brain during the infusion of intravenous contrast
material. Three-dimensional angiographic volume rendered, curved reformatted
and segmented images were generated on a dedicated workstation. This report is
based on interpretation of all of these images.
DOSE: Acquisition sequence:
1) Stationary Acquisition 6.0 s, 0.5 cm; CTDIvol = 29.9 mGy (Body) DLP =
15.0 mGy-cm.
2) Spiral Acquisition 5.3 s, 41.9 cm; CTDIvol = 15.3 mGy (Body) DLP = 639.8
mGy-cm.
Total DLP (Body) = 655 mGy-cm.
COMPARISON: CT Head ___, CT cervical spine ___.
FINDINGS:
CTA HEAD:
There is atheromatous calcification of the carotid siphons bilaterally. The
vessels of the circle of ___ and their principal intracranial branches
appear normal without stenosis, occlusion, or aneurysm. There is a fetal
origin of both posterior cerebral arteries. The dural venous sinuses are
patent.
CTA NECK:
Bilateral carotid and vertebral artery origins are patent.
There is atheromatous calcification at the bifurcation of the right common
carotid artery and the proximal aspect of the left internal carotid artery,
just distal to the bifurcation of the left common carotid artery. There is no
evidence of internal carotid stenosis by NASCET criteria.
The carotidandvertebral arteries and their major branches otherwise appear
normal with no evidence of stenosis or occlusion.
OTHER:
There is mild interlobular septal thickening in the lung apices, more marked
on the right side, which may be secondary to a degree of mild pulmonary
congestion. The visualized portion of the lungs are otherwise clear.
There is an 11 mm hypodense nodule in the superior aspect of the right lobe of
thyroid gland, and an 11 mm hypodense nodule in the inferior aspect of the
left lobe of the thyroid gland. There is no lymphadenopathy by CT size
criteria.
Note is again made of the acute nondisplaced fracture of the left transverse
process of T1. The unchanged appearance of the bone cyst within the dens.
Cervical spondylosis, most marked at the craniocervical junction and at C6-C7
level. There is marked degenerative change of the sternoclavicular joints
bilaterally.
IMPRESSION:
1. Patent circle of ___ without evidence of stenosis,occlusion,or aneurysm.
2. Patent bilateral cervical carotid and vertebral arteries without evidence
of stenosis, occlusion, or dissection.
3. Unchanged acute nondisplaced fracture of the left transverse process of T1.
RECOMMENDATION(S): Thyroid nodule. No follow up recommended.
Absent suspicious imaging features, unless there is additional clinical
concern, ___ College of Radiology guidelines do not recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in patients under
age ___ or less than 1.5 cm in patients age ___ or ___.
Suspicious findings include: Abnormal lymph nodes (those displaying
enlargement, calcification, cystic components and/or increased enhancement) or
invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White
Paper of the ACR Incidental Findings Committee". J ___ ___
12:143-150.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: History: ___ with tSAH, new episode of presyncope // eval
interval change in tSAH
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP 1003.42 mGy-cm
COMPARISON: Multiple priors most recently CT head from ___
FINDINGS:
The subarachnoid hemorrhage in the perimesencephalic cisterns, superior
cerebellar sulci and left sylvian fissure appears stable. No new or expanding
areas of intracranial hemorrhage. There is no evidence of recent territorial
infarction, edema,or mass. There is prominence of the ventricles and sulci
suggestive of involutional changes. Periventricular and subcortical white
matter hypodensities are nonspecific, but likely reflect the sequela of
chronic microvascular infarction.
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are normal.
Dense atherosclerotic calcifications of the cavernous carotid arteries.
IMPRESSION:
1. No significant change in the subarachnoid hemorrhage involving the
perimesencephalic cisterns, superior cerebellar sulci and left sylvian
fissure, as above. No new or expanding intracranial hemorrhage.
Radiology Report
EXAMINATION: Carotid Artery ultrasound
INDICATION: ___ year old man with syncopal episode // occlusion?
TECHNIQUE: Real-time grayscale, color, and spectral Doppler ultrasound
imaging of the carotid arteries was obtained.
COMPARISON: None
FINDINGS:
RIGHT:
There is mild heterogenous atherosclerotic plaque in the right carotid artery.
Segment: PSV (cm/s) / EDV (cm/s)
----------------------------------------------
CCA ___: 73.3 cm/s / 21.7 cm/s
CCA Distal: 78.3 cm/s / 17 cm/s
ICA ___: 96.8 cm/s / 24.6 cm/s
ICA Mid: 62.6 cm/s / 17.6 cm/s
ICA Distal: 57.9 cm/s / 22.4 cm/s
ECA: 57.2 cm/s
Vertebral: 43.5 cm/s
ICA/CCA Ratio: 1.24
The right vertebral artery flow is antegrade with a normal spectral waveform.
LEFT:
There is mild heterogenous atherosclerotic plaque in the left carotid artery.
Segment: PSV (cm/s) / EDV (cm/s)
----------------------------------------------
CCA ___: 87.8 cm/s / 24.3 cm/s
CCA Distal: 76 cm/s / 25.9 cm/s
ICA ___: 68 cm/s / 18 cm/s
ICA Mid: 59.6 cm/s / 23.8 cm/s
ICA Distal: 54.9 cm/s / 23.5 cm/s
ECA: 54.1 cm/s
Vertebral: 38 cm/s
ICA/CCA Ratio: 0.89
The left vertebral artery flow is antegrade with a normal spectral waveform.
IMPRESSION:
Right ICA <40% stenosis.
Left ICA <40% stenosis.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: s/p Fall, Syncope
Diagnosed with Traum subrac hem w LOC of unsp duration, init, Fall (on) (from) other stairs and steps, initial encounter
temperature: 97.6
heartrate: 68.0
resprate: 16.0
o2sat: 96.0
sbp: 132.0
dbp: 88.0
level of pain: 5
level of acuity: 2.0 | SUMMARY:
========
Mr. ___ is an ___ year old M w/ hx of CAD s/p multiple PCI
including to LAD with last in ___ after STEMI from in-stent
restenosis, HTN, migraines, and ___ with history of
falls who presented after a fall at home, found to have a
subarachnoid hemorrhage and non-displaced T1 fracture with
vitals notable for significant orthostatic hypotension.
ACTIVE ISSUES:
==============
# Type 3 left AC dislocation
# T1 non-displaced transverse fracture
He was evaluated by the trauma service and images done
demonstrated that he had suffered a subarachnoid hemorrhage,
non-displaced T1 transverse process fracture, and a type 3 left
AC dislocation. He was admitted to ACS/Trauma service for
further treatment of his injuries. The Orthopedic surgery
service was consulted for the left AC joint separation and they
recommend conservative management with a sling, WBAT, and clinic
follow up in ___ weeks. No surgical intervention for patient's
T1 TP fracture, just pain control as needed.
# Subarachnoid hemorrhage
He was assessed by the neurosurgery service regarding his SAH.
They recommended conservative treatment with neurological
checks, keep SBP < 160, and hold patient's home ASA/Plavix for 3
and 7 days respectively. Plavix can be restarted on ___.
# Orthostatic hypotension
# Dysautonomia
# Syncope
# Recurrent falls
# ___ disease:
Since the patient experienced lightheaded prior to his fall, he
was ordered for a syncopal workup with EKG, TTE, and carotid
duplex. He also was checked for orthostatic hypotension, which
was positive. However, due to his extensive cardiac history and
___ disease, he was transferred to the medicine service
for further management of his medical comorbidities. On the
medicine service, all of his home antihypertensives and beta
blockade were held. Unfortunately, he remained orthostatic, so
his case was discussed with his outpatient Neurologist and he
was ultimately changed to Carbidopa-Levodopa (___) 1.5 TAB
PO/NG 5X/DAY, Carbidopa-Levodopa CR (___) 1 TAB PO DAILY at
2300, and ropinirole was decreased to 4 mg BID. He was given an
abdominal binder and TEDS stockings. ___ evaluated him and
recommended discharge to rehab, which he refused and had
capacity to do so. He stated multiple times that he understood
the risks of going home including recurrent falls and head
strikes which could lead to permanent neurologic damage or
death. His family was informed that we unfortunately could not
force him against his will to go to rehab since he had capacity
to refuse. He was discharged home w/ ___. He was instructed on
fall prevention and management of orthostatic hypotension. While
his blood pressures were still orthostatic before discharge, his
symptoms had resolved and he was able to do the stairs multiple
times. He also did not show any signs of overt stiffness from
his ___, although was feeling some of the effects of his
decreases doses of medications. He should have very close follow
up with Neurology and Cardiology. He and his wife were
instructed that he should not drive.
# Chronic HF, borderline EF
# HTN
# Hx of CAD s/p 2 PCI to LAD
EF 45%, worsening from prior. Imaging consistent with LAD +/-
RCA distribution ischemia. Patient was euvolemic on exam. His
home metoprolol and isradipine were all held given severe
orthostasis. He was intermittently hypertensive to the 160s, but
this quickly resolved. Aspirin held for 3 days and Plavix held
for 7 days per NSGY (restart on ___. He remained on his
home atorvastatin. Consider outpatient stress test given
worsening regional wall motion abnormalities
CHRONIC/STABLE ISSUES:
=======================
# Chronic thrombocytopenia
Plts in 130s going back to ___. Stable.
# Depression
Continued home Fluoxetine daily
# Chronic pain
Held home gabapentin given fall
# GERD
Decreased home pantoprazole to daily as no indication for BID |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
morphine / fentanyl
Attending: ___
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ Esophagoduodenoscopy (EGD)
History of Present Illness:
___ year old female with history with history gallstone
pancreatitis s/p ccy, and recent admission at ___ for
pancreatitis p/w epigastric pain.
Patient was recently admitted to ___ in ___ with bloating,
nausea, emesis, epigastric abdominal pain radiating to the back.
She was treated conservatively for acute pancreatitis with ivfs
and pain control. Her lipase was in the ___ w/ normal LFTs. No
imaging was done at that time. She tolerated clears and was
discharged home with outpatient ERCP follow up for ___.
Since discharge, she did well requiring only a few days of po
zofran/dilaudid. 1 night prior to admission, she developed
severe bloating. The next morning, she ate breakfast, and
experienced burning epigastric pain, ___, radiating to the
back, and associated w/ nausea. She subsequently ate toast,
which exacerbated the pain. Reports pain is similar to prior
episode of pancreatitis. Denies emesis, fevers, chills. No
changes in bowel habits. She had one glass of wine and a
cocktail two nights prior to admission. She also denies
hematuria, dysuria, GERD, bloody/black stools, pain elsewhere.
She was seen by her PCP today, who recommended she go to the ED
for reevaluation and ERCP. Of note, she has had an ERCP in ___
for similar pain, was told that there was sludge, but does not
recall what interventions if any were done.
In the ED, VS: T 97.0, HR 93, BP 136/85, RR 18, O2 100%. Labs:
ALT 19, AST 23, AP 58, Tbili 0.5, Lip 75, WBC 8.1, Cr 0.6. She
received dilaudid 1mg iv x2, zofran 4mg iv x1, and GI cocktail.
Most Recent Vitals: 98.2 83 127/79 17 100%
Lines & Drains: 20g RFA
Currently, she complains of ___ pain.
ROS: 12 point review of system is otherwise negative.
Past Medical History:
BREAST IMPLANTS
FIBROADENOMA- LT BREAST REMOVED
HERPES SIMPLEX TYPE 1 POS ANTIBODY
KIDNEY STONES
THROACIC AORTIC GRAFT- D/T SCREW PUNCTURE, COMPL OF SPINE SURG-
THYROID NODULE-RIGHT
THYROID NODULE
COLD INDUCED ASTHMA
ALOPECIA
DERMATOGRAPHIA
ACUTE PANCREATITIS
H/O CCY
H/O SCOLIOSIS- MULTIPLE SURGERIES IN PAST
Social History:
___
Family History:
Mother has HTN
Father has HLD, melanoma
Grandfather w/ early cad
Physical Exam:
VS: T 99.8 BP 130/83 HR 86 RR 18 O2 99% RA
Gen: NAD, c/o pain
HEENT: OP clear, moist mm, sclera anicteric
Neck: Supple, no LAD
CV: RR, no murmurs/rubs/gallops
Pulm: CTAB, no wheezes/rhonchi/rales
Abd: Three well-healed, old surgical scars noted across the
abdomen. Soft, TTP at epigastric area, mild intentional
guarding, no rebound tenderness, neg psoas and rovsing's sign
GU: No CVAT
Ext: WWP, no edema
Pertinent Results:
___ 08:34PM GLUCOSE-97 UREA N-9 CREAT-0.6 SODIUM-139
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-27 ANION GAP-12
___ 08:34PM ALT(SGPT)-19 AST(SGOT)-23 ALK PHOS-58 TOT
BILI-0.5
___ 08:34PM LIPASE-75*
___ 08:34PM WBC-8.1 RBC-4.57 HGB-15.7 HCT-45.1 MCV-99*
MCH-34.3* MCHC-34.7 RDW-12.4
___ 08:34PM NEUTS-68.9 ___ MONOS-4.6 EOS-0.7
BASOS-0.4
___ 08:34PM PLT COUNT-347
OSH records -- EUS report from ___ at ___: dilated CBD
11.5mm, no sludge or stones, normal ampulla, mild pancr
parencymal abn (hypoechoic strands) and dil pancr side ducts
___ EGD -- Normal mucosa in the esophagus There was mild
erythema in the antrum. Cold forceps biopsies were performed
for histology. Normal mucosa was noted. Random cold forceps
biopsies were performed for histology. Otherwise normal EGD to
third part of the duodenum.
___ MRCP -- Preliminary Report IMPRESSION: 1. Prior
cholecystectomy. There is evidence of common bile duct
dilatation without obstruction or mass lesion. The possibility
of sphincter of Oddi dysfunction cannot be excluded. 2. There
is a left upper pole renal cyst measuring 1.4 cm. It could not
be assessed adequately due to the susceptibility artifact from
the metallic hardware within the patient's spine.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from PatientwebOMR.
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
2. aluminum chloride *NF* 20 % Topical qhs
3. EpiPen *NF* (EPINEPHrine) 0.3 mg/0.3 mL Injection as directed
4. Minocycline 100 mg PO Q12H
5. traZODONE 25 mg PO HS:PRN sleep
6. Ibuprofen 400 mg PO Frequency is Unknown
7. Multivitamins 1 TAB PO DAILY
Discharge Medications:
1. Albuterol Inhaler ___ PUFF IH Q4H:PRN sob
2. traZODONE 25 mg PO HS:PRN sleep
3. aluminum chloride *NF* 20 % Topical qhs
4. EpiPen *NF* (EPINEPHrine) 0.3 mg/0.3 mL Injection as directed
5. Minocycline 100 mg PO Q12H
6. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal pain of unclear cause
Antral (stomach) erythema -- biopsies pending
Insomnia
Mild intermittent asthma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ woman with epigastric abdominal pain, nausea, history
of prior abdominal/back surgeries, rule out obstruction.
COMPARISON: None available.
TECHNIQUE: AP upright and supine radiographs of the abdomen and pelvis show
gas within the stomach to the splenic flexure than the sigmoid colon. There
is also fecal loading of the right colon. The abdominal gas pattern is normal
with no signs of obstruction. No pneumatosis or free air. Extensive hardware
is seen within the lumbar spine.
IMPRESSION: Normal bowel gas pattern with no evidence of obstruction.
Radiology Report
INDICATION: ___ woman with recurrent epigastric pain of unclear
etiology, history of CBD dilatation in the past, labs not consistent with
biliary obstruction or pancreatitis.
TECHNIQUE: Multiplanar T1- and T2-weighted images were acquired on a 1.5
Tesla magnet including dynamic 3D imaging, obtained prior to, during, and
after the intravenous administration of 5 mL of Gadavist. In addition, 2.5 mL
of oral Gadavist was administered to the patient.
COMPARISON: None.
FINDINGS: The study is limited by susceptibility artifact from the metallic
hardware within the patient's spine.
The patient has had a previous cholecystectomy. There is dilatation of the
common bile duct, maximally measuring 1.4 cm. It tapers gradually as it
enters into the ampulla. There is no intrahepatic biliary ductal dilatation.
There is also aberrant biliary ductal anatomy (normal variant) with insertion
of the right posterior duct into the left bile duct.
The pancreas is unremarkable with no enhancing lesions. The main pancreatic
duct is normal in size.
Within the left renal interpolar region, there is a cystic structure which
measures 1.4 cm seen on the HASTE images but cannot be evaluated post contrast
due to the susceptibility artifact from the hardware.
The liver demonstrates normal homogenous enhancement and no focal lesions
identified. The spleen, pancreas, right kidney, and adrenals are unremarkable.
The right adrenal is difficult to assess due to susceptibility artifact.
The visualized large and small bowel are unremarkable.
There is no suspicious lymphadenopathy. There is no ascites.
IMPRESSION:
1. Prior cholecystectomy. There is evidence of common bile duct dilatation
without obstruction or mass lesion. The possibility of sphincter of Oddi
dysfunction cannot be excluded.
2. There is a left upper pole renal cyst measuring 1.4 cm. It could not be
assessed adequately due to the susceptibility artifact from the metallic
hardware within the patient's spine.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: MIDEPIGASTRIC PAIN
Diagnosed with ACUTE PANCREATITIS
temperature: 97.0
heartrate: 93.0
resprate: 18.0
o2sat: 100.0
sbp: 136.0
dbp: 85.0
level of pain: 6
level of acuity: 3.0 | ___ year old female with history with history gallstone
pancreatitis s/p ccy, and recent admission at ___ for acute
pancreatitis p/w epigastric pain. s/p EGD here showing antral
erythema, bx pending. MRCP ordered (ERCP team following).
.
Abdominal pain
- unclear etiology, pancreatitis seems unlikely given her barely
elevated lipase levels (which are non-specific), the lack of
imaging evidence of pancreatitis, and the very quick resolution
- ddx includes biliary tree problem, versus an antral process,
although this seems unlikely
- ERCP consult followed the patient
- EGD showed antral erythema, biopsies pending
- MCRP showed common bile duct dilation -- could be secondary to
sphincter of Oddi dysfunction
- the patient will follow-up with GI after discharge
.
Renal cyst seen on MRCP
- the patient will follow-up with her PCP about this to
determine if more imaging is needed
.
Asthma
- Continued home albuterol
.
Other
- trazodone PRN insomnia
.
Day of discharge
Interval history: Felt much better today. Hasn't need any pain
medication. Tolerated lunch with some nausea, but would like to
go home. We discussed her plan of care and the importance of
follow-up. She understood, and I answered her questions.
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
bee venom (honey bee)
Attending: ___.
Chief Complaint:
Left intertrochanteric hip fracture
Major Surgical or Invasive Procedure:
ORIF left intertrochanteric hip fracture
History of Present Illness:
___ female past medical history of psoriatic arthritis,
presents as a transfer from ___, with a left
intertrochanteric femur fracture after a fall while getting up
from the toilet. On exam the patient is closed neurovascularly
intact with left lower extremity which is externally rotated and
shortened. X-rays demonstrate a comminuted left inner troches
femur fracture.
Past Medical History:
GEN: NAD, A&O
CV: no cardiac distress
PULM: breathing comfortably on room air
EXT:
LLE
Dressing c/d/i
Sensation intact s/s/spn/dpn/t
Fires ___, wwp
Family History:
Noncontributory
Physical Exam:
GEN: NAD, A&O
CV: no cardiac distress
PULM: breathing comfortably on room air
EXT:
LLE
Dressing on and intact and clean
Sensation intact s/s/spn/dpn/t
Fires ___, +DP pulse, wwp
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Calcium Carbonate 500 mg PO DAILY
2. Cyanocobalamin 250 mcg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
4. Citalopram 40 mg PO DAILY
5. Magnesium Oxide 140 mg PO DAILY
6. Tretinoin 0.025% Cream 1 Appl TP QHS
7. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID
8. Losartan Potassium 50 mg PO DAILY
9. amLODIPine 5 mg PO DAILY
10. Gabapentin 300 mg PO TID
11. Simvastatin 20 mg PO QPM
12. Alendronate Sodium 70 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
2. Bisacodyl 10 mg PO DAILY:PRN Constipation - Second Line
3. Docusate Sodium 100 mg PO BID
4. Enoxaparin (Prophylaxis) 40 mg SC DAILY
RX *enoxaparin 40 mg/0.4 mL 40 mg SC dailyl Disp #*28 Syringe
Refills:*0
5. Oxybutynin 5 mg PO TID
6. OxyCODONE (Immediate Release) 2.5-5 mg PO Q4H:PRN Pain -
Moderate
Reason for PRN duplicate override: pacu v floor
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY:PRN Constipation - Third
Line
8. Senna 8.6 mg PO BID:PRN Constipation - First Line
9. amLODIPine 5 mg PO DAILY
10. Calcium Carbonate 500 mg PO DAILY
11. Citalopram 40 mg PO DAILY
12. Cyanocobalamin 250 mcg PO DAILY
13. Gabapentin 300 mg PO TID
14. Losartan Potassium 50 mg PO DAILY
15. Magnesium Oxide 140 mg PO DAILY
16. Simvastatin 20 mg PO QPM
17. Tretinoin 0.025% Cream 1 Appl TP QHS
18. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID
19. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left intertrochanteric hip fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: FEMUR (AP AND LAT) LEFT
INDICATION: ___ woman with left hip fracture.
TECHNIQUE: 18 fluoroscopic views performed without a radiologist present.
COMPARISON: Left hip radiograph ___.
FINDINGS:
18 intraoperative images were acquired without a radiologist present.
Images show steps related to placement of an intramedullary rod with gamma
nail fixation about an intertrochanteric left hip fracture.
Total fluoroscopic time 235.6 seconds.
IMPRESSION:
Intraoperative images were obtained during open reduction internal fixation of
a intertrochanteric left hip fracture. Please refer to the operative note for
details of the procedure.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman reintubated post-op, CXR for verification of
tube placement // re-intubated, eval for ETT placement
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
There are low bilateral lung volumes with new bibasilar atelectasis. No
pleural effusion or pneumothorax. The tip of the endotracheal tube projects
2.6 cm from the carina. The size of the cardiac silhouette is enlarged but
not significantly changed. There are degenerative changes of both shoulders.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: L Hip fracture, s/p Fall
Diagnosed with Displaced intertrochanteric fracture of left femur, init, Fall on same level, unspecified, initial encounter
temperature: 99.4
heartrate: 78.0
resprate: 17.0
o2sat: 94.0
sbp: 132.0
dbp: 67.0
level of pain: 4
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopaedic surgery team. The patient was found
to have left intertrochanteric hip fracture and was admitted to
the orthopaedic surgery service. The patient was taken to the
operating room on ___ for ORIF left intertrochanteric hip
fracture, which the patient tolerated well. For full details of
the procedure please see the separately dictated operative
report. The patient was taken from the OR to the PACU in stable
condition and after satisfactory recovery from anesthesia was
transferred to the floor. The patient was initially given IV
fluids and IV pain medications, and progressed to a regular diet
and oral medications by POD#1. The patient was given
___ antibiotics and anticoagulation per routine. The
patient's home medications were continued throughout this
hospitalization. The patient worked with ___ who determined that
discharge to rehab was appropriate. The ___ hospital
course was otherwise unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weightbearing as tolerated in the left lower extremity, and will
be discharged on Lovenox for DVT prophylaxis. The patient will
follow up with Dr. ___ routine. A thorough discussion
was had with the patient regarding the diagnosis and expected
post-discharge course including reasons to call the office or
return to the hospital, and all questions were answered. The
patient was also given written instructions concerning
precautionary instructions and the appropriate follow-up care.
The patient expressed readiness for discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
___
Attending: ___
Chief Complaint:
Bilateral Lower Extremity Swelling, Hypertensive Urgency
Major Surgical or Invasive Procedure:
n/a
History of Present Illness:
Mr. ___ is a ___ year old male, with past history ESRD ___
DM Type I, s/p kidney/pancreas (bladder drained at ___,
___ transplant in ___, with recent bladder to enteric
drain scheduled and undergone ___, CAD, OSA with severe
pulmonary HTN, paroxysmal atrial fibrillation on amiodarone (not
currently on anticoagulation), who is presenting with concern
for new acute heart failure with lower extremity edema.
Patient was recently hospitalized in ___, with scheduled
conversion from pancreas transplant with bladder drain to
enteric drainage. Patient post-operatively felt like he "blew
up", and hospital course was complicated with new ascites and
concern for pancreatic leak from his surgery, and underwent
ex-lap with revision with improvement. His hospital course was
also complicated with atrial fibrillation for which he was
briefly on amiodarone for, no anticoagulation, pulmonary edema
and worsened hypertension. He was hospitalized for about 1 week,
and started to have improvement and then was discharged on
nifedipine for hypertension. At home, patient then felt
orthostatic, with SBPs in the 100s, for which he was started on
florinef intermittently and discontinued on any diuretic and
anti-hypertensive. During that course, patient underwent cardiac
workup given new pulmonary edema with TTE showing normal LV
systolic function, with mild concentric LVH, ___
dilated, RA moderately dilated, and mild MR.
___ 1.5 weeks ago, found to have new lower extremity swelling.
Patient lost about 20 lbs after his surgery about 195 lbs from
215 lbs, and currently weigh about 210 lbs at home. Further,
over the past two weeks patient has noted increased sinus
congestion. He has finished two different courses of
antibiotics, and was taking Flonase, and afrin x 3 days, and no
relief, and feels that there is a blockage on the left nostril.
He originally thought this was ___ to some irritation from an NG
tube that was placed during that hospitalization, and has an ENT
follow up appointment this week.
Notably, patient has a known diagnosis of severe pulmonary HTN
from likely obstructive sleep apnea, but does not use CPAP at
home. He also underwent a cardiac catheterization earlier in
___ which showed mild distal RCA disease 40-50%, culprit
vessel circumflex (mid disease 50-60%) and ___ OM. ___ and
distal LAD showed ___ stenosis and distal 50% stenosis, Cx
revealed moderate calcification and moderate disease, LAD
moderate calcification and mild luminal disease. After this
surgery, he was found to have systolics in the 160s-170s.
In the ED, initial vitals were 0 98.3 74 193/84 18 96% RA
Labs were notable for WBC 7.7, Hgb 10.9, Hct 34.4, Platetet 406.
MCV 99. BNP 9780. TSH: Pending. Sodium 136, Potassium 5.2,
Chloride 101, Bicarb 23, BUN 12, Creatinine 0.9. Glucose 110.
___ 11.2, PTT 27.3, INR 1.
Imaging: CXR: Pulmonary Edema.
Patient was given:
___ 16:05 IV Furosemide 20 mg
___ 16:05 PO/NG Labetalol 200 mg
___ 16:05 PO/NG Magnesium Oxide 800 mg
Decision was made to admit for new volume overload.
Transfer vitals were: 0 61 174/60 19 94% RA
Upon arrival to the floor, patient reports feeling ok. He feels
that his left nostril is blocked, and his lower extremity edema
is starting to improve.
ROS:
(+)
(-) 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:
type 1 diabetes
hypertension
hyperlipidemia
a history of gangrene in the right toe s/p surgical intervention
BPH
sleep apnea
Social History:
___
Family History:
His mother is alive and well in her ___. He has four children,
all relatively healthy, although his older daughter has a
clotting disorder.
Physical Exam:
Admission physical exam:
=========================
VS: See OMR.
Weight: admit wt: 210 lbs
I/O: Not recorded.
General: Pleasant, well appearing, no acute distress.
HEENT: Normocephalic, atraumatic. No scleral icterus. PERRL.
EOMI. There is mild JVD. There is erythema of bilateral
turbinates without frank mucous.
Neck: supple, no cervical lymphadenopathy appreciated.
CV: RRR, S1, S2. Mild systolic murmur heard at left sternal
border
Lungs: Mild crackles at the bases, no wheezing.
Abdomen: Soft, mildly distended. Scar across well healed.
Lower Extremities: 3+ ___ edema. Soft, no asymmetry. pulses
intact, warm.
NEUROLOGIC: ___, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
Discharge physical exam:
========================
VS: 97.4 PO 178 / 72 5318 98 RA
Weight: admit wt: 210 lbs ->207lb
General: Pleasant, well appearing, no acute distress.
HEENT: No scleral icterus. EOMI. JVD <10cm. There is erythema
of bilateral turbinates without frank mucous.
Neck: supple, no cervical lymphadenopathy appreciated.
CV: RRR, S1, S2. Mild systolic murmur heard at left sternal
border
Lungs: decreased at right base, otherwise CTAB
Abdomen: Soft, mildly distended. Scar across well healed
Lower Extremities: no cyanosis, clubbing, edema
NEUROLOGIC: ___.
Pertinent Results:
Admission labs:
===============
___ 01:45PM BLOOD WBC-7.7 RBC-3.47* Hgb-10.9* Hct-34.4*
MCV-99* MCH-31.4 MCHC-31.7* RDW-15.4 RDWSD-55.8* Plt ___
___ 01:45PM BLOOD Glucose-110* UreaN-12 Creat-0.9 Na-136
K-5.2* Cl-101 HCO3-23 AnGap-17
___ 01:45PM BLOOD ALT-12 AST-36 AlkPhos-94 Amylase-40
TotBili-0.4
___ 01:45PM BLOOD CK-MB-2 proBNP-9780*
___ 01:45PM BLOOD Albumin-3.4* Calcium-9.2 Phos-2.7 Mg-1.7
Pertinent labs:
===============
___ 05:05AM BLOOD Amylase-32
___ 05:01AM BLOOD Amylase-34
___ 01:45PM BLOOD Lipase-48
___ 05:05AM BLOOD Lipase-40
___ 05:01AM BLOOD Lipase-44
___ 01:45PM BLOOD CK-MB-2 proBNP-9780*
___ 01:45PM BLOOD cTropnT-<0.01
___ 09:20PM BLOOD CK-MB-1 cTropnT-<0.01
___ 01:45PM BLOOD TSH-1.6
___ 05:01AM BLOOD tacroFK-5.0
___ 05:05AM BLOOD tacroFK-6.3
Discharge labs:
===============
___ 05:01AM BLOOD WBC-5.4 RBC-2.94* Hgb-9.2* Hct-29.6*
MCV-101* MCH-31.3 MCHC-31.1* RDW-15.5 RDWSD-57.1* Plt ___
___ 05:01AM BLOOD Plt ___
___ 05:01AM BLOOD Glucose-106* UreaN-15 Creat-1.1 Na-140
K-4.3 Cl-103 HCO3-27 AnGap-14
___ 05:01AM BLOOD Calcium-8.9 Phos-3.6 Mg-1.9
Diagnostics:
============
___ CXR
PA and lateral views of the chest provided. Interstitial
pulmonary edema is noted with hilar congestion. Background COPD
is again noted. No large
effusion is seen. Difficult to exclude a subtle pneumonia.
Cardiomediastinal silhouette is unchanged. Bony structures are
intact.
IMPRESSION:
COPD with superimposed pulmonary edema.
___ Renal ultrasound
The left transplant kidney measures 10.7 cm. The transplant
renal morphology is unremarkable. Specifically, the cortex is
of normal thickness and echogenicity, pyramids are unremarkable,
there is no urothelial thickening, and renal sinus fat is
unremarkable. There is no hydronephrosis and no perinephric
fluid collection. Trace fluid is seen around the transplant, as
on prior. The resistive index of intrarenal arteries are again
noted to be elevated measuring in the ___. The main renal
artery shows antegrade flow, with prompt systolic upstroke and
continuous antegrade diastolic flow, with peak systolic velocity
of 135 cm/sec. Please note that there is diminished diastolic
flow in the main renal artery as well. Vascularity is
visualized throughout transplant. The transplant renal vein is
patent and shows antegrade flow.
IMPRESSION:
Continually elevated resistive indices. No hydronephrosis or
significant perinephric fluid collection is identified.
___ CT Sinus/mandible/maxilla
1. No change in paranasal sinus disease compared to ___,
as detailed above. Demineralized cribriform plates and uncinate
processes indicate chronic inflammation. No evidence for fluid
levels.
2. Unchanged polypoid soft tissue density in the left naris. A
polyp is not excluded.
___ EHCO
The left atrium is mildly dilated. There is mild symmetric left
ventricular hypertrophy. The left ventricular cavity is
moderately dilated. There is mild regional left ventricular
systolic dysfunction with focal hypokinesis of the entire
inferior wall and basal to mid inferolateral wall. The remaining
segments contract normally (LVEF = 45-50 %). The estimated
cardiac index is normal (>=2.5L/min/m2). Tissue Doppler imaging
suggests an increased left ventricular filling pressure
(PCWP>18mmHg). Right ventricular chamber size and free wall
motion are normal. The aortic root is mildly dilated at the
sinus level. The aortic valve leaflets (3) are mildly thickened.
There is a minimally increased gradient consistent with minimal
aortic valve stenosis. Trace aortic regurgitation is seen. The
mitral valve leaflets are mildly thickened. There is no mitral
valve prolapse. Mild (1+) mitral regurgitation is seen. There is
at least moderate pulmonary artery systolic hypertension. There
is a trivial/physiologic pericardial effusion.
IMPRESSION: Mild symmetric left ventricular hypertrophy with
dilated cavity and regional left ventricular systolic
dysfunction c/w CAD. Elevated PCWP. Normal right ventricular
cavity size and systolic function. Minimal aortic stenosis. Mild
mitral regurgitation. At least moderate pulmonary artery
systolic hypertension.
Micro:
======
None
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Azathioprine 100 mg PO DAILY
2. Multivitamins 1 TAB PO DAILY
3. Omeprazole 40 mg PO DAILY
4. PredniSONE 5 mg PO DAILY
5. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
6. Vitamin B Complex 1 CAP PO DAILY
7. Senna 8.6 mg PO BID:PRN constipation
8. Ondansetron 4 mg PO Q8H:PRN n/v
9. Tacrolimus 3 mg PO Q12H
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
RX *amlodipine 5 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
2. Amoxicillin-Clavulanic Acid ___ mg PO/NG Q12H Duration: 3
Weeks
RX *amoxicillin-pot clavulanate 875 mg-125 mg 1 tablet(s) by
mouth every twelve (12) hours Disp #*40 Tablet Refills:*0
3. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Carvedilol 3.125 mg PO ONCE:PRN as instructed by your doctor
Duration: 7 Days
RX *carvedilol 3.125 mg 1 tablet(s) by mouth as instructed by
your doctor only for high blood pressures Disp #*7 Tablet
Refills:*0
5. Docusate Sodium 100 mg PO BID:PRN constipation
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily as
needed Disp #*60 Capsule Refills:*0
6. Fluticasone Propionate NASAL 2 SPRY NU BID
RX *fluticasone 50 mcg/actuation 2 spry in twice a day Disp #*60
Spray Refills:*0
7. Furosemide 40 mg PO DAILY
RX *furosemide 40 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
8. Oxymetazoline 2 SPRY NU TID Duration: 3 Days
RX *oxymetazoline 0.05 % 2 spry in three times a day Disp #*6
Spray Refills:*0
9. Sodium Chloride Nasal ___ SPRY NU TID
RX *sodium chloride [Saline Nose] 0.65 % ___ spry in daily Disp
#*60 Spray Refills:*0
10. Azathioprine 100 mg PO DAILY
11. Multivitamins 1 TAB PO DAILY
12. Omeprazole 40 mg PO DAILY
13. Ondansetron 4 mg PO Q8H:PRN n/v
14. PredniSONE 5 mg PO DAILY
15. Senna 8.6 mg PO BID:PRN constipation
16. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
17. Tacrolimus 3 mg PO Q12H
18. Vitamin B Complex 1 CAP PO DAILY
19.Outpatient Lab Work
ICD-10: ___.8
Please draw by ___
Please draw chem-10 panel
Fax results to ___, MD, ___
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnosis:
Acute CHF exacerbation with preserved EF (45-50%)
Hypertension
Chronic sinusitis
Secondary diagnosis:
S/p kidney/pancreas transplant
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with dyspnea// eval for edema, effusion, infiltrate
COMPARISON: ___
FINDINGS:
PA and lateral views of the chest provided. Interstitial pulmonary edema is
noted with hilar congestion. Background COPD is again noted. No large
effusion is seen. Difficult to exclude a subtle pneumonia. Cardiomediastinal
silhouette is unchanged. Bony structures are intact.
IMPRESSION:
COPD with superimposed pulmonary edema.
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S. LEFT
INDICATION: ___ year old man with renal transplant, worsening HTN and volume
overload// please eval with dopplers
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: Transplant renal ultrasound ___
FINDINGS:
The left transplant kidney measures 10.7 cm. The transplant renal morphology
is unremarkable. Specifically, the cortex is of normal thickness and
echogenicity, pyramids are unremarkable, there is no urothelial thickening,
and renal sinus fat is unremarkable. There is no hydronephrosis and no
perinephric fluid collection. Trace fluid is seen around the transplant, as
on prior.
The resistive index of intrarenal arteries are again noted to be elevated
measuring in the ___. The main renal artery shows antegrade flow, with prompt
systolic upstroke and continuous antegrade diastolic flow, with peak systolic
velocity of 135 cm/sec. Please note that there is diminished diastolic flow
in the main renal artery as well. Vascularity is visualized throughout
transplant. The transplant renal vein is patent and shows antegrade flow.
IMPRESSION:
Continually elevated resistive indices. No hydronephrosis or significant
perinephric fluid collection is identified.
Radiology Report
EXAMINATION: CT SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS
INDICATION: ___ year old man with with chronic sinusitis.
TECHNIQUE: Axial images were acquired through the paranasal sinuses. Bone
and soft tissue reconstructed images were generated. Coronal and sagittal
reformatted images were then produced.
DOSE: Acquisition sequence:
1) Spiral Acquisition 1.8 s, 14.2 cm; CTDIvol = 26.8 mGy (Head) DLP = 381.1
mGy-cm.
Total DLP (Head) = 381 mGy-cm.
COMPARISON: CT sinus from ___.
FINDINGS:
Again seen is moderate polypoid mucosal thickening of the bilateral maxillary
sinuses, left worse than right, not significantly changed from prior exam from
___. There is persistent complete opacification of the left
ostiomeatal unit and persistent narrowing of the right ostiomeatal
infundibulum by mucosal thickening. Bilateral uncinate processes appear
demineralized.
Again seen is near complete opacification of the left anterior ethmoid air
cells, extending into the frontoethmoidal recess. There is moderate right
anterior ethmoid air cell mucosal thickening extending into the
frontoethmoidal recess. Remaining frontal sinuses are well-aerated. These
findings are unchanged.
There is unchanged mild mucosal thickening in the left sphenoid sinus and left
greater than right posterior ethmoid air cells.
The lamina papyracea appear intact bilaterally. Bilateral cribriform plates
are demineralized. The nasal septum is mildly deviated to the left
inferiorly, as seen previously. There is unchanged soft tissue density in the
left naris, and a polyp cannot be excluded.
The maxillary alveolar ridge is not fully imaged, limiting assessment for
periapical lucencies, though none were seen on the recent ___ CT.
Middle ear cavities and partially visualized mastoid air cells are well
aerated. The orbits are unremarkable.
This exam is not technically optimized for evaluation of the partially
included brain parenchyma. No concerning abnormalities are seen on limited
assessment. Periventricular white matter hypodensities are again seen,
nonspecific but likely sequela of chronic small vessel ischemic disease in
this age group.
IMPRESSION:
1. No change in paranasal sinus disease compared to ___, as detailed
above. Demineralized cribriform plates and uncinate processes indicate
chronic inflammation. No evidence for fluid levels.
2. Unchanged polypoid soft tissue density in the left naris. A polyp is not
excluded.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, Leg swelling
Diagnosed with Heart failure, unspecified
temperature: 98.3
heartrate: 74.0
resprate: 18.0
o2sat: 96.0
sbp: 193.0
dbp: 84.0
level of pain: 0
level of acuity: 2.0 | ___ year old male, with past history of ESRD ___ Type I DM, now
s/p kidney/pancreas transplant in ___, with recent admission
for conversion of bladder drain to enteric, presenting with
hypertensive urgency and CHF exacerbation. He was treated with
IV Lasix x2 days and put out well. TTE showed EF 45-50% with
changes consistent with known CAD. Cardiac biomarkers were
negative and BNP was in the 9000s. He remained in normal sinus
rhythm. He had head CT for c/o ongoing sinus issues which showed
changes suggestive of chronic sinusitis. He also was started on
new blood pressure medication of amlodipine.
#CHF exacerbation: Presented with dyspnea, orthopnea and lower
extremity edema. VS notable for BP >200s in ED. Labs notable for
elevated BNP. Echo with EF 45-50%, ECG stable, CXR with no
underlying infection but notable for pulmonary edema, telemetry
with no events. Etiology attributed to uncontrolled
hypertension. Patient was treated with labetolol and IV Lasix
20mg BID and then transitioned to amlodipine and 40mg PO
furosemide. After adding carvedilol, patients blood pressure
dropped to 110s, so it was held. Plan for discharge was
initially for just amlodipine for BP control, but after
discharge, plan was changed to carvedilol BID. Patient was
informed via voicemail and prescribed the medication
electronically. Negative orthostatics and ambulatory saturation
within normal limits.
# Uncontrolled HTN: Admitted with SBP 190-200s, please see above
for more detail. Discharged on amlodipine, carvedilol, 40mg
furosemide.
# Type I DM c/b ESRD s/p Kidney/Pancreas Transplant: Renal
ultrasound stable. Amylase, lipase and blood sugars were
monitored daily and stable.
- continued tacrolimus 3 mg BID with tacro levels
- continued prednisone 5 mg daily
- continued azathioprine 100 mg daily
- continued batrim for PJP prophylaxis.
# Chronic sinusitis: Secondary to NG tube placement in the past,
now with significant pain. CT scan c/w chronic sinusitis. ENT
consulted in patient and recommended nasal spray, fluticasone,
neti pot and Augmentin for three weeks. Plan is to follow up as
outpatient with ENT.
# CAD: Known CAD with prior cardiac catherization in ___ per
reports. No chest pains, palpitations, or ischemic changes seen.
Trops negative, EKG stable, echo stable.
- continued aspirin
# Obstructive Sleep Apnea: With PHTN on echo. Noncompliant with
cpap machine, counseled extensively on risks. Patient f/u with
PCP for further management.
***Transitional issues***
- amlodipine for hypertension. Please check blood pressure
regularly and follow up with providers regarding hypertension.
- no changes to immunosuppression regimen. Tacro trough on day
of discharge 5.0.
- will take Augmentin for 3 weeks (___). Follow up with ENT.
- will be discharged on 40 mg PO Lasix daily. Titrate as needed.
Patient will have labs checked in 3 days to monitor electrolytes
and Cr. Admission Cr .9, discharge Cr 1.1.
- Admit weight 210lb, discharge weight 205.8 lb.
FULL CODE |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea; hypoxia
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ F PMHx COPD metastatic lung adenoca (new dx during recent
hospitalization, d/cd ___, plan to start
carboplatin/pemetrexed tomorrow, on home 3L NC) p/w worsening
dyspnea. Pt reports that her breathing has been worse over the
past week and she has developed a productive cough, no
hemoptysis, for the past 3 days. She has had productive cough
off and on for the past several weeks History of COPD. States
she has not noticed wheezing or fever at home. NO fevers/sore
throat. no sick contacts. No lower extremity swelling or weight
gain. No chest pain or palpitations.
Of note she was discharged ___ after admission for acute
hypoxic respiratory failure due to metastatic lung
adenocarcinoma (new finding) and ___ also COPD exacerbation
and CAP. She has
known COPD. PE was ruled out. TTE normal. AFB stains done and
negative x4 (TB exposure when younger w h/o positive PPDs)> Flex
bronch IP for dx ___, cytology showing adenocarcinoma. Staging
imaging showed adenopathy of abdomen c/f mets and bony mets
confirmed by bone scan. MRI brain negative for mets. She was
treated with 5 days of levoflox for possible CAP and 5 days of
prednisone for COPD exacerbation. She is followed by atrius
oncology and had plans for outpatient follow up. She was
discharged on 3L NC supplemental O2. Also given IM b12 before
discharged and started on folic acid anticipating chemo. Hosp
course c/b hyponatremia/SIADH which resolved with 2L fluid
restriction. She also had pan-S pseudomonas on urine culture but
got 5d levoflox as above and given no dysuria or symptoms this
specimen was felt to be contaminated. She also had
hypomagnesemia
requiring supplementation.
Past Medical History:
Hypertension
Hyperlipidemia
Asthma
COPD--recently on 3L oxygen at baseline.
Primary open-angle glaucoma
Diabetes
Angina - stress echo without signs of ischemia
s/p hysterectomy ___
s/p C-section ___
s/p appendectomy ___
s/p tonsillectomy ___
Social History:
___
Family History:
Mother- stomach cancer, died at age ___
Maternal aunt with breast cancer at age ___.
Grandfather and cousin with lung cancer.
Physical Exam:
Admission Physical:
VITAL SIGNS: T 98.9 154/62 109 95%6L NC
General: mildly tachypneic but speaks in full sentences and
appears reasonably comfortable, amicable and making jokes
HEENT: MMM, no OP lesions, no cervical, supraclavicular, or
axillary adenopathy, no thyromegaly
CV: RR, NL S1S2 no S3S4 MRG
PULM: scattered wheezes, coarse breath sounds throughout
GI: BS+, soft, NTND, no masses or hepatosplenomegaly
LIMBS: No edema, clubbing, tremors, or asterixis; no inguinal
adenopathy
SKIN: No rashes or skin breakdown
NEURO: Oriented x3. 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; gait
is normal, coordination is intact.
Discharge Physical:
VS: T98.4 BP 112/60 HR 100 RR 18 96% on 4L
GEN: lying in bed in NAD.
HEENT: PERRLA. MMM. no LAD. no JVD. neck supple. No cervical,
supraclavicular, or axillary LAD
Cards: RR S1/S2 normal. no murmurs/gallops/rubs.
Pulm: CTA with good air entry, faint exp wheeze (prior to
Advair)
Abd: BS+, soft, NT, no rebound/guarding, no HSM.
Extremities: wwp, no edema. DPs, PTs 2+.
Skin: no rashes or bruising
Neuro: AOx3, CNs II-XII grossly intact.
Pertinent Results:
ADMISSION/IMPORTANT LABS:
___ 03:15PM BLOOD WBC-15.9* RBC-3.56* Hgb-8.8* Hct-28.2*
MCV-79* MCH-24.7* MCHC-31.2* RDW-15.6* RDWSD-45.0 Plt ___
___ 03:15PM BLOOD Neuts-88.2* Lymphs-3.7* Monos-6.5
Eos-0.8* Baso-0.2 Im ___ AbsNeut-13.99* AbsLymp-0.59*
AbsMono-1.03* AbsEos-0.12 AbsBaso-0.03
___ 03:15PM BLOOD Glucose-147* UreaN-6 Creat-0.5 Na-134
K-4.4 Cl-88* HCO3-38* AnGap-12
___ 03:31PM BLOOD Lactate-1.5
LABS AT DISCHARGE:
-----------------
___ 07:11AM BLOOD WBC-9.6 RBC-3.37* Hgb-8.5* Hct-26.8*
MCV-80* MCH-25.2* MCHC-31.7* RDW-15.7* RDWSD-45.2 Plt ___
___ 07:11AM BLOOD Glucose-125* UreaN-7 Creat-0.4 Na-131*
K-4.1 Cl-92* HCO3-31 AnGap-12
IMAGING/OTHER STUDIES:
CTA Chest ___
1. No evidence of pulmonary embolism or acute aortic pathology.
2. Significant interval worsening of widespread metastatic
disease including
innumerable parenchymal nodules and lymphangitic carcinomatosis.
3. Widespread mediastinal, hilar, retrocrural, and
paraesophageal
lymphadenopathy. Enlargement of gastrohepatic lymph node.
4. Osseous metastatic disease.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 5 mg PO DAILY
2. Docusate Sodium 200 mg PO BID
3. Ferrous Sulfate 325 mg PO DAILY
4. Hydrochlorothiazide 50 mg PO DAILY
5. Lisinopril 10 mg PO DAILY
6. Montelukast 10 mg PO DAILY
7. Simvastatin 10 mg PO QPM
8. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
9. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
10. Acetaminophen 650 mg PO Q8H:PRN pain, fever
11. Bisacodyl 10 mg PO DAILY:PRN Constipation
12. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
13. Senna 17.2 mg PO BID
14. Albuterol Inhaler ___ PUFF IH Q4H:PRN shorntess of breath
15. Aspirin 81 mg PO DAILY
16. Calcium Carbonate 650 mg PO DAILY
17. GlipiZIDE 5 mg PO DAILY
18. Multivitamins 1 TAB PO DAILY
19. Ipratropium Bromide MDI 2 PUFF IH QID
20. Magnesium Oxide 280 mg PO DAILY
21. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Acetaminophen 650 mg PO Q8H:PRN pain, fever
2. Amlodipine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Bisacodyl 10 mg PO DAILY:PRN Constipation
5. Docusate Sodium 200 mg PO BID
6. Ferrous Sulfate 325 mg PO DAILY
7. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
8. FoLIC Acid 1 mg PO DAILY
9. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
10. Lisinopril 10 mg PO DAILY
11. Montelukast 10 mg PO DAILY
12. Multivitamins 1 TAB PO DAILY
13. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain or
respiratory distress
RX *oxycodone 5 mg one to two tablet(s) by mouth every four
hours Disp #*60 Tablet Refills:*0
14. Fentanyl Patch 12 mcg/h TD Q72H
apply patch every three days.
RX *fentanyl [Duragesic] 12 mcg/hour apply one patch every three
days Disp #*10 Patch Refills:*0
15. Albuterol Inhaler ___ PUFF IH Q4H:PRN shorntess of breath
16. Calcium Carbonate 650 mg PO DAILY
17. Hydrochlorothiazide 50 mg PO DAILY
18. Ipratropium Bromide MDI 2 PUFF IH QID
19. Magnesium Oxide 280 mg PO DAILY
20. Simvastatin 10 mg PO QPM
21. Senna 17.2 mg PO BID
22. Prochlorperazine 10 mg PO Q6H:PRN nausea
RX *prochlorperazine maleate [Compazine] 10 mg 1 tablet(s) by
mouth every six hours Disp #*14 Tablet Refills:*0
23. Lorazepam 0.5 mg PO Q6H:PRN pain
RX *lorazepam [Ativan] 0.5 mg 1 by mouth every six hours Disp
#*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
primary: non small cell lung cancer; COPD exacerbation.
secondary: type 2 diabetes; hypertension
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: History: ___ with DOE // R/O acute process
TECHNIQUE: Chest PA and lateral
COMPARISON: Comparison is made with chest radiographs from ___
and CT chest from ___.
FINDINGS:
Interval increase in interstitial markings left lung, which may reflect
progression of widespread disseminated metastasis or possibly concurrent
infection in left lung. The previously seen pneumonia in the right lung has
improved in the interval but has not completely resolved. There is a small
right pleural effusion. No left pleural effusion. There is no pneumothorax.
Cardiomediastinal silhouette is unremarkable.
IMPRESSION:
1. Interval increase in interstitial markings in the left lung, suggestive of
progressing widespread disseminated metastases or possibly concurrent
infection.
2. Previously seen pneumonia in the right lung has improved in the interval,
but still substantial.
3. Small right pleural effusion.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ with new lung adenoca w/DOE and worsening O2 requirement //
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) = 219 mGy-cm.
COMPARISON: None
FINDINGS:
HEART AND VASCULATURE: Pulmonary vasculature is well opacified to the
subsegmental level without filling defect to indicate a pulmonary embolus.
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: Extensive mediastinal and bilateral hilar
lymphadenopathy is again noted, including prevascular lymph node conglomerate
measuring 2.3 x 1.2 cm and sub carinal lymphadenopathy measuring 2.7 x 1.5 cm.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Since the prior examination, there has been significant
interval worsening of widespread metastases in both the form of discrete
nodules and bronchovascular lymphangitic spread. There is diffuse
peribronchial wall thickening. Bilaterally, slightly worse on the right.
Nodular interlobular septal thickening is noted diffusely. The largest
parenchymal consolidation is in the posterior right lower lobe (2:83),
significantly increased since the prior study.
BASE OF NECK: There is a 1.3 cm hypodense nodule left thyroid lobe, unchanged
(2:6).
ABDOMEN: Extensive retrocrural and paraesophageal lymphadenopathy is again
noted. There has been interval enlargement, specifically of a gastrohepatic
lymph node currently measuring 2.2 x 2.4 cm (2:108), previously 1.6 x 1.5 cm.
There are several small, subcentimeter incompletely characterized hyper
enhancing foci in the liver.
BONES: Mixed sclerotic and lytic foci in the T5 and T9 vertebral bodies are
compatible with previously described widespread osseous metastatic disease.
Other predominantly sclerotic foci are also noted in the T10 and T12 vertebral
bodies and right scapular tip (02:49).
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic pathology.
2. Significant interval worsening of widespread metastatic disease including
innumerable parenchymal nodules and lymphangitic carcinomatosis.
3. Widespread mediastinal, hilar, retrocrural, and paraesophageal
lymphadenopathy. Enlargement of gastrohepatic lymph node.
4. Osseous metastatic disease.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dyspnea on exertion
Diagnosed with Dyspnea, unspecified, Hypoxemia
temperature: 97.6
heartrate: 116.0
resprate: 18.0
o2sat: 93.0
sbp: 133.0
dbp: 55.0
level of pain: 0
level of acuity: 2.0 | Ms ___ is a ___ w/ PMHx COPD (on 3L oxygen at home) and newly
diagnosed metastatic lung adenocarcinoma who presents with
worsening dyspnea with CTA negative for PE/PNA, but showing
progression of disease.
#Worsening dyspnea/hypoxia: likely secondary to combination of
progression of disease and underlying COPD. CTA obtained which
did not reveal PNA or PE but demonstrated significant interval
worsening of widespread metastatic disease including innumerable
parenchymal nodules and lymphangitic carcinomatosis. She was
pre-treated with dexamethasone and received carboplatin and
pemetrexid on ___ without issues. Breathing noted to
improve significantly with steroids and duoneb therapy. Oxygen
was downtitrated to 3L NC.
#Metastatic lung adenocarcinoma: Recently diagnosed on
admission ___. Negative for EGFR. As mentioned above,
lymphangitic spread was noted to have worsened over short
interval and thus she was given carboplatin/pemetrexid on ___.
Patient with worsening pain from known bone mets. Fentanyl patch
was added to pain regimen and she was given zoledronic acid on
___. Further chemo as per new oncologist.
#Hyponatremia - Sodium persistently in low 130s on this
admission, requiring no intervention.
# Type II Diabetes: Initially had elevated blood sugars in
setting of high dose steroids managed with SSI. After finishing
steroids, blood sugar consistently < 200 and required no
insulin. Given risk of hypoglycemia, home glyburide held out of
concern for hypoglycemia to restart at PCP ___.
# Hypertension: SBP 150 on arrival. Continued amlodipine 5 mg
daily and lisinopril 10 mg daily. HCTZ 50 mg held.
TRANSITIONAL ISSUES:
- Next chemo to be determined by Dr. ___.
- Patient started on fentanyl patch for pain on this admission.
- Glyburide not restarted due to BS in the 100's with no insulin
requirements by discharge
- Will need ongoing assessment of pulmonary status and titration
of oxygen requirements.
- Code status: DNR/DNI, BiPAP is OK |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
s/p fall
Major Surgical or Invasive Procedure:
1. Left hip ORIF
History of Present Illness:
___ w/ PMHx metastatic pancreatic cancer (lung, liver mets) on
chemotherapy presenting s/p fall this morning when his feet felt
weak. He has baseline bilateral neuropathy in the lower
extremities which he feels contributed to the fall. No
lightheadedness, chest pain, shortness of breath, abd pain,
diarrhea, vomiting, or presyncopal component to the fall. Fell
directly onto his left side without HS or LOC. Since then he has
been having pain directly over his left hip. Denies numbness,
weakness, or tingling.
For the past ___ days the patient has been having intermittent
spiking fevers, worsening fatigue, malaise, and decreased PO
intake, and is undergoing infectious workup with outpatient
providers, without ___ source yet found. Of note, bilirubin was
noted to be rising suggestive potentially of the palliative
biliary stents as etiology.
Past Medical History:
Metastatic pancreatic CA
Laparoscopic CCY
Social History:
___
Family History:
No relevant family history.
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: Afebrile, BP 110s-120s/60s-70s, HR ___, SPO2 96% on
RA
General: AOx3, answering questions appropriately.
HEENT: Mild scleral icterus.
Neck: Supple.
CV: RRR, nl S1/S2, no m/r/g.
Lungs: CTAB, no w/w/r.
Abdomen: Soft, nontender, nondistended. +BS.
GU: Foley in place with clear yellow urine.
Ext: WWP. TTP over left hip. No ecchymoses.
Neuro: CN2-12 intact. Strength and sensation grossly intact and
symmetric.
DISCHARGE PHYSICAL EXAM:
Vital Signs: 98.2 138 / 80 84 18 98 RA
General: Appears fatigued, alert and oriented though slow in
responding to questions
HEENT: NC/AT.
Lungs: diminished bilaterally, no adventitial sounds heard.
CV: Distant, RRR, S1, S2. No extra sounds.
GI: nontender, guarding or peritoneal signs. Mildly distended.
BS present but diminished
Extremities: warm and well perfused, wearing compression
stockings.
No Lower extremity edema bilaterally. Hip surgical wound c/d/I.
Pertinent Results:
ADMISSION LABS:
___ 01:25PM BLOOD WBC-12.7*# RBC-3.62* Hgb-10.5* Hct-33.6*
MCV-93 MCH-29.0 MCHC-31.3* RDW-16.8* RDWSD-56.4* Plt Ct-70*
___ 01:25PM BLOOD Neuts-77* Bands-0 Lymphs-11* Monos-7
Eos-3 Baso-1 Atyps-1* ___ Myelos-0 NRBC-1* AbsNeut-9.78*
AbsLymp-1.52 AbsMono-0.89* AbsEos-0.38 AbsBaso-0.13*
___ 01:25PM BLOOD Hypochr-OCCASIONAL Anisocy-OCCASIONAL
Poiklo-NORMAL Macrocy-OCCASIONAL Microcy-NORMAL Polychr-1+
___ 01:37PM BLOOD ___ PTT-28.0 ___
___ 01:25PM BLOOD Glucose-143* UreaN-6 Creat-0.8 Na-135
K-3.8 Cl-99 HCO3-24 AnGap-16
___ 04:22AM BLOOD ALT-22 AST-19 AlkPhos-177* TotBili-1.6*
___ 04:22AM BLOOD Lipase-22
___ 04:55AM BLOOD Calcium-8.0* Phos-2.0* Mg-1.7
___ 01:37PM BLOOD Lactate-1.8
___ 04:47PM URINE Color- Appear-Clear Sp ___
___ 04:47PM URINE Blood-LG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-1 pH-6.5 Leuks-NEG
___ 04:47PM URINE RBC-7* WBC-<1 Bacteri-NONE Yeast-NONE
Epi-0
Microbiology: Urine cultures and blood cultures with no growth.
Hyponatremia workup:
___ 06:40AM BLOOD Cortsol-12.3
___ 10:54AM URINE Hours-RANDOM Creat-91 Na-172
DISCHARGE LABS:
___ 06:23AM BLOOD WBC-15.6* RBC-2.85* Hgb-8.2* Hct-26.5*
MCV-93 MCH-28.8 MCHC-30.9* RDW-16.5* RDWSD-55.3* Plt ___
___ 06:23AM BLOOD ___ PTT-75.5* ___
___ 06:23AM BLOOD Glucose-101* UreaN-9 Creat-0.6 Na-133
K-3.8 Cl-96 HCO3-26 AnGap-15
___ 06:23AM BLOOD ALT-24 AST-29 LD(LDH)-328* AlkPhos-217*
TotBili-0.9
___ 06:23AM BLOOD Albumin-2.6* Calcium-8.1* Phos-2.8 Mg-2.0
Imaging:
___ femur xray:
FINDINGS:
Re- demonstrated is a nondisplaced left mid cervical femoral
neck fracture. No dislocation is identified. Remainder of the
left femur demonstrates no additional fractures, and no focal
lytic or sclerotic osseous abnormality is identified. Moderate
degenerative changes of the left femoral acetabular joint with
joint space narrowing, subchondral sclerosis and osteophyte
formation is noted. Well-circumscribed ovoid calcification
lateral to the left greater trochanter likely reflects
heterotopic ossification. Imaged aspect of the left knee
demonstrates severe tricompartmental degenerative changes with
marked joint space narrowing, subchondral sclerosis, and large
osteophytes. Small joint effusion is noted. Spiral tacks are
seen in the left pelvis compatible with prior herniorrhaphy.
Minimal vascular calcifications are seen.
IMPRESSION: Nondisplaced left mid cervical femoral neck
fracture. No dislocation.
___ CT torso:
IMPRESSION:
1. Mildly displaced and angulated acute left subcapital femoral
neck
fracture.
2. Interval progression of known metastatic pancreatic cancer
with growth in the pancreatic head mass and loss of fat plane
between the mass and the
adjacent proximal duodenum, persistent contact with multiple
peripancreatic vessels as above, growth in peripancreatic
lymphadenopathy, increased size and number of hepatic
metastases, and a new left lower lobe pulmonary nodule,
likely a metastasis.
3. No specific CT evidence for intra-abdominal infection or
abscess.
4. Unchanged position of the common bile duct stent with
pneumobilia
confirming stent patency, although there is a small amount of
debris within the common bile duct stent.
5. No pneumonia.
___ CT c-spine:
IMPRESSION:
1. Overall similar alignment to the prior CT with multiple
levels of mild
anterolisthesis and retrolisthesis as above.
2. No evidence of acute cervical spine fracture.
3. Severe multilevel degenerative changes as above with
multiple levels of severe narrowing of the central canal and and
bilateral severe neural
foraminal narrowing, most pronounced at C5-6 and C6-7. These
degenerative
changes predisposes the patient to cord injury in the setting of
minimal
trauma. Consider MRI for further assessment of cord injury if
there are
neurological symptoms referable to a specific level.
EKG ___
Sinus tachycardia. Low precordial lead voltage. Diffuse
non-specific
repolarization abnormalities. Compared to the previous tracing
of ___ the
heart rate is increased.
CT Sinus ___
1. No evidence of mandible fracture.
2. Mild asymmetric widening of the left temporal mandibular
joint space
relative to the right could suggest subluxation without evidence
of frank
dislocation.
3. Missing right mandibular first molar.
4. Paranasal sinus disease as above with probable active
sinusitis.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
2. LORazepam 1 mg PO Q4-6H PRN nausea, insomnia, anxiety
3. Omeprazole 40 mg PO DAILY
4. PredniSONE 20 mg PO DAILY
5. Prochlorperazine 10 mg PO BID:PRN nausea
6. OxyCODONE SR (OxyconTIN) 60 mg PO Q12H
7. Fexofenadine 60 mg PO BID
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice daily
Disp #*30 Capsule Refills:*0
2. Phosphorus 500 mg PO DAILY
RX *sod phos di, mono-K phos mono [Phospha 250 Neutral] 250 mg 1
tablet(s) by mouth daily Disp #*30 Tablet Refills:*0
3. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 17 gram 1 powder(s) by mouth daily
Disp #*30 Packet Refills:*0
4. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [Senexon] 8.6 mg 1 tablet by mouth daily Disp
#*30 Tablet Refills:*0
5. PredniSONE 60 mg PO DAILY Duration: 5 Days
RX *prednisone 20 mg 3 tablet(s) by mouth daily Disp #*6 Tablet
Refills:*0
6. Fexofenadine 60 mg PO BID
7. HYDROmorphone (Dilaudid) ___ mg PO Q4H:PRN Pain - Moderate
8. LORazepam 1 mg PO Q4-6H PRN nausea, insomnia, anxiety
9. Omeprazole 40 mg PO DAILY
10. OxyCODONE SR (OxyconTIN) 60 mg PO Q12H
11. Prochlorperazine 10 mg PO BID:PRN nausea
12.Rolling Walker
Diagnosis: Malignant neoplasm of pancreas, unspecified
Prognosis: Good
Length of need: 13 months
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
1. Left femoral neck fracture
2. Hypophosphatemia
SECONDARY DIAGNOSIS:
1. Metastatic Pancreatic Cancer
2. Hyponatremia
3. Dehydration
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 SINUS/MANDIBLE/MAXILLOFACIAL W/O CONTRAST Q116 CT HEADSINUS
INDICATION: ___ man with metastatic pancreatic cancer presented to
outside hospital after fall to face, broken left hip, febrile, concern for
infection preceding trauma. Evaluate for jaw dislocation/fracture.
TECHNIQUE: Helically-acquired multidetector CT axial images were obtained
through the maxillofacial bones and mandible. Intravenous contrast was not
administered. Axial images reconstructed with soft tissue and bone algorithm
to display images with 1.25 mm slice. Coronal and sagittal reformations were
also constructed. All produced images were evaluated in production of this
report.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.0 s, 23.3 cm; CTDIvol = 25.9 mGy (Head) DLP = 603.3
mGy-cm.
Total DLP (Head) = 603 mGy-cm.
COMPARISON: Head CT from an outside facility dated ___, earlier on
the same day at 10:10 and uploaded onto PACs.
CTA head and neck dated ___.
FINDINGS:
SOFT TISSUES: There is no stranding, fluid collection, hematoma, or other
soft tissue abnormality.
MAXILLOFACIAL BONES: The maxillofacial bones are intact, without fracture.
The zygomatico-maxillary complex is intact. The lateral pterygoid plates are
intact.
MANDIBLE: The mandible is without fracture. Asymmetric mild widening of the
left relative to the right temporal mandibular joint space may suggest
subluxation, but there is no evidence of frank dislocation. The
temporomandibular joints are without significant degenerative change.
DENTITION: Dental hardware creates streak artifact limiting detailed
evaluation of surrounding structures including adjacent teeth. No evidence of
dental fractures.A right mandibular molar tooth is not present (series 2,
image 116).
SINUSES: The paranasal sinuses are intact. The left frontal sinus is
underpneumatized. Some of the bilateral ethmoidal air cells are partially or
completely opacified with a right posterior ethmoidal air cell containing
aerosolized secretions suggesting component of active sinusitis. Polypoid
mucosal thickening in the bilateral maxillary sinuses is mild. Mucosal
thickening in the right sphenoid sinus is minimal. The left sphenoid sinus is
essentially clear. The ostiomeatal units are patent. The mastoid air cells
and middle ear cavities are clear.
NOSE: There is no nasal bone fracture. Nasopharyngeal soft tissues are
unremarkable. There is no nasal septal hematoma.
ORBITS: The orbits, including the laminae papyracea, are intact. The globes
are intact with non-displaced lenses and no intraocular hematoma. There is no
preseptal soft tissue edema. There is no retrobulbar hematoma or fat
stranding.
Allowing for imaging technique optimized for the face, the limited included
portion of the brain is grossly unremarkable.
Please refer to the dedicated cervical spine report from the same day for
description of findings in the cervical spine.
IMPRESSION:
1. No evidence of mandible fracture.
2. Mild asymmetric widening of the left temporal mandibular joint space
relative to the right could suggest subluxation without evidence of frank
dislocation.
3. Missing right mandibular first molar.
4. Paranasal sinus disease as above with probable active sinusitis.
Radiology Report
EXAMINATION: CT C-SPINE W/O CONTRAST Q311 CT SPINE
INDICATION: ___ man with metastatic pancreatic cancer presented to
outside hospital after fall to face, broken left hip, febrile, concern for
infection preceding trauma. 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) Spiral Acquisition 5.8 s, 22.6 cm; CTDIvol = 37.1 mGy (Body) DLP = 838.3
mGy-cm.
Total DLP (Body) = 838 mGy-cm.
COMPARISON: CTA head and neck dated ___.
FINDINGS:
Overall alignment of the cervical spine is similar to the prior CT.
Anterolisthesis of C3 on C4 is mild, unchanged. Retrolisthesis of C6 on C7 is
mild, unchanged. Anterolisthesis of C7 on T1 is also mild, unchanged.
Multilevel degenerative changes of the cervical spine are severe and most
pronounced at C4 through C7 with prominent anterior and posterior osteophytes,
loss of intervertebral disc height, and subchondral cyst formation. Mild
anterior wedging of the C4 and C5 vertebral bodies is similar in appearance to
the prior exam.
No evidence of an acute cervical spine fracture. No prevertebral soft tissue
swelling.
The bones are diffusely demineralized. No lytic or sclerotic lesion
concerning for malignancy or infection.
At C4-C5, a broad-based disc bulge and posterior osteophytes result in
narrowing of the anterior spinal canal and probably indents are flattens the
spinal cord. At C5-C6, a broad-based disc bulge and posterior osteophytes
indents the anterior spinal cord resulting in severe spinal canal stenosis.
At C6-C7, posterior osteophytes and a broad-based disc bulge also indent the
anterior spinal cord, resulting in severe spinal canal narrowing. Multilevel
moderate to severe severe bilateral neural foraminal narrowing is most
pronounced at C5-6 and C6-7.
Please refer to the dedicated CT torso and CT facial bones exam from the same
day for description of findings in areas.
IMPRESSION:
1. Overall similar alignment to the prior CT with multiple levels of mild
anterolisthesis and retrolisthesis as above.
2. No evidence of acute cervical spine fracture.
3. Severe multilevel degenerative changes as above with multiple levels of
severe narrowing of the central canal and and bilateral severe neural
foraminal narrowing, most pronounced at C5-6 and C6-7. These degenerative
changes predisposes the patient to cord injury in the setting of minimal
trauma. Consider MRI for further assessment of cord injury if there are
neurological symptoms referable to a specific level.
RECOMMENDATION(S): Consider MRI for further assessment of cord injury if
there are neurological symptoms referable to a specific level.
Radiology Report
EXAMINATION: CT torso
INDICATION: ___ man with metastatic pancreatic cancer presented to
outside hospital after fall to face, broken left hip, febrile, concern for
infection preceding trauma. Evaluate for fracture, pneumonia, pancreatic
mass/prior stents/intraabdominal infection.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the torso 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 0.5 s, 0.5 cm; CTDIvol = 2.4 mGy (Body) DLP = 1.2
mGy-cm.
2) Stationary Acquisition 7.0 s, 0.5 cm; CTDIvol = 33.7 mGy (Body) DLP =
16.9 mGy-cm.
3) Spiral Acquisition 6.9 s, 75.0 cm; CTDIvol = 12.3 mGy (Body) DLP = 920.1
mGy-cm.
Total DLP (Body) = 938 mGy-cm.
COMPARISON: MRI liver dated ___.
CT abdomen and pelvis dated ___.
CT chest dated ___.
FINDINGS:
CHEST:
A left subclavian approach central venous catheter tip ends in the distal SVC.
The thoracic aorta is normal in caliber without evidence of stenosis or
dissection. The heart is not enlarged. Coronary artery calcifications are
moderate. Trace pericardial fluid is new (series 601b, image 26).
The main, left, and right pulmonary arteries are normal in caliber without
filling defect to indicate any incidental central acute pulmonary embolus.
No pathologically enlarged axillary, supraclavicular, hilar, or mediastinal
lymphadenopathy. Tiny hypodensity in the right thyroid lobe is unchanged from
___ (series 2, image 2). Epicardial lymph nodes measure up to 3 mm in short
axis but appear morphologically normal (series 601b, image 30; series 2, image
45).
A lobulated left lower lobe nodule measuring up to 1 cm is new, concerning for
metastasis (series 2, image 38). Other bilateral pulmonary nodules and
micronodules are unchanged (e.g., series 2, image 30, 32, 33). Bibasilar
atelectasis is mild. The airways are patent to at least the subsegmental
level. No pneumothorax. No pleural effusion.
No osseous lesions in the chest concerning for metastasis or infection.
Multilevel degenerative changes in lower thoracic spine are moderate. Mild
anterior compression deformity of the T11 vertebral body is unchanged. No
acute fractures in the thoracic cage.
ABDOMEN:
HEPATOBILIARY: Numerous hepatic hypodensities throughout the liver have
increased in both number and size substantially since ___, most
consistent with progression of metastases. Pneumobilia is compatible with a
common bile duct stent patency. No intrahepatic biliary ductal dilation. The
main portal vein is patent. A small amount of perihepatic fluid anterior to
the liver is new (series 2, image 55; series 602b, image 32); no associated
gas or peripheral rim enhancement. Small amount of subhepatic ascites is also
noted (series 2, image 67). The gallbladder is not visualized. The position
of the common bile duct is unchanged; however, there may be some debris within
the stent (series 2, image 65).
PANCREAS: This exam is not tailored for pancreatic staging. A hypoenhancing
known pancreatic mass centered at the head of the pancreas has grown since
___, now measuring up to 4 x 3.8 cm (series 2, image 71).
Associated dilation of the main pancreatic duct up to 7 mm distally is also
more pronounced from the prior exam. The pancreatic body and tail are
markedly atrophic. The mass is closely approximated with the main portal vein
with probably at least 180 degrees contact. The mass also contacts the
proximal SMV by about 180 degrees. The mass encases the replaced right
hepatic artery which arises from the SMA. Mass abuts the medial aspect of the
proximal SMA with less than 180 degrees contact (series 2, image 69). The
left hepatic artery arises from the left gastric artery and is not contacted
by the pancreatic mass. The mass does not contact the splenic vein. Multiple
peripancreatic lymph nodes are enlarged, measuring up to 8 mm in short axis,
increased in size from the prior exam (e.g., series 2, image 61). The
peripancreatic vasculature appears patent without critical narrowing or
thrombus.
SPLEEN: The spleen is top-normal in size measuring up to 13 mm. No focal
splenic lesion.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
Tiny right renal cortical hypodensities are unchanged and too small to
accurately characterize on CT. No concerning focal renal lesions,
hydronephrosis, or perinephric abnormality.
GASTROINTESTINAL: Gastric varices are noted in the proximal stomach (series 2,
image 53, 55). The fat plane between the pancreatic mass and duodenum
proximally is more indistinct compared to the prior exam. Otherwise,
remaining small bowel loops demonstrate normal caliber, wall thickness, and
enhancement throughout. The colon and rectum are within normal limits. No
bowel obstruction. No free air or intra-abdominal fluid collection.
PELVIS: Streak artifact from the right hip prosthesis limits detailed
evaluation of surrounding structures. The urinary bladder is partially
distended with a Foley catheter in place. Moderate amount of air within the
bladder lumen is compatible with Foley placement. The distal ureters are
within normal limits. Small amount of free fluid in the pelvis is minimally
complex.
REPRODUCTIVE ORGANS: The prostate is not enlarged.
LYMPH NODES: No pelvic or inguinal lymphadenopathy. Peripancreatic enlarged
lymph nodes have grown since the prior exam are as detailed above.
VASCULAR: No abdominal aortic aneurysm. Minimal calcified atherosclerotic
disease is noted. An accessory left hepatic artery arises from the left
gastric artery.
BONES: A lucency through the left femoral neck is consistent with a mildly
displaced and angulated acute subcapital fracture (series 601 B, image 32).
No associated soft tissue hematoma. No osseous lesions concerning for
metastasis. Multilevel degenerative changes of the lumbar spine are
extensive, unchanged. L4-L5 fusion is unchanged. Mild anterolisthesis of L2
on L3 is also unchanged. Severe narrowing of the neural foramina in the lower
lumbar spine also similar. A right hip prosthesis is partially imaged but
appears intact without evidence of complication.
SOFT TISSUES: A fat-containing umbilical hernia is tiny, unchanged. No
organized fluid collections or soft tissue in the abdomen or pelvis.
IMPRESSION:
1. Mildly displaced and angulated acute left subcapital femoral neck
fracture.
2. Interval progression of known metastatic pancreatic cancer with growth in
the pancreatic head mass and loss of fat plane between the mass and the
adjacent proximal duodenum, persistent contact with multiple peripancreatic
vessels as above, growth in peripancreatic lymphadenopathy, increased size and
number of hepatic metastases, and a new left lower lobe pulmonary nodule,
likely a metastasis.
3. No specific CT evidence for intra-abdominal infection or abscess.
4. Unchanged position of the common bile duct stent with pneumobilia
confirming stent patency, although there is a small amount of debris within
the common bile duct stent.
5. No pneumonia.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 8:45 ___, 60 minutes after discovery
of the findings.
Radiology Report
INDICATION: ___ male status post fall with left femoral neck
fracture, please obtain full length femur films for pre-operative planning
TECHNIQUE: Left femur, two views
COMPARISON: Reference left hip radiographs ___ at 09:27, CT torso
___ at 16:32
FINDINGS:
Re- demonstrated is a nondisplaced left mid cervical femoral neck fracture.
No dislocation is identified. Remainder of the left femur demonstrates no
additional fractures, and no focal lytic or sclerotic osseous abnormality is
identified. Moderate degenerative changes of the left femoral acetabular
joint with joint space narrowing, subchondral sclerosis and osteophyte
formation is noted. Well-circumscribed ovoid calcification lateral to the
left greater trochanter likely reflects heterotopic ossification. Imaged
aspect of the left knee demonstrates severe tricompartmental degenerative
changes with marked joint space narrowing, subchondral sclerosis, and large
osteophytes. Small joint effusion is noted. Spiral tacks are seen in the
left pelvis compatible with prior herniorrhaphy. Minimal vascular
calcifications are seen.
IMPRESSION:
Nondisplaced left mid cervical femoral neck fracture. No dislocation.
Radiology Report
INDICATION: Left hip ORIF.
TECHNIQUE: 4 intraoperative fluoroscopic images were obtained without a
radiologist present. Total fluoroscopic time of 104.8 seconds.
COMPARISON: Radiographs from ___.
FINDINGS:
4 intraoperative fluoroscopic images demonstrate fixation of a left femoral
neck fracture. Hernia repair tacks are partially visualized. Please see
operative note for further details.
IMPRESSION:
Left hip ORIF. Please see operative note for further details.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, s/p Fall, Confusion, Transfer
Diagnosed with Unsp intracapsular fracture of left femur, init for clos fx, Fall on same level, unspecified, initial encounter
temperature: 98.9
heartrate: 98.0
resprate: 10.0
o2sat: 94.0
sbp: 113.0
dbp: 80.0
level of pain: unable
level of acuity: 2.0 | ___ year old male, with past history of metastatic pancreatic
cancer (known metastasis to the liver and lung, on palliative
chemotherapy), who presented after a fall at home. He was found
to have a L femoral head fracture, underwent fixation by
orthopedic surgery on ___ and was transferred to the
medicine service for management of subacute generalized
weakness. He was found to have dehydration, severe
hypophosphatemia, as well as progression of pancreatic cancer on
imaging.
.
>> ACTIVE ISSUES:
# Fall/Left Femoral Neck Fracture: Patient fell at home while
getting out of bed, thought to be ___ to generalized weakness
from underlying progressive metastatic pancreatic cancer,
nutritional deficiency, peripheral neuropathy ___ to
chemotherapy, as well as increased dehydration. patient was
found to have a left femoral neck fracture, underwent fixation
by Orthopedic Surgery on ___. On POD#1, patient was then
transferred to the medical service, and continued to have
physical therapy. Given underlying progressive metastatic
disease (see below), further discussions regarding optimizing
post-operative care was discussed with family. Patient continued
to work with physical therapy, ambulate, and continued on DVT
prophylaxis while in house. It was discussed with family to
continue to limit medications and discussed < 5 days further DVT
prophylaxis with anticoagulants as an outpatient for which
family then declined given not within goals of care, and
enrollment into hospice program. Patient was instructed to
continue to work with physical therapy, weight bearing as
tolerated and continue to ambulate maximally given underlying
risks. Hospice services to continue to work with patient, with
daily sterile dressing changes, and follow up within 2 weeks for
orthopedic surgery evaluation.
.
# Severe hypophosphatemia: Patient was noted to have a phosphate
of 1.2, that depleted again rapidly even after IV repletion.
This is likely explained by hypermetabolism from his pancreatic
cancer. He was started on a standing PO phosphate repletion
regimen and was ultimately discharged on phosphate supplement.
He was instructed to follow up closely with his oncologist's
office near home for frequent electrolyte monitoring and IV
repletion as needed.
# Metastatic Pancreatic Cancer (lung, liver), with progression:
Patient has been on palliative chemotherapy with
gemcitabine/abraxane regimen at ___ with Dr.
___. Unfortunately, interval imaging this admission does
suggest disease progression on this regimen. He also had an
elevated bilirubin on admission that downtrended; imaging
demonstrated patency of the CBD stent without need for stent
exchange (this was discussed with Dr. ___, but it was
believed that he likely had a mild obstruction that relieved
without need for antibiotics or intervention. After discussion
with Dr. ___ and with the patient and his wife, it was decided
to enroll the patient in Hospice Services. He will follow up
closely with Dr. ___ on ___ for further discussion of his
treatment goals and plans. He will likely need to come in to the
office for electrolyte checks and repletion and IV fluids on an
as-needed basis.
#Adrenal insufficiency: Patient has chronically been on 20mg
prednisone daily at home for symptom management related to his
cancer. He was noted to be persistently hyponatremic with high
urine sodium during this admission and given recent orthopedic
surgery he was started on stress dose prednisone at 60mg on
___. He was discharged with this dose and asked to follow up
with Dr. ___ on ___. He had no vital sign instability or
other signs of adrenal insufficiency.
# Hyponatremia: Pt with Na in the 120s, which did not improve
with fluid rescusitation. In the context of elevated urine Na of
172, the patient was started on stress dose prednisone (60mg)
for likely adrenal insufficiency as he is chronically on 20mg of
prednisone. His sodium then improved to 133 on the day of
discharge.
# Cervical Spine foraminal narrowing: Imaging indicates
extremely severe foraminal narrowing, pronounced at C5-C7, with
degenerative changes predisposing patient to cord injury in the
setting of minimal trauma. The patient remained asymptomatic
this admission.
# Hyperbilirubinemia: Mildly elevated 1.7 on arrival, which
normalized. Patient with low grade fevers at home and may have
had a transient CBD stent obstruction, but imaging demonstrated
___ stent patency without need for stent exchange. This was
discussed with Dr. ___.
# Thrombocytopenia and anemia: Likely ___ to chemotherapy and
marrow suppression. Remained stable.
#Sinus Tachycardia: Patient was tachycardic from 100s-130s this
admission, which did not correct with hydration. We spoke with
the patient's oncologist office, and the patient appeared to
have been tachycardic on several office visits prior to this
admission. It was believed that this was ___ metastatic
pancreatic cancer.
#?Sinusitis: Imaging concerning for sinusitis, with parnasal
sinus disease. Patient was asymptomatic and fevers resolved
during this admission without antibiotics, so likely not active.
#DVT prophylaxis: At time of discharge patient had 5 days
remaining for total course of DVT prophylaxis with home
injections of lovenox. This was discussed with the family, but
they ultimately decided that was not within their goals of care
and declined.
===================================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
Percocet
Attending: ___.
Chief Complaint:
Bleeding/ulceration from RUE AVG
Major Surgical or Invasive Procedure:
___ Revision and thrombectomy of RUE AVG
History of Present Illness:
HPI: Ms. ___ is a ___ female with ESRD due to
hypertensive nephropathy on HD via RUE AV graft (TuThSa), who
presents for evaluation due to report of bleeding from a new
ulceration on her AVG.
In brief, she has had a complex history in regards to dialysis
access, with history of multiple failed LUE AV fistulas,
numerous
temporary and tunneled catheters in the past, multiple central
venous stenoses, and currently with a RUE AV graft created in
___ which is being used till this time for HD. She has required
multiple fistulagrams in the past ___ and ___ for
angioplasties, thrombectomies for clot, and multiple stent
placements. She is seen in AV Care, last seen on ___ by Dr
___, at which time she appeared to be doing well with no
graft-related issues.
Today, she is referred to the ED due to report of bleeding from
an ulceration on her graft. On evaluation, patient reports that
she noticed "slow" bleeding from an ulcerated area on the graft
while at rest this morning. She ran the site under some cold
water, and then placed a wet towel on top of it, after which it
stopped spontaneously. She reports noticing this ulcer over the
past ___ days, and has also had ___ days of subjective chills
and
shakes, no measured fevers. She systemically has no complaints
and reports feeling well, with no aches/pains, no
nausea/vomiting, tolerating POs. When she presented to dialysis
today, they were able to access proximal to the ulcer, and
completed a full dialysis treatment without any issues. She was
given vancomycin due to the appearance of the ulcer. As noted
below, the patient does take coumadin.
Past Medical History:
ESRD secondary to HTN, renal clots, Hep C pos, Hep B core
Ab pos, HTN, hyperlipidemia, gout, uterine CA, B-cell lymphoma
BSO in ___, multiple AVF on L arm (non-funtioning)
Miscarriage
Social History:
___
Family History:
Non-Contributory
Physical Exam:
A&O, NAD, interactive and cooperative
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: Clear to auscultation b/l
ABD: Soft, nondistended, nontender
RUE: graft palpable with good thril, palpable +distal radial
pulse, ~1cm diameter dark-colored ulcer over graft with no
visible bleeding at this time, no purulence or surrounding
erythema, no warmth
Laboratory: pending at time of evaluation
Imaging: None obtained
Pertinent Results:
On Admission: ___
WBC-6.0 RBC-3.29* Hgb-9.7* Hct-29.8* MCV-91 MCH-29.5 MCHC-32.6#
RDW-14.2 Plt ___ PTT-38.2* ___
Glucose-102* UreaN-25* Creat-4.0* Na-139 K-4.2 Cl-95* HCO3-33*
AnGap-15
Calcium-8.9 Phos-4.2 Mg-1.8
.
Labs at discharge: ___
___ PTT-28.3 ___
Glucose-96 UreaN-63* Creat-8.1*# Na-138 K-4.5 Cl-99 HCO3-25
AnGap-19
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Metoprolol Tartrate 100 mg PO BID
2. Losartan Potassium 50 mg PO BID
3. NIFEdipine CR 60 mg PO BID
4. Warfarin 5 mg PO DAILY
5. sevelamer CARBONATE 800 mg PO TID W/MEALS
6. Sodium Bicarbonate 650 mg PO TID
Discharge Medications:
1. Losartan Potassium 50 mg PO BID
2. Metoprolol Tartrate 100 mg PO BID
3. NIFEdipine CR 60 mg PO BID
4. sevelamer CARBONATE 800 mg PO TID W/MEALS
5. Sodium Bicarbonate 650 mg PO TID
6. Warfarin 5 mg PO DAILY
Have INR checked per home regimen
7. Acetaminophen 650 mg PO Q6H:PRN arm pain
___ use up to 8 of the 325 mg tablets daily
Discharge Disposition:
Home
Discharge Diagnosis:
ESRD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ w/ESRD on HD TuThSa, h/o central stenoses multiple access
operations, fistulograms/stents, p/w bleeding from ulcer over AVG s/p revision
RUE AVG segment beneath ulceration // Needs tunneled HD cath; revision to RUE
AVG - unable to use, will need catheter for discharge home
COMPARISON: Tunneled dialysis line ___
TECHNIQUE: OPERATORS: Dr. ___ radiology fellow), Dr.
___ resident), and Dr. ___ radiology
attending) performed the procedure. The attending, Dr. ___ was present
and supervising throughout the procedure. Dr. ___ radiologist,
personally supervised the trainee during the key components of the procedure
and reviewed and agreed with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
100mcg of fentanyl and 2 mg of midazolam throughout the total intra-service
time of 45 min during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: Fentanyl, midazolam, lidocaine
CONTRAST: 0 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 2.5 min, 7 mGy
PROCEDURE: PROCEDURE DETAILS: Following the explanation of the risks,
benefits and alternatives to the procedure, written informed consent was
obtained from the patient. The patient was then brought to the angiography
suite and placed supine on the exam table. A pre-procedure time-out was
performed per ___ protocol. The right/left, upper chest/groin was prepped
and draped in the usual sterile fashion.
Under continuous ultrasound guidance, the patent internal jugular vein on the
left was compressible and accessed using a micropuncture needle. Permanent
ultrasound images were obtained before and after intravenous access, which
confirmed vein patency. Subsequently a Nitinol wire was passed into the right
atrium using fluoroscopic guidance. The needle was exchanged for a
micropuncture sheath. The Nitinol wire was removed and a short ___ wire was
advanced to make appropriate measurements for catheter length. The ___ wire
was then passed distally into the IVC.
Next, attention was turned towards creation of a tunnel over the upper
anterior chest wall. After instilling superficial and deeper local anesthesia
using lidocaine mixed with epinephrine, a small skin incision was made at the
tunnel entry site. A 23cm tip-to-cuff length catheter was selected. The
catheter was tunneled from the entry site towards the venotomy site from where
it was brought out using a tunneling device. The venotomy tract was dilated.
During dilation, the bent wire became caught on the dilator and vascular
access was lost. The left internal jugular vein was accessed through the same
skin incision using ultrasound guidance and a micropuncture needle. Using a
Nitinol wire and micropuncture sheath, ___ wire was advanced again into
the IVC. The venotomy site was dilated. Following this, the peel-away sheath
was placed over the ___ wire through which the catheter was threaded into
the right side of the heart with the tip in the right atrium. The sheath was
then peeled away. The catheter was sutured in place with 0 silk sutures. ___
subcuticular Vicryl sutures and Steri-strips were also used to close the
venotomy incision site. Final spot fluoroscopic image demonstrating good
alignment of the catheter and no kinking. The tip is in the right atrium. The
catheter was flushed and both lumens were capped. Sterile dressings were
applied. The patient tolerated the procedure well.
FINDINGS:
Patent internal jugular vein on the left. Final fluoroscopic image showing
catheter with tip terminating in the right atrium.
IMPRESSION:
Successful placement of a 23cm tip-to-cuff length tunneled dialysis line.
The tip of the catheter terminates in the right atrium. The catheter is ready
for use.
Gender: F
Race: HISPANIC/LATINO - DOMINICAN
Arrive by WALK IN
Chief complaint: FISTULA EVAL
Diagnosed with DUE TO RENAL DIALYSIS DEVICE,IMPLANT,GRAFT, ACCIDENT NOS, END STAGE RENAL DISEASE
temperature: 98.0
heartrate: 76.0
resprate: 18.0
o2sat: 100.0
sbp: 160.0
dbp: 50.0
level of pain: 0
level of acuity: 3.0 | On ___, she underwent revision and thrombectomy of right
upper extremity arteriovenous graft for bleeding/ulceration of
AVG. Surgeon was Dr. ___. Please refer to operative
note for details. PTFE graft was placed, and some clot was
removed prior to assuring hemostasis, and at the end of the case
there was an excellent thrill.
She did receive two units of FFP to reverse the INR of 2.6
Patient was stable at the end of the case and transferred to
PACU.
Patient had received a dose of Vancomycin, based on the open
area of the graft prior to excision, however during surgical
inspection it was not felt that this was an infection in the
graft and no antibiotics were continued.
Due to the extensive nature of the revision, it was decided the
graft should be rested and healed, and a tunneled line placed
for hemodialysis in the meantime.
Patient receives dialysis two times a week, and there was not an
urgent indication for the line placement. The line was finally
placed on ___. A potassium of 5,5 on POD 1 was controlled
using Lasix and a dose of kayexalate with good results.
Low dose Coumadin was continued as patient has been
anticoagulated for graft patency.
After the line was placed the patient underwent routine
hemodialysis without difficulty.
The revised access has a bruit and thrill, and the suture line
was clean dry and intact upon 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:
Hypotension, altered mental status
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ man with COPD, orthostatic hypotension, and recent
admission for sepsis likely from osteomyelitis (vs HCAP), who
was referred to the ED on ___ for removal of his PICC line. In
the ambulance, pt was found to be altered, hypoxemic to the ___,
and hypotensive. On arrival the ED, pt was arousable only by
sternal rub, with blood pressures in the 70's/40's. He
reportedly was grimacing with palpation over his abdomen.
However after 2L NS, he became verbal and responsive, without
any localizing symptoms. Pt has dementia at baseline, but is
normally able to answer yes/no questions.
He was discharged from ___ on ___ after a long
hospitalization for sepsis, likely due to osteomyelitis of his R
great toe. During that admission, vascular and podiatry followed
closely, and the foot wound was debrided at the bedside. He was
not deemed a surgical candidate for aggressive amputation given
his multiple co-morbidities and overall frailty. His course was
also complicated by HCAP, for which he completed a 7-day course
of antibiotics. Of note, he has HCPs on file which were not
reachable (has been a problem in the past as well), and so legal
guardianship was obtained. He was discharged to ___ to complete
a prolonged course of vancomycin, through ___.
In the ED, initial vitals were: 97.7 65 74/43 30 100% RA
Exam notable for: apparent abdominal tenderness, interactive
and answering questions after 2L NS
Labs notable for: Hgb 6.2, trop 0.06 -> 0.04
Imaging notable for: head CT without acute process, CT
abd/pelvis without acute process (circumfrential bladder wall
thickening of unclear significance)
Patient was given: 2L NS, 1g vanco (12:49), 2g cefepime x2
(12:07 and 22:45)
Vitals prior to transfer: 97.6 70 147/80 18 100% RA
On the floor, pt is conversant and has no complaints, including
no abdominal pain, no leg pain, and no shortness of breath. He
is oriented to being in the hospital, and understands that he
has a severe infection in his foot.
Past Medical History:
- COPD
- HTN
- Asthma
- VT with choking incident
- Mild-mod MR
- Mod TR
- Chronic orthostatic hypotension on florinef
- ___: T12-L1, L4-L5, L5-S1 LAMINECTOMIES
Social History:
___
Family History:
non-contributory
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
Vital Signs: 98.2 149/70 83 38 97% RA
General: NAD, chatty, knows he's in the hospital in ___
HEENT: dry MM, temporal wasting, cataract in L eye
Neck: supple, no JVP
CV: irreg, no murmurs
Lungs: limited by effort, decreased breath sounds RLL, no
wheezes
Abdomen: + BS, non-tender, non-distended, no RUQ tenderness, no
CVA tenderness
Back: healed ulcer, no skin breakdown
Skin: R foot ulcer: 5 x 6 x 2 cm hole with visible bone, healthy
pink granulation tissue, minimal odor, no purulence or drainage.
Foot is WWP.
DISCHARGE PHYSICAL EXAM
=======================
Vital Signs: 98.2, 113/55, 75, 16, 98%RA
General: fetal position, AAOx2 (Knows hospital today, does not
know city)
HEENT: temporal wasting, L eye with severe dense cataract and
purulence (does not appear to use L eye); R eye with mild
cataract
Neck: supple
CV: RRR, S1/S2
Lungs: Decreased breath sounds over R lung base, no
rales/crackles
Abdomen: NTND, BS present
Back: grade 2 sacral wound
GU: Foley in place (tube likely from OSH, draining clear yellow
fluid)
EXTREMITY: R foot wrapped in dressing, increased warmth, no
response to stimulus, possible numbness. L ankle dry ulcer no
purulence.
Pertinent Results:
ADMISSION LABS
===============
___ 11:15AM BLOOD WBC-6.9 RBC-2.29* Hgb-6.2* Hct-20.7*
MCV-90 MCH-27.1 MCHC-30.0* RDW-16.5* RDWSD-52.4* Plt ___
___ 11:15AM BLOOD Neuts-70.0 Lymphs-17.1* Monos-8.3 Eos-3.9
Baso-0.3 Im ___ AbsNeut-4.82# AbsLymp-1.18* AbsMono-0.57
AbsEos-0.27 AbsBaso-0.02
___ 11:15AM BLOOD ___ PTT-26.0 ___
___ 07:50AM BLOOD ___ 07:50AM BLOOD Ret Aut-2.8* Abs Ret-0.07
___ 11:15AM BLOOD Glucose-92 UreaN-13 Creat-1.0 Na-142
K-4.8 Cl-104 HCO3-31 AnGap-12
___ 11:15AM BLOOD estGFR-Using this
___ 11:15AM BLOOD ALT-14 AST-24 AlkPhos-52 TotBili-0.2
___ 11:15AM BLOOD Albumin-2.6* Calcium-8.4 Phos-3.4 Mg-1.8
___ 11:24AM BLOOD ___ O2 Flow-2 pO2-26* pCO2-55*
pH-7.42 calTCO2-37* Base XS-7 Intubat-NOT INTUBA Comment-NASAL
___
___ 07:50AM BLOOD ___ 07:50AM BLOOD Ret Aut-2.8* Abs Ret-0.07
___ 11:15AM BLOOD cTropnT-0.06*
___ 06:15PM BLOOD cTropnT-0.04*
___ 07:50AM BLOOD Hapto-243*
___ 07:50AM BLOOD CRP-43.0*
DISCHARGE LABS
===============
___ 08:05AM BLOOD WBC-6.0 RBC-2.63* Hgb-7.4* Hct-24.6*
MCV-94 MCH-28.1 MCHC-30.1* RDW-17.4* RDWSD-56.2* Plt ___
___ 08:05AM BLOOD Plt ___
___ 08:05AM BLOOD Glucose-72 UreaN-9 Creat-0.9 Na-144 K-4.1
Cl-104 HCO3-30 AnGap-14
___ 08:05AM BLOOD CK(CPK)-45*
___ 08:05AM BLOOD CK-MB-2 cTropnT-0.05*
___ 08:05AM BLOOD Calcium-8.4 Phos-2.3* Mg-1.7
MICRO
===============
Foot Ulcer Swab - COAG + Staph
IMAGING
===============
CT ABD & PELVIS WITH CONTRAST Study Date of ___
IMPRESSION:
1. Circumferential bladder wall thickening, which should
correlated with urinalysis for signs of urinary tract infection.
2. Resolution of the right pleural effusion, with persistent
but improved ill-defined right basilar opacification, likely due
to chronic aspiration.
3. Cholelithiasis without cholecystitis.
4. Aneurysmal dilatation of the ascending aorta measuring up to
4.8 cm.
5. Infrarenal abdominal aortic aneurysm measuring up to 3.7 cm
with a chronic dissection flap extending into the proximal right
common iliac artery.
CT HEAD W/O CONTRAST Study Date of ___:
IMPRESSION:
1. No evidence of acute intracranial process.
2. Chronic left frontal lobe encephalomalacia.
3. Basilar invagination of the odontoid process with
significant narrowing of the foramen magnum, unchanged and
likely chronic, however a cervical spine MRI is recommended, if
not already obtained, as suggested on the prior CT.
CHEST (PA & LAT) Study Date of ___
IMPRESSION:
Interval removal of the left PICC. Improvement in the right
basilar patchy opacity likely reflective of chronic aspiration
with resolution of previously noted small right pleural
effusion.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins W/minerals 1 TAB PO DAILY
2. Vancomycin 1000 mg IV Q 24H
3. Acetaminophen 325 mg PO Q8H:PRN Pain - Mild
4. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
5. Aspirin 81 mg PO DAILY
6. Bisacodyl 10 mg PO QHS:PRN constipation
7. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing
8. Lactulose 30 mL PO Q8H:PRN constipation
9. Metoprolol Succinate XL 12.5 mg PO DAILY
10. Senna 8.6 mg PO BID:PRN constipation
11. Tamsulosin 0.4 mg PO QHS
12. TraZODone 25 mg PO Q12H:PRN agitation
Discharge Medications:
1. Linezolid ___ mg PO Q12H
RX *linezolid ___ mg 1 tablet(s) by mouth twice a day Disp #*28
Tablet Refills:*0
2. Acetaminophen 325 mg PO Q8H:PRN Pain - Mild
3. Albuterol Inhaler ___ PUFF IH Q6H:PRN wheezing
4. Aspirin 81 mg PO DAILY
5. Bisacodyl 10 mg PO QHS:PRN constipation
6. Ipratropium Bromide Neb 1 NEB IH Q6H:PRN wheezing
7. Lactulose 30 mL PO Q8H:PRN constipation
8. Metoprolol Succinate XL 12.5 mg PO DAILY
9. Multivitamins W/minerals 1 TAB PO DAILY
10. Senna 8.6 mg PO BID:PRN constipation
11. Tamsulosin 0.4 mg PO QHS
12. TraZODone 25 mg PO Q12H:PRN agitation
13.Outpatient Lab Work
Weekly labs starting ___- CBC w/ diff, BUN, Cr, ESR, CRP.
Please send to ___, MD, Phone: ___ ___:
___.
ICD: M86.2
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Osteomyelitis
Secondary: Anemia of chronic disease, atrial fibrillation,
malnutrition
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Lethargic but arousable.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (AP AND LAT)
INDICATION: History: ___ with altered mental status
TECHNIQUE: Upright AP and lateral views of the chest
COMPARISON: ___ at 13:08
FINDINGS:
Exam is slightly limited by patient rotation. Previously demonstrated left
PICC is no longer visualized. Cardiac and mediastinal contours are unchanged
with tortuosity of thoracic aorta again noted. Pulmonary vasculature is not
engorged. Patchy opacity in the right lung base appears slightly improved,
likely reflective of residual aspiration. Small right pleural effusion also
appears resolved compared to the prior study. No pneumothorax is appreciated.
Degenerative changes of the right AC joint are again noted.
IMPRESSION:
Interval removal of the left PICC. Improvement in the right basilar patchy
opacity likely reflective of chronic aspiration with resolution of previously
noted small right pleural effusion.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with altered mental status
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 1,003 mGy-cm.
COMPARISON: Noncontrast head CT dated ___.
FINDINGS:
There is no evidence of acute infarction, hemorrhage, edema, or mass. There
is chronic encephalomalacia of the left frontal lobe. The subcortical, deep,
and periventricular white matter hypodensities are nonspecific, but likely
represent the sequela of chronic microvascular ischemic disease. There is
prominence of the ventricles and sulci suggestive of involutional changes.
There is no evidence of fracture. Basilar invagination of the odontoid
process with significant narrowing of the foramen magnum is re- demonstrated,
unchanged compared to ___, likely chronic. The visualized portion of
the paranasal sinuses, mastoid air cells, and middle ear cavities are clear.
There are bilateral lens resections. Otherwise, the been visualized portion
of the orbits are unremarkable. Mild soft tissue swelling overlies the
posterior occiput, towards the vertex, as seen previously.
IMPRESSION:
1. No evidence of acute intracranial process.
2. Chronic left frontal lobe encephalomalacia.
3. Basilar invagination of the odontoid process with significant narrowing of
the foramen magnum, unchanged and likely chronic, however a cervical spine MRI
is recommended, if not already obtained, as suggested on the prior CT.
RECOMMENDATION(S): Basilar invagination of the odontoid process with
significant narrowing of the foramen magnum, unchanged and likely chronic,
however a cervical spine MRI is recommended, if not already obtained, as
suggested on the prior CT.
Radiology Report
EXAMINATION: CT abdomen and pelvis with IV contrast.
INDICATION: ___ with altered mental status. Intrabdominal infection?
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 624 mGy-cm.
COMPARISON: CT chest dated ___.
FINDINGS:
LOWER CHEST: There is aneurysmal dilatation of the ascending aorta measuring
up to 4.8 cm. Calcifications are seen involving the aortic valve and coronary
arteries. There is moderate centrilobular emphysema. The previously
visualized right pleural effusion has almost entirely resolved. There is
right basilar bronchiectasis and ill-defined opacification, which has improved
since ___, likely due to recurrent aspiration. There is no evidence
of 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 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: There is a large exophytic simple cyst arising from the lower pole of
the right kidney. There are multiple additional subcentimeter hypodensities
within the kidneys bilaterally, which are too small to characterize, but
likely also represent simple cysts. Otherwise, the kidneys are atrophic
bilaterally with multiple foci of cortical scarring. No evidence of solid
lesions or perinephric abnormality. There is mild dilation of the proximal
right ureter, but no evidence of hydronephrosis.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. Diverticulosis is
noted, without evidence of wall thickening and fat stranding. The appendix is
not visualized. There is a large stool ball within the rectum.
PELVIS: There is mild circumferential bladder wall thickening, which should be
correlated with urinalysis for the signs of urinary tract infection. 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: Moderate atherosclerotic disease is noted. There is an infrarenal
abdominal aortic aneurysm measuring approximately 3.7 x 3.6 cm in axial
___ (series 300, image 50). There appears to be a chronic dissection
flap, which extends into the proximal right common iliac artery.
BONES: There are extensive degenerative changes within the lumbar spine.
There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Circumferential bladder wall thickening, which should correlated with
urinalysis for signs of urinary tract infection.
2. Resolution of the right pleural effusion, with persistent but improved
ill-defined right basilar opacification, likely due to chronic aspiration.
3. Cholelithiasis without cholecystitis.
4. Aneurysmal dilatation of the ascending aorta measuring up to 4.8 cm.
5. Infrarenal abdominal aortic aneurysm measuring up to 3.7 cm with a chronic
dissection flap extending into the proximal right common iliac artery.
Radiology Report
INDICATION: ___ year old man with new L PICC // L DL Power PICC 46cm ___
___ Contact name: ___: ___
COMPARISON: Radiographs from ___
IMPRESSION:
There has been placement of a left-sided PICC line with the distal lead tip in
the distal SVC. Heart size is enlarged but stable. Patient is somewhat
rotated on the study. No focal consolidation or overt pulmonary edema or
pleural effusions are seen. There are no pneumothoraces.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Hypotension
Diagnosed with Hypotension, unspecified
temperature: 97.7
heartrate: 65.0
resprate: 30.0
o2sat: 100.0
sbp: 74.0
dbp: 43.0
level of pain: 0
level of acuity: 1.0 | ___ man with COPD, orthostatic hypotension, and recent
admission for sepsis likely from osteomyelitis (vs HCAP), who
was referred to the ED on ___ for removal of his PICC line and
found to be hypotensive with AMS likely due to hypovolemia.
Blood pressure improved following fluid administration. Patient
not able to tolerate PICC (pulled out twice), so he was
transition to oral Linezolid for osteomyelitis of R foot.
Patient was transitioned to hospice given patient's age, altered
mental status, impaired functional status and R foot
osteomyelitis without definitive treatment. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Augmentin / Nsaids / Tramadol / Niacin
Attending: ___.
Chief Complaint:
L Shoulder Pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with history of coronary artery disease presents to the
emergency room with progressive L shoulder pain after recent ICU
stay at ___ for pancreatitis and alcohol withdrawal.
The patient initially presented to ___ on ___ with progressive
abdominal pain. He states that he was previously sober for over
___ years, however, due to the abrupt discontinuation of his
outpatient benzodiazepines, he started drinking again. He was
admitted to the ICU with acute respiratory failure and
aspiration and klebsiella PNA. He required intubation and was
treated with ceftriaxone. This hospitalization was complicated
further by delirium and alcohol withdrawal.
Towards the end of the hospitalization, the patient started to
note the progressive onset of acute on chronic left shoulder
pain. he had undergone L shoulder arthroplasty in ___ and has
had shoulder pain since. The patient states that the pain was
exacerbated by lying in bed while he was critically ill. He has
no radiation of the pain and does not note any dyspnea,
palpitations or chest pain. He has no fevers/chill, no
nausea/vomiting or diarrhea.
In the ED initial vitals were:
T 98.6 HR 99 BP 119/81 R 18 Spo2 100% RA
EKG:
Sinus Rhythm Rate 77. Sub mm STE II without reciprocal changes.
J point elevation V2-V3.
Labs/studies notable for:
139|98|6
---------<109
4.0|28|0.9
Ca: 8.8 Mg: 2.0 P: 3.1
ALT: 12 AP: 72 Tbili: <0.2 Alb: 3.0
AST: 17 Lip: 45
Trop-T: 0.47
Lactate:1.5
9.3
8.0>----<550
29.5
___: 13.3 PTT: 29.1 INR: 1.2
Imaging:
___ Imaging GLENO-HUMERAL SHOULDER
IMPRESSION:
Status post left total shoulder arthroplasty without hardware
complications or alignment change. No acute fracture or
dislocation.
___ Imaging CHEST (PA & LAT)
IMPRESSION:
Right lower lobe opacification concerning for pneumonia, with
small right pleural effusion.
Patient was given:
___ 13:29 PO Acetaminophen
___ 13:30 PO Aspirin 324 mg
___ 14:12 IV Heparin 4000 UNIT
___ 14:12 IV Morphine Sulfate 2 mg
On the floor he endorses the history above
REVIEW OF SYSTEMS:
Per HPI
Past Medical History:
hypertension, anxiety.
Past surgical history includes tonsillectomy, appendectomy, and
a
Bankart repair, left shoulder in ___.
Social History:
___
Family History:
bone cancer, diabetes, and
heart disease.
Physical Exam:
ADMISSION PHYSICAL EXAM
GEN: NAD
HEENT: Clear OP
___: RRR no MRG
RESP: No increased WOB, no wheezing, rhonchi or crackles
ABD: NTND No HSM
EXT: Warm, pitting edema to knee
NEURO: No tremor
PSYCH: Odd affect, tangential speech
DISCHARGE PHYSICAL EXAM
VS: T: 98.7 PO BP: 138/90 R Sitting HR: 90 RR: 17 O2 sat: 93% O2
delivery: Ra
GEN: NAD, well-appearing
HEENT: Clear OP, neck supple
___: RRR no MRG
RESP: No increased WOB, no wheezing, rhonchi or crackles
ABD: NTND No HSM
EXT: Warm, pitting edema to knee
NEURO: No tremor, ROM at left shoulder decreased, however distal
strength intact
PSYCH: Odd affect, tangential speech
Pertinent Results:
ADMISSION LABS
==============
___ 12:28PM ___ PTT-29.1 ___
___ 12:28PM NEUTS-55.3 ___ MONOS-9.0 EOS-2.8
BASOS-1.0 IM ___ AbsNeut-4.41 AbsLymp-2.47 AbsMono-0.72
AbsEos-0.22 AbsBaso-0.08
___ 12:28PM WBC-8.0 RBC-2.94* HGB-9.3* HCT-29.5* MCV-100*
MCH-31.6 MCHC-31.5* RDW-14.5 RDWSD-52.5*
___ 12:28PM ALBUMIN-3.0* CALCIUM-8.8 PHOSPHATE-3.1
MAGNESIUM-2.0
___ 12:28PM CK-MB-2
___ 12:28PM cTropnT-0.47*
___ 12:28PM LIPASE-45
___ 12:28PM ALT(SGPT)-12 AST(SGOT)-17 ALK PHOS-72 TOT
BILI-<0.2
___ 12:28PM GLUCOSE-109* UREA N-6 CREAT-0.9 SODIUM-139
POTASSIUM-4.0 CHLORIDE-98 TOTAL CO2-28 ANION GAP-13
___ 02:14PM LACTATE-1.5
___ 09:50PM CK-MB-2 cTropnT-0.49*
___ 09:50PM CK(CPK)-27*
DISCHARGE LABS
==============
___ 03:55PM BLOOD WBC-7.2 RBC-3.16* Hgb-10.0* Hct-31.8*
MCV-101* MCH-31.6 MCHC-31.4* RDW-14.6 RDWSD-54.8* Plt ___
___ 06:00AM BLOOD Glucose-97 UreaN-6 Creat-1.0 Na-141 K-3.8
Cl-101 HCO3-29 AnGap-11
___ 06:00AM BLOOD ALT-9 AST-13 CK(CPK)-25* AlkPhos-59
TotBili-<0.2
___ 06:00AM BLOOD CK-MB-2 cTropnT-0.42*
___ 06:00AM BLOOD Calcium-8.5 Phos-3.3 Mg-2.0
REPORTS
=======
___ STRESS
EKG: SINUS, Q-WAVES V1-V3
HEART RATE: 73BLOOD PRESSURE: 144/80
PROTOCOL /
STAGETIMESPEEDELEVATIONWATTSHEARTBLOODRPP
(MIN)(MPH)(%) RATEPRESSURE
___ MG/5 ML ___
TOTAL EXERCISE TIME: 0.33% MAX HRT RATE ACHIEVED: 60
ST DEPRESSION:NONE
INTERPRETATION: ___ yo man with HL and HTN, prior ETT-ECHO in
___
reporting evidence of prior MI, however no ischemia was referred
to
evaluate his chronic left-shoulder discomfort in the setting of
elevated troponin. The patient was administered 0.4 mg
Regadenoson IV bolus over 20 seconds. Prior to the infusion the
patient reported the chronic left-shoulder discomfort; ___.
This discomfort did not change in intensity during the
procedure. No other chest, back or neck discomforts were
reported during the procedure. No significant ST segment changes
were noted during the procedure. The rhythm was sinus with rare
isolated VPBs. Resting systolic hypertension with an appropriate
hemodynamic response to the Regadenoson infusion. Post-infusion,
60 mg IV caffeine was administered.
IMPRESSION: Non-anginal type symptoms with no ischemic ST
segment
changes. Nuclear report sent separately.
___ CARDIAC PERFUSION PHARM
IMPRESSION:
1. Moderate to severe reversible perfusion defects involving the
anterior septal wall and apex, associated with decreased wall
motion.
2. Enlarged left ventricular cavity size with EDV of 155 mL
(normal < 110 mL).
___ L GLENO-HUMERAL SHOULDER/CLAVICLE
Status post left total shoulder arthroplasty without hardware
complications or alignment change. No acute fracture or
dislocation.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lidocaine 5% Patch 1 PTCH TD QAM
2. Metoprolol Succinate XL 50 mg PO DAILY
3. Nicotine Patch 21 mg TD DAILY
4. Omeprazole 40 mg PO DAILY
5. Fluticasone Propionate NASAL 2 SPRY NU DAILY
6. Creon 12 Dose is Unknown PO TID W/MEALS
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 a day Disp #*30
Tablet Refills:*0
3. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
4. Multivitamins 1 TAB PO DAILY
RX *multivitamin 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
5. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth once a
day Disp #*30 Tablet Refills:*0
6. Creon 12 2 CAP PO TID W/MEALS
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. Lidocaine 5% Patch 1 PTCH TD QAM
9. Metoprolol Succinate XL 50 mg PO DAILY
10. Nicotine Patch 21 mg TD DAILY
11. Omeprazole 40 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY
Non-ST Elevated MI
L shoulder pain
Coronary Artery Disease
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with left shoulder pain// assess for fracture
TECHNIQUE: Chest PA and lateral
COMPARISON: None.
FINDINGS:
Heart size is mildly enlarged. The aorta is unfolded. The mediastinal and
hilar contours are unremarkable. The pulmonary vasculature is not engorged.
Focal opacity in the right lower lobe is concerning for pneumonia, with a
trace right pleural effusion. Left lung is clear. No pneumothorax is
identified. No acute osseous abnormalities detected. Patient is status post
left shoulder arthroplasty.
IMPRESSION:
Right lower lobe opacification concerning for pneumonia, with small right
pleural effusion.
Radiology Report
INDICATION: History: ___ with left shoulder pain// assess for fracture
TECHNIQUE: Left clavicle, two views and left shoulder, three views
COMPARISON: Left shoulder radiographs ___
FINDINGS:
Patient is status post left shoulder arthroplasty without hardware
complications or change in alignment. No acute fracture or dislocation is
evident. Degenerative spurring of the left acromioclavicular joint is
re-demonstrated. No concerning lytic or sclerotic osseous abnormalities are
seen. There are no periarticular soft tissue calcifications. The imaged left
shoulder is clear.
IMPRESSION:
Status post left total shoulder arthroplasty without hardware complications or
alignment change. No acute fracture or dislocation.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain, L Shoulder pain
Diagnosed with Unspecified abdominal pain
temperature: 98.6
heartrate: 99.0
resprate: 18.0
o2sat: 100.0
sbp: 119.0
dbp: 81.0
level of pain: 9
level of acuity: 2.0 | ___ with CAD and recent admission at ___ for alcoholic
pancreatitis presents with progressive L shoulder pain and found
to have an elevated troponin concerning for an NSTEMI.
#L Shoulder Pain
#Elevated troponin:
Patient present with acute on chronic L shoulder pain after
recent ICU hospitalization requiring intubation for pancreatitis
and pneumonia. The shoulder pain is likely MSK in etiology as he
said it is an exacerbation of his pre-existing pain. He states
that the pain started to get worse towards the end of his recent
hospitalization due to lying in bed while intubated. He had no
ECG changes though his troponin was noted to be elevated to
0.47. His CK-MB was flat, therefore this likely represents a
resolving Type II NSTEMI from his recent critical illness rather
than a true NSTEMI. He was started on a heparin gtt which was
quickly discontinued and he was begun on aspirin and
atorvastatin. Interestingly, the patient has had a stress test
from ___ which demonstrated an area consistent with a prior MI
without an area of inducible ischemia. This therefore suggests
pre-existing CAD. Reassuringly, a recent TTE performed during
his last hospitalization showed no WMA. Although due to
non-compliance with prior medications, the patient would not be
a good stent candidate so angiography was differed. He underwent
a PMIBI to assess if he had CAD to require ongoing medical
optimization. PMIBI showed Reversible perfusion defects
involving anterior septal wall apical area with associated wall
motion defect He was continued on his home metoprolol and was
initiated on aspirin and atorvastatin. The Cardiovascular
institute was contacted to arrange a follow up appointment with
the patient within the next month.
#History of Pancreatitis: Patient presented to ___ with
alcoholic
pancreatitis after binging on alcohol after his benzos were
d/c'd
by his outside provider. Currently without abdominal pain.
Lipase
wnl.
#History of EtOH Abuse: Prior history of heavy use, quit ___
years
ago, then restarted as above. Last drink was prior to recent CHA
admission. Out of the window for withdrawal.
-started on folate, thiamine, MVI
#Anxiety: Patient appears anxious on exam with tangential
thought
process. Was previously on multiple medications including
buspirone, gabapentin and trazadone, but these were discontinued
during his last hospitalization. Patient was not started on any
new psychiatric medications. Will defer initiation of
anxiolytics/antidepressants to PCP.
#Anemia:
#History of Polycythemia ___:
Prior history of PV thought to be from cigarette smoking due to
negative mutation testing. Previously treated with phlebotomy.
Currently anemia is below baseline, but is stable from recent
hospitalization without evidence of bleeding. No abdominal pain
to suggest hemorrhagic pancreatitis.
#Thrombocytosis: Newly elevated from prior ___ labs in ___.
Was elevated to 400s at CHA, currently 550. Likely reactive due
to stress of recent critical illness. However, given h/o PV, may
suggest underlying marrow disease.
#Exposure to TB: Patient's PCP notified us that he was notified
that the patient was exposed to TB during a recent
hospitalization at ___. We became aware of this
information as the patient was being prepared for discharge. He
was having no symptoms of active TB. Therefore, we will defer TB
testing to his PCP follow up appointment. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
___: Technically successful ultrasound-guided drainage of
right upper quadrant subcapsular hepatic collection with 2.1
liters of cloudy yellow-green fluid withdrawn. A small sample
was sent for analysis. No immediate post-procedural
complications.
.
___: Successeful placement of a 10 ___ external biliary
drainage catheter on the left. Successful exchange of a right
biloma drain with a new 10 ___ drainage catheter.
History of Present Illness:
___ was recently discharged to rehab following admission
(___) for a bile duct transection sustained during
laparoscopic cholecystectomy at an OSH. On ___, she underwent R
PTC placement. Post-procedure, she developed a hemodynamically
significant bleed that required exploratory laparotomy & washout
on ___. She was discharged with the PTC/biliary drain and 2
PTCs.
She returns to ED w/ band-like central abd pain since yesterday
afternoon. She reports it worsened last night. She is unable
to
say whether it is better/worse/the same right now. She denies
fevers, chills, and nausea; however, she reports night sweats
overnight. She vomited (undigested food, no blood, no bile) 4
days ago and reports she has not eaten anything since then
because she doesn't like the food at rehab. She says she drinks
water, but is unable to quantify the amount. No diarrhea; she
had 2 normal BMs yesterday.
She initially was brought to ___, where her
systolic BP was ___ the ___, HRs 110-120, WBC 26.2, and lactate
5.0. A R femoral CVL was placed. She was given vanc/Zosyn and
7L of NS and started on Levophed. CT scan reportedly showed a
fluid collection around the liver that was felt to be c/w
subacute hematoma.
Past Medical History:
PAST MEDICAL HISTORY:
Biliary colic/cholecystitis
Osteoarthritis
Hypertension
Type II diabetes
Obstructive sleep apnea
Severe panic disorder
Bilateral carpel tunnel syndrome
Fibromyalgia
GERD
Seasonal allergies
PAST SURGICAL HISTORY
Laparoscopic cholecystectomy
Right knee arthroplasty
Left hand sesamoid bone removal
Left shoulder surgery
Right hand cyst removal
Tonsillectomy
Adenoidectomy
Social History:
___
Family History:
Father: CAD, gallbladder disease
Mother: ___ disease
Physical Exam:
On Admission:
PE: Levo 0.25 91 111/54 25 97%RA
Gen: NAD, nondiaphoretic, mental status at baseline
___: RRR
Pulm: CTA b/l
Abd: soft, obese, NT, ND, +BS, subcostal incision healing well
without erythema or drainage, 2 JPs with minimal serous fluid (1
is faintly bile-tinged), PTC w/ free flowing bile
Ext: +edema b/l ___
Prior Discharge:
VS: 97.6, 83, 127/68, 18, 98% RA
GEN: NAD, menatl status at baseline
CV: RRR, no m/r/g
PULM: CTAB
ABD: Obese, right and left biliary drains to gravity drainage,
sites with dry dressing and c/d/i. Minimal tenderness around
drain site. Old incision healed well, ols JP sites with dry
gauze dressing and c/d/i.
EXTR: 2+ bilateral pitting edema
Pertinent Results:
___ 03:52AM BLOOD WBC-14.7* RBC-3.29* Hgb-9.2* Hct-29.7*
MCV-90 MCH-28.0 MCHC-31.0 RDW-15.0 Plt ___
___ 05:41AM BLOOD Glucose-119* UreaN-8 Creat-0.7 Na-132*
K-8.6* Cl-99 HCO3-29 AnGap-13
___ 05:41AM BLOOD ALT-40 AST-82* AlkPhos-207* TotBili-0.4
___ 05:41AM BLOOD Calcium-8.5 Phos-3.8# Mg-1.9
___ 7:21 am BILE
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
1+ (<1 per 1000X FIELD): GRAM POSITIVE COCCI.
___ PAIRS AND CLUSTERS.
FLUID CULTURE (Final ___:
STAPH AUREUS COAG +. MODERATE GROWTH.
Staphylococcus species may develop resistance during
prolonged
therapy with quinolones. Therefore, isolates that are
initially
susceptible may become resistant within three to four
days after
initiation of therapy. Testing of repeat isolates may
be
warranted.
ENTEROCOCCUS SP.. MODERATE GROWTH.
SENSITIVITIES: MIC expressed ___
MCG/ML
_________________________________________________________
STAPH AUREUS COAG +
| ENTEROCOCCUS SP.
| |
AMPICILLIN------------ <=2 S
CLINDAMYCIN-----------<=0.25 S
ERYTHROMYCIN----------<=0.25 S
GENTAMICIN------------ <=0.5 S
LEVOFLOXACIN---------- 0.25 S
OXACILLIN------------- 0.5 S
PENICILLIN G---------- 2 S
TETRACYCLINE---------- <=1 S
TRIMETHOPRIM/SULFA---- <=0.5 S
VANCOMYCIN------------ 1 S
ANAEROBIC CULTURE (Final ___: NO ANAEROBES ISOLATED.
___: CT ABD
CT abd/pelvis (OSH, reviewed w/ radiology fellow): extensive
subcapsular fluid collection along lateral & superior aspect of
the liver, ?biloma v. resolving hematoma (compared to ___ MRCP
w/ small subcapsular fluid collection, MR characteristics more
c/w bile)
___ ABD CT:
IMPRESSION:
Significant interval decrease ___ size of the subcapsular biloma
status post percutaneous drainage catheter placement. There
does remain a persistent collection though, which would benefit
from continued percutaneous drainage.
Stable organizing hematoma around multiple proximal loops of
jejunum.
Worsening right-sided pleural effusion and right lower lobe
atelectasis.
Medications on Admission:
Dulcolax prn, Klonopin 0.5 qAM/1 qHS, lisinopril 40',
metformin 500", omeprazole 20', Fleets prn, MVI', Tylenol prn,
Maalox prn, milk of magnesia prn, oxycodone prn, simethicone prn
Discharge Medications:
1. Amoxicillin-Clavulanic Acid ___ mg PO Q12H
last dose on ___. ClonazePAM 0.5 mg PO QAM
3. ClonazePAM 0.5 mg PO QPM
4. Heparin 5000 UNIT SC TID
5. Miconazole Powder 2% 1 Appl TP TID:PRN rash
6. Omeprazole 20 mg PO DAILY
7. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg ___ tablet(s) by mouth every six (6) hours
Disp #*20 Tablet Refills:*0
8. Citalopram 10 mg PO DAILY
9. MetFORMIN (Glucophage) 500 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Hepatic subcapsular biloma
2. Biliary sepsis
3. Failure to thrive
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
HISTORY: Leukocytosis and new oxygen requirement.
TECHNIQUE: Portable upright AP view of the chest.
COMPARISON: CT abdomen pelvis ___ and chest radiograph ___.
FINDINGS:
Elevation of the right hemidiaphragm is due to the presence of a right
subcapsular complex hepatic fluid collection as seen on the CT. Small right
pleural effusion is also demonstrated with associated mild right basilar
atelectasis. Minimal left basilar atelectasis is also present. The cardiac,
mediastinal and hilar contours are unremarkable. There is no pulmonary
vascular engorgement. There are multilevel degenerative changes in the
thoracic spine.
IMPRESSION:
Small right pleural effusion with bibasilar atelectasis. Elevation of the
right hemidiaphragm is due to the presence of a right subcapsular complex
hepatic fluid collection as seen on CT.
Radiology Report
HISTORY: ___ woman status post laparoscopic cholecystectomy comes
back with CBD transection, status post right PTC comes back with bleed, status
post ex lap/washout, now with WBC 16, subcapsular fluid collection. Please
drain. ?biloma.
PHYSICIANS: Dr. ___, abdominal radiology attending, and Dr.
___, abdominal radiology fellow.
PROCEDURE:
The procedure including risks, benefits and alternatives were explained to the
patient and after a detailed discussion, informed written consent was obtained
from the patient. A preprocedure timeout was performed using three patient
identifiers as per ___ protocol.
The patient was prepped and draped in the usual sterile fashion. 3 cc of 1%
lidocaine were used for local anesthesia in the subcutaneous tissues. An
additional 5 cc of 1% lidocaine were administered under ultrasound guidance in
the region of the peritoneum for local anesthetic effect.
Under ultrasound guidance, an 8 ___ ___ pigtail catheter was inserted
into the large right upper quadrant subcapsular hepatic collection and a total
of 2.1 liters of cloudy yellow-green fluid were withdrawn, a small sample of
which was sent for culture, cell count and chemistries. The pigtail was
formed, fixed in place with a Statlock and attached to a drainage bag. There
were no immediate post-procedural complications and the patient tolerated the
procedure well. Post-procedure orders were entered into the ___ medical
record.
Moderate sedation was provided by administering fentanyl throughout the total
intraservice time of 45 minutes, during which the patient's hemodynamic
parameters were continuously monitored. A total of 25 mcg of fentanyl were
administered to the patient.
The attending radiologist, Dr. ___, was present throughout the
entire duration of the procedure.
IMPRESSION:
Technically successful ultrasound-guided drainage of right upper quadrant
subcapsular hepatic collection with 2.1 liters of cloudy yellow-green fluid
withdrawn. A small sample was sent for analysis. No immediate post-procedural
complications.
Radiology Report
HISTORY: New right PICC.
COMPARISON: ___.
FINDINGS: Single frontal radiograph of the chest demonstrates interval
placement of a right PICC with the tip terminating in the right atrium. To be
positioned at the approximate cavoatrial junction, this should be pulled back
by approximately 3 cm.
When compared to the prior radiograph, there has been interval layering of the
right pleural effusion, likely due to patient positioning. The heart,
mediastinal, and hilar contours are unchanged.
IMPRESSION: Placement of right PICC line with the tip projecting into the
right atrium. For approximate placement at the cavoatrial junction, this
should be pulled back by no less than 3 cm.
These findings were relayed to the venous access team, at 9:48 a.m. on the day
of the examination.
Radiology Report
PORTABLE AP CHEST FILM ___ AT 1643
CLINICAL INDICATION: ___ with bile duct transection status post NG
tube placement, check position.
Comparison is made to the patient's prior study of ___.
Portable AP upright chest film ___ at 1643 is submitted.
IMPRESSION:
1. Interval placement of a nasogastric tube with its tip projecting over the
expected location of the stomach. The right subclavian PICC line is unchanged
in position with its tip in the mid SVC. Lung volumes are lower and there is
a moderate-sized right pleural effusion which may have somewhat increased in
size since ___. Left lung grossly clear given interval reduction in
lung volumes. Overall, cardiac and mediastinal contours are likely stable.
No pneumothorax.
Radiology Report
HISTORY: Biloma status post percutaneous drainage catheter placement,
evaluate for interval change.
TECHNIQUE: Volumetric CT imaging was performed through the abdomen after the
administration of 130 mL Omnipaque nonionic intravenous contrast. Post
processing performed in the coronal and sagittal planes.
COMPARISON: CT from ___.
FINDINGS:
There is interval increase in size of the right-sided pleural effusion with
worsening atelectasis of the right lower lobe. There is scarring at the left
base. The liver is again noted to be markedly, diffusely hypodense. No focal
liver lesions are identified. A percutaneous drainage catheter is noted in
the right upper quadrant within the subcapsular biloma which is significantly
decreased in size compared to the previous exam now measuring up to 2.7 cm in
greatest thickness, previously measuring approximately 6.7 cm. Two other
right upper quadrant drains are also noted. The percutaneous biliary drain
has been removed. The gallbladder is surgically absent. Multiple clips are
noted in the hepatic hilum. There is a left adrenal myelolipoma. The right
adrenal gland is normal. The pancreas and both kidneys are normal in
appearance. An NG tube is in the stomach. An organized hematoma adjacent to
multiple proximal jejunal loops in the left upper quadrant appears unchanged.
The visualized bowel loops and mesentery are otherwise normal. There is no
significant mesenteric or retroperitoneal lymphadenopathy. The abdominal
vasculature appears widely patent. The osseous structures are unremarkable.
IMPRESSION:
Significant interval decrease in size of the subcapsular biloma status post
percutaneous drainage catheter placement. There does remain a persistent
collection though, which would benefit from continued percutaneous drainage.
Stable organizing hematoma around multiple proximal loops of jejunum.
Worsening right-sided pleural effusion and right lower lobe atelectasis.
Radiology Report
HISTORY: CBD transection with a new biloma.
COMPARISON: CT of the abdomen from ___.
TECHNIQUE: OPERATORS: Dr. ___ radiology fellow) and Dr.
___ radiology attending) performed the procedure. The
attending was present and supervising throughout the procedure.
ANESTHESIA: General anesthesia was administered by the anesthesiology
department.
MEDICATIONS: The patient received pre-procedure antibiiotics.
CONTRAST: 35 ml of Optiray contrast.
FLOURORSCOPY TIME AND DOSE: 32 min, 959 mGy
PROCEDURE:
1. Flouroscopic guided left percutaneous transhepatic bile duct access.
2. Left over-the-wire cholangiogram
3. Attempt to cross the CBD.
4. 10 ___ left external biliary drain placement.
5. 10 ___ right biloma drain exchange.
PROCEDURE DETAILS: Following explanation of the risks, benefits and
alternatives to the procedure, written informed consent was obtained. The
patient was then brought to the angiographic suite and placed supine on the
imaging table. The mid upper abdomen was prepped and draped in the usual
sterile fashion. A pre-procedural time out was performed according to
departmental protocol.
Under flouroscopic guidance, a 21 gauge Cook needle was advanced into left
biliary system and contrast was injected until the biliary tree was
identified. A Headliner wire was advanced under fluoroscopic guidance into
the common bile duct. A skin ___ was made over the needle and the needle was
removed over the wire. An Accustick set was advanced over the wire and the
inner stiffener was withdrawn. A contrast injection was performed to confirm
biliary anatomy. The Headliner wire was exchanged for ___ wire which
was placed into the common hepatic duct. The Accustick set was exchanged for
a 6 ___ sheath. An over the wire cholangiogram was performed.
The ___ wire was exchanged for a Roadrunner wire. Attempts to cross the
CBD using the angle Glide catheter, a RDC guiding catheter and the sheath were
unsuccessful.
The catheters and sheath were removed. A 10 ___ Urasil biliary catheter
was advanced and the pig-tail formed. Contrast injection confirmed good
position. The catheter was flushed with saline, secured with stay sutures and
a statlock device to the skin and sterile dressings were applied. The
catheter was cattached to a bag.
Next attention was turned to the existing biloma drain. A contrast injection
showed appropriate position. The ___ wire was advanced through the
catheter and looped around the liver. The existing catheter was removed and
exchanged for a 10 ___ biliary drainage catheter. The loop was formed.
Contrast injection confirmed good position. The catheter was flushed with
saline, secured with stay sutures and a statlock device to the skin and
sterile dressings were applied. The catheter was cattached to a bag. The
patient tolerated the procedure well.
FINDINGS:
1. Non dilated biliary system with non-opacification of the distal common
bile duct and contrast leak from the right biliary tree (likely at the site of
the prior tube entry into the liver).
2. Successful placement of a 10 ___ left PTBD catheter in the common
hepatic duct.
3. Successful exchange of a right biloma drain for a 10 ___ biliary
drainage catheter.
IMPRESSION: Successeful placement of a 10 ___ external biliary drainage
catheter on the left. Successful exchange of a right biloma drain with a new
10 ___ drainage catheter.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Dobbhoff placement.
COMPARISON: Chest radiograph from ___.
FINDINGS: As compared to the previous radiograph, the patient has received a
right upper abdominal pigtail catheter. The Dobbhoff catheter shows normal
course, the tip projects over the middle parts of the stomach. The right PICC
line is in unchanged position.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Hypotension
Diagnosed with SEPTICEMIA NOS, SEVERE SEPSIS , SEPTIC SHOCK, ACCIDENT NOS
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: 4
level of acuity: 1.0 | The patient well know for Dr. ___ was admitted to the
___ Surgical Service for evaluation and treatment of new
subcapsular fluid collection. Patient was admitted ___ the ICU
secondary for hypotension requiring pressors support and sepsis.
She was started on IV Vancomycin and Zosyn empirically.
Patient's INR was 2.3 on admission and she received 3 units of
FFP on HD # 1. She underwent ultrasound-guided drainage of
right upper quadrant subcapsular hepatic collection and fluid
was sent for cultures. On HD 3, patient's Levophed was weaned
off. On HD # 4, patient was transferred on the floor on regular
diet, on IV fluid and antibiotics, with Foley, biliary drain and
2 old JP drains. The patient was hemodynamically stable.
Neuro: The patient received PO Oxycodone with good effect and
adequate pain control.
CV: The patient remained stable from a cardiovascular
standpoint; vital signs were routinely monitored.
Pulmonary: The patient remained stable from a pulmonary
standpoint; vital signs were routinely monitored. Good pulmonary
toilet, early ambulation and incentive spirrometry were
encouraged throughout hospitalization.
GI: The patient was advanced to regular diet, her albumin was
2.0 and NJ tube was placed on HD # 5. Nutrition was called for
consult and tubefeed was started. Calorie count demonstrated
poor oral intake and tubefeed will be continued post discharge.
Patient's bile was refeeded back to the patient via NJ tube from
left sided drain catheter. On HD # 6 patient lost her biliary
drain and ___ was called to replace the drain. ___ requested new
CT and abdominal CT was obtained on HD 7. CT demonstrated
significant interval decrease ___ size of the subcapsular biloma,
with still large residual collection. On HD 8, patient underwent
placement of right and left hepatic drains. Old JPs were removed
on HD 9 as output was low.
ID: The patient's white blood count and fever curves were
closely watched for signs of infection. Patient was started on
IV Zosyn/Vanc on admission. Her bile cultures grew Staph aureus
coag positive and Enterococcus. She underwent treatment with IV
Zosyn/Vancomycin for 8 days. Prior discharge patient's
antibiotics were changed to PO Augmentin. She still to have
mildly elevated prior discharge.
Endocrine: The patient's blood sugar was monitored throughout
his stay; insulin dosing was adjusted accordingly.
Hematology: The patient's complete blood count was examined
routinely; no transfusions were required.
Prophylaxis: The patient received subcutaneous heparin and
venodyne boots were used during this stay; was encouraged to get
up and ambulate as early as possible.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a tubefeed
at goal, ambulating, voiding without assistance, and pain was
well controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Optiray 350 / Gadolinium-Containing Agents /
Keflex / CT CONTRAST / Cipro / Miralax / Sorbitol / Ultram /
mirtazapine
Attending: ___.
Chief Complaint:
Hip Fracture
Major Surgical or Invasive Procedure:
___ - Intrameduallary nail placement (short trochanteric
fixation nail), right hip
History of Present Illness:
___ with hx of HTN, DM, HLD, dCHF, Afib not on warfarin,
Dementia who presents from her nursing home s/p fall found to
have R hip fracture. Per nursing home reports, patient fell ~1
week ago and xray was equivocal for fracture. She was then
monitored for a week but fell again on day of admission and had
signficiant R hip pain on external rotation per report therefore
she was transferred to ___ for further eval.
On arrival to the ED, vitals afebrile, HR 79, BP 121/51, RR 18,
94%RA. Exam in ED with reported tenderness with hip flexion and
palpation of anterior hip but patient with fullr ROM and able to
ambulate with limp. Labs notable for elevated BUN to 36 with
otherwise unremarkable Chem 7, mild leukocytosis to 11.1, Hgb
8.5, INR 1. UA with >180 WBCs with no epis. CT head without
acute intracranial process, CT C-Spine with no acute fractures
but evidence of volume overload. CT of R lower extremity with
minimally displaced comminuted fracture involving the right
greater trochanter. EKG NSR. Ortho and trauma surgery consulted
in the ED and recommended admission to medicine with ortho
following.
Upon arrival to the floor, patient resting comfortably in bed
and denies any acute complaints.
REVIEW OF SYSTEMS: Per HPI. Limited history due to mental
status/dementia
Past Medical History:
(per OMR)
1. CARDIAC RISK FACTORS:
+hypertension
-dyslipidemia
-diabetes
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: None
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- ___
- Atrial fibrillation, on Warfarin
- MVR St Judes ___ with tricupsid valve repair
- CKD
- dementia
- s/p Left CEA
- h/o AAA
- pulmonary HTN
- B12 deficiency
- GERD
- Fibromylagia
- Hearing loss
- osteopenia
- Sciatica
- s/p APPY
- b/l cataracts
- varicose vein stripping ___
- s/p hysterectomy, has ovaries
Social History:
___
Family History:
- history of breast cancer and ovarian cancer (per OMR)
Physical Exam:
===========================
PHYSICAL EXAM ON ADMISSION
===========================
VITALS: 98.6; 161/71; 98; 20; 95
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PER, EOMI, OP clear.
NECK: Supple, no LAD, no thyromegaly, JVP flat.
CARDIAC: irregularly irregular, ___ SEM
PULMONARY: bibasilar faint crackles
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema. No external rotation of RLE. No pain with palpation of R
hip.
SKIN: Without rash.
NEUROLOGIC: Pleasant, not answering questions appropriately. A&O
to name only. Moving all extremities purposefully
===========================
PHYSICAL EXAM ON DISCHARGE
===========================
VITALS: 97.2 HR ___ BP 150/60 (108-150/50-60) 97 RA
24H I/O: 840/900+
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus.
CARDIAC: irregularly irregular, ___ SEM
PULMONARY: bibasilar crackles
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema. R hip bandage c/d/I, mild tenderness to palpation
SKIN: Without rash. Scattered hyperkeratotic papules over torso.
NEUROLOGIC: Pleasant, not answering questions appropriately. A&O
to name only. Moving all extremities purposefully
Pertinent Results:
=====================
LABS ON ADMISSION
=====================
___ 04:03PM BLOOD WBC-11.1*# RBC-3.44* Hgb-8.5* Hct-29.2*
MCV-85 MCH-24.7* MCHC-29.1* RDW-15.5 RDWSD-47.7* Plt ___
___ 04:03PM BLOOD Neuts-78.2* Lymphs-10.2* Monos-7.8
Eos-2.5 Baso-0.3 Im ___ AbsNeut-8.68* AbsLymp-1.13*
AbsMono-0.86* AbsEos-0.28 AbsBaso-0.03
___ 04:03PM BLOOD ___ PTT-26.9 ___
___ 04:03PM BLOOD Glucose-102* UreaN-36* Creat-1.1 Na-141
K-4.0 Cl-105 HCO3-26 AnGap-14
___ 05:05AM BLOOD Calcium-8.9 Phos-3.4 Mg-2.2
___ 11:30PM URINE Color-Yellow Appear-Cloudy Sp ___
___ 11:30PM URINE Blood-SM Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.5 Leuks-LG
___ 11:30PM URINE RBC-1 WBC->182* Bacteri-FEW Yeast-NONE
Epi-0
=====================
PERTINENT INTERVAL LABS
=====================
___ 05:35AM BLOOD CK-MB-5 cTropnT-<0.01
=====================
LABS ON DISCHARGE
=====================
___ 07:00AM BLOOD WBC-6.8 RBC-3.53* Hgb-8.7* Hct-30.1*
MCV-85 MCH-24.6* MCHC-28.9* RDW-15.7* RDWSD-48.6* Plt ___
___ 07:00AM BLOOD Glucose-94 UreaN-23* Creat-0.9 Na-142
K-3.9 Cl-106 HCO3-24 AnGap-16
___ 07:00AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.1
=====================
MICROBIOLOGY
=====================
___ 11:30 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.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
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---- =>16 R
=====================
IMAGING/STUDIES
=====================
HIP (UNILAT 2 VIEW) W/PELVIS (1 VIEW) LEFT Study Date of
___
1. Oblique linear lucency involving the right greater trochanter
suspicious for a minimally distracted fracture. No dislocation.
Further assessment with CT is recommended.
2. Diffuse demineralization of the osseous structures.
CT HEAD ___ CONTRAST Study Date of ___
No acute intracranial process.
CT C-SPINE ___ CONTRAST Study Date of ___
1. No acute fracture or prevertebral soft tissue swelling.
2. Multilevel moderate to severe degenerative changes.
3. Minimal chronic anterolisthesis of C7 on T1.
4. Mild fluid overload.
CT LOW EXT ___ C RIGHT Study Date of ___
1. Minimally displaced comminuted fracture involving the right
greater
trochanter.
2. Infrarenal abdominal aortic aneurysm measuring up to 3.3 cm.
MR HIP ___ CONRAST RIGHT Study Date of ___
Comminuted avulsion fracture of the right greater trochanter
again seen, in keeping with findings on the ___ CT scan.
In addition, curvilinear marrow edema traversing the
intertrochanteric portion of the right femur suggests the
presence of an occult, more extensive intertrochanteric
fracture component than suggested on the recent CT scan.
Surrounding edema, fluid and hemorrhage noted.
No other fractures detected in the pelvic girdle.
15.6 mm rounded high T2 focus left pelvis raises the possibility
of a left
adnexal cystic structure in this patient status post prior
hysterectomy.
Clinical correlation and if indicated, followup assessment
assessment by
ultrasound in ___ months to assess for stability, could be
considered.
CHEST (PORTABLE AP) Study Date of ___
Mild interstitial pulmonary edema, improved from ___.
LOWER EXTREMITY FLUORO WITHOUT RADIOLOGIST IN O.R. Study Date of
___
Images from the operating suite show placement of a fixation
device about
previous fracture of the proximal femur. Further information
can be gathered from the operative report
HIP NAILING IN OR W/FILMS & FLUORO RIGHT IN O.R. Study Date of
___
Images from the operating suite show placement of a fixation
device about
previous fracture of the proximal femur. Further information
can be gathered from the operative report.
=====================
OPERATIVE REPORT
=====================
PREOPERATIVE DIAGNOSIS: Right intertrochanteric hip
fracture.
POSTOPERATIVE DIAGNOSIS: Right intertrochanteric hip
fracture.
PROCEDURE: Intramedullary nailing of right hip with Synthes
TFN System, 11 x ___ x ___ with 95 mm spiral blade.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amiodarone 200 mg PO DAILY
2. Artificial Tears ___ DROP BOTH EYES PRN Dry eyes
3. Cyanocobalamin 1000 mcg PO DAILY
4. Docusate Sodium 100 mg PO DAILY
5. Donepezil 5 mg PO Q24H
6. Fexofenadine 60 mg PO Q24H:PRN Allergies
7. Furosemide 40 mg PO DAILY
8. Memantine 10 mg PO BID
9. Metoprolol Tartrate 12.5 mg PO BID
10. Multivitamins 1 TAB PO DAILY
11. Pantoprazole 40 mg PO Q12H
12. Ranitidine 150 mg PO BID
13. Sertraline 100 mg PO QHS
14. Sucralfate 1 gm PO QID
15. Vitamin D 1000 UNIT PO DAILY
16. Ferrous Sulfate 325 mg PO DAILY
17. magnesium hydroxide 400 mg (170 mg) ORAL DAILY:PRN
constipation
18. Acetaminophen 650 mg PO Q4H:PRN fever
19. Aspirin 81 mg PO DAILY
20. QUEtiapine Fumarate 25 mg PO QHS
21. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Medications:
1. Acetaminophen 650 mg PO TID
2. Amiodarone 200 mg PO DAILY
3. Artificial Tears ___ DROP BOTH EYES PRN Dry eyes
4. Aspirin 81 mg PO DAILY
5. Cyanocobalamin 1000 mcg PO DAILY
6. Docusate Sodium 100 mg PO DAILY
7. Donepezil 5 mg PO Q24H
8. Ferrous Sulfate 325 mg PO DAILY
9. Furosemide 20 mg PO DAILY
10. Memantine 10 mg PO BID
11. Metoprolol Tartrate 12.5 mg PO BID
12. Multivitamins 1 TAB PO DAILY
13. Ranitidine 150 mg PO BID
14. Sertraline 100 mg PO QHS
15. Sucralfate 1 gm PO QID
16. Vitamin D 1000 UNIT PO DAILY
17. Enoxaparin Sodium 30 mg SC QHS
Start: Today - ___, First Dose: Next Routine Administration
Time
18. Fexofenadine 60 mg PO Q24H:PRN Allergies
19. magnesium hydroxide 400 mg (170 mg) ORAL DAILY:PRN
constipation
20. QUEtiapine Fumarate 12.5 mg PO QHS:PRN agitation
21. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnoses
==================
Right intertrochanteric hip fracture
Leukocytosis
Urinary Tract Infection
Hypoxia
Delirium
Acute Kidney Injury
Secondary Diagnoses
==================
Atrial fibrillation
Dementia
Congestive heart failure
Gastroesophageal reflux disease
Depression
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
INDICATION: ___ year old woman with R hip fracture // better characterize
fracture
TECHNIQUE: 1.5 Tesla. Body array coil. Routine routine unilateral right
hip protocol.
COMPARISON: CT scan dated ___.
FINDINGS:
As demonstrated on the previous CT, there is a comminuted slightly distracted
fracture of the greater tuberosity. In addition, there is marrow edema
extending across the intertrochanteric portion of the right proximal femur
(06:18 05:17). This suggests that there is an occult, more extensive
intertrochanteric component to the fracture, that is nondisplaced.
There is considerable fluid interposed between the right greater tuberosity
fragment and the main portion of the femur (06:19, at 09:24) and a prominent
amount of fluid/edema surrounding the fracture site and surrounding the
intertrochanteric portion of the femur (07:14). The gluteus medius and
minimus tendons remain intact, inserted, respectively, on the greater
tuberosity fragment and the intact posterior aspect of the greater trochanter.
(06:20, 06:19 6: 15). Marked atrophy of right and left gluteus minimus
muscles is noted (05:15).
The right femoroacetabular joint remains congruent, with relatively mild
changes of osteoarthritis and without a significant effusion.
Aside from mild degenerative changes, the left hip joint proximal an femur are
within normal limits.
Bones about the pelvic girdle are otherwise intact, without marrow edema to
suggest fracture.
Assessment of intrapelvic soft tissue structures is quite limited. Free
intrapelvic fluid is noted posteriorly. There are multiple diverticuli.
Apparent surgical absence of the uterus. A 15.6 mm high T2 focus in the left
pelvis (06:19) could represent a left adnexal cystic structure.
Limited assessment of the lower lumbar spine shows advanced degenerative
changes, not fully evaluated on this examination.
Chondrocalcinosis seen about the right hip and pubic symphysis on the recent
CT are not well appreciated radiographically. The abdominal aortic aneurysm
seen by CT is also not well visualized on this MRI due to a more limited
field-of-view.
IMPRESSION:
Comminuted avulsion fracture of the right greater trochanter again seen, in
keeping with findings on the ___ CT scan.
In addition, curvilinear marrow edema traversing the intertrochanteric portion
of the right femur suggests the presence of an occult, more extensive
intertrochanteric fracture component than suggested on the recent CT scan.
Surrounding edema, fluid and hemorrhage noted.
No other fractures detected in the pelvic girdle.
15.6 mm rounded high T2 focus left pelvis raises the possibility of a left
adnexal cystic structure in this patient status post prior hysterectomy.
Clinical correlation and if indicated, followup assessment assessment by
ultrasound in ___ months to assess for stability, could be considered.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old woman with HTN, DM, dCHF, Afib with chest pain and
shortness of breath with new O2 requirement // eval for edema, effusion,
infiltrate, acute process
TECHNIQUE: Portable chest radiograph
COMPARISON: Chest radiograph ___
FINDINGS:
There is mild interstitial pulmonary edema, which has slightly improved from ___. There is otherwise no focal consolidation. No pleural
effusion or pneumothorax. Stable cardiomegaly. Median sternotomy wires are
intact.
IMPRESSION:
Mild interstitial pulmonary edema, improved from ___.
Radiology Report
EXAMINATION: HIP NAILING IN OR W/FILMS AND FLUORO RIGHT IN O.R.
INDICATION: RT HIP FX.ORIF
IMPRESSION:
Images from the operating suite show placement of a fixation device about
previous fracture of the proximal femur. Further information can be gathered
from the operative report.
Gender: F
Race: WHITE - EASTERN EUROPEAN
Arrive by AMBULANCE
Chief complaint: s/p Fall, R Hip pain
Diagnosed with Disp fx of greater trochanter of right femur, init, Fall on same level, unspecified, initial encounter, Unspecified atrial fibrillation, Long term (current) use of anticoagulants, Unspecified dementia without behavioral disturbance
temperature: 98.4
heartrate: 79.0
resprate: 18.0
o2sat: 94.0
sbp: 121.0
dbp: 51.0
level of pain: unable
level of acuity: 2.0 | ___ with hx of HTN, DM, HLD, dCHF, Afib not on Warfarin,
Dementia who presents from her nursing home s/p fall found to
have R hip fracture.
#Mechanical fall complicated by comminuted avulsion fracture of
R greater trochanter: The patient presented from nursing
facility after two falls at her rehab facility. CT head negative
for acute intracranial process, CT C Spine negative for acute
fracture or pre-vertebral soft tissue swelling. Right hip XR and
subsequent CT of right lower extremity revealed minimally
displaced comminuted fracture of the right greater trochanter.
Trauma surgery evaluated the patient in the ED and no other
injuries were identified. Orthopedic surgery was consulted who
recommended MRI of the right hip or further evaluation of the
fracture. This revealed a comminuted avulsion fracture of the
right greater trochanter. The patient underwent uncomplicated
intramedullary nailing of the right hip with orthopedics on
___. Post operatively the patient was continued on daily SC
lovenox, and pain was well controlled with oral pain
medications. The patient was tolerating an oral diet well. The
patient as evaluated by ___ who recommended discharge to rehab.
# Leukocytosis:
The patient developed a mild leukocytosis on POD #1. that was
likely a stress reaction. The patient had been previously
treated with IV ceftriaxone for a susceptible E coli UTI. There
were no pulmonary symptoms or CXR evidence of pulmonary
infection. The leukocytosis resolved on POD #2.
#UTI:
Patient presented with + UA and UCx growing E coli, in the
setting of multiple recent falls and leukocytosis. Unclear if
symptomatic on exam though concerning for contribution to fall
and delirium as below. Patient received Ceftriaxone in ED
without reported issue, and daughter unaware of ___ allergy
reported. The patient was successfully treated with ceftriaxone
x 3 days for an uncomplicated UTI.
# Hypoxia:
The patient developed acute hypoxia on ___ with an SpO2 of 80%
of unclear etiology. EKG was non ischemic, and troponins were
negative. There was no evidence of significant volume overload
on exam or CXR. There was no tachycardia to sugest PE, and the
patient had been maintained on DVT prophylaxis. There was no
evidence of focal infiltrate on CXR. This was thought to have
been secondary to microaspiration. This resolved rapidly and did
not recur.
#Delirium:
The patient developed worsening delirium on HD #2 likely
secondary to infection, fracture, and hospital environment
overlying underlying dementia. There was concern that the micro
aspiration event as above may bave been the trigger given the
acute changes. The patient had no further episodes of acute
agitation.
# ___:
The patient developed ___ on HD#3 thought to be pre renal
secondary to her NPO status pre operatively and concuren
diuretic use for CHF. The ___ resolved with IV fluids and
holding home furosemide. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ ia ___ ___ woman with hypertension
as well as past history of H. pylori gastritis presenting with
abdominal pain.
Per review of OMR, patient with history of chronic GI
complaints; per ___ note, PCP ___ that Ms ___ had
been experiencing intermittent nausea, belching, bloating, and
occasional epigastric discomfort. At that time symptoms were
thought secondary to gastritis and GERD. Work-up in the past,
including an EGD in ___ showed evidence of gastritis and
H. pylori. She was placed on omeprazole with some improvement in
symptoms.
Patient was in OSH when developed right sided abdominal pain on
___. Pain, described as sharp, is poorly localized but most
severe in RUQ'epigastrium with occasional radiation to the back.
No clear trigger to pain onset. No correlation with eating,
urinating, defectating. Moving aggravates pain. Laying still
seems to alleviate pain. No associated back pain, No associated
GYN symptoms with last menses ___. Denies melena, BRPBR.
Pain prompted presentation to ___ over the weekend with largely
negative work-up. CT A/P: non cont> few small calc in liver.
RUQ: NL study, no GB stones. Per patient returned home and
developed worsening pain as well as vomiting and represented to
___.
In the ___ ED, 97.5 63 121/54 16 100% RA. Labs unremarkable.
UA negative. RUQ: Mildly distended gallbladder, sludge,
equivocal positive sonographic ___ sign. No pericholecystic
fluid or gallbladder wall thickening. "In the correct clinical
setting this may represent acute cholecystitis". CT abdomen
pelvis also performed without findings to explain the patient's
abdominal pain. Decision made to admit to medicine for ?
cholecystitis and likely HIDA
On arrival to the floor, patient reports pain is "better" and
currently a ___. No episodes of vomiting today but notes ___
NBNB episodes yesterday. Denies recent NSAID use; consumption of
alcohol. Drinks one caffenated beverage/day.
Past Medical History:
# Hypertension
# H.Pylori
Social History:
___
Family History:
Many family members; history of "many cancers"
Physical Exam:
ADMISSION EXAM
VS: 97.1 113/66 48 16 99%RA
GENERAL: pleasant NAD
HEENT: NC/AT, PERRLA, EOMI, sclerae anicteric, MMM
NECK: supple, no appreciable LAD
LUNGS: CTA bilat, no r/rh/wh, good air movement, resp unlabored,
no accessory muscle use
HEART: RRR, no MRG, nl S1-S2
ABDOMEN: soft, NABS, soft/ND, tenderness to palp in R>L upper
quadrant as well as epigastrium, no obvious masses or HSM, no
rebound/guarding
EXTREMITIES: WWP, no edema bilaterally in lower extremities, no
erythema, induration, or evidence of injury or infection
NEURO: awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout, gait stable
DISCHARGE EXAM
VS: Tc/m 97.7 113-114/64-66 48-63 16 99% RA
GENERAL - Alert, interactive, well-appearing woman in NAD
HEENT - PERRLA, EOMI, sclerae anicteric, MM dry, OP clear
HEART - RRR, nl S1-S2, no MRG
LUNGS - Clear anteriorly, no w/r/r
ABDOMEN - Soft, nondistended. TTP RUQ with ___ sign. NABS.
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses
NEURO - awake, A&Ox3, CNs II-XII grossly intact
Pertinent Results:
ADMISSION/DISCHARGE LABS
___ 04:03PM WBC-6.6 RBC-4.99 HGB-13.5 HCT-41.5 MCV-83
MCH-26.9* MCHC-32.4 RDW-14.3
___ 04:03PM NEUTS-54.8 ___ MONOS-4.9 EOS-1.5
BASOS-0.7
___ 04:03PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-5.5
LEUK-NEG
___ 04:03PM URINE UCG-NEGATIVE
___ 04:03PM ALBUMIN-4.8
___ 04:03PM LIPASE-32
___ 04:03PM ALT(SGPT)-13 AST(SGOT)-19 ALK PHOS-70 TOT
BILI-0.9
___ 04:03PM GLUCOSE-97 UREA N-12 CREAT-0.7 SODIUM-145
POTASSIUM-4.6 CHLORIDE-105 TOTAL CO2-29 ANION GAP-16
IMAGING
HIDA SCAN ___:
IMPRESSION: Normal hepatobiliary scan with no evidence for acute
cholecystitis.
CT ABD/PELVIS ___:
CT ABDOMEN: The lung bases are clear. The visualized portions
of the heart
and pericardium are unremarkable. The liver enhances
homogenously and there
is no focal liver lesion. The hepatic and portal veins are
patent. The
gallbladder, pancreas, spleen, and adrenals are normal. The
kidneys enhance
symmetrically and excrete contrast without evidence of
hydronephrosis or mass.
The stomach and small bowel are unremarkable. There is no
portacaval,
mesenteric, or retroperitoneal lymphadenopathy. There is no
free air or free
fluid.
CT PELVIS: The appendix is not visualized, but there are no
secondary signs
of inflammation. The colon, rectum, uterus, adnexa, and urinary
bladder are
unremarkable. There is no pelvic lymphadenopathy. Trace free
fluid is likely
physiologic.
OSSEOUS STRUCTURES: There is no lytic or blastic lesion
worrisome for
malignancy.
IMPRESSION: No CT findings to explain the patient's abdominal
pain.
RUQ U/S ___:
IMPRESSION: Mildly distended gallbladder which contains sludge.
Positive
sonographic ___ sign. No gallbladder wall thickening or
pericholecystic
fluid. Given above findings, acute cholecystitis is not
excluded in the
appropriate clinical setting. Consider further evaluation with
HIDA if
clinically appropriate.
CXR ___:
FINDINGS: Frontal and lateral views of the chest were obtained.
Lungs are
clear without focal consolidation. No pleural effusion or
pneumothorax is
seen. Cardiac and mediastinal silhouettes are unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Hydrochlorothiazide 25 mg PO DAILY
hold for sbp<100
2. Omeprazole 20 mg PO BID
3. Prochlorperazine ___ mg PO Q8H:PRN nausea
4. Ferrous Sulfate 325 mg PO BID
Discharge Medications:
1. Ferrous Sulfate 325 mg PO BID
2. Hydrochlorothiazide 25 mg PO DAILY
hold for sbp<100
3. Omeprazole 20 mg PO BID
4. Prochlorperazine ___ mg PO Q8H:PRN nausea
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Abdominal Pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: Right upper quadrant pain, question right lower lobe
pneumonia.
COMPARISON: None.
FINDINGS: Frontal and lateral views of the chest were obtained. Lungs are
clear without focal consolidation. No pleural effusion or pneumothorax is
seen. Cardiac and mediastinal silhouettes are unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
INDICATION: Right upper quadrant pain. Evaluate for cholelithiasis.
COMPARISON: Abdominal ultrasound on ___.
FINDINGS: The liver is normal in echogenicity and there are no focal liver
lesions. There is no intrahepatic or extrahepatic biliary duct dilatation.
The common bile duct measures 4 mm. The gallbladder is mildly distended and
there is sludge within the gallbladder. Positive sonographic ___ sign. No
cholelithiasis. There is no pericholecystic fluid or gallbladder wall
thickening. The spleen measures 8.5 cm and is normal. The pancreatic head
and body are normal, the tail is not well visualized due to overlying bowel
gas. The portal vein is patent with hepatopetal flow. Limited views of the
right kidney demonstrate no hydronephrosis.
IMPRESSION: Mildly distended gallbladder which contains sludge. Positive
sonographic ___ sign. No gallbladder wall thickening or pericholecystic
fluid. Given above findings, acute cholecystitis is not excluded in the
appropriate clinical setting. Consider further evaluation with HIDA if
clinically appropriate.
Radiology Report
INDICATION: Right upper quadrant abdominal pain.
TECHNIQUE: MDCT images were obtained from the lung bases to the pelvic outlet
after the administration of intravenous contrast. Coronal and sagittal
reformations were acquired.
COMPARISON: Abdominal ultrasound, ___.
CT ABDOMEN: The lung bases are clear. The visualized portions of the heart
and pericardium are unremarkable. The liver enhances homogenously and there
is no focal liver lesion. The hepatic and portal veins are patent. The
gallbladder, pancreas, spleen, and adrenals are normal. The kidneys enhance
symmetrically and excrete contrast without evidence of hydronephrosis or mass.
The stomach and small bowel are unremarkable. There is no portacaval,
mesenteric, or retroperitoneal lymphadenopathy. There is no free air or free
fluid.
CT PELVIS: The appendix is not visualized, but there are no secondary signs
of inflammation. The colon, rectum, uterus, adnexa, and urinary bladder are
unremarkable. There is no pelvic lymphadenopathy. Trace free fluid is likely
physiologic.
OSSEOUS STRUCTURES: There is no lytic or blastic lesion worrisome for
malignancy.
IMPRESSION: No CT findings to explain the patient's abdominal pain.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: ABDOMINAL PAIN
Diagnosed with ABDOMINAL PAIN RUQ, HYPERTENSION NOS
temperature: 97.5
heartrate: 63.0
resprate: 16.0
o2sat: 100.0
sbp: 121.0
dbp: 54.0
level of pain: 10
level of acuity: 3.0 | ___ female with HTN and h/o H.pylori who p/w acute onset of RUQ
pain and nausea/vomiting.
ACTIVE ISSUES
# Abdominal Pain. Unclear etiology; differential included
gallbladder pathology or hepatobiliary pathology given location,
however, LFTs, bili, amylase, electrolytes, WBC all wnl and CT
abd without findings. Had HIDA scan which was negative for
cholecysitis. CXR was normal indicating no possibility of lower
lobe pneumonia causing the pain. Had constipation/gas over last
few days prior to admission. Pain management overnight; patient
felt much improved the following day and nausea resolved. Diet
was advanced and this was tolerated well. Patient has
outpatient colonoscopy scheduled and GI was contacted to
recommend adding endoscopy given h/o gastritis.
CHRONIC ISSUES
# HTN. Normotensive, home HCTZ continued.
TRANSITIONAL ISSUES
-Patient recommended to have EGD in addition to colonoscopy
scheduled for ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
ruptured appendicitis complicated by abscess
Major Surgical or Invasive Procedure:
Interventional drainage of abscess and placement of drain
History of Present Illness:
___ presents with 2-week history of abdominal pain, originally
across upper abdomen, now predominantly band-like pain in lower
abdomen presented to ___ on ___. Sought medical attention
twice at urgent care clinic and diagnosed with constipation.
Presented to PCP earlier
today and referred to ED for a CT scan given ongoing pain, which
showed perforated appendicitis with abscess formation. Patient
denies fevers, chills, nausea, vomiting, melena, hematochezia.
Had constipation but now diarrhea after having taken stool
softeners. Currently feels weak and dehydrated. Had colonoscopy
years ago with unremarkable results per patient.
Past Medical History:
PMH: anxiety, depression, hyperlipidemia
PSH: greater saphenous vein ablation (___)
Social History:
___
Family History:
non-contributory
Physical Exam:
Discharge Physical Exam:
GEN: AA&O x 3, NAD, calm, cooperative.
HEENT: mucous membranes moist, trachea midline, EOMI, PERRL.
CHEST: Clear to auscultation bilaterally
ABDOMEN: soft, mildly tender to palpation incisionally,
non-distended. Incisions: clean, dry and intact, dressed and
closed with steristrips.
EXTREMITIES: Warm, well perfused, pulses palpable
Pertinent Results:
CT Abd & Pelvis w/ contrast ___:
1. Acute, perforated appendicitis with large rim enhancing,
loculated fluid collection in the pelvis concerning for large
periappendiceal abscess. Of note, the fluid collection appears
to have 2 large pockets, one within the right hemipelvis
adjacent to the cecum and one in the deep pelvis.
2. Dependent radiopacity in the RLQ fluid collection may
represent an
appendicolith or fecalith.
CT Interventional Procedure ___:
1. CT-guided placement of a ___ pigtail catheter into the
presacral abscess. A sample was sent for microbiology
evaluation.
2. Ultrasound-guided placement of a 10 ___ pigtail catheter
into the right lower quadrant abscess. A sample was sent for
microbiology evaluation.
3. Hyperdensity within the right lower quadrant collection is
likely an
appendicolith.
CT Pelvis w/o contrast ___:
1. Complete decompression of previously seen right lower
quadrant and presacral fluid collections since prior study.
Right lower quadrant and presacral drainage catheters are again
in appropriate position. R ght lower quadrant mesenteric fat
stranding likely inflammatory changes.
2. Small 2.7 x 2.4 cm fluid collection likely an abscess in the
right mid abdomen which appears smaller from comparison study.
3. Radiopacity within the right lower quadrant likely
representing fecalith or
appendicolith.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. ClonazePAM 0.5-1 mg PO DAILY:PRN anxiety
3. Fluoxetine 20 mg PO DAILY
4. Multivitamins 1 TAB PO DAILY
5. Simvastatin 20 mg PO QPM
Discharge Medications:
1. Acetaminophen 650 mg PO TID
RX *acetaminophen 650 mg 1 tablet(s) by mouth three times a day
Disp #*60 Tablet Refills:*0
2. Amoxicillin-Clavulanic Acid ___ mg PO Q8H
RX *amoxicillin-pot clavulanate 500 mg-125 mg 1 tablet(s) by
mouth three times a day Disp #*42 Tablet Refills:*0
3. ClonazePAM 0.5 mg PO BID Anxiety
4. Docusate Sodium 100 mg PO BID
take this while taking narcotics to prevent constipation
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
5. Fluoxetine 20 mg PO DAILY
6. OxycoDONE (Immediate Release) 5 mg PO Q4H:PRN pain
RX *oxycodone 5 mg 1 tablet(s) by mouth every 4 hours Disp #*30
Tablet Refills:*0
7. Senna 8.6 mg PO BID:PRN constipation
take this while taking narcotics to prevent constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
8. Simvastatin 20 mg PO QPM
9. Aspirin 81 mg PO DAILY
10. Multivitamins 1 TAB PO DAILY
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
ruptured appendicitis complicated by abscess
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CT INTERVENTIONAL PROCEDURE.
INDICATION: ___ year old woman with ruptured appendicitis and subsequent
abscesses // Please drain abscesses and leave drain in place. Send fluid for
culture and Gram stain.
COMPARISON: CT ___
PROCEDURE: 1. CT-guided drainage of presacral collection.
2. Ultrasound-guided drainage of a right lower quadrant collection.
OPERATORS: Dr. ___, MD (___), and Dr. ___, attending
radiologist. Dr. ___ ___ supervised the trainee during the entire
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.
CT-GUIDED DRAINAGE OF PRESACRAL COLLECTION: 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. A 0.038 ___ wire was placed
through the needle and needle was removed. This was followed by placement of a
___ Exodus pigtail catheter into the collection. The metal stiffener and
the wire were removed. The pigtail was deployed. The position of the pigtail
was confirmed within the collection via CT fluoroscopy.
Approximately 200 cc of purulent fluid was aspirated with a sample sent for
microbiology evaluation. The catheter was secured by a StatLock. The catheter
was attached to bag to gravity. Sterile dressing was applied.
ULTRASOUND-GUIDED DRAINAGE OF RIGHT LOWER QUADRANT COLLECTION: Attention was
then turned to the right lower quadrant collection. The patient was placed in
a supine position on the CT scan table. Limited preprocedure ultrasound was
performed to localize the collection. Based on the ultrasound findings, an
appropriate skin entry site for the drain placement was chosen. The site was
marked. Local anesthesia was administered with 1% Lidocaine solution.
Using continuous sonographic guidance, a ___ Exodus drainage catheter
was advanced via trocar technique into the collection. A sample of fluid was
aspirated, confirming catheter position within the collection. The pigtail
was deployed. The position of the pigtail was confirmed within the collection
via ultrasound.
Approximately 180 cc of purulent fluid was drained with a sample sent for
microbiology evaluation. The catheter was secured by a StatLock. The catheter
was attached to suction bulb. Sterile dressing was applied.
The procedure was tolerated well, and there were no immediate post-procedural
complications.
DOSE: DLP: Total DLP (Body) = 992 mGy-cm.
SEDATION: Moderate sedation was provided by administering divided doses of
1.5 mg Versed and 75 mcg fentanyl throughout the total intra-service time of
40 minutes during which patient's hemodynamic parameters were continuously
monitored by an independent trained radiology nurse.
FINDINGS:
1. Limited preprocedure CT scan again demonstrates multiple intra-abdominal
fluid collections, better assessed on CT ___. An 8.3 x 7.1 cm
presacral fluid collection (3:27) was targeted for CT-guided catheter
drainage. A 10.5 x 6.2 cm right lower quadrant fluid collection (03:11) was
targeted for ultrasound guided catheter drainage. A hyperdensity within the
right lower quadrant fluid collection (3:19) is likely an appendicolith.
Multiple additional smaller fluid collections are better evaluated on the
prior contrast-enhanced CT.
2. Postprocedure CT scan demonstrates a 10 ___ catheter within the
presacral collection, which is largely collapsed. A 10 ___ catheter is
seen in the right lower quadrant fluid collection, which is also partially
collapsed. Additional smaller fluid collections are better assessed on the
prior contrast-enhanced CT.
IMPRESSION:
1. CT-guided placement of a ___ pigtail catheter into the presacral
abscess. A sample was sent for microbiology evaluation.
2. Ultrasound-guided placement of a 10 ___ pigtail catheter into the right
lower quadrant abscess. A sample was sent for microbiology evaluation.
3. Hyperdensity within the right lower quadrant collection is likely an
appendicolith.
RECOMMENDATION(S): Followup microbiology.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr.
___ on the telephoneon ___ at 2:30 ___, upon procedure
completion.
Radiology Report
INDICATION: ___ year old woman s/p ruptured appens s/p ___ drainage // eval
drain for obstruction/eval drain patency
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.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence: 1) CT Localizer Radiograph 2) CT Localizer
Radiograph 3) Spiral Acquisition 3.0 s, 33.4 cm; CTDIvol = 13.7 mGy (Body) DLP
= 456.4 mGy-cm. Total DLP (Body) = 456 mGy-cm.
COMPARISON: ___ CT abdomen pelvis
FINDINGS:
PELVIS
HEPATOBILIARY: Images of the inferior portions of the liver showed no focal
lesion. The gallbladder is within normal limits.
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: Drainage catheter is seen terminating within the right
lower quadrant. Previously seen large right fluid collection has been
completely decompressed. There is a small fluid collection measuring 2.7 x
2.4 cm (02:23) in the right mid abdomen which appears smaller from comparison
study, likely an abscess. There is significant mesenteric fat stranding in the
right lower quadrant secondary inflammatory changes. There is a 9 x 8 mm
high-density focus within the bowel in the right lower quadrant likely
consistent with a fecalith or appendicolith (02:32)
PELVIS: Another drainage catheter is seen terminating in the presacral space.
Previously described large presacral fluid collection has been completely
decompressed since prior study.
REPRODUCTIVE ORGANS: Fibroid uterus is again seen.
LYMPH NODES: Prominent mesenteric lymph node measuring 1 cm (02:17) likely
reactive .
VASCULAR: There is no abdominal aortic aneurysm. Mild calcified plaques within
the infrarenal aorta and bilateral common iliac arteries. No evidence of
stenosis.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: The pelvic wall is within normal limits.
IMPRESSION:
1. Complete decompression of previously seen right lower quadrant and
presacral fluid collections since prior study. Right lower quadrant and
presacral drainage catheters are again in appropriate position. R ght lower
quadrant mesenteric fat stranding likely inflammatory changes.
2. Small 2.7 x 2.4 cm fluid collection likely an abscess in the right mid
abdomen which appears smaller from comparison study.
3. Radiopacity within the right lower quadrant likely representing fecalith or
appendicolith.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: RLQ abdominal pain
Diagnosed with Right lower quadrant pain
temperature: 99.5
heartrate: 109.0
resprate: 16.0
o2sat: 97.0
sbp: 110.0
dbp: 62.0
level of pain: 2
level of acuity: 3.0 | ___ with 2-week history of abdominal pain due to perforated
appendicitis with subsequent abscess formation and significant
leukocytosis (though also component of hemoconcentration) who
presented to ___ on ___. Patient was admitted to ___
surgery service for IV antibiotics (zosyn), IV fluids, pain
control and ___ consult for drainage. CT scan done at this time
showed loculated fluid collection in the pelvis concerning for
large periappendiceal abscess. In particular, 2 large pockets
were present (one within right hemipelvis adjacent to the cecum
and one in the deep pelvis). ___ was consulted on ___ and
patient underwent drainage of fluid collections with subsequent
placement of ___ pigtail ___. Two ___ pigtail
catheters were placed, one in the right lower quadrant and one
placed presacral region. After undergoing ___ drainage, patient
was monitored with serial exams, continued antibiotics and seen
by social work and case management. Her diet was advanced and
drain output decreased. On ___, a repeat CT and drain study
was ordered to assess the patency of drains and remnant fluid.
Interval decrease in size of the fluid collections. The drains
were left in place and the patient was then transitioned to PO
antibiotics (Augmentin) for a 14 day course. The patient
continued to do well and was discharged home with ___ services
and close family supervision on ___ in good condition. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
dyspnea, leg swelling
Major Surgical or Invasive Procedure:
CORONARY ANGIOGRAPHY (___)
History of Present Illness:
Mr. ___ is an ___ man with HFrEF (EF 40%), LBBB, HTN,
HLD who presents with dyspnea, progressive leg swelling, and
weight gain consistent with acute on chronic heart failure
exacerbation.
The patient had an ECHO in ___ that demonstrated a newly
reduced ejection fraction of 40% and was started on diuretic
therapy at that time. He's been compliant with his medical
therapy but over the past two weeks has noticed progressive leg
swelling with adjustments made to his diuretics. Most recently,
his cardiologist put him on torsemide 40mg this past ___.
Despite these interventions, he continued to have progressive
leg
swelling with the development of orthopnea and worsening
shortness of breath. Additionally, his weight has increased
approximately 25 lb over the past four weeks. He's not
experienced any chest pain or shortness of breath at rest over
this time.
Of note, the patient carries a diagnosis of biopsy-proven
inclusion body myositis for which he is followed by rheumatology
at ___. Over the past several months, he's had significant leg
pain and has been taking 800mg of ibuprofen TID. Giving his
progressive symptoms of decompensated heart failure, he
presented
to the ED for further evaluation.
In the ED initial vitals were: T 98.1, HR 87, BP 128/57, 94% on
RA.
EKG: LBBB (known) not meeting Sgarbosa's criteria.
Labs/studies notable for: trop 0.7 -> 0.63, CK-MB 30, CK 393.
ProBNP ___. Patient was given: 40mg IV Lasix, ibuprofen 600mg,
ASA 243mg, and heparin. Vitals on transfer: HR 83, BP 102/54 RR
18, 92% RA.
On the floor the patient confirms the above history. He denies
any current shortness of breath or chest pain. He is
particularly
bothered by his bilateral leg pain that has been worsening over
the past several weeks and attributed to his known inclusion
body
myositis.
Past Medical History:
- HFrEF (40%)
- LBBB
- HTN
- Inclusion Body Myositis (followed at ___; not on any
immunosuppressant)
- gout (last flare > ___ years ago)
Social History:
___
Family History:
Family History: brother - kidney stones, valve replacement;
father - died from heart disease at ___ yo; sister - died from
heart disease at age ___ brother - heart disease. No family
history of gallstones.
Physical Exam:
ADMISSION PHYSICAL EXAM
VITALS: ___ 2230
Temp: 98.1 PO BP: 129/74 R Lying HR: 90 RR: 20 O2 sat: 95% O2
delivery: ra Dyspnea: 0 RASS: 0 Pain Score: ___
GENERAL: Well-developed, well-nourished. NAD. Mood, affect
appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva pink, no
pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 15 cm.
CARDIAC: RRR, normal S1, S2. No murmurs/rubs/gallops. No
thrills,
lifts.
LUNGS: + crackles to mid-lung fields bilaterally.
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: Significant 3+ edema to thighs bilaterally
SKIN: warm, bilateral stasis dermatitis noted without evidence
of
superimposed SSTI.
PULSES: Distal pulses palpable and symmetric
DISCHARGE PHYSICAL EXAM
VS: 24 HR Data (last updated ___ @ 820)
Temp: 98.2 (Tm 99.4), BP: 155/62 (72-155/40-75), HR: 61
(58-67 marching in place), RR: 18 (___), O2 sat: 93% (90-100),
O2 delivery: ra
Fluid Balance (last updated ___ @ 817)
Last 8 hours Total cumulative -50ml
IN: Total 400ml, PO Amt 400ml
OUT: Total 450ml, Urine Amt 450ml
Last 24 hours Total cumulative -685ml
IN: Total 1140ml, PO Amt 1140ml
OUT: Total 1825ml, Urine Amt 1825ml
GENERAL: Pleasant elderly man, lying down in bed, appears
comfortable and in no acute distress
NECK: Supple with JVP 6 cm
CARDIAC: RRR, nl s1/s2, no m/r/g
LUNGS: Intermittent anterior rhonchi, no wheezes or rales
ABDOMEN: Soft, non tender, non distended, normal bowel sounds
EXTREMITIES: Trace ___ edema to the ankles, no clubbing or
cyanosis, warm and well perfused
SKIN: Warm, bilateral stasis dermatitis
Pertinent Results:
ADMISSION LABS
___ 05:40PM BLOOD WBC-11.2* RBC-3.61* Hgb-10.9* Hct-33.8*
MCV-94 MCH-30.2 MCHC-32.2 RDW-14.7 RDWSD-50.1* Plt ___
___ 05:40PM BLOOD Neuts-62.0 ___ Monos-7.2 Eos-7.1*
Baso-0.4 Im ___ AbsNeut-6.92* AbsLymp-2.55 AbsMono-0.80
AbsEos-0.79* AbsBaso-0.04
___ 05:45PM BLOOD ___ PTT-26.0 ___
___ 05:40PM BLOOD Glucose-89 UreaN-57* Creat-1.3* Na-142
K-3.6 Cl-102 HCO3-26 AnGap-14
___ 05:40PM BLOOD CK(CPK)-394*
___ 05:40PM BLOOD CK-MB-34* MB Indx-8.6* ___
PERTINENT/DISCHARGE LABS
___ 06:26AM BLOOD WBC-9.6 RBC-3.22* Hgb-9.9* Hct-30.3*
MCV-94 MCH-30.7 MCHC-32.7 RDW-15.0 RDWSD-51.6* Plt ___
___ 06:12AM BLOOD WBC-11.4* RBC-3.66* Hgb-11.0* Hct-34.4*
MCV-94 MCH-30.1 MCHC-32.0 RDW-15.2 RDWSD-51.7* Plt ___
___ 06:12AM BLOOD Glucose-90 UreaN-30* Creat-1.1 Na-143
K-4.5 Cl-102 HCO3-27 AnGap-14
___ 05:40PM BLOOD cTropnT-0.71*
___ 05:52PM BLOOD CK-MB-34* cTropnT-1.17*
___ 07:30AM BLOOD CK-MB-15* cTropnT-1.15*
___ 06:12AM BLOOD Calcium-8.6 Phos-3.4 Mg-1.7
___ 07:30AM BLOOD calTIBC-173* Ferritn-437* TRF-133*
___ 08:15AM BLOOD %HbA1c-5.3 eAG-105
___ 03:24AM BLOOD Triglyc-78 HDL-28* CHOL/HD-4.4 LDLcalc-78
IMAGING/STUDIES
CXR ___- No significant interval change. Chronic blunting
of the right lateral costophrenic angle lead, likely due to
component of pleural thickening and effusion. No definite
superimposed acute process.
LENIs ___- No evidence of deep venous thrombosis in the
imaged portion of the right or left lower extremity veins.
Bilateral posterior tibial and peroneal veins not well assessed
due to edema, similar in appearance to prior.
TTE ___- CONCLUSION:
The left atrium is elongated. The right atrium is mildly
enlarged. There is normal left ventricular wall thickness with a
normal cavity size. There is normal regional left ventricular
systolic function. There is visual left ventricular dyssnchrony.
The visually estimated left ventricular ejection fraction is
55-60%. There is no resting left ventricular outflow tract
gradient. Normal right ventricular cavity size with normal free
wall motion. There is abnormal septal motion c/w conduction
abnormality/paced rhythm. The aortic sinus is mildly dilated
with mildly dilated ascending aorta. The aortic arch diameter is
normal with a mildly dilated descending aorta. The aortic valve
leaflets (3) are mildly thickened. There is no
aortic valve stenosis. There is no aortic regurgitation. The
mitral leaflets are mildly thickened with no mitral valve
prolapse. There is mild [1+] mitral regurgitation. The tricuspid
valve leaflets appear structurally normal. There is physiologic
tricuspid regurgitation. The pulmonary artery systolic pressure
could not be estimated. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Normal biventricular
global systolic function with evidence of intraventricular LV
dyssynchrony. Mild mitral regurgitation. ___ , the left
ventricular systolic function is slightly improved.
Cardiac cath ___- Impressions:
Low filling pressures.
Diffuse CAD involving proximal LAD, proximal Ramus and LCx
(CTO).
CT chest ___- 1. No acute cardiopulmonary process.
2. Moderate atherosclerotic calcifications of the thoracic aorta
and marked coronary artery disease.
3. Trace bilateral pleural effusions. Lower lobe
bronchiectasis.
4. 1 cm hypodense nodule in the right thyroid lobe.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Allopurinol ___ mg PO DAILY
2. Citalopram 20 mg PO DAILY
3. Torsemide 40 mg PO DAILY
4. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety
5. Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate
6. Pantoprazole 20 mg PO Q24H
7. Spironolactone 25 mg PO BID
8. Zolpidem Tartrate 10 mg PO QHS
9. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Atorvastatin 80 mg PO QPM
2. Metoprolol Succinate XL 25 mg PO DAILY
3. Allopurinol ___ mg PO DAILY
4. ALPRAZolam 0.5 mg PO DAILY:PRN anxiety
5. Aspirin 81 mg PO DAILY
6. Citalopram 20 mg PO DAILY
7. Pantoprazole 20 mg PO Q24H
8. Spironolactone 25 mg PO BID
9. Torsemide 40 mg PO DAILY
10. Zolpidem Tartrate 10 mg PO QHS
11. HELD- Ibuprofen 800 mg PO Q8H:PRN Pain - Moderate This
medication was held. Do not restart Ibuprofen until your primary
care physician says it is alright to restart
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
PRIMARY DIAGNOSIS
================
Acute on chronic heart failure exacerbation
Heart failure with recovered ejection fraction
NSTEMI/multivessel CAD
SECONDARY DIAGNOSES
===================
Anemia
HTN
Inclusion body myositis
Depression
Insomnia
Gout
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ with new onset heart failure and crackles on exam//
?pulmonary edema, effusion, cardiomegaly
COMPARISON: ___
FINDINGS:
AP and lateral views of the chest provided. Since prior, there has been no
significant interval change. There is chronic blunting of the right lateral
costophrenic angle likely in part due to pleural thickening though underlying
effusion would be possible. There is no large left pleural effusion.
Posterior costophrenic angles are excluded from the field of view. Lung
volumes are relatively lower compared to the prior exam resulting in crowding
of bronchovascular structures. There is mild bibasilar atelectasis. No
pneumothorax. Cardiomediastinal silhouette is unchan within normal limits
when allowing for AP technique and low lung volumes.
IMPRESSION:
No significant interval change. Chronic blunting of the right lateral
costophrenic angle lead, likely due to component of pleural thickening and
effusion. No definite superimposed acute process.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old man with history of inclusion body myositis and heart
failure with worsening ___ edema and very little ambulation// Please eval for
___ DVT b/l
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: Lower extremity ultrasound from ___
FINDINGS:
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. The bilateral posterior tibial
and peroneal veins were not well assessed, as on prior secondary to technical
considerations from body habitus.
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 imaged portion of the right or
left lower extremity veins. Bilateral posterior tibial and peroneal veins not
well assessed due to edema, similar in appearance to prior.
Radiology Report
EXAMINATION: CT CHEST W/O CONTRAST
INDICATION: ___ year old man with HFpEF, HTN, HLD found to have three vessel
CAD now getting worked up for CABG// evaluate aortic calcification
TECHNIQUE: Axial CT images of the thorax from the thoracic inlet through the
diaphragm were performed without IV contrast. Coronal and sagittal reformats
were recreated at the workstation.
DOSE: Acquisition sequence:
1) Spiral Acquisition 8.7 s, 33.5 cm; CTDIvol = 16.3 mGy (Body) DLP = 521.1
mGy-cm.
Total DLP (Body) = 531 mGy-cm.
COMPARISON: CT chest ___.
FINDINGS:
BASE OF NECK: 1 cm hypodense nodule in the right thyroid lobe.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar adenopathy.
HEART AND VASCULATURE: The heart is normal size. No pericardial effusion.
Moderate atherosclerotic calcifications of the thoracic aorta and great
vessels. Marked coronary artery disease. Calcifications of the mitral and
aortic valve.
PLEURAL SPACES: Trace bilateral pleural effusion with compressive atelectasis.
No pneumothorax.
LUNGS/AIRWAYS: Mild bilateral dependent atelectasis right greater than left as
well as right greater than left basilar bronchiectasis.
ABDOMEN: Unremarkable.
BONES: Degenerative changes of the spine with anterior osteophytes. No
suspicious osseous lesions.
IMPRESSION:
1. No acute cardiopulmonary process.
2. Moderate atherosclerotic calcifications of the thoracic aorta and marked
coronary artery disease.
3. Trace bilateral pleural effusions. Lower lobe bronchiectasis.
4. 1 cm hypodense nodule in the right thyroid lobe.
RECOMMENDATION(S): Thyroid nodule. No follow up recommended.
Absent suspicious imaging features, unless there is additional clinical
concern, ___ College of Radiology guidelines do not recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in patients under
age ___ or less than 1.5 cm in patients age ___ or ___.
Suspicious findings include: Abnormal lymph nodes (those displaying
enlargement, calcification, cystic components and/or increased enhancement) or
invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White
Paper of the ACR Incidental Findings Committee". J ___ ___
12:143-150.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by AMBULANCE
Chief complaint: Dyspnea, Leg swelling
Diagnosed with Heart failure, unspecified
temperature: 98.1
heartrate: 87.0
resprate: 24.0
o2sat: nan
sbp: 128.0
dbp: 57.0
level of pain: 0
level of acuity: 2.0 | ___ man with HF recovered EF (EF 40%), LBBB, HTN, HLD
who presents with dyspnea, progressive leg swelling, and weight
gain consistent with acute on chronic heart failure exacerbation
with associated elevated cardiac enzymes. Warm and wet on exam
s/p diuresis. Repeat TTE with preserved EF, now s/p RHC/LHC with
low filling pressures but multivessel disease pending csurg
eval.
# Acute on Chronic Heart Failure Exacerbation
# HFpEF:
Patient with signs of volume overload and elevated proBNP on
admission. Concern for ischemia as provoking factor given
elevated cardiac enzymes, though no acute ischemic changes noted
on EKG and recovered EF on TTE with no FWMA. Cardiac involvement
from his known Inclusion Body Myositis is unlikely. Coronary
angio with multivessel CAD. The patient was diuresed, seemingly
euvolemic on discharge. Cardiac surgery was consulted and did
not feel he was a surgical candidate given his frailty. He was
actively diuresed and then transitioned back to his torsemide 40
mg qd, metop XL 25 mg qd was started, he was continued on his
spironolactone 25 mg BID. Lisinopril was not added due to
orthostatic hypotension.
# NSTEMI:
# Multivessel CAD:
Suspected etiology of CHF exacerbation. Trop and MB rose on
admission and peaked to 1.19. Continued heparin gtt for 48
hours. Coronary angio ___ showed multivessel disease not
amenable to PCI. Cardiac surgery consulted for CABG evaluation
and patient initiated on workup, however, he was ultimately
declined for surgery. Complex PCI is deferred at this time given
his frailty and lack of continued ischemic symptoms and
preserved EF. Discussion will need to be continued with
interventional cardiology as an outpatient. He was started on
atorvastatin 80 mg qd in addition to metoprolol 25 mg XL qd. His
aspirin 81 mg qd was continued.
# Diarrhea:
Multiple loose stools iso neutrophilic predominance and elevated
white count. White count improving and C diff negative. Improved
prior to discharge.
CHRONIC CONDITIONS
=====================
# Normocytic anemia:
Hgb at recent baseline ___. Last colonoscopy ___ with
fragments of adenoma on biopsy, was supposed to have repeat
scope in ___ years. Iron studies unremarkable. Likely anemia of
chronic disease iso myositis. Should have scheduled repeat
outpatient colonoscopy.
# HTN:
Recently amlodipine and metop succ discontinued. Continued
spironolactone and re-added metoprolol. His orthostatic
hypotension prevented starting Lisinopril.
# Inclusion Body Myositis:
Followed at ___. Not on any therapy other than NSAIDs as disease
traditionally poorly responsive to immunosuppresants. No known
history of cardiac involvement. Deferred sending
rheumatologic/inflammatory markers as these are commonly not
elevated in ___. Held NSAIDS during admission and on discharge
given volume overload. Should follow w/ Dr. ___ in
___ clinic. CK was elevated on admission (~200-300),
likely secondary to NSTEMI, started atorvastatin and several
days later CK normalized.
# Depression:
# Insomnia:
Continue home citalopram and zolpidem.
# Gout:
Continued home allopurinol.
TRANSITIONAL ISSUES
==================
-His predicted LOS at rehab will be less than 30 days.
-He will follow-up with his PCP, who is also his cardiologist.
He will also follow-up with his neurologist as an outpatient.
-DISCHARGE WEIGHT: 122 kg
-DIURETIC: Torsemide 40 mg qd (continued home dose)
-NEW MEDICATIONS: Atorvastatin 80 mg qd, metoprolol succinate 25
mg qd
-STOPPED MEDICATIONS: Ibuprofen (please discuss restarting as an
outpatient)
-DISCHARGE CR: 1.1
-DISCHARGE HGB: 11
-Please recheck a chem10 1 week upon discharge to evaluate
electrolytes and kidney function. Consider checking a CK 1 week
after discharge. He was started on a statin with a normal CK
after 4 days of being on a statin.
-Colonoscopy: He had adenoma in the past which was not
completely excised. He will need colonoscopy as an outpatient to
evaluate.
#CODE: full with limited trial
#CONTACT: HCP: ___ (wife) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
right frontal/parietal stroke
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is an ___ left handed man with a history of hypertension,
BPH, dementia of unkwown variety, history of longstanding
tobacco abuse and recent hospitalization for a drug resistant
UTI who presents to the ED as a transfer
from an OSH where a subacute stroke was discovered on CT scan.
I received a brief report of his baseline status when speaking
with his daughter on the phone. She did clarify that he is DNR.
She reoprts that he has had dementia for some years now. While
he is quite physically able at baseline, he does get assistance
for help with his ADLs due to his ongoing issues with
confusion, disorientation and inattention. He had been doing
well until very recently when he was hospitalized for an
infection. She mentioned that there was a "drug resistant
organism", and a UTI caused "acute kidney failure". He was sent
home after placing a power PICC line and sent home with
instructions to get imipenem/cilastatin until the ___
___. His PICC line was being flushed with heparin at home
and maintained by a home IV nurse.
This morning, when getting showered, the nurse noted that he was
having difficulty getting words out. The family was notified.
Instead of going to the ED directly, they decided to keep their
appointment with the PCP later this morning. The PCP referred
them to the ED where a CT scan was done and was read as subacute
right frontal stroke. I do not have the actual report. The CT
has
been uploaded to our system. He was transferred for further
neurologic evaluation. His daughter reports that at baseline, he
is not dysarthric and there is no left sided weakness.
Review of systems: Is difficult in this patient at this time,
given his mental status. Daughter did report no new symptoms in
the past couple of days other than what is described above.
Past Medical History:
- Hypertension
- H/o tobacco abuse
- BPH and urinary retention
- recurrent UTI
- Dementia (long standing, is not oriented to time or to place
at baseline)
- Hypercholesterolemia
- Right frontal and parietal embolic stroke
Social History:
___
Family History:
Unable to obtain.
Physical Exam:
ADMISSION EXAM:
Vitals: 97.2, 71, 188/93, 16, 95%
General: Thin, appears younger than stated age, awake,
cooperative, NAD, no specific complaints. + right picc line
HEENT: NC/AT, no scleral icterus noted, MMM, no lesions noted in
oropharynx, edentulous
Neck: Supple, no masses or lymphadenopathy
Pulmonary: Lungs CTA bilaterally without R/R/W
Cardiac: RRR, nl. S1S2, no murmurs
Abdomen: soft, NT/ND, no masses or organomegaly noted.
Extremities: warm and well perfused
Skin: no rashes or lesions noted.
Neurologic:
- Mental Status: Alert, awake. He can tell me his name, but does
not know where he is or why he is here. He relates no specific
complaints. He does not know the date. He could not recall his
address or phone number. He was significantly dysarthric but
somewhat comprehensible. He was able to identify and name
"reading glasses", key and glove, but could not identify
feather, cactus or hammock. He could not identify the color of
my scrubs as blue. He was able to read, but would often skip
words. So instead of "they heard him speak on the radio last
night", he read "heard speak radio last night". When having him
describe the scene on the stroke cards, he had very limited
verbal
incomprehensible output. Could not test memory, attention.
- Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk.
III, IV and VI: EOM are intact with saccadic intrusions, no
nystagmus
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: Paratonia without atrophy. Relative paucity of movement
in the LUE, with ? neglect when asking him to perform specific
instructions.
Delt Bic Tri WrE FFl FE IP Quad Ham TA Gastroc
L 4 ___ ___ 5 5 5 5
R 5 ___ ___ 5 5 5 5
- Sensory: Was not attentive to formal sensory testing.
- DTRs: 1+ in upper extremities.
- Coordination: Gait testing deferred. Was not able to cooperate
for FTN testing.
DISCHARGE EXAM:
AF VSS
Mental Status: fluctuates between being arousable to voice/light
touch and being somewhat interactive/following simple commmands
(wriggling toes, showing thumb) to being very somnolent and
difficult to arouse even with sternal rub. When patient is
difficult to arouse, occasionally becomes combative with noxious
stimuli and then goes right back to sleep. Says few words when
awake but not very conversant.
Motor: Right side is strong and has good spontaneous movements.
Left side has less spontaneous movements but withdraws briskly
from noxious stimuli (nailbed pressure).
Pertinent Results:
ADMISSION LABS:
___ 05:45PM BLOOD WBC-11.1* RBC-4.26* Hgb-12.3* Hct-36.9*
MCV-87 MCH-29.0 MCHC-33.4 RDW-14.8 Plt ___
___ 05:45PM BLOOD Neuts-55.9 ___ Monos-5.4 Eos-5.3*
Baso-0.4
___ 05:45PM BLOOD ___ PTT-32.2 ___
___ 05:45PM BLOOD Glucose-109* UreaN-18 Creat-1.5* Na-140
K-4.2 Cl-105 HCO3-28 AnGap-11
___ 05:45PM BLOOD ALT-31 AST-31 AlkPhos-111 TotBili-0.4
___ 05:45PM BLOOD Albumin-3.6 Calcium-9.1 Phos-2.1* Mg-2.0
CARDIAC ENZYMES:
___ 05:45PM BLOOD cTropnT-0.03*
___ 05:26AM BLOOD CK-MB-2 cTropnT-0.04*
___ 06:50PM BLOOD CK-MB-2 cTropnT-0.03*
RELEVANT LABS:
___ 11:13AM BLOOD %HbA1c-PND
___ 05:26AM BLOOD Triglyc-85 HDL-45 CHOL/HD-3.4 LDLcalc-89
___ 06:50PM BLOOD TSH-PND
___ 05:45PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 09:00PM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
DISCHARGE LABS:
___ 05:18AM BLOOD WBC-9.2 RBC-4.01* Hgb-11.5* Hct-34.1*
MCV-85 MCH-28.6 MCHC-33.6 RDW-15.1 Plt ___
___ 05:18AM BLOOD Glucose-98 UreaN-13 Creat-1.5* Na-139
K-3.6 Cl-107 HCO3-24 AnGap-12
___ 05:15AM BLOOD Calcium-8.8 Phos-2.4* Mg-2.0
MICROBIOLOGY:
___ 09:00PM URINE Color-Straw Appear-Clear Sp ___
___ 09:00PM URINE Blood-NEG Nitrite-NEG Protein-NEG
Glucose-NEG Ketone-TR Bilirub-NEG Urobiln-2* pH-7.0 Leuks-NEG
___ 9:00 pm URINE CULTURE (Final ___: <10,000
organisms/ml.
**
___ 3:00 am URINE
URINE CULTURE (Preliminary):
ESCHERICHIA COLI. >100,000 ORGANISMS/ML..
Piperacillin/tazobactam sensitivity testing available
on request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMIKACIN-------------- <=2 S
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- 16 I
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- =>64 R
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- =>64 R
CIPROFLOXACIN--------- 1 S
GENTAMICIN------------ =>16 R
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ 8 I
TRIMETHOPRIM/SULFA---- =>16 R
=============================
IMAGING:
___ MRI/MRA OF HEAD/NECK:
IMPRESSION:
1. Multiple cortical foci of acute infarction in the right
frontal and anterior parietal lobes, in the right middle
cerebral artery territory. No significant mass effect at this
time. No evidence of hemorrhagic transformation.
2. Two punctate chronic microhemorrhages in the paramedian right
frontal lobe, which could be related to amyloid angiopathy,
hypertension, or less likely a cavernous malformation.
3. Unremarkable neck MRA.
4. The superior and inferior division branches of the right
middle cerebral artery are smaller in caliber compared to the
left.
___ TTE: The left atrium is normal in size. No thrombus/mass
is seen in the body of the left atrium. 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. No masses or thrombi are
seen in the left ventricle. There is no ventricular septal
defect. Right ventricular chamber size and free wall motion are
normal. The diameters of aorta at the sinus, ascending and arch
levels are normal. The aortic valve leaflets (3) are mildly
thickened but aortic stenosis is not present. No masses or
vegetations are seen on the aortic valve. No aortic
regurgitation is seen. The mitral valve leaflets are mildly
thickened. No mass or vegetation is seen on the mitral valve.
Trivial mitral regurgitation is seen. The tricuspid valve
leaflets are mildly thickened. The pulmonary artery systolic
pressure could not be determined. There is no pericardial
effusion.
EEG ___:
IMPRESSION: This is an abnormal video EEG recording with slowed
theta background frequencies seen during most awake portion of
this recording. In addition, there were bursts of generalized
and more focal slowing over the right frontocentral regions.
Multifocal sharp transients were seen as
described above as well as broad-based right hemisphere sharp
and slow discharges. One clinical event described above
concerning for seizure. (At 00:06 a.m., the patient can be seen
lying in bed asleep with right side of his face down when he
wakes, suddenly turns head towards left with tonic flexion of
upper extremities which lasts a few seconds and is followed by
chewing movements as he scans the space around him appearing
confused.)
Medications on Admission:
- Simvastatin 20mg daily
- Imipenem/cilastatin 250mg q8 until ___
- Rivastigmine 1.5mg BID
- Flomax 0.4mg QHS
- Lisinopril 5mg daily
- Tylenol ___ q4hrs
- Metoprolol 25mg BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN pain/fever
2. Metoprolol Tartrate 25 mg PO BID
hold if SBP <100 or HR <60
3. Simvastatin 20 mg PO DAILY
4. Tamsulosin 0.4 mg PO HS
5. LeVETiracetam 500 mg PO BID
6. rivastigmine *NF* 1.5 mg Oral BID
7. Aspirin (Buffered) 325 mg PO DAILY
8. Meropenem 500 mg IV Q8H
day 1 = ___
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis: right frontal and parietal ischemic stroke,
dementia, hypertension, urinary tract infection, hypoactive
delirium
Secondary Diagnosis: benign hypertrophic prostate
Discharge Condition:
Mental Status: Confused - most of the time. Not oriented to
month/year, oriented to the fact he's in the hospital but not to
reason.
Level of Consciousness: fluctuates between being alert and
interactive and being lethargic but arousable to noxious stimuli
Activity Status: Ambulatory - requires assistance or aid (walker
or cane). Needs supervision.
Neurologic Status: fluctuating level of alertness, does not move
left side as much as right side, but withdraws all extremities
to noxious stimuli. Appears to have left sided neglect, though
difficult to determine.
Followup Instructions:
___
Radiology Report
INDICATION: ___ man with acute neurological change. Evaluate for
evidence of intracranial process.
COMPARISON: Non-contrast head CT performed on ___ at ___
___. Prior Brain MRI dated ___ from ___.
TECHNIQUE: Axial contiguous MDCT images were obtained through the brain
without the administration of IV contrast.
FINDINGS: There is no evidence of hemorrhage, or mass effect. The ventricles
and sulci are slightly prominent, consistent with age-related degeneration.
Unchanged cortical foci of low attenuation, consistent with acute infarction
in the right frontal and anterior parietal lobes, right middle cerebral artery
territory, demonstrated on the prior brain MRI. Periventricular white matter
changes suggest chronic small vessel ischemic disease. An area of hypodensity
in the area of the coronal radiata of the right frontal lobe (2:19) suggests a
small area of encephalomalacia due to prior infarction. The basal cisterns
appear patent.
There is no fracture. There is an air-fluid level in the left maxillary sinus
but the remaining paranasal sinuses, mastoid air cells and middle ear cavities
are clear. There are no soft tissue abnormalities.
IMPRESSION: 1. Unchanged cortical foci of low attenuation, consistent with
acute infarction in the right frontal and anterior parietal lobes, right
middle cerebral artery territory. No evidence of hemorrhagic transformation.
2. Periventricular white matter changes suggest chronic small vessel ischemic
disease.
Radiology Report
CHEST ON ___
HISTORY: Verify PICC line placement.
FINDINGS: There is a right-sided PICC line with tip in the mid SVC. The
lungs are clear without infiltrate or effusion. The right hemidiaphragm is
mildly elevated. The aorta is mildly tortuous. Cardiac silhouette is normal.
Radiology Report
HEAD MRI WITHOUT CONTRAST, HEAD MRA WITHOUT CONTRAST, NECK MRA WITH AND
WITHOUT CONTRAST
INDICATION: New onset of right frontal stroke.
COMPARISON: Non-contrast head CT performed on ___ at ___
___.
TECHNIQUE: Sagittal T1-weighted, and axial T2-weighted, FLAIR, gradient echo,
and diffusion-weighted images of the head were obtained. Three-dimensional
time-of-flight MRA of the head was obtained, with multiplanar maximal
intensity projection reformatted images. Coronal VIBE imaging of the neck was
performed before, during, and after intravenous gadolinium administration,
with multiplanar maximal intensity projection reformatted images of the neck
arteries.
FINDINGS:
HEAD MRI: There are multiple cortical foci of slow diffusion in the right
posterior frontal and anterior parietal lobes, in the middle cerebral artery
territory. Several smaller foci of slow diffusion are also noted in the
anterior right frontal lobe. These demonstrate faint high signal on FLAIR
images, indicating that the evolving acute infarction is more than six hours
old. There are no associated blood products. However, there are two punctate
foci of low signal intensity on gradient echo images in the paramedian right
frontal lobe, indicating chronic microhemorrhages, which could be related to
amyloid angiopathy, hypertension, or less likely a cavernous malformation.
FLAIR images also demonstrate multiple foci of high signal in the deep and
periventricular white matter, and to a lesser extent in the subcortical white
matter of the cerebral hemispheres, likely sequela of chronic small vessel
ischemic disease in a patient of this age. There is a small chronic
infarction in the left inferior cerebellar hemisphere. There is moderate
cerebral atrophy with associated prominence of the ventricles and sulci.
There is fluid and mild mucosal thickening in the left maxillary sinus. There
is moderate mucosal thickening in the ethmoid air cells bilaterally.
NECK MRA: There is a three-vessel aortic arch. The cervical common carotid,
internal carotid, and vertebral arteries appear patent without evidence of
hemodynamically significant stenoses.
HEAD MRA: Flow is visualized in the intracranial internal carotid and
vertebral arteries, and their major branches. M1 segment of the middle
cerebral arteries demonstrate symmetric flow. However, superior and inferior
division branches of the right middle cerebral artery are smaller in caliber
compared to the left. There is no evidence for an intracranial aneurysm.
IMPRESSION:
1. Multiple cortical foci of acute infarction in the right frontal and
anterior parietal lobes, in the right middle cerebral artery territory. No
significant mass effect at this time. No evidence of hemorrhagic
transformation.
2. Two punctate chronic microhemorrhages in the paramedian right frontal
lobe, which could be related to amyloid angiopathy, hypertension, or less
likely a cavernous malformation.
3. Unremarkable neck MRA.
4. The superior and inferior division branches of the right middle cerebral
artery are smaller in caliber compared to the left.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: SLURRED SPEECH
Diagnosed with CEREBRAL ART OCCLUS W/INFARCT
temperature: 97.2
heartrate: 71.0
resprate: 16.0
o2sat: 95.0
sbp: 188.0
dbp: 93.0
level of pain: 0
level of acuity: 2.0 | TRANSITIONAL ISSUES:
[] Complete course of IV meropenem for urinary tract infection
[] f/u as urology as outpatient for further management of his
recurrent urinary tract infection/BPH
** Stroke Core Measure **
[ AHA/ASA Core Measures for Ischemic Stroke and Transient
Ischemic Attack ]
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
3. Antithrombotic therapy administered by end of hospital day 2?
(x) Yes - () No
4. LDL documented? (x) Yes (LDL = 89) - () No
5. Intensive statin therapy administered? (for LDL > 100) (x)
Yes - () No (if LDL >100, Reason Not Given: )
6. Smoking cessation counseling given? () Yes - (x) No (Reason
(x) non-smoker - () unable to participate)
7. Stroke education given? (x) Yes - () No
8. Assessment for rehabilitation? (x) Yes - () No
9. Discharged on statin therapy? (x) Yes - () No (if LDL >100,
Reason Not Given: )
10. Discharged on antithrombotic therapy? (x) Yes (Type: (x)
Antiplatelet - () Anticoagulation) - () No
11. Discharged on oral anticoagulation for patients with atrial
fibrillation/flutter? () Yes - () No - (x) N/A
___ left handed man with PMH of HTN, BPH, dementia and recent
hospitalization for MDR UTI who p/w new difficulty speaking and
L sided weakness, found to have posterior right frontal and
parietal infarct. His examination is limited by his inattention
and motor left hemineglect, but shows nonfluent aphasia with
anomia and left/right confusion.
#NEURO: patient with acute posterior right frontal and parietal
infarct, appears embolic given the scattered lesions. He was
started on aspirin 325mg daily. BCx and TTE were done to rule
out endocarditis given recent infection and did not show any
evidence of endocarditis. He passed bedside dysphagia screen and
was started on pureed diet and nectar thick liquid. MRI showed
the right frontal and parietal infact. His hospitalization was
complicated by fluctuating awakefulness during the
hospitalization, and EEG was done which did not show any
seizures but there was one event questionable for seizure. He
was started on Keppra for this event. His labs showed LDL of 89,
so his home simvastatin was continued. His A1C was 6.2% and
patient did not require insulin during this hospitalization. He
was seen by ___ who recommended discharge to rehab.
Patient did have periods of decreased arousal and poor PO
intake, NG tube placement was attempted but patient resisted the
attempts. Spoke with the daughter ___ who stated that
patient frequently refuses medications and food when he is not
feeling well, and that she did not want him to undergo
procedures he did not want such as NG tube placement or PEG
placement.
#CV: no known cardiac history but patient with multiple risk
factors, also with mild troponinemia on admission, which was
likely due to demand ischemia with elevated BP on admission
given low CK and flat MB in setting of kidney disease. His
troponin decreased on its own. His blood pressure was managed
with his home metoprolol after 2 days. He was continued on home
simvastatin for hypercholesterolemia.
#ENDO: His TSH was 1.8 and his A1C was 6.2%
#RENAL: creatinine 1.5 on admission and remained stable
throughout this hospitalization. Unclear baseline, though
reportedly had acute kidney injury in the setting of recent MDR
E coli UTI. His medications were renally dosed.
#ID: recent MDR E Coli UTI per family requiring IV abx at home
(was on imipenem). No WBC or fevers to suggest ongoing
infection. UA without evidence of UTI on admission, but patient
developed malodorous urine and repeat UA showed moderate leuk
esterase and increased WBC. He was started on meropenem and his
UCx showed E Coli that was sensitive to meropenem and
ciprofloxacin. Given his age, IV meropenem was continued. TTE
was also done to rule out endocarditis as the cause of stroke,
and it was negative.
#GI: dysphagia screen was done and patient was cleared for puree
diet and nectar thick liquid. Patient occasionally had poor PO
intake in setting of decreased level of arousal.
#GU: continued on flomax for BPH. Will require outpatient
urology follow up appointment for recurrent urinary tract
infection.
#FEN: heart healthy diet after passing bedside s/s
#PPx: heparin SQ TID, bowel regimen
#CODE: DNR/DNI |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Syncope
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: The patient is a ___ year old ___ woman who comes in with LOC
and a MVC who is 5 weeks pregnant with a history of anxiety,
depression, ADHD, OCD, migraine headaches, h/o gastric bypass
___ and subsequent 130 lb wt loss. We were consulted to
evaluate
___ weeks of episodes of bizarre visual symptoms,
lightheadedness, syncope.
For the past ___ weeks the patient has been having recurrent
episodes of visual phenomenon, lightheadedness, and generalized
weakness. These three symptoms sometimes occur separately and at
other times occur together. They have been growing more frequent
and are now occuring at least ___ times per day. The visual
phenomenon she describes as "checkers" of skinny, tan colored,
horizontal lines across her vision that mostly obscures her
vision. There is also a variation on this which she calls "sand"
which also covers her vision and obscures it. There is no
migration or progression from one quadrant to another, instead
the phenomenon covers her entire visual field. These episodes
tend to occur mostly when she is standing up for a prolonged
period, or when she goes from sitting to standing quickly. Thus
she has started to try to stand up slower. Generally when this
happens she has to grab onto things around her and lowers
herself
to the ground which helps. The symptoms generally resolved after
___ minutes. She has also been having episodes of
lightheadedness
intermittently which can be associated with the visual symptoms
but not always. Finally, she has epsideso of "legs going
noodles"
which she describes as a generalized weakness. When she tries to
stand up from her bed to go to the bathroom especialyl she notes
that she feels generally weak and her legs give out on her. On
several occasions she has had to lower herself to the ground and
call for help. She also notes that she finds herself needing to
sit down or lean against objects more often than prior.
The patient has had 3 episodes of syncope in the past 2 weeks
(including the episode leading to her current MVC). Her first
episode occured when she was walking down the hallway in her
house. She then felt lightheaded and felt her legs buckle, and
she remembers lowering herself towards the floor, but she then
lost conciousness and awoke to find her daughter next to her.
The
second episode occured when she was in the shower and she sat
down in the shower, she does not remember this episode well. The
third episode was today leading to her MVC. She was driving back
from ___ when she experienced the visual
"checkers" phenomenon, and then blacked out. She slammed her car
into a pole and does not remember waking up until after the
accident. This is one of the first times she has had an episode
like this while she was sitting down.
On neurologic review of systems, the patient denies current
headache, lightheadedness, or confusion.
Endorses some recent word finding difficulty in the past several
weeks.
Denies loss of vision, blurred vision, diplopia, vertigo
Denies muscle weakness.
Denies loss of sensation, although she notes she occasionally
gets tingling in 2 toes on her R foot
Denies bowel or bladder incontinence or retention.
Denies difficulty with gait.
On general review of systems, the patient denies fevers, rigors,
she does get "hot sweats" day and night. 130 lb weight loss
recently after gastric bypass.
Denies chest pain, palpitations, dyspnea, or cough.
Endorses nausea, vomiting with the pregnancy, endorses
constipation
Denies dysuria or hematuria.
Denies myalgias, arthralgias, or rash.
Endorses occasional anxiety attacks but no palpitations
associated with the events above.
Past Medical History:
- 5 weeks pregnant
- s/p gastric banding procedure ___, lost 130 lbs since
then
- anxiety
- depression
- ADHD
- OCD
- h/o headaches, likely migrinous: she describes a throbbing
pressure on the top of her head, no nausea or vomiting but +
photo and phonophobia. These occur 2x per month. No recent
increase in frequency.
Social History:
___
Family History:
No history of seizure. M aunt with stroke. DM in
the family. Fathers side has fibromyalgia, RSD.
Physical Exam:
General: NAD, lying in bed comfortably.
Head: NC/AT, no conjunctival icterus, no oropharyngeal lesions
Neck: Supple, no nuchal rigidity, no meningismus
Pulmonary: non labored
Abdomen: Soft, obese
Extremities: Warm, no edema
Skin: No rashes or lesions
Neurologic Examination:
- Mental Status -
Awake, alert, oriented x 3. She is moderately inattentive. She
gets the MOYB all mixed up and cannot proceed, she is able to do
DOWB. History is disjointed. Structure of speech demonstrates
fluency with full sentences, intact repetition, and intact
verbal
comprehension. Content of speech demonstrates intact naming
(high
and low frequency) and no paraphasias. Normal prosody. No
dysarthria. Verbal registration and recall ___. No evidence of
hemineglect. No left-right agnosia.
- Cranial Nerves -
I. not tested
II. Equal and reactive pupils (3mm to 2mm). On fundoscopic exam,
optic disc margins were sharp. Visual acuity was ___ R eye
and ___ L eye, and visual fields were full to finger wiggling.
III, IV, VI. smooth and full extraocular movements without
diplopia or nystagmus.
V. facial sensation was intact, muscles of mastication with full
strength
VII. face was symmetric with full strength of facial muscles
VIII. hearing was intact to finger rub bilaterally.
IX, X. symmetric palate elevation and symmetric tongue
protrusion
with full movement.
XI. SCM and trapezius were of normal strength and volume.
- Motor -
Muscule bulk and tone were normal. No pronation, no drift. No
tremor or asterixis.
Delt Bic Tri ECR FExt FFlx IP Quad Ham TA Gas
L 5 5 ___ 5 5 5 5 5 5
R 5 5 ___ 5 5 5 5 5 5
- Sensation -
Intact to light touch, pinprick, and proprioception at the great
toes.
- DTRs -
Bic Tri ___ Quad Gastroc
L 2 2 2 2 2
R 2 2 2 2 2
Plantar response flexor bilaterally.
- Cerebellar -
No dysmetria with finger to nose testing bilaterally. Good speed
and intact cadence with rapid alternating movements.
- Gait -
Normal initiation. Narrow base. Normal stride length and arm
swing.
Pertinent Results:
___ 10:45AM ___ PTT-33.6 ___
___ 10:45AM PLT COUNT-199
___ 10:45AM WBC-9.5 RBC-4.65 HGB-12.5 HCT-39.8 MCV-86
MCH-27.0 MCHC-31.5 RDW-13.3
___ 10:45AM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-POS barbitrt-NEG tricyclic-NEG
___ 10:57AM HGB-13.4 calcHCT-40 O2 SAT-59 CARBOXYHB-3 MET
HGB-0
___ 04:21PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-NEG
___ 04:21PM URINE bnzodzpn-POS barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 05:56AM WBC-6.8 RBC-4.16* HGB-11.4* HCT-36.0 MCV-86
MCH-27.4 MCHC-31.7 RDW-13.5
___ 05:56AM VIT B12-315
___ 05:56AM TSH-1.5
___ 05:56AM CALCIUM-8.8 PHOSPHATE-4.7* MAGNESIUM-2.0
___ 05:56AM ALT(SGPT)-13 AST(SGOT)-13 CK(CPK)-41 ALK
PHOS-49 TOT BILI-0.3
___ 05:56AM GLUCOSE-82 UREA N-9 CREAT-0.6 SODIUM-137
POTASSIUM-3.6 CHLORIDE-105 TOTAL CO2-27 ANION GAP-9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Diazepam 5 mg PO TID
2. BuPROPion 300 mg PO DAILY
Discharge Medications:
1. Diazepam 5 mg PO TID
2. BuPROPion 300 mg PO DAILY
3. OxycoDONE (Immediate Release) 10 mg PO Q4H:PRN pain
refractory to tylenol
RX *oxycodone 10 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
SYNCOPE
MOTOR VEHICLE ACCIDENT
BACK PAIN
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: MRV HEAD W/O CONTRAST
INDICATION: ___ year old pregnant woman status post syncope. Evaluate for
dural venous sinus thrombosis.
TECHNIQUE: 2D time-of-flight MRV of the brain with angiographic maximal
intensity projection reformatted images.
COMPARISON: None
FINDINGS:
Flow is visualized in the major dural venous sinuses, including the superior
sagittal sinus, straight sinus, bilateral transverse sinuses, bilateral
sigmoid sinuses, and visualized upper internal jugular veins, without evidence
for occlusion. There are 2 small, centrally located, nonocclusive apparent
filling defects in the left transverse sinus on image 100:9, which are most
likely related to invagination of arachnoid granulations, or less likely
fenestrations. Their central location and nonocclusive nature are not
consistent with thrombus. This may be confirmed by conventional routine brain
MRI.
IMPRESSION:
No evidence for dural venous sinus thrombosis. Arachnoid granulations
invaginating into the left transverse sinus versus fenestrations, which may be
better defined with conventional routine brain MRI, if clinically warranted.
Radiology Report
EXAMINATION: EARLY OB US <14WEEKS
INDICATION: ___ year old woman with 5 weeks pregnant // assess location of
fetus
LMP: unknown
TECHNIQUE: Transabdominal and transvaginal examinations were performed.
Transvaginal exam was performed for better visualization of the embryo.
COMPARISON: None available
FINDINGS:
An intrauterine gestational sac is seen and a single living embryo is
identified with a crown rump length of 5.3 mm representing a gestational age
of 6 weeks 3 days for an estimated due date of ___. The uterus
is normal. The left ovary is normal. The right ovary demonstrates a 0.6 x 0.7
x 0.6 cm echogenic focus in addition to a collapsed or hemorrhagic corpus
luteum cyst.
IMPRESSION:
1. Single live intrauterine pregnancy with gestational age of 6 weeks 3 days
correlating with estimated due date of ___
2. 7 mm echogenic focus within the right ovary likely representing an ovarian
dermoid. Recommend followup ultrasound after pregnancy.
NOTIFICATION: The findings were discussed by Dr. ___ with Dr. ___
on the telephone on ___ at 13:20 AM
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: MRV with some irregularity in the transverse sinuses. // Eval
for stroke, venous sinus thrombosis.
TECHNIQUE: Routine ___ nonenhanced MRI examination of the brain, including
sagittal T1 FLAIR, axial T2, axial FLAIR, axial T2 GRE, and axial diffusion
images.
COMPARISON: MRV from ___ and CT head from ___
FINDINGS:
There is no acute infarct or intra cerebral hemorrhage. Principal intracranial
vascular flow voids are preserved. Flow voids of the dural venous sinuses are
also preserved. There is no increased signal on T1 and FLAIR and no negative
susceptibility in the medial left transverse sinus to correspond to the
possible filling defect seen on the MRV. The tiny filling defect in the
lateral left transverse sinus is below the resolution of this exam. There is
no T2 hyperintense focus to suggest an arachnoid granulation. A punctate focus
of FLAIR hyperintensity in the left frontal lobe is nonspecific. No
extra-axial blood or fluid collection is present. The ventricles and sulci are
normal in size and configuration. No diffusion abnormality is detected. No
intracranial mass is identified.
The brainstem, posterior fossa, and cervicomedullary junction are preserved.No
abnormality of the skull base or calvarium is identified.
IMPRESSION:
1. No increased signal on T1 or FLAIR and no evidence of negative
susceptibility in the medial left transverse sinus to suggest thrombosis. The
finding seen on the MRV is likely due to slow flow.
2. The tiny filling defect in the lateral left transverse sinus is below the
resolution of this exam. No T2 hyperintense signal to suggest an arachnoid
granulation. If there is still concern for a small dural venous thrombosis,
consider CTV
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: MVC
Diagnosed with OTH CURR COND-ANTEPARTUM, MYALGIA AND MYOSITIS NOS, MV COLLISION NOS-DRIVER
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | # Neuro: Ms. ___ was admitted and had a MRI of the brain that
was normal. She had an EEG that was also normal. She did not
have any further episodes while admitted. She had CT scans of
the spine that were unremarkable. She was given oxycodone for
pain management due to musculoskeletal pain ___ her MVA.
#CV: She had an echocardiogram and a EKG of her heart that were
both unremarkable. due to concern that her symptoms are not
epileptic and may be cardiac in etiology, we have ordered a
holter monitor to be done as an outpatient. She will be
discharged with the instructions to go to cardiology department
to be fitted with the holter.
# OB/GYN: She was seen by obgyn who stated that it was fine to
continue the diazepam. She had a pelvic US that showed an
intrauterine fetus. She stated her desire to terminate the
pregnancy and has an outpatient appointment scheduled with
obgyn. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Cipro
Attending: ___
Chief Complaint:
Shortness of breath and chest pain
Major Surgical or Invasive Procedure:
Cardiac catheterization ___
History of Present Illness:
___ with H/O CAD s/p CABG x 3v in ___, S/P permanent pacemaker
for paroxysmal atrial fibrillation with sick sinus syndrome,
with recent admission for chest pain with recent
dipyridamole-MIBI showing no reversible defects (but chest
discomfort with vasodilator administration), who presents with
several day history of jaw and left arm pain (which is her
anginal equivalent), chest pain, and dyspnea.
She reports that the pain in her jaw has been constant and is
worsened over the past several days. The pain is worse with
exertion, with associated shortness of breath and diaphoresis.
Patient endorses chronic dyspnea, slightly worse from baseline
recently. She reported no cough, no nausea or vomiting, and no
other changes in symptoms in the interval since discharge.
Patient was admitted ___ for similar symptoms and
underwent dipyridamole-MIBI with no evidence of ischemia on
nuclear imaging and LVEF 65%, but dipyridamole induced chest
pressure radiating to throat and jaw. Her pacemaker was adjusted
at that point for increased rate responsiveness with exertion,
but there has not been any substantial improvement in her
respiratory symptoms. Overall, respiratory symptoms seem to have
come on gradually without any inciting event over the course of
multiple weeks.
In the ED initial vitals were: T 98.1 BP 142/81 HR 62 RR 16 SaO2
99% on RA. EKG showed atrial pacing at 63 bpm, normal axes and
intervals, and no ST elevations. CXR showed no acute
cardiopulmonary process with stable elevation of the right
hemidiaphragm. Labs/studies notable for Troponin-T <0.01, Na
127; Chem 7, CBC, coags otherwise normal. Patient was given ASA
325 mg, acetaminophen 1000 mg, and lorazepam 0.5 mg. Vitals on
transfer: T 97.8 BP 135/50 HR 61 RR 18 SaO2 98% on RA
On arrival to the cardiology ward, the patient reported some
ongoing shortness of breath and jaw pain with minimal chest
pressure.
Past Medical History:
-Coronary Artery Disease
-Stents (3) to RCA ___
-Stent to RCA ___
-POBA PDA and stent to LCX ___
-Stent to RCA ___
-CABG in ___ (LIMA-LAD, SVG-RCA, SVG-OM; Dr. ___
-Paroxysmal atrial fibrillation
-S/P pacemaker for sick sinus syndrome ___ after syncope with
10 second pauses after conversion to NSR from atrial
fibrillation
-Raynaud's
-subdural hematoma ___
-Depression
-Gastroesophageal Reflux Disease
-Hemorrhoids
-Hyperlipidemia
-Irritable Bowel Syndrome (Constipation)
-Left Leg Weakness following Spine Surgery
-Low Back Pain
-Sciatica
-Osteoarthritis
Past Surgical History:
-S/P Hemorrhoidectomy ___
-S/P Laminectomy L4-L5 ___
-S/P Total Abdominal Hysterectomy ___
-S/P Cholecystectomy ___
-S/P Bladder Sling ___
Social History:
___
Family History:
Mother - died of myocardial infarction, age ___
Father - died of stroke, age uncertain
Brother - died of complications from Diabetes mellitus, history
of CABG x3, age ___
Physical Exam:
On admission
GENERAL: elderly white woman in NAD. Oriented x3. Mood, affect
appropriate.
VS: T 97.8 BP 135/50 HR 61 RR 18 SaO2 98% on RA
HEENT: NCAT. Sclera anicteric. PERRL, EOMI.
NECK: Supple with JVP flat at 90 degrees
CARDIAC: RR, normal S1, S2. No murmurs, rubs, gallops.
LUNGS: Resp were unlabored, no accessory muscle use, speaking
without difficulty. CTAB--no crackles, wheezes or rhonchi.
ABDOMEN: Soft, not distended. No HSM or tenderness.
NEURO: CN ___ intact, strength ___ and sensation intact
throughout
At discharge
GENERAL: elderly woman in NAD. Oriented x3. Mood, affect
appropriate.
VS: T 98.3 BP 111-147/47-107 HR 60-71 RR 18 SaO2 95% on RA
24 hours ins/outs: 1140/none reported
Overnight ins/outs: 0/none reported
Wt 68.2 kg
HEENT: NCAT. Sclera anicteric. MMM
NECK: Supple with JVP to lower third of neck.
CARDIAC: RR, normal S1, S2. No murmurs, rubs, gallops.
LUNGS: Resp were unlabored, no accessory muscle use, speaking
without difficulty. CTAB--no crackles, wheezes or rhonchi.
ABDOMEN: Soft, non-tender, not distended.
Ext: warm and well perfused; +1 distal and radial pulses
bilaterally, no edema. Right femoral arteriotomy site clean, dry
and intact; no femoral bruit.
Pertinent Results:
___ 12:00PM BLOOD WBC-5.9 RBC-4.76 Hgb-13.6 Hct-41.3 MCV-87
MCH-28.6 MCHC-32.9 RDW-13.5 RDWSD-43.2 Plt ___
___ 12:00PM BLOOD Glucose-95 UreaN-17 Creat-0.7 Na-127*
K-4.4 Cl-92* HCO3-24 AnGap-15
___ 12:00PM BLOOD cTropnT-<0.01
___ 06:05PM BLOOD cTropnT-<0.01
___ 07:55AM BLOOD cTropnT-<0.01
___ 06:00AM BLOOD CK(CPK)-39
___ 06:00AM BLOOD CK-MB-1 cTropnT-<0.01 proBNP-99
___ 08:20AM BLOOD proBNP-168
___ 08:20AM BLOOD WBC-5.0 RBC-4.49 Hgb-13.0 Hct-39.0 MCV-87
MCH-29.0 MCHC-33.3 RDW-13.5 RDWSD-43.1 Plt ___
___ 08:20AM BLOOD ___ PTT-39.9* ___
___ 08:20AM BLOOD Glucose-107* UreaN-9 Creat-0.7 Na-134
K-4.5 Cl-99
HCO3-25 AnGap-15
___ 08:20AM BLOOD Calcium-8.8 Phos-3.8 Mg-2.3
ECG ___ 11:04:03 AM
Atrial paced rhythm with intrinsic ventricular conduction. RSR'
pattern in lead V1 (normal variant). Compared to the previous
tracing of ___ the findings are similar.
CXR ___
A left-sided pacemaker and dual leads as well as sternotomy
wires are unchanged from prior examinations.
The heart is normal in size. Aorta is unfolded, similar to
prior. On lateral view, calcified or stented coronary artery is
noted, also unchanged.
Elevation and possible eventration of the right hemidiaphragm
is similar to the prior film.
No focal consolidation, pleural effusion, pulmonary edema or
pneumothorax is identified. In the right cardiophrenic region,
there is subsegmental atelectasis and/or scarring similar to ___ and ___. Linear atelectasis and/or
scarring at the left base is also unchanged. Minimal blunting of
one of the costo vertebral angles posteriorly is also unchanged.
IMPRESSION:
No acute pulmonary process identified. Stable elevation of the
right hemidiaphragm. Stable atelectasis/scarring at both bases.
Cardiac catheterization ___
Hemodynamics: State: Baseline
LV 196/10 HR 64
AO 194/71/116 HR 64
Coronary Anatomy
Dominance: Right
* Left Main Coronary Artery: The LMCA is normal.
* Left Anterior Descending: The LAD is moderately diseased mid,
supplied by ___. The ___ Diagonal is supplied by ___.
* Circumflex: The Circumflex is minimally diseased. The ___
Marginal is minimally diseased, supplied by SVG jump graft
* Right Coronary Artery: The RCA is moderately diffusely
diseased. Modest ostial dz. The Right PDA is minimally diseased.
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.
There is a background of moderate calcific and noncalcific
atherosclerosis.
There is a dual lead pacemaker in situ, with leads located in
the right ventricle in the right atrium.
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. There
is no evidence of pericardial effusion. There is no pleural
effusion.
Mild bibasal linear atelectasis. There is a small calcified
right apical granuloma. There is minimal bronchial wall
thickening within the right lower lobe.
Limited images of the upper abdomen demonstrate multiple
hypodense lesions within the liver, representing cysts or
biliary hamartomas.
No lytic or blastic osseous lesion suspicious for malignancy is
identified. There has been prior sternotomy.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Mild bibasal linear atelectasis.
3. Multiple hepatic cysts versus biliary hamartomas.
Echocardiogram ___
The left atrium is elongated. There is mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global systolic function (LVEF>55%). Right ventricular
chamber size and free wall motion are normal. The aortic valve
leaflets are mildly thickened (?#). There is no aortic valve
stenosis. No aortic regurgitation is seen. Trivial mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is normal. There is no pericardial effusion.
IMPRESSION: Symmetric LVH with normal global and regional
biventricular systolic function.
Compared with the prior study (images reviewed) of ___,
the findings are similar.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 650 mg PO BID:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 20 mg PO BID
4. Escitalopram Oxalate 5 mg PO TID
5. Fluticasone Propionate NASAL 1 SPRY NU BID
6. Hydrocortisone Acetate Suppository ___AILY:PRN rectal
pain
7. Lidocaine 5% Patch 3 PTCH TD DAILY:PRN pain
8. LORazepam 0.5 mg PO TID
9. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
10. Phenazopyridine 100 mg PO DAILY:PRN urinary pain
11. Vitamin D ___ UNIT PO DAILY
12. Zolpidem Tartrate 5 mg PO QHS
13. Cyclobenzaprine 5 mg PO TID:PRN back pain
14. Dexilant (dexlansoprazole) 60 mg oral DAILY
15. Lidocaine Jelly 2% 1 Appl TP Q6H:PRN hemorrhoids
16. Mylanta 2 teaspoons oral TID
17. salt irrigation solution ___ % nasal unknown
18. Senna with Docusate Sodium (sennosides-docusate sodium)
8.6-50 mg oral DAILY
19. TheraTears (carboxymethylcellulose sodium) 1 drop OPHTHALMIC
Frequency is Unknown
Discharge Medications:
1. Acetaminophen 1000 mg PO BID:PRN pain
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 40 mg PO BID
4. Escitalopram Oxalate 5 mg PO TID
5. Fluticasone Propionate NASAL 1 SPRY NU BID
6. Hydrocortisone Acetate Suppository ___AILY:PRN rectal
pain
7. Lidocaine 5% Patch 3 PTCH TD DAILY:PRN pain
8. Lidocaine Jelly 2% 1 Appl TP Q6H:PRN hemorrhoids
9. LORazepam 0.5 mg PO TID
10. Mylanta 2 teaspoons oral TID
11. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
12. Phenazopyridine 100 mg PO DAILY:PRN urinary pain
13. Vitamin D ___ UNIT PO DAILY
14. Zolpidem Tartrate 5 mg PO QHS
15. Cyclobenzaprine 5 mg PO TID:PRN back pain
16. Dexilant (dexlansoprazole) 60 mg oral DAILY
17. salt irrigation solution ___ % nasal unknown
18. Senna with Docusate Sodium (sennosides-docusate sodium)
8.6-50 mg oral DAILY
19. TheraTears (carboxymethylcellulose sodium) 1 drop OPHTHALMIC
Frequency is Unknown
20. Diltiazem 30 mg PO Q8H
RX *diltiazem HCl 30 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
- Shortness of breath
- Chest wall pain unlikely to be ischemic in origin
- Costochondritis
- Coronary artery disease
- Prior coronary artery bypass surgery
- Sick sinus syndrome
- Paroxysmal atrial fibrillation
- Prior implantation of a dual-chamber permanent pacemaker
- Hyponatremia
- Chronic back pain
- Gastroesophageal reflux disease
- Chronic abdominal pain
- Depression and anxiety
- Insomnia
- Raynaud's 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 radiograph
INDICATION: History: ___ with chest pressure // Eval for acute process
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiographs from ___ through ___
FINDINGS:
A left-sided pacemaker and dual leads as well as sternotomy wires are
unchanged from prior examinations.
The heart is normal in size. Aorta is unfolded, similar to prior. On lateral
view, calcified or stented coronary artery is noted, also unchanged.
Elevation and possible eventration of the right hemidiaphragm is similar to
the prior film.
No focal consolidation, pleural effusion, pulmonary edema or pneumothorax is
identified. In the right cardiophrenic region, there is subsegmental
atelectasis and/or scarring similar to ___ and ___.
Linear atelectasis and/or scarring at the left base is also unchanged.
Minimal blunting of one of the costo vertebral angles posteriorly is also
unchanged.
IMPRESSION:
No acute pulmonary process identified. Stable elevation of the right
hemidiaphragm. Stable atelectasis/scarring at both bases.
Radiology Report
INDICATION: ___ with PMHx of CAD s/p CABG x 3 in ___, PPM for paroxysmal
afib/sick sinus syndrome, with recent admission for chest pain w/ recent
negative p-MIBI, who presents with several day history of jaw pain (which is
her anginal equivalent), diaphoresis, and dyspnea. // any e/o PE or
dissection
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 0.5 s, 1.0 cm; CTDIvol = 1.2 mGy (Body) DLP = 1.2
mGy-cm.
2) Stationary Acquisition 8.0 s, 1.0 cm; CTDIvol = 18.5 mGy (Body) DLP =
18.5 mGy-cm.
3) Stationary Acquisition 2.0 s, 1.0 cm; CTDIvol = 4.6 mGy (Body) DLP = 4.6
mGy-cm.
4) Spiral Acquisition 8.4 s, 32.2 cm; CTDIvol = 9.2 mGy (Body) DLP = 282.6
mGy-cm.
Total DLP (Body) = 317 mGy-cm.
COMPARISON: None
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.
There is a background of moderate calcific and noncalcific atherosclerosis.
There is a dual lead pacemaker in situ, with leads located in the right
ventricle in the right atrium.
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.
There is no evidence of pericardial effusion. There is no pleural effusion.
Mild bibasal linear atelectasis. There is a small calcified right apical
granuloma. There is minimal bronchial wall thickening within the right lower
lobe.
Limited images of the upper abdomen demonstrate multiple hypodense lesions
within the liver, representing cysts or biliary hamartomas.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
There has been prior sternotomy.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Mild bibasal linear atelectasis.
3. Multiple hepatic cysts versus biliary hamartomas.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain, L Arm pain
Diagnosed with Other chest pain
temperature: 98.1
heartrate: 62.0
resprate: 16.0
o2sat: 99.0
sbp: 142.0
dbp: 81.0
level of pain: 7
level of acuity: 2.0 | ___ with H/O CAD s/p CABG x 3 in ___ (LIMA-LAD, SVG-OM,
SVG-RCA), S/P permanent pacemaker for paroxysmal atrial
fibrillation with sick sinus syndrome in ___, with recent
admission for chest pain with no objective evidence of ischemia
on dipyridamole-MIBI, who presented now with several day history
of jaw and left arm pain (which is her anginal equivalent),
chest pain, and dyspnea.
# Chest pain, CAD s/p CABG: Patient re-presenting with jaw and
left arm pain with chest pressure and shortness of breath, her
known angina equivalent. She had been admitted ___ with
similar presentation, which was thought to be musculoskeletal in
origin. She had a similar presentation during this admission.
Chest pain was not relieved with SL NTG. ECG was benign, and
troponin-T negative X 4. Since she had continued chest pain
despite a recent negative and reassuring pharmacological stress
test, cardiac catheterization was undertaken via the right
femoral artery which showed a normal LVEDP of 10 mm Hg. The LAD
had moderate disease with a patent LIMA. The RCA had moderate
ostial and disease disease. The CX was patent, as was the
SVG-OM. The SVG-RCA was not imaged. There was no evidence of
significant valvular or structural abnormalities by TTE.
Ultrasound technologist was able to reproduce Ms. ___
symptoms with pressure over sternum, directly over surgical
scar. There was no evidence of aortic dissection or pulmonary
embolus on chest CTA. Patient discharged on acetaminophen 1 g
TID for presumed musclosketal pain/costochondritis and diltiazem
30 mg TID for possible coronary microvascular disease. Given
prior CABG, her atorvastatin was increased from 20 mg BID to 40
mg BID. She was continued on home dose of ASA 81 mg daily for
cardiovascular prevention. Patient was not on a beta-blocker
given H/O exacerbation of Raynaud's with beta-blockers.
# Dyspnea - Chronic shortness of breath with acute worsening.
Limited functional capacity due to exertional dyspnea. No clear
cardiac etiology with vasodilator stress test negative for
imaging evidence of ischemia (and no reported bronchospasm).
LVEDP normal at left heart catheterization, and very low
NT-Pro-BNP twice. Pulmonary workup as an outpatient seems
warranted.
# Sick sinus syndrome/paroxysmal atrial fibrillation: s/p PPM.
A-paced with HR of 60. Pacemaker interrogated by EP at prior
admission and rate responsiveness was increased. Dyspnea did not
improve following adjustment of settings, suggesting non-optimal
pacemaker settings are unlikely to be contributing to her
respiratory complaints. CHADS2VASC score 4 suggested she may
benefit from anticoagulation, which she elected to discuss with
her outpatient providers.
# Hyponatremia: Patient intermittently hyponatremic in the past,
baseline Na of 129-135. On presentation had Na of 127, which
improved to 134 on discharge with fluid restriction.
# Chronic abdominal pain/IBS/GERD: Changed home dexilant 60 mg
daily to omeprazole 40 daily due to non-formulary. Continued
hydrocortisone suppository daily PRN.
# Chronic back pain: No pain. Held home cyclobenzaprine PRN.
Continued lidocaine patch BID PRN
# Anxiety: Continued home lorazepam 0.5 mg TID.
# Depression: Continued home Lexapro BID.
# Insomnia: Continued home Ambien 5 mg qHS. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins / Codeine
Attending: ___.
Chief Complaint:
Abdominal pain.
Major Surgical or Invasive Procedure:
Liver biopsy ___.
History of Present Illness:
___ male with BRCA1 mutation, breast cancer s/p
mastectomy and axillary lymph node dissection, chemotherapy and
radiation, prostate cancer, melanoma, and left ___ DVT s/p
coumadin treatment presenting with abdominal pain. The
patient's history is challenging secondary to slight confusion
from dilaudid in the ER and his admittedly being overwhelmed
with being told he likely has metastasis in the ER. He states
that he has chronic abdominal pain but the morning of admission,
it awoke ___ from sleep. It was on the right side of his
abdomen, ___ in intensity, sharp, and not relieved by Maalox.
He also "slipped" but did not his his head. He was admitted at
another hospital 3 days ago for a routine endoscopy which was
unrevealing; he was also started on Bactrim there for a UTI
which he does not like because sulfa upsets his stomach. On
arrival to the floor, he is anxious, frustrated, and overwhelmed
but has less abdominal pain with the dilaudid.
.
Review of Systems: Unable to obtain complete ROS secondary to
patient not cooperating.
Past Medical History:
Right breast cancer s/p mastectomy
Secondary malignancy of breast to right axilla
Prostate cancer treated ___ ago
Melanoma s/p excision ___ years ago
Left lower lobe pulmonary nodules
arthritis
Left lower extremity DVT ___ duplex
Chronic left renal obstruction due to staghorn calculus noted on
CT ___
.
Right modified radical ___
Right rotator cuff repair
cholecystectomy
colon resection
prostatectomy
multiple excisions of skin lesions
.
CURRENT ONCOLOGY HISTORY (from note on ___:
He was diagnosed with breast cancer in ___. He is a BRCA1
mutation carrier. The tumor in the right breast was 1.8 cm, ER
positive, PR positive, grade 3 infiltrating ductal cancer, HER-2
negative. There were two involved lymph nodes also positive
LVI.
He had a right mastectomy. He started tamoxifen in ___.
.
When we started, his CEA was 14 that came down to about 11 in
___, has been stable. His ___ had been 40 and has
been
normal since then.
His biggest issue is that when he went to get radiation therapy,
there was so much erythema and inflammation of his chest wall
and
his right arm. He had already had right shoulder and arm
discomfort ever since right shoulder surgery. The pain was so
intolerable.
.
he still suffers from chronic pain. He takes 600
mg gabapentin (Neurontin) at night and one pill of 300 mg in the
morning. The only other medicine is tamoxifen.
.
He had a DVT in his leg previously and had been on Coumadin, but
he is off of that now.
.
He has a history of prostate cancer as well as a tumor at the
base of his brain ___ years ago.
.
He had a CTA of his chest in ___ because of some shortness
of breath and other symptoms. He had had some pulmonary nodules
seen on his initial staging. It was unclear whether they were
benign or cancerous. In any case, they were stable on the
___ CAT scan compared to ___.
.
Each time he comes over six months, we will draw extensive labs
including tumor markers.
Social History:
___
Family History:
Significant for having two daughters with breast cancer at ages
___s a sister. He underwent genetic testing and is
a mutation carrier.
Physical Exam:
ADMISSION EXAM:
Vitals: T 97.8 bp 122/40 HR 73 RR 18 SaO2 96RA Wt 143.6 lbs
GENERAL - Somewhat somnlent but easily aurosable
HEENT - EOMI, sclerae anicteric, MMM, OP clear
NECK - Supple, no thyromegaly, no JVD
HEART - PMI non-displaced, RRR, nl S1-S2, no MRG, surgical scar
from right mastectomy, tender on palpation of chest with
discolored skin
LUNGS - CTAB, no r/rh/wh, good air movement, resp unlabored, no
accessory muscle use
ABDOMEN - diffusely tender with no distention, no rigidity or
peritoneal signs, cannot fully appreciate liver margin secondary
to pain
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses, reports
decreased sensation in both feet due to neuropathy; limited
range of motion of right shoulder, tender on palpation of right
arm/axilla/chest
NEURO - awake, A&Ox3, CNs II-XII grossly intact
PSYCH - tangential thought process, normal thought content,
irritable
Pertinent Results:
ADMISSION LABS:
___ 03:30PM URINE COLOR-Yellow APPEAR-Hazy SP ___
___ 03:30PM URINE BLOOD-TR NITRITE-POS PROTEIN-TR
GLUCOSE-NEG KETONE-40 BILIRUBIN-NEG UROBILNGN-NEG PH-6.0 LEUK-LG
___ 03:30PM URINE RBC-12* WBC->182* BACTERIA-FEW
YEAST-NONE EPI-0
___ 11:41AM LACTATE-1.1
___ 11:36AM GLUCOSE-90 UREA N-25* CREAT-1.0 SODIUM-140
POTASSIUM-4.4 CHLORIDE-104 TOTAL CO2-27 ANION GAP-13
___ 11:36AM ALT(SGPT)-20 AST(SGOT)-26 ALK PHOS-77 TOT
BILI-0.4
___ 11:36AM LIPASE-24
___ 11:36AM ALBUMIN-3.6 CALCIUM-8.9 PHOSPHATE-2.8
MAGNESIUM-2.0
___ 11:36AM WBC-5.5 RBC-4.06* HGB-12.9* HCT-39.7* MCV-98
MCH-31.8 MCHC-32.5 RDW-13.0
___ 11:36AM NEUTS-73.2* LYMPHS-17.0* MONOS-7.1 EOS-1.9
BASOS-0.7
___ 11:36AM PLT COUNT-240
___ 11:36AM ___ PTT-27.8 ___
.
___ CXR: No acute cardiopulmonary abnormality.
.
___ CT ABD/PELVIS: IMPRESSION:
1. At least two new ill-defined hypodense hepatic lesions,
measuring up to 2.0 cm, with new distal CBD wall enhancement and
thickening resulting in intra- and extra-hepatic biliary
obstruction. Findings are concerning for metastases from breast
cancer involving the liver and distal common bile duct, although
primary cholangiocarcinoma with hepatic metastases may also be
considered. ERCP/MRCP is recommended for further evaluation.
2. Innumerable subcentimeter hepatic hypodensities, previously
characterized as biliary hamartomas, grossly stable in size and
number.
3. Chronic left renal obstruction due to staghorn calculus.
4. Numerous bilateral renal cysts, one of which has enlarged
and another of which is complex. Renal ultrasound may be
obtained for further evaluation if indicated.
5. No evidence of bowel obstruction or diverticulitis.
.
___ RUQ U/S: FINDINGS: Within segment VIII near the junction
with segment ___, there is a 2.0 cm round hypoechoic lesion with
central slight relative increased echogenicity compared to the
periphery. This lesion is concerning for metastasis. Similarly
within segment VI, there is a slightly smaller lesion measuring
1.2 cm, also hypoechoic and concerning for metastasis. These
lesions are feasible for US guided biopsy.
.
DISCHARGE LABS:
___ 07:42AM BLOOD WBC-5.9 RBC-3.82* Hgb-12.4* Hct-36.8*
MCV-96 MCH-32.5* MCHC-33.8 RDW-13.3 Plt ___
___ 07:55AM BLOOD Neuts-72.8* Lymphs-15.5* Monos-7.2
Eos-3.9 Baso-0.6
___ 06:40AM BLOOD ___ PTT-28.3 ___
___ 07:42AM BLOOD Glucose-139* UreaN-11 Creat-0.8 Na-139
K-4.2 Cl-106 HCO3-25 AnGap-12
___ 07:55AM BLOOD Albumin-3.4* Calcium-8.6 Phos-3.1 Mg-1.7
___ 06:20AM BLOOD ALT-14 AST-21 LD(LDH)-131 AlkPhos-68
TotBili-0.3
___ 07:55AM BLOOD TSH-1.5
___ 07:55AM BLOOD T4-6.8 calcTBG-1.07 TUptake-0.93
T4Index-6.3
___ 06:40AM BLOOD Cortsol-5.7
___ 07:55AM BLOOD CEA-19* ___
Medications on Admission:
GABAPENTIN 300 mg PO qAM and 600mg PO qHS
[M-VIT]
TAMOXIFEN 10 mg PO BID (NOT TAKING)
TEMAZEPAM 15 mg PO qHS PRN
Bactrim
ACETAMINOPHEN [TYLENOL EXTRA STRENGTH] 500-1000mg PO PRN pain
MELATONIN - 1 mg PO at night
OMEPRAZOLE [PRILOSEC]
Colace 100mg PO BID
Maalox ___ PO QID PRN heartburn
Clarilax PRN
Discharge Medications:
1. gabapentin 600 mg PO TID.
Disp:*180 Capsule(s)* Refills:*2*
2. tamoxifen 10 mg PO BID.
Disp:*60 Tablet(s)* Refills:*1*
3. temazepam 15 mg PO HS.
4. acetaminophen 325-650mg PO q6HR PRN pain.
5. omeprazole 20 mg PO DAILY.
6. oxycodone 20 mg Extended Release 12 hr PO Q12H.
Disp:*60 Tablet Extended Release 12 hr(s)* Refills:*0*
7. hydromorphone 2 mg Tablet Sig: ___ Tablets PO Q3H PRN pain.
Disp:*100 Tablet(s)* Refills:*0*
8. docusate sodium 100 mg PO BID.
9. senna 8.6 mg PO BID.
10. polyethylene glycol 3350 17 gram Powder in Packet PO DAILY.
Disp:*20 Powder in Packet(s)* Refills:*1*
11. prochlorperazine maleate ___ PO q6HR PRN nausea.
Disp:*20 Tablet(s)* Refills:*1*
12. alum-mag hydroxide-simeth 200-200-20mg/5mL Sig: ___ PO
QID PRN heartburn.
13. ciprofloxacin 500 mg PO Q12H x2 days.
Disp:*4 Tablet(s)* Refills:*0*
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
1. Abdominal pain.
2. New liver metastases.
3. Breast cancer.
4. Chronic right arm and chest pain/neuropathy.
5. Urinary tract infection (UTI).
6. Kidney stone.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Esophageal dilatation one week ago.
COMPARISON: ___.
PA AND LATERAL VIEWS OF THE CHEST:
The heart size is normal. The aorta is mildly tortuous and demonstrates mild
calcification at the aortic arch. The pulmonary vascularity is normal. A
7-mm calcified nodule within the left lower lobe is again demonstrated
compatible with a granuloma. Hyperinflation of lungs is unchanged suggestive
of underlying COPD. There are no acute osseous abnormalities. Surgical
anchors from prior rotator cuff repair are seen within the right humeral head,
partially imaged.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
INDICATION: ___ man with right lower quadrant abdominal pain and
tenderness. History of appendectomy and cholecystectomy. Evaluate for
obstruction or diverticulitis.
COMPARISONS: Multiple prior CT abdomen and pelvis, most recently CT torso of
___.
TECHNIQUE: MDCT images were obtained from the lung bases to the pubic
symphysis. 130 cc of IV Omnipaque contrast were administered. Axial images
were interpreted in conjunction with coronal and sagittal reformats.
DLP: 279 mGy-cm.
FINDINGS: The visualized heart is normal. Bibasilar opacities are compatible
with atelectasis or scarring. Right calcified pleural plaques are again seen.
Previously described pulmonary nodules are not imaged on this exam.
At least two new ill-defined hypodense lesions are seen in the liver, the
largest of which measures 2.0 x 1.2 cm in hepatic segment VIII (601B:18). A
smaller new 1.3 x 0.9 cm hepatic segment VI hypodensity (2:19) is also seen.
Innumerable subcentimeter hypodense hepatic lesions, previously characterized
as biliary hamartomas, are again seen. There is increased intra- and
extra-hepatic bile duct dilatation with wall thickening and enhancement of the
distal common bile duct (___), with the distal CBD now measuring 1 cm in
diameter. The gallbladder is absent. The pancreas and pancreatic duct are
unremarkable. No pancreatic mass is seen. The spleen and bilateral adrenal
glands are unremarkable.
A large staghorn calculus is again seen in the left kidney and the left kidney
demonstrates subtly decreased enhancement relative to the right kidney. No
excreted contrast is seen in the left ureter. Numerous bilateral renal
hypodensities are again seen. A 1.6 x 1.5 cm left lower pole hypodensity has
enlarged since the prior exam, previously 9-mm. A complex left renal cyst
with a peripheral calcification (2:23) is again seen.
The stomach is unremarkable. The visualized small and large bowel have a
normal course and caliber. Diverticulosis is present without evidence of
diverticulitis. The appendix is absent, compatible with history of
appendectomy.
No retroperitoneal or mesenteric lymphadenopathy. The portal vasculature is
normal. Dense abdominal aortic calcifications are again seen. A large
atherosclerotic calcification is present at proximal left renal artery. Left
perirenal varices are again seen. No abdominal wall hernia, pneumoperitoneum,
or abdominal free fluid.
PELVIS: The bladder is normal. Evaluation of pelvic structures is obscured
by beam hardening from numerous metallic pelvic clips, compatible with
prostatectomy, and inguinal clips. No inguinal or pelvic side wall
lymphadenopathy. No free pelvic fluid or inguinal hernia.
OSSEOUS STRUCTURES: No focal lytic or sclerotic lesion concerning for
malignancy.
IMPRESSION:
1. At least two new ill-defined hypodense hepatic lesions, measuring up to
2.0 cm, with new distal CBD wall enhancement and thickening resulting in
intra- and extra-hepatic biliary obstruction. Findings are concerning for
metastases from breast cancer involving the liver and distal common bile duct,
although primary cholangiocarcinoma with hepatic metastases may also be
considered. ERCP/MRCP is recommended for further evaluation.
2. Innumerable subcentimeter hepatic hypodensities, previously characterized
as biliary hamartomas, grossly stable in size and number.
3. Chronic left renal obstruction due to staghorn calculus.
4. Numerous bilateral renal cysts, one of which has enlarged and another of
which is complex. Renal ultrasound may be obtained for further evaluation if
indicated.
5. No evidence of bowel obstruction or diverticulitis.
Radiology Report
CLINICAL HISTORY: Patient with new liver lesions suspicious for metastases.
Feasibility to assess for ultrasound-guided biopsy.
STUDY: Limited ultrasound, liver.
___.
FINDINGS:
Within segment VIII near the junction with segment ___, there is a 2.0 cm
round hypoechoic lesion with central slight relative increased echogenicity
compared to the periphery. This lesion is concerning for metastasis.
Similarly within segment VI, there is a slightly smaller lesion measuring 1.2
cm, also hypoechoic and concerning for metastasis.
These lesions are feasible for US guided biopsy.
Radiology Report
ULTRASOUND-GUIDED LIVER BIOPSY DATED ___
INDICATION: ___ man with liver mass. History of breast, prostate and
melanoma. Biopsy liver lesion.
COMPARISON: Comparison is made to previous ultrasound dated ___ and
CT dated ___.
PHYSICIANS: Dr. ___ and Dr. ___, performed the
procedure. Dr. ___ attending radiologist, was present throughout the
procedure.
SEDATION: Moderate sedation was provided by administering divided doses of
Versed 1 mg and fentanyl 50 mcg throughout the total intraservice time of 20
minutes, during which the patient's hemodynamic parameters were continuously
monitored.
PROCEDURE: Following a detailed discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained. The
patient was transferred to the ultrasound suite and placed in a supine
position. Initial preprocedure timeout was performed to localize the segment
VIII liver lesion. A suitable skin point for biopsy was obtained. A
preprocedure timeout was performed using three unique patient identifiers as
per ___ protocol.
The skin overlying the right upper quadrant was prepped and draped in usual
sterile fashion. Approximately 6 mL of 1% lidocaine was infiltrated into the
skin, subcutaneous tissue and to the liver capsule for local anesthesia. An
18-gauge core biopsy needle was advanced into the liver lesion and a single
18-gauge core biopsy sample was obtained. Onsite cytology confirmed sample
adequacy. The patient tolerated the procedure well. There were no immediate
complications. The patient was transferred back to the floor in stable
condition.
Sample was sent to pathology for further analysis.
IMPRESSION: Technically successful ultrasound-guided 18-gauge core biopsy of
segment VIII liver lesion. Onsite cytology confirmed sample adequacy. No
immediate complication.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with ABDOMINAL PAIN RUQ
temperature: 97.4
heartrate: 86.0
resprate: 22.0
o2sat: 97.0
sbp: 105.0
dbp: 68.0
level of pain: 10
level of acuity: 3.0 | ___ man with BRCA1 mutation, breast cancer s/p right mastectomy
and axillary lymph node dissection, chemotherapy and radiation,
prostate cancer, melanoma, and LLE DVT s/p warfarin [on
tamoxifen] admitted for abdominal pain and new liver lesions.
.
# Abdominal pain: Likely due to new liver mets. Liver biopsy
done ___ without complication. Started OxyContin, increased
to 20mg BID. Mr. ___ noted improvement in pain with OxyContin
and PRN hydromorphone.
- F/U LIVER BIOPSY, RESULTS PENDING.
.
# Breast cancer: Likely new liver mets. CEA 19, ___ 52.
Mr. ___ admitted to ___ with tamoxifen, but may be
open to trying it again. Liver biopsy done ___, results
pending. Consulted Social Work. Anti-emetics PRN. Restarted
tamoxifen.
.
# Hypotension: Improved with IV fluids. Unclear etiology. Low
AM cortisol, but did not do Cosyntropin stim test as BP improved
with IV fluids.
.
# UTI: TMP-SMX changed to ciprofloxacin due to GI upset. Urine
culture negative.
.
# Right chest pain from radiation changes and peripheral
neuropathy: Titrated up gabapentin to 600mg TID. Continued
temazepam.
.
# Anemia: Secondary to inflammation. Chronic, stable.
.
# Depession: His family believes he is depressed, but Mr. ___
denied this. Consulted Social Work.
.
# GERD: Chronic, stable. Continued PPI and aluminum/mag
hydroxide PRN.
.
# Constipation: Continued bowel regimen.
.
# DVT PPx: Heparin SQ.
.
# FEN: Regular diet. IV fluids.
.
# Precautions: Fall. ___ consulted.
.
# Lines: Peripheral IV.
.
# CODE: FULL. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
___ TEE
___ Cardiac Catheterization
___ CABG x1 (SVG-PDA), MVR (31mm ___ tissue valve)
History of Present Illness:
___ male with history of untreated HTN and 80 pack-year
smoking history, presenting with progressive dyspnea.
Patient presented to ___ for 3 months of progressive
dyspnea. The patient that his first symptoms was worsening
sleep
at night, as he has severe PND limiting him to 1 hour of sleep
at
night. Because of this he quit smoking around 4 weeks ago, but
he
has become progressively dyspneic since this time. He has
significant dyspnea on exertion and is limited to only ___
steps
before becoming short of breath. He also notes fatigue during
this time because he cannot sleep.
Denies full review of systems including fevers, chills, cough,
abdominal pain, nausea, vomiting, chest.
At ___, he underwent an ECHO that showed severe MR, a
flail mitral leaflet, and possible mass on the valve cusp. He
was
transferred to ___ for further evaluation, including cardiac
surgery.
In the ___ ED, he underwent bedside ECHO with cardiology which
confirmed the above findings. He was then admitted to the ___
service for further management.
In the ED...
- Initial vitals: 96.7 ___ 18 96% RA
- EKG: NSR, poor R wave progression
- Labs/studies notable for: BNP 5168
On the floor, the patient endorsed the above history. Last seen
a primary care doctor ___ years ago, at which time he was told he
has hypertension but declined any medical therapies. He has not
had a colonoscopy or any other routine screening.
Past Medical History:
Hypertension
Social History:
___
Family History:
Noncontributory to presenting complaint
Physical Exam:
Admission:
___ Temp: 97.6 PO BP: 169/121 HR: 103 RR: 20 O2 sat:
95% O2 delivery: ra
GEN: Well appearing, NAD
HEENT: Conjunctiva clear, PERRL, MMM
NECK: No JVD noted
LUNGS: Decreased lungs sounds apically
HEART: RRR, nl S1, S2. III/VI holosystolic murmur heard at apex,
radiating into back
ABD: NT/ND, normal bowel sounds.
EXTREMITIES: No edema. WWP.
SKIN: No rashes.
NEURO: AOx3.
Discharge:
Vital Signs I/O
24 HR Data (last updated ___ @ 1123)
Temp: 97.4 (Tm 98.5), BP: 125/84 (123-156/78-108), HR: 62
(62-72), RR: 18 (___), O2 sat: 99% (94-99), O2 delivery: Ra,
Wt: 198.63 lb/90.1 kg
Fluid Balance (last updated ___ @ 1123)
Last 8 hours Total cumulative -1460ml
IN: Total 290ml, PO Amt 240ml, IV Amt Infused 50ml
OUT: Total 1750ml, Urine Amt 1750ml
Last 24 hours Total cumulative -2645ml
IN: Total 530ml, PO Amt 480ml, IV Amt Infused 50ml
OUT: Total 3175ml, Urine Amt 3175ml
Physical Examination:
General: NAD [x]
Neurological: A/O x3 [x] non-focal [x]
HEENT: PEERL [x]
Cardiovascular: RRR [x] Irregular [] Murmur [] Rub []
Respiratory: Decreased bilat [x] No resp distress [x]
GI/Abdomen: Bowel sounds present [x] Soft [x] ND [x] NT
[x]
Extremities:
Right Upper extremity Warm [x] Edema
Left Upper extremity Warm [x] Edema
Right Lower extremity Warm [x] Edema 1
Left Lower extremity Warm [x] Edema 1
Pulses:
DP Right:1 Left:1
___ Right:1 Left:1
Radial Right: Left:
Skin/Wounds: Dry [x] intact [x]
Sternal: CDI [x] no erythema [x] Bone stable & small amount
serous drainage[x]
Sternum stable [x]
Lower extremity: Right [] Left [x] CDI [x]
Other:
Pertinent Results:
Admission Labs:
___ 02:40PM BLOOD WBC-8.9 RBC-5.26 Hgb-14.9 Hct-46.7 MCV-89
MCH-28.3 MCHC-31.9* RDW-13.2 RDWSD-43.3 Plt ___
___ 02:40PM BLOOD ___ PTT-32.1 ___
___ 02:40PM BLOOD Glucose-94 UreaN-12 Creat-0.8 Na-137
K-4.6 Cl-100 HCO3-20* AnGap-17
___ 02:40PM BLOOD Albumin-3.7 Calcium-9.4 Phos-3.3 Mg-1.8
___ 07:25AM BLOOD %HbA1c-5.4 eAG-108
Discharge Labs:
___ 04:24AM BLOOD WBC-10.7* RBC-3.53* Hgb-9.9* Hct-31.3*
MCV-89 MCH-28.0 MCHC-31.6* RDW-13.7 RDWSD-43.8 Plt ___
___ 04:24AM BLOOD ___
___ 04:33AM BLOOD ___
___ 04:18AM BLOOD ___ PTT-29.9 ___
___ 04:24AM BLOOD Glucose-91 UreaN-12 Creat-0.7 Na-134*
K-4.5 Cl-98 HCO3-24 AnGap-12
=========================================================
Studies:
PA/LAT CXR ___ pulmonary edema has resolved. Small
bilateral pleural effusions.
Intraop TEE ___
PRE-OPERATIVE STATE: Pre-bypass assessment. Sinus rhythm.
Preop Comments: Sever MR. ___ thickened leaflets. Ruptured
chordae tendineae in A1 and A3 region eith
a large echodense mass attached to the chord in the A1 region
which may represent part of the papillary
muscle or a vegetation.
Left Atrium ___ Veins: Dilated ___. No spontaneous
echo contrast is seen in the ___.
Right Atrium (RA)/Interatrial Septum/Inferior Vena Cava (IVC):
DIlated RA. Normal interatrial
septum. No atrial septal defect by 2D/color flow Doppler.
Left Ventricle (LV): Mild symmetric hypertrophy. Normal cavity
size. No apical aneurysm Normal regional &
global systolic function Normal ejection fraction. No resting LV
outflow tract gradient. Grade III diastolic
dysfunction.
Right Ventricle (RV): Normal wall thickness. Normal cavity size.
Low normal free wall motion.
Aorta: Normal sinus diameter. Normal ascending diameter. Normal
arch diameter. Normal descending aorta
diameter. No dissection. Siimple atheroma of ascending aorta. No
arch atheroma. Simple descending
atheroma.
Aortic Valve: Mildly thickened (3) leaflets. Mild leaflet
calcification. Mild (>1.5cm2) stenosis. No
regurgitation.
Mitral Valve: Mildly thickened leaflets. Mild leaflet
calcification. Large (>1.0cm) mobile MASS on ___ of
valve most c/w a vegetation, tumor, or thrombus. No valvular
___. No stenosis. Mild annular calcification.
SEVERE [4+] regurgitation. Eccentric, inferolaterally directed
jet.
Tricuspid Valve: Normal leaflets. Mild-moderate [___]
regurgitation. Eccentric, interatrial septal directed
jet.
Pericardium: No effusion.
POST-OP STATE: The post-bypass TEE was performed at 18:00:00. AV
paced rhythm.
Support: Vasopressor(s): norepinephrine.
Interatrial Septum: No atrial septal defect by 2D/color flow
Doppler.
Left Ventricle: Similar to preoperative findings. Global
ejection fraction is normal.
Right Ventricle:No change in systolic function.
Aorta: Intact. No dissection.
Aortic Valve: No change in aortic valve morphology from
preoperative state.
Mitral Valve: Bioprosthesis. Well-seated prosthesis. Normal
leaflet motion. Post-bypass, mean mitral valve
gradient = 5mmHg. Trace regurgitation.
Tricuspid Valve: No change in tricuspid valve morphology vs.
preoperative state.
Pericardium: No effusion.
Cardiac Cath ___
Normal left and right heart filling pressures.
Single vessel coronary artery disease.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild/Fever
max 4000mg/day
2. Amiodarone 400 mg PO BID postop AFib
400mg BID x 3 days, then 200mg BID x 7 days, then 200mg daily
RX *amiodarone 400 mg 1 tablet(s) by mouth as directed Disp #*30
Tablet Refills:*2
3. Aspirin EC 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*1
4. Atorvastatin 10 mg PO DAILY
RX *atorvastatin 10 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*1
5. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
6. Furosemide 40 mg PO BID
40mg po BID x 3 days, then decrease to 40mg daily x 7 days
RX *furosemide [Lasix] 40 mg 1 tablet(s) by mouth twice a day
Disp #*13 Tablet Refills:*0
7. Metoprolol Tartrate 6.25 mg PO TID
RX *metoprolol tartrate 25 mg 0.25 tablet(s) by mouth three
times a day Disp #*30 Tablet Refills:*1
8. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*20 Tablet Refills:*0
9. Potassium Chloride 20 mEq PO BID
20meq po BID x 3 days, then 20meq po daily x 7 days
RX *potassium chloride [K-Tab] 20 mEq 1 tablet(s) by mouth as
directed Disp #*13 Tablet Refills:*0
10. Ranitidine 150 mg PO BID
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*1
11. Warfarin 1 mg PO ASDIR tiss MVR & postop Afib Duration: 3
Months
0.5-2 tablets daily as directed for goal INR ___
RX *warfarin 1 mg ___ tablet(s) by mouth as directed Disp #*60
Tablet Refills:*1
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Acute mitral regurgitation
atrial fibrillation
Secondary:
Hypertension
Discharge Condition:
Alert and oriented x3, non-focal
Ambulating, gait steady
Sternal pain managed with oral analgesics
Sternal Incision - healing well, no erythema. Small amount
serous drainage from middle incision. Stable bone.
Edema- 1+ BLE
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PRE-OP PA AND LAT)
INDICATION: ___ year old man with history of HTN presents with severe MR and
concern for flail leaflet// pre-op CXR Surg: ___ (MVR)
COMPARISON: Chest radiograph from ___.
FINDINGS:
PA and lateral views of the chest provided.
Since the prior radiograph from ___, mild pulmonary edema has
improved. There is no pleural effusion or pneumothorax. Borderline
cardiomegaly is stable.
Multiple healed right posterior rib fractures. Mild vertebral body height
loss in the midthoracic spine, of uncertain chronicity.
IMPRESSION:
Mild pulmonary edema, improved.
Radiology Report
EXAMINATION: CHEST PORT. LINE PLACEMENT
INDICATION: ___ yo M s/p MVR// cardiac surgery protocol Contact name: icu
provider, Phone: 1
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___.
IMPRESSION:
There are postsurgical changes from mitral valve replacement. The
endotracheal tube terminates 5.4 cm above the carina. The right internal
jugular Swan-Ganz catheter terminates in the main pulmonary outflow tract.
The enteric tube terminates in the fundus of the stomach. A left chest tube
and pericardial and mediastinal drains are in place.
The cardiac silhouette remains enlarged. There is mild widening of the upper
mediastinum, in keeping with recent postsurgical changes. Patchy opacities in
the left lung most likely represent asymmetric pulmonary edema. No pleural
effusion or pneumothorax is identified. No acute osseous abnormalities are
identified.
Radiology Report
INDICATION: ___ year old man s/p MVR, CABG// eval for pneumothorax s/p CT
removal
COMPARISON: Radiographs from ___
IMPRESSION:
Endotracheal tube, Swan-Ganz catheter, feeding tube, and chest tube have been
removed. There is a residual right IJ Cordis. There is cardiomegaly which is
stable. There has been mild improvement of the pulmonary edema which is now
mild. No large pleural effusions or pneumothoraces are seen. Old left upper
posterior rib fractures are seen.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP) ___
INDICATION: ___ year old man with s/p CABG/MVR// eval pulmonary edema/pleural
effusion eval pulmonary edema/pleural effusion
IMPRESSION:
Compared to postoperative chest radiographs ___.
Mild pulmonary edema has developed since ___. Postoperative appearance
of the cardiomediastinal silhouette is expected, and unchanged. Pleural
effusions are small if any. No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old man s/p MVR, CABG// please check after 2pm
todaypredischarge eval
COMPARISON: Chest radiograph ___
FINDINGS:
PA and lateral views of the chest provided.
There has been interval resolution of mild pulmonary edema. There are small
bilateral pleural effusions. There is no pneumothorax. Cardiomediastinal
silhouette is within normal postoperative limits. There are multiple healed
posterior left rib fractures.
Median sternotomy wires are well aligned.
IMPRESSION:
Mild pulmonary edema has resolved. Small bilateral pleural effusions.
Gender: M
Race: NATIVE HAWAIIAN OR OTHER PACIFIC ISLANDER
Arrive by AMBULANCE
Chief complaint: Dyspnea, Transfer
Diagnosed with Dyspnea, unspecified
temperature: 96.7
heartrate: 102.0
resprate: 18.0
o2sat: 96.0
sbp: 152.0
dbp: 105.0
level of pain: 0
level of acuity: 2.0 | Mr ___ is a ___ male with no significant past
medical history presenting with subacute onset of dyspnea, found
to have evidence of pulmonary edema, with ECHO concerning
for severe mitral regurgitation. He underwent cardiac
catheterization which showed single vessel coronary disease. He
underwent TEE to help evaluate the mitral valve prior to
surgery. He then was transferred to C-Surg for surgical repair.
Mr. ___ was brought to the Operating Room on ___ where
the patient underwent CABG x1 (SVG-PDA), MVR (31mm ___
tissue valve). Overall the patient tolerated the procedure well
and post-operatively was transferred to the CVICU in stable
condition for recovery and invasive monitoring.
POD 1 found the patient extubated, alert and oriented and
breathing comfortably. The patient was neurologically intact
and hemodynamically stable. Beta blocker start was delayed due
to junctional rhythm. Low dose Lopressor was trialed with SB
___ on POD 2, but patient's HR dropped to ___ and he remained in
ICU for Apacing support. Coumadin was started for goal INR ___.
Chest tubes were removed per protocol. POD 3, he developed
rapid atrial fibrillation and was treated with IV/PO Amiodarone
and lopressor. He was gently diuresed toward the preoperative
weight and was transferred to the telemetry floor for further
recovery. He remained in NSR and his pacing wires were removed
on POD 6 (delayed d/t INR 2.1). The patient was evaluated by
the Physical Therapy service for assistance with strength and
mobility. His Lasix was increased for serous sternal drainage,
but the bone and wound itself remained stable. By the time of
discharge on POD 7, he was ambulating with rolling walker, the
wound was healing and pain was controlled with oral analgesics.
The patient was discharged to home with ___ and ___ services in
good condition with appropriate follow up instructions. Patient
had no prior medical doctors and ___ to arrange a formal PCP.
At time of discharge, ___ office is waiting to confirm
follow up visit with Dr. ___ who saw patient at ___
___ preoperatively. Dr. ___ will manage INR
dosing until patient's PCP or ___ follow up can be
confirmed and management transitioned. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Bactrim / pravastatin / simvastatin / Tricor / rosuvastatin
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
TEE and Ablation on ___
History of Present Illness:
Mr. ___ is a ___ yo M with hx of aortic stenosis s/p AVR
(tissue), CAD s/p CABGx2 ___, DM, ESRD on HD (MWF), HLD,
HTN,
AV block who presents with progressively worsening dyspnea for
___ days despite regularly scheduled dialysis sessions. Dyspnea
worse with minimal exertion, initially saw PCP on ___, who
recommended ED evaluation but he instead went to scheduled
dialysis and had 2.2L fluid removed which improved his dyspnea.
However, since then, dyspnea worsened. He slept in chair the
night before admission and notes increased leg swelling
particularly starting last night. He notes improving chest pain
surrounding his sternal incision (required less pain medicine).
On exertion, patient sometimes has chest tightness and
lightheadedness with SOB, but none at rest. Denies palpitations
and syncope. Most recent TTE on ___ showed mild LVH and normal
LV systolic function (EF > 55%) with well-seated biopresthetic
AVR, no aortic regurgitation and mild pulmonary artery systolic
hypertension (PASP 31)
In the ED initial vitals were: T 97, HR 54-62, BP 133-164/53-57,
RR ___, 96% 3L NC. Exam notable for JVP 10 cm H2O, ___
systolic
murmur at RUSB, decreased BS in the lung bases, 1+ ___ pitting
edema. EKG showed NSR at 71, atrial flutter with 3:1, no STE &
TWI in V6. Labs remarkable for BUN 30, Cr 5.6, Hb 9.9, BNP 9610,
Troponin 0.17 (decreased from 0.40 on ___, INR 1.7,
lactate
1.7. UA positive for 33 WBC, 15 RBC, proteinuria. Urine and
blood
cultures pending.
CTA showed no evidence of PE but had interval minimal dehiscence
of median sternotomy with erosion of the margins and stranding
of
the subcutaneous concerning for inflammation/infection and near
complete collapse of RLL (progressed since ___ with
bilateral pleural effusions (right greater than left), stable
lung nodules in RUL. Renal was consulted and patient underwent
hemodialysis.
On the floor, patient reports improved SOB after dialysis. He
denies fevers, chills, dysuria, abdominal pain, diarrhea. Denies
changes in diet other than decreased appetite due to abdominal
distension. Patient states lowest weight has been after dialysis
on ___ (94.5 kg).
Past Medical History:
Aortic Stenosis
Arrhythmia
Colitis
Coronary Artery Disease
Depression
Diabetes Mellitus, Insulin Dependent
Difficult Intubation
End-Stage Renal Disease, HD ___ via right chest access
Facial Droop, ___, self-resolved
First Degree AV block
Gastroesophageal Reflux Disease
Gout
Hearing Loss
Hyperlipidemia
Hypertension
Hypothyroid
Lipomas bilateral axilla
Low Testosterone
Neuropathy
Reflux Laryngitis
Pancreatic Insufficiency
Pancreatitis s/p resection
Scoliosis
? Seizure while on Depakote for diabetic nerve pain ___ yrs ago
Sleep Apnea
Surgical History:
Cholycystectomy and Partial Pancreatectomy
Left Radiocephalic AVF and Left brachiocephalic AVF
Right otologic procedure x ___
Microlaryngeal procedure
Tooth extraction
Social History:
___
Family History:
Non contributory
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
VS: 98.1F 149/79, HR 65, RR 22, 94% 3L
GENERAL: Well developed, well nourished in NAD
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
Conjunctiva were pink. MMM, oropharynx clear
NECK: Supple. JVP of 12 cm sitting up.
CARDIAC: regular rate, ___ systolic ejection murmur at RUSB
CHEST: midline sternotomy scar with dried granulomatous tissue,
mildly tender with palpation
LUNGS: Decreased BS at bases, no crackles or wheezing
ABDOMEN: soft, non-distended, nontender, normoactive BS
EXTREMITIES: warm, 1+ pitting edema to knees bilaterally
PULSES: DP pulses 2+ bilaterally
NEURO: CN II-XII intact except decreased bilateral hearing,
sensation intact bilaterally, strength symmetric
DISCHARGE PHYSICAL EXAMINATION:
VS: 98.3F, 125/58, HR 55, RR 18, 94% RA
GENERAL: Well developed, well nourished in NAD
HEENT: Normocephalic atraumatic. Sclera anicteric. PERRL. EOMI.
MMM, oropharynx clear
NECK: Supple. No JVP elevation
CARDIAC: bradycardic, ___ systolic ejection murmur at RUSB
CHEST: left chest pain reproducible with palpation
LUNGS: Decreased BS at RLL, no crackles or wheezing
ABDOMEN: soft, non-distended, nontender, normoactive BS
EXTREMITIES: warm, non-edematous, non-tender bilaterally.
PULSES: ___ pulses 2+ bilaterally
Pertinent Results:
ADMISSION LABS
___ 09:39AM BLOOD WBC-7.8 RBC-3.32* Hgb-9.9* Hct-33.3*
MCV-100* MCH-29.8 MCHC-29.7* RDW-17.4* RDWSD-63.7* Plt ___
___ 09:39AM BLOOD Neuts-76.1* Lymphs-12.4* Monos-7.4
Eos-2.0 Baso-0.8 NRBC-0.3* Im ___ AbsNeut-5.96
AbsLymp-0.97* AbsMono-0.58 AbsEos-0.16 AbsBaso-0.06
___:39AM BLOOD ___ PTT-33.4 ___
___ 09:39AM BLOOD Plt ___
___ 09:39AM BLOOD Glucose-299* UreaN-30* Creat-5.6*# Na-137
K-4.5 Cl-94* HCO3-28 AnGap-15
___ 09:39AM BLOOD proBNP-9610*
___ 09:39AM BLOOD cTropnT-0.17*
___ 09:40PM BLOOD CK-MB-4 cTropnT-0.17*
___ 09:39AM BLOOD Calcium-8.9 Phos-2.5* Mg-2.1
___ 10:45AM BLOOD VitB12-426 Hapto-204*
___ 09:39AM BLOOD TSH-1.8
___ 08:00AM BLOOD CRP-27.7*
___ 07:42AM BLOOD CRP-19.9*
DISCHARGE LABS
___ 06:19AM BLOOD WBC-7.6 RBC-3.41* Hgb-9.9* Hct-33.3*
MCV-98 MCH-29.0 MCHC-29.7* RDW-16.3* RDWSD-59.3* Plt ___
___ 06:19AM BLOOD Plt ___
___ 07:51AM BLOOD ___ PTT-84.1* ___
___ 06:19AM BLOOD Glucose-146* UreaN-46* Creat-6.3*# Na-140
K-5.0 Cl-95* HCO3-26 AnGap-19*
___ 06:19AM BLOOD Calcium-9.5 Phos-3.8 Mg-2.4
IMAGING
CTA ___
1. No evidence of acute pulmonary embolism.
2. Interval minimal dehiscence of the median sternotomy by 4 mm
with erosion
of the margins and stranding of the overlying subcutaneous
tissue, concerning
for inflammation/infection. No drainable fluid collection.
Wires are intact.
3. Near complete collapse of the right lower lobe, progressed
since ___. Mild enlargement of the bilateral nonhemorrhagic
pleural
effusions, moderate on the right and small on the left.
4. Stable solid lung nodules as described above. 8 mm
ground-glass nodule is
likely inflammatory given short term interval change. Please
refer to the
prior exams for follow-up.
CXR ___
Compared to chest radiographs ___. Moderate
right pleural effusion and severe right lower lobe atelectasis
are unchanged.
Moderate enlargement of the cardiac silhouette has increased and
mild
interstitial edema has developed best appreciated in the left
lower lung. No
pneumothorax. Right jugular line ends in the right atrium as
before.
CXR ___
Moderate right and small left pleural effusions with overlying
atelectasis.
CXR ___
The tip of a right hemodialysis catheter extends to the right
atrium. The
patient is post median sternotomy and aortic valve replacement.
Atelectasis is noted at the right lung base as well as a small
pleural
effusion. No pneumothorax. Pulmonary vascular congestion is
present without
frank pulmonary edema. The size of the cardiac silhouette is
enlarged but
unchanged.
CXR ___
Mild venous congestion with unchanged small right and minimal
left pleural
effusions.
CXR ___
Mild pulmonary venous congestion. Possible small right
effusion.
MICROBIOLOGY
Urine Culture ___: no growth
Blood Culture ___: no growth
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Lactulose 30 mL PO Q6H:PRN constipation
2. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
3. Allopurinol 50 mg PO DAILY
4. Aspirin EC 81 mg PO DAILY
5. DULoxetine 60 mg PO DAILY
6. Fluticasone Propionate 110mcg 2 PUFF IH BID SOB
7. HydrALAZINE 25 mg PO BID
8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
9. Levothyroxine Sodium 50 mcg PO DAILY
10. LORazepam 1 mg PO TID
11. Nephrocaps 1 CAP PO DAILY
12. Pantoprazole 40 mg PO Q24H
13. Rosuvastatin Calcium 5 mg PO QPM
14. Warfarin 2.5 mg PO DAILY16
15. TraMADol ___ mg PO Q4H:PRN Pain - Severe
16. Asmanex HFA (mometasone) 200 mcg/actuation inhalation
Q4H:PRN
17. Baclofen ___ mg PO QHS:PRN Muscle Spasms
18. Calcium Acetate 1334 mg PO TID W/MEALS
19. Hydrocortisone Cream 2.5% 1 Appl TP BID:PRN rash
20. Hydrocortisone Oint 2.5% 1 Appl TP PRN rash
21. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain:
moderate/severe
22. QUEtiapine Fumarate 25 mg PO QHS
23. Torsemide 100 mg PO DAILY
24. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN rash
25. amLODIPine 10 mg PO DAILY
26. Glargine 55 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
Reason for PRN duplicate override: Alternating agents for
similar severity
2. Ezetimibe 10 mg PO DAILY
RX *ezetimibe 10 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
3. Glargine 35 Units Breakfast
Insulin SC Sliding Scale using HUM Insulin
4. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain:
moderate/severe
6. QUEtiapine Fumarate 25 mg PO QHS
7. HydrALAZINE 100 mg PO TID
RX *hydralazine 100 mg 1 tablet(s) by mouth three times a day
Disp #*90 Tablet Refills:*0
8. LORazepam 0.5 mg PO QHS:PRN anxiety/airhunger without
hypoxia
RX *lorazepam 0.5 mg 1 tablet by mouth at bedtime Disp #*15
Tablet Refills:*0
9. Warfarin 5 mg PO DAILY16
RX *warfarin [Coumadin] 1 mg 5 tablet(s) by mouth daily Disp
#*150 Tablet Refills:*0
10. Allopurinol 50 mg PO EVERY OTHER DAY
11. amLODIPine 10 mg PO DAILY
12. Asmanex HFA (mometasone) 200 mcg/actuation inhalation
Q4H:PRN
13. Aspirin EC 81 mg PO DAILY
14. Baclofen ___ mg PO QHS:PRN Muscle Spasms
15. Calcium Acetate 1334 mg PO TID W/MEALS
16. DULoxetine 60 mg PO DAILY
17. Fluticasone Propionate 110mcg 2 PUFF IH BID SOB
18. Hydrocortisone Cream 2.5% 1 Appl TP BID:PRN rash
19. Hydrocortisone Oint 2.5% 1 Appl TP PRN rash
20. Lactulose 30 mL PO Q6H:PRN constipation
21. Levothyroxine Sodium 50 mcg PO DAILY
22. LORazepam 1 mg PO TID
23. Nephrocaps 1 CAP PO DAILY
24. Pantoprazole 40 mg PO Q24H
25. TraMADol ___ mg PO Q4H:PRN Pain - Severe
26. Triamcinolone Acetonide 0.1% Cream 1 Appl TP TID:PRN rash
27.Outpatient Lab Work
___ INR, Na, K, Cl, HCO3, BUN, creatinine.
786.09, ___
Fax: Dr. ___ ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY
========
Heart failure with preserved ejection fraction
Pleural effusion
Right lung collapse
Atrial flutter
Coronary artery disease
Thrombocytopenia
End stage renal disease
Hypertension
SECONDARY
==========
Diabetes Mellitus
Anemia
Hyperlipidemia
Gastroesophageal reflux disease
Hypothyroidism
Depression
Anxiety
Gout
Back spasm
Constipation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with sob, recent cardiac surgery// ? infectious
process, effusions
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: Chest radiographs from ___ and CT from ___.
FINDINGS:
Right subclavian dialysis catheter root tip over the right atrium. Median
sternotomy wires are aligned intact. Aortic valve replacement is again noted.
Since ___, right pleural effusion has increased in size, now
moderate. Small left pleural effusion is also likely increased. There is no
pneumothorax. Resultant atelectasis of the lower lobes have worsened, right
greater than left. The aerated upper lungs remain mostly clear. The
cardiomediastinal silhouette is grossly stable, though persistently moderately
enlarged.
IMPRESSION:
Increasing pleural effusions, now moderate on the right and small on the left
with worsening atelectasis.
Radiology Report
EXAMINATION: CTA chest
INDICATION: History: ___ with 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: Acquisition sequence:
1) Stationary Acquisition 4.0 s, 0.5 cm; CTDIvol = 12.1 mGy (Body) DLP =
6.1 mGy-cm.
2) Spiral Acquisition 3.9 s, 30.6 cm; CTDIvol = 14.7 mGy (Body) DLP = 448.5
mGy-cm.
3) Spiral Acquisition 0.8 s, 6.1 cm; CTDIvol = 12.1 mGy (Body) DLP = 73.9
mGy-cm.
4) Spiral Acquisition 0.8 s, 6.1 cm; CTDIvol = 12.1 mGy (Body) DLP = 74.0
mGy-cm.
Total DLP (Body) = 602 mGy-cm.
COMPARISON: Chest CT from ___ and CTA from ___.
FINDINGS:
The aorta and its major branch vessels are patent, with no evidence of
stenosis, occlusion, dissection, or aneurysmal formation. Postsurgical
changes along the ascending aorta is noted with unchanged appearance
calcifications as seen on ___ (3:61, 71, 99). Patient is status
post endovascular aortic valvular replacement, though the evaluation of the
valve placement is limited on the this non gated study. Right internal
jugular central venous catheter tip terminates in the right atrium, unchanged.
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 or segmental
pulmonary arteries. The main and right pulmonary arteries are normal in
caliber.
Patient is status post median sternotomy with cerclage wires, which are
intact. However, compared to prior exam, there is evidence of dehiscence of
the sternotomy by 4 mm with irregularity of the cortical margins, concerning
for erosion. There is stable amount of hyperdense stranding in the
mediastinum, presumably postsurgical changes. However, increased soft tissue
stranding along the median sternotomy, extending slightly into the anterior
abdomen is concerning for inflammatory changes.
There is no supraclavicular, axillary or hilar lymphadenopathy. The thyroid
gland appears unremarkable.
There is no evidence of pericardial effusion. There is no pleural effusion.
There is near complete collapse of the right lower lobe, progressed since ___. 8 mm ground-glass opacity in the aerated portion of the right
lower lobe is likely inflammatory (3:101). Moderate nonhemorrhagic pleural
effusions have also increased, moderate on the right and small on the left.
Atelectasis in the left lower lobe is stable. Scattered calcified granulomas
are again noted. 7 mm nodule in the right upper lobe with peripheral
calcification is unchanged from ___ (03:35). The airways are
patent to the subsegmental level.
Limited images of the upper abdomen are unremarkable.
Pre-existing nondisplaced right first, second and fifth rib fractures are
again noted. There is evidence of interval healing of the right fifth rib
fracture. No new fractures are seen.
IMPRESSION:
1. No evidence of acute pulmonary embolism.
2. Interval minimal dehiscence of the median sternotomy by 4 mm with erosion
of the margins and stranding of the overlying subcutaneous tissue, concerning
for inflammation/infection. No drainable fluid collection. Wires are intact.
3. Near complete collapse of the right lower lobe, progressed since ___. Mild enlargement of the bilateral nonhemorrhagic pleural
effusions, moderate on the right and small on the left.
4. Stable solid lung nodules as described above. 8 mm ground-glass nodule is
likely inflammatory given short term interval change. Please refer to the
prior exams for follow-up.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with ESRD, hypoxia found to have RLL collapse on
CTA and pleural effusions before dialysis// Interval change after dialysis
Interval change after dialysis
IMPRESSION:
Compared to chest radiographs ___. Moderate
right pleural effusion and severe right lower lobe atelectasis are unchanged.
Moderate enlargement of the cardiac silhouette has increased and mild
interstitial edema has developed best appreciated in the left lower lung. No
pneumothorax.
Right jugular line ends in the right atrium as before.
Radiology Report
INDICATION: ___ year old man with pleural effusions, atelectasis and RLL
collapse on prior CTA.// Please evaluate for interval change after dialysis
TECHNIQUE: Chest PA and lateral
COMPARISON: ___
FINDINGS:
The tip of the right hemodialysis catheter projects over the right atrium,
unchanged. The sternotomy wires are intact.
There are moderate right and small left pleural effusions with overlying
atelectasis. No pneumothorax. The size and appearance of the
cardiomediastinal silhouette is unchanged..
IMPRESSION:
Moderate right and small left pleural effusions with overlying atelectasis.
Radiology Report
INDICATION: ___ year old man with atrial flutter and known right sided
pneumothorax with new onset dyspnea// please evaluate for fluid overload
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
IMPRESSION:
The tip of a right hemodialysis catheter extends to the right atrium. The
patient is post median sternotomy and aortic valve replacement.
Atelectasis is noted at the right lung base as well as a small pleural
effusion. No pneumothorax. Pulmonary vascular congestion is present without
frank pulmonary edema. The size of the cardiac silhouette is enlarged but
unchanged.
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: ___ year old man with pleural effusions, hypoxia// interval
change?
TECHNIQUE: AP portable.
COMPARISON: ___
FINDINGS:
Right double-lumen hemodialysis catheter terminates in the right atrium. Mild
cardiomegaly is stable. Patient is status post sternotomy and aortic valve
replacement. Mild venous congestion is unchanged and small right and minimal
left pleural effusion are stable.
IMPRESSION:
Mild venous congestion with unchanged small right and minimal left pleural
effusions.
Radiology Report
INDICATION: ___ year old man with cough, dyspnea, ESRD on HD// Please evaluate
for volume overload, consolidation, infiltrates
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest x-ray ___
FINDINGS:
The right-sided hemodialysis catheter terminates in the right atrium. Sternal
wires appear intact. The patient is status post valve replacement. There is
mild pulmonary venous congestion. There are low lung volumes. There may be a
small right effusion. There is mild cardiomegaly, similar to previous. The
trachea is midline.
IMPRESSION:
Mild pulmonary venous congestion. Possible small right effusion.
Gender: M
Race: WHITE - OTHER EUROPEAN
Arrive by WALK IN
Chief complaint: Dyspnea
Diagnosed with Dyspnea, unspecified
temperature: 97.0
heartrate: 71.0
resprate: 20.0
o2sat: 91.0
sbp: 164.0
dbp: 49.0
level of pain: 5
level of acuity: 2.0 | BRIEF HOSPITAL COURSE
=====================
Mr. ___ is a ___ yo M with history of aortic stenosis s/p AVR
(tissue), CAD s/p CABGx2 on ___, DM, ESRD on HD (MWF), HLD,
HTN, who presented with progressively worsening dyspnea for ___
days despite regularly scheduled dialysis sessions found to have
collapsed RLL, bilateral pleural effusions.
ACTIVE ISSUES:
==============
#Dyspnea
#RLL collapse
#Bilateral pleural effusions
#HFpEF
Dypsnea likely multifactorial, likely secondary to volume
overload from HFpEF exacerbation iso elevated BNP, JVP and leg
swelling. Repeat TTE showed normal LV systolic function but RV
pressure/volume overload. Infection unlikely as patient denied
fever, chills, localizing symptoms, and urine/blood cultures
were negative. Also considered bradycardia as trigger, but HRs
have been higher than previous. Dietary indiscretion unlikely as
patient's appetite has decreased. Unlikely due to ischemia given
absence of EKG findings and stable troponin iso ESRD. TEE showed
well seated aortic valve without AR on ___. Notably, has RLL
collapse and bilateral atelectasis, pleural effusions, which
likely contributed to hypoxia. Repeat CXR after dialysis on
___ showed mild improvement in right effusion. IP was
consulted, who recommended aggressive volume removal with
dialysis and no thoracentesis. Patient should follow-up with IP
as outpatient. In coordination with hemodialysis, patient was
dialyzed to a new dry weight of 88.8kg. Patient's dyspnea
improved to where he was ambulating at 96% RA. However, patient
continued to have episodes of air hunger without documented
desaturations while sleeping. Given patient's weight had
improved and patient looked more euvolemic, negative cardiac
work up, negative CTA, these episodes thought to be mainly due
to anxiety. Patient agreed with this assessment and did feel
improvement with Lorazepam 0.5mg QHS PRN in addition to his home
1mg TID (on this for many years). Patient also has a history of
OSA and was on CPAP ___ years ago, however discontinued using
this. Recommended repeat Sleep study and evaluation.
Patient's home torsemide was stopped given minimal urine output
- Nephrology in agreement with this. He was continued on
isosorbide mononitrate and hydralazine was uptitrated for
hypertension to 100mg TID.
#CAD s/p CABG
#Sternotomy wound dehiscence
On exam, appears dry without discharge, but signs of possible
inflammation/infection on CTA. Evaluated by cardiac surgery who
did not believe wound was infected. ESR (55) and CRP initially
elevated, but CRP trended down during admission (27.7 -> 19.9).
Wound care consulted. Patient continued on aspirin, tylenol,
tramadol and oxycodone. Patient's chest pain was tender to
palpation and there were no EKG changes or CKMB elevations (trop
high due to ablation procedure and ESRD), and so thought to be
musculoskeletal in origin.
#Aflutter
#History of AV Block
Patient had advanced AV block with junctional escape in the ___,
immediately followed by 2:1 AV conduction on previous admission.
Has hx of AV Wenckeback and 2:1 AV block. EP consulted then and
decision was potential pacemaker in the future if conduction
abnormalities worsened or symptomatic. HRs have been 50-60s on
admission. Patient denies lightheadedness at rest and no
syncope. EKG on admission showed aflutter with 3:1. EP was
reconsulted and patient underwent TEE and ablation for aflutter
on ___. Findings from the procedure were notable for "high grade
AV block in AVN." Afterwards, his HRs remained in ___
degree AV delay and 2:1 conduction on serial EKGs. He was
heparin bridged and continued on warfarin. Final dose at
discharge was 5mg daily for goal INR ___. Should recheck INR on
___ by ___ and results faxed to PCP, ___.
#Thrombocytopenia
Platelet count trended down from 188 to 110 during admission
possibly in the setting of procedure. 4T score calculated to be
___ (low to moderate risk of HIT). Blood smear showed occasional
schistocytes, though haptoglobin and LDH were unremarkable.
Platelets rebounded without intervention several days prior to
discharge.
#DM
Patient on lantus 55U in morning and novolin sliding scale at
home. He was managed with lantus 35U QAM and HISS while
inpatient. Restarted home insulin on discharge.
#ESRD on hemodialysis
Patient continued on dialysis with aggressive UF to remove fluid
to lower dry weight according to hemodynamics. Continued on
nephrocaps and calcium.
#Anemia
Hgb stable at baseline Hb ___ in recent months. Likely due to
ESRD.
#HTN
Patient was consistently hypertensive during this admission.
Uptitrated hydralazine to 100 mg TID and continued amlodipine 10
mg daily.
#Anxiety
Patient noted to be subjectively short of breath at night,
though no clear oxygen desaturation. Patient reported missing
wife and art at home and stating the hospital was too "sterile."
PCP has been considering increasing Ativan dosing. Continued on
home seroquel and provided Ativan 0.5 mg QHS, in addition to his
home lorazepam 1mg TID. Patient felt improved. PCP was notified
of these changes.
CHRONIC ISSUES:
==============
#HLD
On ___, patient developed whole body myalgias similar to
symptoms he had on simvastatin and pravastatin. CK and LFTs were
normal. Held home rosuvastatin 5 mg qpm. Of note, at this point
patient has been tried on three statins and has not tolerated
these. Started on ezetimibe 10 mg daily.
#GERD
Continued home pantoprazole.
#Hypothyroid
Continued home levothyroxine.
#Depression/Anxiety/Agitation
Continued home quietiapine (dose reduced per patient request),
duloxetine and lorazepam. Added lorazepam 0.5mg QHS:PRN.
#Gout
Continued home allopurinol.
#Back spasms
Continued home baclofen.
#Constipation
Continued home lactulose.
======================= |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / levofloxacin
Attending: ___.
Chief Complaint:
Shortness of breath
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F h/o COPD p/w SOB. Pt had onset of worsening SOB 3 wks
ago. Reports "bad cold" at that time, which she could not get
ride of. She got Z-pack and prednisone. Both "definitely"
helped. However, SOB recurred and got worse. Has SOB with
walking. SOB was at its worst yesterday, prompting her to
present to ED. Has sensation of chest heaviness but denies frank
chest pain. She reports cough x 2 weeks, but just today she
started coughing up green mucous, no hemoptysis. Getting mucous
out has led to subjective improvement in symptoms. She reports
sweating at night but denies fever/chills. Also reports sore
throat x 1 day and runny nose x 2 day. Today, the right eye
"closed over" with crust. It is sore, "annoying," no burning.
In the ED, initial vitals were: 96.9 76 158/86 20 98%. Pt had
CTA neg for PE and two neg troponins.
On the floor, VS 98.4 127/84 80 20 94% RA. Pt is comfortable
appearing with non-labored breathing on room air.
Review of systems:
Gen: Weight 110->95 since this ___
HEENT: No vision/hearing change. Otherwise as per HPI.
Pulm: As per HPI
CV: Chest heaviness
GI: No abd pain/n/v/c/d/hematochezia
GU: No hematuria, no dysuria, no foul smelling urine
MSK: No myalgia/arthralgia
Skin: No rash
Heme: No LAD, no abnormal bruising/bleeding
Past Medical History:
COPD
Heart murmur
Depression
Social History:
___
Family History:
Father with lung cancer at age ___, no history of blood clots, no
DM, no heart disease, no early MI
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 98.4 127/84 80 20 94% RA
General: Lean female laying in bed, NAD
HEENT: Injected sclera of right eye with purulent drainage in
medial canthus. White patches on superior palate and mucosa of
left inner cheek.
Neck: No cervical/supraclavicular/submandibular LAD.
CV: RRR, no appreciable murmur, no gallops/rubs
Lungs: No wheezes/crackles/rhonchi b/l but tight breath sounds.
Non labored breathing on room air.
Abdomen: +BS, soft, nontender, nondistended
Ext: Warm, well perfused
Neuro: Grossly nonfocal
Skin: No obvious rashes.
DISCHARGE PHYSICAL EXAM:
VS: 97.8 116/61 79 18
Tmax 98.6 SBP 116-133 HR ___ 94-96% on RA
I/O (24H): 1060 PO / BRP
I/O (since MN): 200 PO / BRP
General: Lean female laying in bed, NAD
HEENT: Sclera not injected. No purulent drainage.
CV: RRR, no appreciable murmur, no gallops/rubs
Lungs: Decreased aeration in all lung fields, mild left basilar
wheeze. Non labored breathing on room air.
Abdomen: +BS, soft, nontender, nondistended
Back: Poorly circumscribed erythematous patch in midline of
superior buttocks. Skin intact.
Ext: Warm, well perfused
Neuro: Grossly nonfocal
Skin: No obvious rashes
Pertinent Results:
ADMISSION LABS
___ 04:50PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 04:50PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 04:50PM ___ PTT-34.2 ___
___ 04:50PM PLT COUNT-228
___ 04:50PM NEUTS-91.0* LYMPHS-6.4* MONOS-2.3 EOS-0.1
BASOS-0.2
___ 04:50PM WBC-13.3*# RBC-4.12* HGB-12.3 HCT-38.8 MCV-94
MCH-29.9 MCHC-31.8 RDW-13.5
___ 04:50PM D-DIMER-756*
___ 04:50PM CALCIUM-8.8 PHOSPHATE-3.0 MAGNESIUM-2.2
___ 04:50PM proBNP-143
___ 04:50PM cTropnT-<0.01
___ 04:50PM GLUCOSE-138* UREA N-8 CREAT-0.8 SODIUM-141
POTASSIUM-3.9 CHLORIDE-107 TOTAL CO2-24 ANION GAP-14
___ 05:00PM LACTATE-1.4
___ 11:10PM cTropnT-<0.01
INTERIM STUDIES
___ Sputum cytology
NEGATIVE FOR MALIGNANT CELLS; (evaluation is limited, see note.)
Squamous cells, neutrophils and few macrophages.
Note: Only few macrophages are identified, limiting evaluation.
DISCHARGE LABS
___ 05:45AM BLOOD WBC-11.2* RBC-4.31 Hgb-12.8 Hct-40.2
MCV-93 MCH-29.8 MCHC-31.9 RDW-13.4 Plt ___
___ 05:45AM BLOOD Plt ___
___ 05:45AM BLOOD Glucose-116* UreaN-10 Creat-0.7 Na-142
K-4.1 Cl-107 HCO3-25 AnGap-14
___ 05:45AM BLOOD Calcium-8.4 Phos-3.7 Mg-2.2
IMAGING/OTHER STUDIES
ECG ___
Sinus rhythm. Poor R wave progression in the right precordial
leads.
Non-specific diffuse ST-T wave abnormalities. Compared to the
previous tracing
of ___ ST-T wave abnormalities are new. Ventricular rate is
faster and
the premature atrial beat is absent.
CXR (PA/lateral) ___
There is no pleural effusion,
pneumothorax or focal airspace consolidation worrisome for
pneumonia.
Irregular linear opacities are consistent with emphysema
changes. The heart
is normal size and the mediastinal contours are unremarkable.
CTA chest ___
Contrast is seen opacifying the segmental and subsegmental
vessels
of the pulmonary arterial tree, without filling defects indicate
a pulmonary
embolus. The main pulmonary artery and aorta are normal caliber.
There is no
evidence for aortic injury. The heart is normal size and there
is no
pericardial effusion.
The trachea is normal. The airways are patent the subsegmental
level. There
is diffuse bronchial wall thickening. Small amount of retained
secretions are
seen at the level of the carina (3:95). No pleural effusion or
pneumothorax.
There is no focal airspace consolidation worrisome for
pneumonia. Scattered
ground-glass opacities within the right middle lobe may reflect
early atypical
infection (3:36). Linear opacities in this same area are likely
scarring.
There are severe changes of centrilobular emphysema. There is
no axillary,
supraclavicular or central lymphadenopathy.
The esophagus is unremarkable. Views of the arterially enhanced
liver,
adrenal glands, kidneys and spleen are unremarkable.
IMPRESSION:
1. No pulmonary embolus.
2. Diffuse bronchial wall thickening compatible with
bronchitis.
3. ___ opacities within the right middle lobe may
reflect early small
airways infection.
4. Severe changes of centrilobular emphysema.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Topiramate (Topamax) 350 mg PO DAILY
2. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
3. PredniSONE 20 mg PO DAILY
Tapered dose - DOWN
4. Azithromycin 250 mg PO Q24H
5. Estradiol 1 mg PO DAILY
6. Albuterol 0.083% Neb Soln 1 NEB IH PRN dyspnea
7. proGESTerone micronized 100 mg oral q HS
8. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
PRN dyspnea
9. Venlafaxine XR 75 mg PO DAILY
10. Simvastatin 40 mg PO QHS
11. Tiotropium Bromide 1 CAP IH DAILY
12. BuPROPion (Sustained Release) 200 mg PO QAM
13. QUEtiapine Fumarate 200 mg PO BID
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH PRN dyspnea
2. Azithromycin 250 mg PO Q24H
Stop taking this medication after two more doses on ___ and
___.
RX *azithromycin [Zithromax] 250 mg 1 tablet(s) by mouth daily
Disp #*2 Tablet Refills:*0
3. BuPROPion (Sustained Release) 200 mg PO QAM
4. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
5. QUEtiapine Fumarate 200 mg PO BID
6. Simvastatin 40 mg PO QHS
7. Topiramate (Topamax) 350 mg PO DAILY
8. Venlafaxine XR 75 mg PO DAILY
9. Erythromycin 0.5% Ophth Oint 0.5 in BOTH EYES QID Duration: 7
Days
Stop taking this medication on ___ (or as early as ___ if
symptoms have resolved).
RX *erythromycin 5 mg/gram (0.5 %) 0.5 (One half) inch each eye
four times a day Disp #*2 Bottle Refills:*0
10. Nicotine Patch 7 mg TD DAILY
RX *nicotine 7 mg/24 hour 1 patch daily Disp #*14 Unit
Refills:*0
11. Nystatin Oral Suspension 5 mL PO TID
Take this medication until 48 hours after symptoms resolve.
RX *nystatin 100,000 unit/mL 5 mL by mouth three times a day
Disp #*1 Bottle Refills:*0
12. Estradiol 1 mg PO DAILY
13. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation q
___ hrs PRN dyspnea
14. proGESTerone micronized 100 mg oral q HS
15. Tiotropium Bromide 1 CAP IH DAILY
16. PredniSONE 40 mg PO DAILY Duration: 5 Days
Tapered dose - DOWN
RX *prednisone 10 mg 4 tablet(s) by mouth daily Disp #*20 Tablet
Refills:*0
17. PredniSONE 20 mg PO DAILY Duration: 3 Days
Tapered dose - DOWN
RX *prednisone 10 mg 2 tablet(s) by mouth daily Disp #*6 Tablet
Refills:*0
18. PredniSONE 10 mg PO DAILY Duration: 2 Days
Tapered dose - DOWN
RX *prednisone 10 mg 1 tablet(s) by mouth daily Disp #*2 Tablet
Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnosis: COPD exacerbation, bronchitis, small airway
infection
Secondary diagnosis: Conjunctivitis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Chest pain with dyspnea. Evaluate for an acute process.
COMPARISON: Chest radiograph ___.
FRONTAL AND LATERAL VIEWS OF THE CHEST: There is no pleural effusion,
pneumothorax or focal airspace consolidation worrisome for pneumonia.
Irregular linear opacities are consistent with emphysema changes. The heart
is normal size and the mediastinal contours are unremarkable.
Radiology Report
HISTORY: Chest pain and elevated D-dimer. Evaluate for pulmonary embolus.
TECHNIQUE: MDCT axial images were acquired through the chest during the
pulmonary arterial phase of enhancement with 100 mL of Omnipaque. Coronal and
sagittal reformations were provided and reviewed. Maximum intensity
projection images were created and reviewed as well.
DLP: 154.35 mGy/cm.
COMPARISON: None.
FINDINGS: Contrast is seen opacifying the segmental and subsegmental vessels
of the pulmonary arterial tree, without filling defects indicate a pulmonary
embolus. The main pulmonary artery and aorta are normal caliber. There is no
evidence for aortic injury. The heart is normal size and there is no
pericardial effusion.
The trachea is normal. The airways are patent the subsegmental level. There
is diffuse bronchial wall thickening. Small amount of retained secretions are
seen at the level of the carina (3:95). No pleural effusion or pneumothorax.
There is no focal airspace consolidation worrisome for pneumonia. Scattered
ground-glass opacities within the right middle lobe may reflect early atypical
infection (3:36). Linear opacities in this same area are likely scarring.
There are severe changes of centrilobular emphysema. There is no axillary,
supraclavicular or central lymphadenopathy.
The esophagus is unremarkable. Views of the arterially enhanced liver,
adrenal glands, kidneys and spleen are unremarkable.
IMPRESSION:
1. No pulmonary embolus.
2. Diffuse bronchial wall thickening compatible with bronchitis.
3. ___ opacities within the right middle lobe may reflect early small
airways infection.
4. Severe changes of centrilobular emphysema.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: DYSPNEA
Diagnosed with SHORTNESS OF BREATH, OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION
temperature: 96.9
heartrate: 76.0
resprate: 20.0
o2sat: 98.0
sbp: 158.0
dbp: 86.0
level of pain: 8
level of acuity: 2.0 | ___ F h/o COPD p/w worsening SOB x 3 wks, now with cough
productive of green sputum and CTA indicating bronchitis and
small airway infection. Ms. ___ was seen in ED and had
CTA chest negative for PE as well as negative troponins in the
setting of chest heaviness. She was admitted due to persistent
SOB and treated with PO prednisone for a COPD exacerbation. She
was also started on a five-day course of azithromycin for
bronchitis/small airway infection.
ACTIVE DIAGNOSES
# Acute bronchitis and small airway infection: Pt endorsed
infectious symptoms including cough productive of green sputum,
sore throat and rhinorrhea. CTA chest in the ED revealed
diffuse bronchial wall thickening compatible with bronchitis and
___ opacities within the right middle lobe, possibly
reflecting early small
airways infection. Differential diagnosis included viral
(coronavirus, adenovirus, rhinorvirus, less likely influenza A
or B given lack of systemic symptoms) versus bacterial
(Mycoplasma pneumoniae, Chlamydophila pneumoniae, Bordetella
pertussis) bronchitis/small airways infection. There was a low
threshold for treatment with antibiotics in the setting of COPD
exacerbation. She was started on azithromycin 500mg PO x 1 and
then 250mg PO x 4 days. (In combination with psychotropic
medications including quetiapine, QTc prolongation was
considered, and QTc was within normal limits at 422 msec.)
Supportive care was provided with acetaminophen PRN and
albuterol/ipratropium nebs.
Sputum was collected in efforts to test for MAC via AFB smear
and culture, but the sample was not processed as expected.
Sputum cytology was negative for malignant cells (although the
yield is low). On CTA chest, there was an opacity in the
periphery of the right middle lobe which was not specifically
commented upon in the radiology report. Repeat CT chest imaging
in ___ weeks is advised. If lungs have not cleared in the
interim, further evaluation for MAC pulmonary infection ("Lady
___ syndrome") and malignancy is advised. Patient was
scheduled for outpatient follow-up with Pulmonary Medicine.
# COPD exacerbation: Pt had decreased aeration in all lung
fields. She reported symptomatic improvement after
administration of steroids in the ED, and PO prednisone was
continued on the floor. She saturated normally on room air and
had non-labored breathing at rest. She passed ambulatory O2
monitoring on hospital day 2 with SpO2>/=92% throughout, but she
was not able to walk far and had purse-lipped breathing with
exertion. She was treated with standing albuterol/ipratropium
nebulizers and continued on fluticasone-salmeterol diskus. By
hospital day 3, there was additional subjective improvement in
SOB. She was discharged with a ten-day prednisone taper and her
usual home COPD medications. ___ was arranged for outpatient
oxygen monitoring, and she should be referred for pulmonary
rehabilitation. She was also scheduled to follow-up with
Pulmonary Medicine as an outpatient. CTA chest showed severe
changes of centrilobular emphysema. She should have repeat
chest CT imaging in ___ weeks after discharge, as described
above.
# Conjunctivitis: Pt developed erythema and soreness of right
eye, which progressed to involve both eyes. Cream-colored
opaque discharge was visualized in the medial canthus of right
eye on admission, and there was yellow crust on both eyelids in
the morning of hospital day 2. Ddx includes viral versus
bacterial or allergic conjunctivitis. Most common causes of
bacterial conjunctivitis include Staphylococcus aureus,
Streptococcus pneumoniae, Haemophilus influenzae, and Moraxella
catarrhalis. She was prescribed erythromycin ophthalmic
ointment to apply to both eyes.
# Smoking cessation: Pt started on a nicotine patch and was
given a prescription for nicotine replacement therapy to
continue as an outpatient. Smoking cessation was encouraged.
CHRONIC DIAGNOSES
# Psych: Pt has h/o depression for which she takes a variety of
other psych meds. Topiramate 350mg daily, quetiapine 200mg PO
BID, bupropion SR 200mg PO q AM, and venlafaxine 75mg PO daily
were continued in order to maintain stable regimen compared to
home. However, this combination of medications increases risk
for serotonin syndrome. Optimization/simplification of
psychiatric medication regimen as an outpatient is advised, in
part to reduce risk of serotonin syndrome.
# Menopause: Pt takes estradiol and progesterone at home for
menopausal symptoms. She had a CTA chest in the ED which was
negative for PE, given her SOB and increased risk for blood clot
while on estradiol. Pt reported feeling like these medications
were not necessary. Estradiol and progesterone were held during
hospitalization so as to minimize risk for PE while monitoring
for improvement in shortness of breath. Duration of treatment
with these medications should be reassessed as an outpatient.
# HLD: Continued home simvastatin.
TRANSITIONAL ISSUES
* Pt will be discharged with home ___ services. Please do oxygen
saturation monitoring as an outpatient and refer to pulmonary
rehab as appropriate.
* Pt should follow-up with Pulmonary Medicine as an outpatient.
Please repeat chest CT in ___ weeks as an outpatient to assess
interval change. If lung findings have not cleared in the
interim, further evaluation for MAC pulmonary infection ("Lady
___ syndrome") and malignancy is advised (see below).
* Sputum was collected to test for AFB smear/culture, but the
specimen did not get processed as expected. If repeat chest CT
is abnormal, consider testing sputum for AFB smear and culture
to assess for MAC pulmonary infection ("___
syndrome").
* Given history of smoking and COPD, family history of lung
cancer, and finding of peripheral opacity in right lung on CTA,
sputum cytology was tested and returned negative for malignant
cells. Please note that sputum cytology has a low yield for
abnormal cells, and further work-up would be necessary to
definitively rule out malignancy if repeat chest CT remains
abnormal after pulmonary/small airway infection clears.
* Also of note, pt is on a variety of psychiatric medications at
home, including bupropion, quetiapine, venlafaxine, and
topiramate. This combination of medications increases risk of
serotonin syndrome. Optimization/simplification of psychiatric
medication regimen as an outpatient is encouraged.
* Please consider whether estradiol and progesterone remain
necessary and, if so, determine their expected duration.
Discontinue when possible so as to avoid risk for blood clot and
other complications. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Major Surgical or Invasive Procedure:
EGD ___
attach
Pertinent Results:
ADMISSION LABS
==============
___ 01:27AM BLOOD WBC-7.2 RBC-3.72* Hgb-10.9* Hct-34.9*
MCV-94 MCH-29.3 MCHC-31.2* RDW-14.2 RDWSD-48.0* Plt ___
___ 01:27AM BLOOD Neuts-86.6* Lymphs-9.6* Monos-3.4*
Eos-0.0* Baso-0.1 Im ___ AbsNeut-6.20* AbsLymp-0.69*
AbsMono-0.24 AbsEos-0.00* AbsBaso-0.01
___ 01:50PM BLOOD ___ PTT-28.9 ___
___ 01:27AM BLOOD Glucose-525* UreaN-89* Creat-15.0* Na-137
K-6.4* Cl-89* HCO3-21* AnGap-27*
___ 01:50PM BLOOD Calcium-9.7 Phos-5.5* Mg-2.1
___ 03:09AM BLOOD ___ pO2-109* pCO2-48* pH-7.36
calTCO2-28 Base XS-0 Comment-GREEN TOP
IMAGING
=======
CXR ___
Mild pulmonary vascular congestion. No edema.
MICRO
=====
___ 1:30 pm BLOOD CULTURE Source: Line-R fem line 2 OF
2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
STUDIES
=======
EGD ___
- Grade C esophagitis in the mid and distal esophagus
- A small, non-bleeding ___ tear was noted in the
distal esophagus
- A brief view of the stomach body was notable for normal mucosa
without any blood
- Due to the large esophageal clot, a full endoscopic view of
the stomach fundus, antrum or duodenum was not obtained.
DISCHARGE LABS
==============
___ 07:42AM BLOOD WBC-5.7 RBC-2.67* Hgb-8.0* Hct-25.0*
MCV-94 MCH-30.0 MCHC-32.0 RDW-14.4 RDWSD-47.3* Plt ___
___ 07:42AM BLOOD Glucose-134* UreaN-27* Creat-6.5*# Na-139
K-4.4 Cl-97 HCO3-27 AnGap-15
___ 07:42AM BLOOD Calcium-8.5 Phos-4.9* Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 5 mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Atorvastatin 80 mg PO QPM
4. Glargine 50 Units Breakfast
Insulin SC Sliding Scale using REG Insulin
5. Pantoprazole 40 mg PO Q24H
6. Losartan Potassium 25 mg PO DAILY
7. TraMADol 50 mg PO BID:PRN Pain - Moderate
8. Gabapentin 100 mg PO TID
9. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
10. Apixaban 2.5 mg PO BID
11. sevelamer CARBONATE 800 mg PO TID W/MEALS
12. CARVedilol 12.5 mg PO BID
Discharge Medications:
1. Glargine 55 Units Dinner
Humalog 8 Units Breakfast
Humalog 8 Units Lunch
Humalog 8 Units Dinner
2. amLODIPine 5 mg PO DAILY
3. Aspirin 81 mg PO DAILY
4. Atorvastatin 80 mg PO QPM
5. CARVedilol 12.5 mg PO BID
6. Gabapentin 100 mg PO TID
7. Losartan Potassium 25 mg PO DAILY
8. Pantoprazole 40 mg PO Q24H
9. sevelamer CARBONATE 800 mg PO TID W/MEALS
10. TraMADol 50 mg PO BID:PRN Pain - Moderate
11. Zolpidem Tartrate 10 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
Acute Gastrointestinal Bleed
SECONDARY DIAGNOSES
===================
Gastroparesis
Atrial Fibrillation with RVR
ESRD on HD
Hypoxemic respiratory failure, Resolved
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: History: ___ with esrd on dialysis, missed dialysis, k >6 //
eval for pulmonary congestion
TECHNIQUE: Chest PA and lateral
COMPARISON: None
FINDINGS:
A vascular stent projects over the left axilla. Patient is status post
sternotomy with intact wires.
Lung volumes are low, exaggerating pulmonary vascular congestion. No no
definite pulmonary edema. Cardiomediastinal contours are normal. No pleural
effusion or pneumothorax.
IMPRESSION:
Mild pulmonary vascular congestion. No edema.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with hypotension. // Please evaluate for
pneumonia.
TECHNIQUE: AP radiograph of the chest.
COMPARISON: Chest radiograph ___.
IMPRESSION:
There are postsurgical changes from CABG. There is no focal consolidation,
pleural effusion or pneumothorax. The cardiomediastinal silhouette is within
normal limits. No acute osseous abnormalities are identified. There is a
vascular stent in the left subclavian/axillary region.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Abnormal labs, Transfer
Diagnosed with Hyperkalemia
temperature: 97.2
heartrate: 88.0
resprate: 18.0
o2sat: 100.0
sbp: 128.0
dbp: 90.0
level of pain: 0
level of acuity: 2.0 | TRANSITIONAL ISSUES
===================
[ ] Discharge HGB 8.0
[ ] Please complete repeat labs in 1 week by ___ to
follow-up his anemia.
[ ] Patient left AMA before receiving repeat endoscopy to
evaluate suspected ___ tear. Therefore, would greatly
benefit from repeat endoscopy within the next week to ensure
healing. We did not feel comfortable restarted his apixaban
without this re-evaluation. His CHADs2VASc is ___ so we felt it
was reasonable to hold apixaban on discharge, but he will need
to be restarted on this medication when repeat EGD shows
healing.
[ ] Patient likely with ___ tear in setting of
nausea/vomiting due to gastroparesis flare and missed HD
session. Patient should continue PPI as well as prn reglan for
nausea and to help with motility. Patient reports that he has
infrequent gastroparesis flares (yearly) but would benefit from
outpatient gastroparesis management.
BRIEF HOSPITAL COURSE
======================
Mr ___ is a ___ man with history of IDDM, ESRD on
HD (MWF), CAD s/p CABG in ___, Afib w/ RVR history of
gastroparesis on reglan, presented with nausea/vomiting,
initially admitted to ICU in setting of respiratory distress
after missing dialysis, then re-admitted to ICU in setting of
hematemesis found to have possible ___ tear on EGD.
Patient was treated with IV PPI and standing Zofran. Apixaban
was held during this time in setting of bleeding. Course was
also complicated by Afib with RVR resolved with addition of
standing metoprolol. Patient left AMA right as he was been
called for repeat EGD to assess healing of his ___
tear. Patient became belligerent and hostile to medical staff.
He is fully aware that his apixaban is being held until he has a
repeat EGD and therefore has a risk of stroke, and he is willing
to take this risk. Hemoglobin has been stable with no further
bleeding on discharge.
ACUTE ISSUES
===============
#Discharged AMA
Patient left AMA right as he was been called for repeat EGD to
assess healing of his ___ tear. Patient became
belligerent and hostile to medical staff. He is fully aware that
his apixaban is being held until he has a repeat EGD and
therefore has a risk of stroke, and he is willing to take this
risk. Hemoglobin has been stable with no further bleeding on
discharge.
# Acute upper GI bleed
Patient developed hematemesis after multiple episodes of emesis.
EGD on ___ showed esophagitis and a clot with possible
___ tear. Patient was kept on IV PPI, standing Zofran
until nausea resolved and stable. Apixaban was held in the
setting of active bleeding. Patient has been hemodynamically
stable with stable hemoglobin. No further nausea/vomiting or
melena. Patient left AMA right as he was been called for repeat
EGD to assess healing of his ___ tear. Patient became
belligerent and hostile to medical staff. He is fully aware that
his apixaban is being held until he has a repeat EGD and
therefore has a risk of stroke, and he is willing to take this
risk. Hemoglobin has been stable with no further bleeding on
discharge.
# Nausea and Vomiting
# Gastroparesis
Patient presented with nausea/vomiting likely in the setting of
known gastroparesis as well as uremia from missed HD session.
Patient was on standing anti-emetics given ___ tear.
Zofran and reglan were made prn. He has been tolerating oral
intake with no N/v. Mild epigastric pain with belching.
# Paroxysmal Afib/flutter
Discharged ___ from ___ on metop, apixaban, amiodarone
but recently switched to carvedilol. His fill history however
does not reflect this, and it appears he has not filled these
meds which his story collaborates. On ___, patient had elevated
HRs in 150s with 2:1 block requiring IV metop with conversion to
NSR. Standing metoprolol tartrate 6.25mg QID was added with
patient continuing in NSR until left AMA. As above, holding
apixaban in setting of bleeding. Unable to get repeat EGD before
left and medical team not comfortable sending him on apixaban
without visualizing his esophagus.
# HTN
Had held home amlodipine, losartan iso GI bleed. Started
metoprolol as above. Restarted home amlodipine as blood
pressures have tolerated.
#Likely OSA
Concern for apneic periods during sleep throughout admission.
Would benefit from outpatient sleep study.
CHRONIC ISSUES
===============
# ESRD
Continued HD per renal
# IDDM
Continued insulin 50 units glargine daily, sliding scale
# HLD
Continued atorvastatin
#CODE STATUS: FULL
>30 min spent on discharge planning including face to face time.
Pt was deemed to have capacity at time of AMA and understood the
risks of leaving prematurely. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Aspirin / Tetanus / Demerol
Attending: ___.
Chief Complaint:
Hematemesis, shock
Major Surgical or Invasive Procedure:
___ EGD with variceal ligation
___ intubation for EGD s/p extubation ___
History of Present Illness:
___ is a ___ y/o woman with PMH of EtOH cirrhosis
c/b EV, PHG, GAVE who p/w hematemesis.
Yesterday afternoon, felt dizzy in the afternoon and nauseous
after dinner. Had episode of dark red emesis. Presented to
___ hypotensive with SBP 68, and had 2 large volume
episodes of coffee ground emesis. Hgb 7.1. Lactate 3.0. Received
2U pRBCs. Hgb up to 8.8. Received 1L NS. Started CTX and
octreotide gtt. Had a 20g L AC, 18g R FA PIV placed.
Last Hepatology visit ___ ___. Has been declining
relapse prevention. In ___ and ___ had
admissions for anemia, hematemesis, and melena with Hgb < 5.
Most
recent EGD ___ with GAVE, PHG, and 3 cords of medium size
varices w/o active bleeding. Hgb had been stable at 9.0.
She also recently had a car accident one month ago where she was
rear-ended. Hurt her shoulder, had hematuria, and had a
concussion.
In the ED,
Initial Vitals: T 97.7 HR 70 BP 107/70 RR 16 SaO2 94% RA
Exam:
Labs:
- Hgb 7.4
- CMP ___
- ALT 17 AST 41 AP 121 Tbili 1.7 Alb 3.4 lipase 70
Imaging:
Consults:
- Hepatology
Interventions:
- octreotide gtt
VS Prior to Transfer: HR 80 BP ___ RR 18 SaO2 95% RA
ROS: Positives as per HPI; otherwise negative.
Past Medical History:
EtOH cirrhosis c/b EV, PHG, GAVE, ascites
EtOH hepatitis
anxiety
phobias - of choking, needs sedation with Propofol for EGD
depression
hypothyroidism
back pain
T12 compression fracture
scoliosis
Social History:
___
Family History:
Mother - migraines, COPD (died at ___)
Father - esophageal cancer (died at ___)
Son - ___ muscular dystrophy (died at ___)
Physical Exam:
ADMISSION PHYSICAL EXAM:
========================
VS: AF HR 76 BP 85/38 (53) Sa97% 1LNC
GEN: alert, NAD
HEENT: sclera white
CV: RRR, normal S1/S2, no m/r/g
RESP: CTAB
GI: abd soft, NTND, normoactive BS
EXT: warm, well-perfused, trace ___ edema
NEURO: EOMI
DISCHARGE PHYSICAL EXAM:
========================
___ 2337 Temp: 99.0 PO BP: 125/80 HR: 89 RR: 18 O2 sat: 88%
O2 delivery: Ra
GENERAL: NAD. Comfortable
Eyes: Anicteric
ENT: MMM.
___: RRR, no m/r/g
LUNGS: CTAB, no w/r/c
ABDOMEN: soft, nontender, nondistended, normoactive bowel
sounds,
no rebound or guarding
SKIN: Warm. Dry.
EXT: well perfused, trace bilateral edema
NEURO: No asterixis.
Pertinent Results:
ADMISSION LABS
===============
___ 03:15AM BLOOD WBC-6.4 RBC-3.56* Hgb-7.4* Hct-26.3*
MCV-74* MCH-20.8* MCHC-28.1* RDW-22.5* RDWSD-59.2* Plt Ct-88*
___ 05:43AM BLOOD WBC-6.0 RBC-3.27* Hgb-6.8* Hct-23.7*
MCV-73* MCH-20.8* MCHC-28.7* RDW-22.1* RDWSD-58.0* Plt Ct-85*
___ 10:51AM BLOOD WBC-8.7 RBC-3.57* Hgb-7.6* Hct-25.9*
MCV-73* MCH-21.3* MCHC-29.3* RDW-22.1* RDWSD-57.2* Plt ___
___ 03:15AM BLOOD Neuts-62.8 ___ Monos-8.4 Eos-2.8
Baso-0.8 Im ___ AbsNeut-4.02 AbsLymp-1.58 AbsMono-0.54
AbsEos-0.18 AbsBaso-0.05
___ 03:15AM BLOOD Plt Smr-LOW* Plt Ct-88*
___ 05:43AM BLOOD ___ PTT-31.5 ___
___ 03:15AM BLOOD Glucose-150* UreaN-22* Creat-0.6 Na-130*
K-4.6 Cl-95* HCO3-19* AnGap-16
___ 03:15AM BLOOD ALT-17 AST-41* AlkPhos-121* TotBili-1.7*
___ 03:15AM BLOOD Lipase-70*
___ 03:15AM BLOOD Albumin-3.4* Calcium-7.9* Phos-2.8
Mg-1.4*
___ 05:43AM BLOOD ___
___ 05:39AM BLOOD Lactate-2.7*
___ 11:22AM BLOOD Lactate-2.0
DISCHARGE LABS:
===============
___ 05:20AM BLOOD WBC-4.8 RBC-3.26* Hgb-7.7* Hct-25.6*
MCV-79* MCH-23.6* MCHC-30.1* RDW-22.5* RDWSD-64.7* Plt Ct-73*
___ 05:20AM BLOOD ___ PTT-30.6 ___
___ 05:20AM BLOOD Glucose-188* UreaN-11 Creat-0.6 Na-138
K-3.6 Cl-99 HCO3-28 AnGap-11
___ 05:20AM BLOOD ALT-15 AST-25 AlkPhos-102 TotBili-1.4
___ 05:20AM BLOOD Albumin-3.5 Calcium-8.6 Phos-3.1 Mg-1.6
MICROBIOLOGY:
=============
__________________________________________________________
___ 11:10 am BLOOD CULTURE Source: Venipuncture 1 OF
2.
Blood Culture, Routine (Pending): No growth to date.
IMAGING/STUDIES:
================
___ CXR PORTABLE
FINDINGS:
Endotracheal tube tip is approximately 1 cm above the carina.
The heart
remains enlarged. There is mild pulmonary vascular congestion.
No
pneumothorax. Bibasilar opacities which could represent
atelectasis.
PROCEDURES:
===========
___ EGD
-4 cords of grade II varices were seen in the distal esophagus.
One cord of varices below gastroesophageal junction most likely
represent GOV was oozing. Three bands were applied for
hemostasis successfully.
-Congestion, petechiae, and mosaic mucosal pattern in the
stomach fundus and stomach body compatible with portal
hypertensive gastropathy.
-Blood in the stomach.
-Normal mucosa in the whole examined duodenum.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. MetFORMIN (Glucophage) 500 mg PO BID
2. DULoxetine ___ 90 mg PO DAILY
3. TraZODone 150 mg PO QHS:PRN sleep
4. Omeprazole 40 mg PO DAILY
5. Levothyroxine Sodium 175 mcg PO DAILY
6. Furosemide 40 mg PO DAILY
7. Nadolol 40 mg PO DAILY
8. HydrOXYzine 25 mg PO Q8H:PRN itching
9. Spironolactone 100 mg PO DAILY
10. Thiamine Dose is Unknown PO DAILY
11. FoLIC Acid 1 mg PO DAILY
Discharge Medications:
1. Sucralfate 1 gm PO QID Duration: 2 Weeks
RX *sucralfate 1 gram 1 tablet(s) by mouth four times a day Disp
#*56 Tablet Refills:*0
2. Thiamine 200 mg PO DAILY
3. DULoxetine ___ 90 mg PO DAILY
4. FoLIC Acid 1 mg PO DAILY
5. Furosemide 40 mg PO DAILY
6. HydrOXYzine 25 mg PO Q8H:PRN itching
7. Levothyroxine Sodium 175 mcg PO DAILY
8. MetFORMIN (Glucophage) 500 mg PO BID
9. Nadolol 40 mg PO DAILY
10. Omeprazole 40 mg PO DAILY
11. Spironolactone 100 mg PO DAILY
12. TraZODone 150 mg PO QHS:PRN sleep
Discharge Disposition:
Home
Discharge Diagnosis:
#Acute decompensated alcohol cirrhosis
#Upper gastrointestinal bleeding
#Acute blood loss anemia
#Hyponatremia
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 upper GI bleed now intubated// Evaluate ET
tube placement Evaluate ET tube placement
COMPARISON: Chest x-ray ___ 122 hours
FINDINGS:
Endotracheal tube tip is approximately 1 cm above the carina. The heart
remains enlarged. There is mild pulmonary vascular congestion. No
pneumothorax. Bibasilar opacities which could represent atelectasis.
NOTIFICATION: The findings were discussed with ___, M.D. by
___, M.D. on the telephone on ___ at 11:50 am, 1 minutes after
discovery of the findings.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Hematemesis, Transfer
Diagnosed with Gastrointestinal hemorrhage, unspecified
temperature: 97.7
heartrate: 70.0
resprate: 16.0
o2sat: 94.0
sbp: 107.0
dbp: 70.0
level of pain: 0
level of acuity: 2.0 | SUMMARY:
========
___ is a ___ with PMH of alcoholic liver
cirrhosis, PHT in the form of EV (on NSBB for primary
prophylaxis), PHG, ascites on diuretics (well controlled),
jaundice, overt obscure GI bleeding and chronic anemia (baseline
___, and ongoing alcohol use who presented with hematemesis
and hemorrhagic shock. She had an EGD ___ showing esophageal
varices and GOV (oozing) s/p banding after which her bleeding
and HgB stabilized, without recurrence of hematemesis or melena.
ACUTE ISSUES:
=============
#UGIB
#Hemorrhagic shock, improving
Ms. ___ initially presented with hematemesis and
hemorrhagic shock (hypotensive to SBP in the ___, lactate 3.0)
to ___. Her initial HgB there was noted to be 7.1
(from baseline ___. She required 2 U pRBCs and 1L IVF with
improvement in hemodynamics, and was started on octreotide gtt,
IV PPI, and IV CTX. She was subsequently transferred to ___
for further management. On arrival, she underwent EGD (___)
showing 4 cords of grade II varices in the distal esophagus, as
well as one cord of varices below the gastroesophageal junction
(most likely representing GOV) which was oozing. Three bands
were applied for hemostasis successfully. Since admission, she
has required an additional 3u pRBCs (last transfusion ___ for
resuscitation, after which her HgB has stabilized without
recurrent hematemesis/melena. She was continued on an octreotide
drip (___), then transitioned to home nadolol on day of
discharge. She finished a course of ceftriaxone for SBP
prophylaxis also on ___, and will continue on daily PPI and
sucralfate on discharge. Discharge HgB 7.7.
# EtOH cirrhosis:
Followed by Dr. ___. MELDNa 19. Decompensated this admission
by variceal bleed s/p banding as above. As of his
hospitalization, the patient was noted to be actively using
alcohol with positive alcohol level. She was seen by social work
and provided relapse prevention resources. She otherwise will
continue on home nadolol for bleeding prophylaxis. Home
diuretics were temporarily held given bleed, but restarted prior
to discharge. She will continue on furosemide
40mg/spironolactone 100mg. She has no history of SBP and
completed 5 day course of CTX for SBP prophylaxis given GIB. She
also has no history of hepatic encephalopathy and no evidence of
encephalopathy this admission. She will follow up with Dr. ___
in liver clinic ___ as scheduled.
# Alcohol use disorder
Serum EtOH 138 on admission. She was continued on thiamine,
folate, multivitamin. Social work was consulted for relapse
prevention, and patient accepted resources for this.
CHRONIC ISSUES
===============
#T2DM
Home metformin 500 BID was held in setting of acute illness.
Hyperglycemia managed with ISS while inpatient. Metformin
restarted on discharge.
#Pruritus
Continued home hydroxyzine 25 TID PRN.
#GERD
Will continue home omeprazole daily.
#Hypothyroidism
Continued home levothyroxine 175mcg daily.
#Depression
Continued home duloxetine 90 daily, home trazodone 150 QHS PRN
for sleep. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Labetalol
Attending: ___.
Chief Complaint:
DKA, hypertensive urgency
Major Surgical or Invasive Procedure:
1) Hemodialysis ___ and ___
History of Present Illness:
___ yo male w/ history diabetes type 1, ESRD on HD, multiple
hospitalizations for DKA/hyperglycemia, and recent ER visit ___
for hypoglycemic seizure presents for critically high blood
sugar at ___ center. Noted to be sweating, tired, and vomited x2
so he did not get HD. His fasting glucose was 287 on the morning
of admission before breakfast, took 10u Humalog. His blood sugar
was running in the 300s yesterday with recent systolic blood
pressures in the 150s. He reports compliance with insulin and
home blood pressure medications.
Recently he has felt generally fatigued, but at dialysis
center he was sweating and more tired. He denies recent lows
other than the hypoglycemic seizure he had ___ while at HD,
which resulted in a tounge laceration but no other
complications. He denies any prior history of seizures. He
denies recent illness, cough, dysuria, rash, HA, diarrhea, CP,
or vomiting prior to today.
Of note he has had multiple complications of Type1DM and
HTN, including total blindness in L eye secondary to retinopathy
and nephropathy requiring dialysis. He has no known coronary
disease or peripheral vascular disease though head MRI in ___
was found to be consistent with multiple hypertensive infarcts.
In the ED:
- blood glucose elevated to > 700
-K+ was elevated at 5.4.
-VBG w/ pH 7.2
-8 units bolus insulin, then insulin gtt at 7u/h.
-2L NS
Also noted to have elevated troponins to 0.83 (baseline 0.6-0.8
in the setting of poor renal clearance) thought to be due to
demand ischemia given elevated HR and BP > 200 systolic.
Baseline EKG (___): LAD, ___, TWI in lateral
leads, delayed R-wave progression possibly due to anteroseptal
infarct.
EKG on admission: All of the same in addition to peaked TW in
V2,V3 and possible 2mm ST elevations in V2/V3. Chest pain free.
VS T 97.8 HR 105 BP 211/113 RR 16 Sa02 100% r/a
Past Medical History:
- Diabetes, type 1 - admitted for hyperglycemia DKA from ___ to
___ and again from ___ to ___. Most recent A1c 8.0 ___.
- Hypertension - h/o malignant HTN since ___ on multiple meds
- Nephropathy - CKD stage V, PD failure ___ s/p HD line
placement in the setting of metabolic encephalopathy -> now on
TTS HD
- UGIB: s/p D with clipping, injection and cautery of a bleeding
duodenal ulcer EGD ___
- MRI w/likely hypertensive infarcts discovered ___
- Jejunitis/c. diff infection ___
- Anemia of chronic disease
- Hyperlipidemia
- Depression, not currently on therapy
- Blindness in L eye ___ diabetic retinopathy
- Vitrectomy R eye w/laser therapy ___
- Erectile dysfunction
Social History:
___
Family History:
Hypertension in mother and father, and hypercholesterolemia in
mother. No family hx of DM, renal disease, MI or CVA.
Physical Exam:
ICU ADMISSION EXAM
Vitals: T 97.8 HR 105 BP 211/113 RR 16 Sa02 100% r/a
General: Healthy-appearing, pleasant man lying in bed in NAD
HEENT: Anicteric sclerae, R tongue with 3cm linear laceration
with white fibrinous tissue at base. No surrounding suppuration,
swelling.
Neck: JVP non-elevated
CV: RRR, loud S2, ___ SEM
Lungs: Coarse breath sounds R>L, otherwise no rales, wheezes
Abdomen: PD catheter, soft, NT, ND, non-obese
GU: No foley
Ext: Warm, 2+ DP pulses, no edema
Neuro: A&Ox3. CNII-XII intact. ___ in UE and ___ bilaterally.
Normal DTRs throughout. Gait not evaluated
Pertinent Results:
___ 03:10PM BLOOD Glucose-787* UreaN-58* Creat-12.4*#
Na-125* K-6.4* Cl-82* HCO3-11* AnGap-38*
___ 06:16PM BLOOD Glucose-722* UreaN-58* Creat-12.1* Na-133
K-4.3 Cl-91* HCO3-15* AnGap-31*
___ 12:32AM BLOOD Glucose-256* UreaN-62* Creat-12.7* Na-138
K-3.7 Cl-99 HCO3-24 AnGap-19
___ 04:57AM BLOOD Glucose-85 UreaN-64* Creat-13.1* Na-141
K-4.3 Cl-101 HCO3-26 AnGap-18
___ 03:10PM BLOOD WBC-6.1 RBC-4.56* Hgb-12.5* Hct-41.4
MCV-91# MCH-27.4 MCHC-30.2*# RDW-14.3 Plt ___
___ 03:10PM BLOOD ALT-42* AST-56* AlkPhos-79 TotBili-0.2
___ 03:10PM BLOOD cTropnT-0.83*
___ 06:16PM BLOOD CK-MB-8
___ 12:32AM BLOOD CK-MB-7 cTropnT-0.85*
___ 04:57AM BLOOD CK-MB-6 cTropnT-0.89*
___ 03:10PM BLOOD %HbA1c-9.5* eAG-226*
___ 03:17PM BLOOD ___ pO2-84* pCO2-35 pH-7.20*
calTCO2-14* Base XS--13 Comment-GREEN TOP
___ 06:33PM BLOOD ___ Temp-36.6 pO2-45* pCO2-39
pH-7.26* calTCO2-18* Base XS--8 Intubat-NOT INTUBA
___ 12:45AM BLOOD ___ pO2-58* pCO2-43 pH-7.38
calTCO2-26 Base XS-0
___ 03:17PM BLOOD Glucose->500 Lactate-2.2* Na-129* K-5.4*
Cl-89* calHCO3-13*
___ 05:09PM BLOOD Glucose-GREATER TH K-4.8
___ 12:45AM BLOOD Lactate-2.0 K-3.7
---------------
IMAGING ___ CXR:
FRONTAL AND LATERAL VIEWS OF THE CHEST: No pleural effusion,
pneumothorax or focal airspace consolidation. Heart size is
normal. The mediastinal and hilar structures are unremarkable.
The pulmonary vascularity is normal. A right double-lumen
dialysis catheter terminates in the right atrium.
IMPRESSION: No acute cardiopulmonary process
---------------
EKG showed LAD, peaked Tw in precordial leads compared to
baseline, as well as ?ST changes in V2/V3 with apparent old
anteroseptal infarct given poor Rwave progression
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO BID
2. Aspirin 81 mg PO DAILY
3. CloniDINE 0.2 mg PO BID
4. Lisinopril 40 mg PO DAILY
5. Minoxidil 2.5 mg PO BID
6. Nephrocaps 1 CAP PO DAILY
7. Pantoprazole 40 mg PO Q24H
8. sevelamer CARBONATE 2400 mg PO TID W/MEALS
9. Simethicone 40-80 mg PO QID:PRN gas
10. Torsemide 100 mg PO DAILY
11. Glargine 25 Units Bedtime
12. Insulin SC
Sliding Scale
Insulin SC Sliding Scale using HUM Insulin
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary diagnoses:
1. DKA
2. Malignant hypertension
3. ESRD on HD
Secondary diagnoses:
1. DM type I
2. Anemia
3. Hyperlipidemia
4. Duodenal ulcer s/p bleed and cauterization
5. Diabetic retinopathy
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Diabetes on hemodialysis with fevers and chills. Evaluate for
pneumonia or an acute infectious process.
COMPARISON: Chest radiographs ___ and ___.
FRONTAL AND LATERAL VIEWS OF THE CHEST: No pleural effusion, pneumothorax or
focal airspace consolidation. Heart size is normal. The mediastinal and
hilar structures are unremarkable. The pulmonary vascularity is normal.
A right double-lumen dialysis catheter terminates in the right atrium.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
REASON FOR EXAMINATION: Diabetes mellitus, hemodialysis, fever.
Portable AP radiograph of the chest was reviewed in comparison to ___.
The central vein catheter tip terminates at the level of the right atrium.
Heart size and mediastinum are unremarkable. Lungs are essentially clear. No
pleural effusion or pneumothorax is seen.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: HYPERGLYCEMIA
Diagnosed with DIAB KETOACIDOSIS IDDM
temperature: 98.0
heartrate: 104.0
resprate: 18.0
o2sat: 100.0
sbp: 190.0
dbp: 110.0
level of pain: 0
level of acuity: 2.0 | ___ yo male with severe type 1 diabetes with multiple
complications, malignant hypertension, and ESRD who presents
from HD center with DKA and hypertensive urgency without
neurologic compromise or obtundation.
# DKA/Type1DM: Multiple prior episodes of DKA (see OMR). Unclear
provocating factor given history of no recent illness, reported
medication adherence, and no CP to suggest MI, though
hypertensive urgency may have been significant stressor. His
glucose management is complicated by ESRD. He had breakfast and
sliding scale 10u Humalog ___ AM per patient. On admission
glucose >700 and anion gap ~34. In the ER he was bolused 2L IVF
and given 8 units bolus insulin, then insulin gtt at 7units/hr.
When he arrived in the MICU his glucose was >700 still. He
received additional IV bolus insulin in the evening of ___ and
rapidly dropped down to 200s during the night, at which point
the insulin gtt was turned down and D5W gtt was started. On ___
he was switched from from an insulin gtt to sliding scale after
his anion gap closed. His sugars remained in the 100-200 range
on ___ and he was tolerating a diet. Long acting glargine was
started at his home dose of 25u qHS and Humalog sliding scale
insulin was continued. Electrolytes were repleted aggresively.
___ was consulted and followed patient throughout his
admission. Blood glucose ranged between 100-400 over the next
several days despite regular monitoring. Sliding scale was
increased with limited effect.
Given multiple complications from T1DM (L eye blindness,
ESRD) he is at risk for signficant morbidity and even death
given dangerous episodes of DKA and now hypoglycemic seizure in
recent history (___). He has follow up with his NP at ___
scheduled for ___.
# Malignant HTN: Developed in ___ around the time of
dialysis initiation. Presents with BPs in 210s systolic on
multiple medications for BP at home. Required IV nitroglycerine
and hydralazine in ICU to obtain good control. On admission to
the floor BP controlled at 110/68 and remained controlled
w/systolic BP <140 throughout remainder of inpatient admission
on home BP medications.
As outpatient BPs noted to be 150-180s on amlodipine,
minoxidil, torsemide, ACEI, and clonidine. These were continued
in house, though lisinopril was held initially given
hyperkalemia, and then restarted ___ after dialysis. His long
term BP goal is <130/80, though this has been very difficult to
achieve despite aggressive BP regimen. Patiet reports
understanding of how and when to take his medications, although
he admits to sometimes forgetting his evening doses. He also
reports that taking the pills on an empty stomach makes him
throw up, and that he has also thrown up a few times recently
because of hypoglycemia. He thinks this may have contributed to
the very high pressures noted on admission.
# Unexplained fevers: Patient became febrile to 101.5 early AM
on ___ and 99.6 on ___. No inciting event for the fever could
be determined. Patient denied nausea, vomiting, abdominal pain,
flank pain, cough, SOB, sinus congestion. He had a negative CXR
and negative blood and PD fluid cultures from ___ and ___.
Repeat blood cultures from both the HD line and peripheral blood
were sent and are pending at the time of discharge. Given that
the patient had no identifying symptoms, antibiotics were not
started. Will follow up with Mr. ___, Dr. ___
nephrologist), and ___ if cultures return positive
as in transitional issues below.
# Elevated trops/EKG changes: TropT to 0.89 on admission and EKG
w/ peaked T waves and possible small ST elevations in V2/V3.
Baseline trop 0.6-0.8, consistent w/ poorly controled htn and
ESRD preventing effective renal clearance. No known hx MI
although past EKG w/changes c/w anteroseptal infarct. Last ECHO
___ showed LVH w/out valvular pathology or focal wall motion
abnormalities. Presentation initially concerning for ACS but
CK-MBs were serially negative and EKG changes resolved to
baseline with nitroglycerin gtt overnight and BP control to
<160.
Trop leak most likely due to hypertensive urgency w/SBP elevated
above 200. Repeat EKG on ___ again consistant with baseline EKG
prior to admission.
# ESRD: TTS. Secondary to diabetic nephropathy. PD catheter
placed ___, but developed a metabolic encephalopathy and was
switched to HD on ___ via tunnelled catheter. Currently
undergoing repeat PD training so he can attempt to swtich back.
Has residual kidney function, on torsemide. Continued
nephrocaps. Low K, low Phos diet. K was repleted gently during
DKA given ESRD. He received HD ___, ___ and ___ without
complications.
# Elevated Transaminases: ALT/AST in ___ on admission.
Negative for HBV and HCV in ___ be related to
hypertensive urgency. Resolved by ___.
# Hx CVA: Discovered ___ in the setting of "altered mental
status" thought most likely due to metabolic encephalopathy in
the setting of failed PD dialysis. MR at the time showed
multiple foci of restricted diffusion identified in the pons,
right occipital lobe, bilateral basal ganglia involving the
internal capsule, genu of the corpus callosum and both centrum
semiovale. CTA of neck showed no carotid atherosclerosis. This
suggests hypertensive infarcts. Long term blood pressure conrol
130/80, but this has been difficult for the patient to achieve
as above. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Doxycycline / Amoxicillin / Penicillins / Tetracyclines
Attending: ___.
Chief Complaint:
Dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ M w/ COPD, alcohol induced chronic
pancreatitis w/ pseudocyst s/p Whipple, and chronic pain
presenting with tachypnea.
Patient developed productive cough with clear sputum 4 days
prior to admission associated with tachypnea, dyspnea on
exertion, and squeezing chest pressure (___) radiating to the
back. He also had chills, nausea, and a loose stool this
morning. Patient is usually on prednisone 10mg daily and was
using his albuterol inhaler more frequently.
ROS negative for fever, abdominal pain, vomitting/diarrhea, and
dysuria, ___ edema, PND, orthopnea, or sick contacts
In the ED, initial vitals: Temp. 97.8, HR 121, BP 186/126, RR
16
Labs showed: WBC 8.7, Hg 14.9, Hct 43.8, platelets 157. Trop
0.01, D-dimer 242, lactate 1.6. Patient given total of 13 mg
morphine, 500 mg azithromycin, 125 mg methylprednisone X 1, and
nebulizer treatment. CXR obtained without any acute
cardiopulmomary process. Patient was placed on non-rebreather
initially with marginal sats at which time bipap was placed with
improvement of tachypnea. No ABG available.
On transfer, vitals were:
Temp 98.2, HR 112, BP 120/75, RR 19, 97% RA
On arrival to the MICU, breathing comfortably on BiPAP.
Past Medical History:
S/P WHIPPLE PROCEDURE pylorus sparing Dr ___
___ -none since early ___
CHRONIC OBSTRUCTIVE PULMONARY DISEASE
TOBACCO ABUSE
DEPRESSION
NARCOTICS AGREEMENT
*S/P CHOLECYSTECTOMY
*S/P PNEUMOTHORAX AND RIB FRACTURES
traumatic
HEARING LOSS
traumatic
CELIAC DISEASE
LUNG NODULES
Social History:
___
Family History:
Mother ALZHEIMER'S DISEASE
Father COLON CANCER
Brother ALCOHOLIC CIRRHOSIS
Sister ALCOHOLIC CIRRHOSIS
Physical Exam:
ADMISSIONS PHYSICAL:
====================
Temp 98.2, HR 112, BP 120/75, RR 19, 97% RA
GENERAL: Head bobbing and weaving but alert and attentive,
unable to complete sentences due to SOB
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Little air movement with end expiratory wheezing
intermittently
CV: Difficult to appreciate heart sounds
ABD: soft, non-tender, non-distended, bowel sounds present, no
rebound tenderness or guarding,
EXT: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
NEURO: Alert and attentive, moving all extremities
DISCHARGE PHYSICAL:
===================
Vitals: 97.7 125/74 85 18 95% on RA
General: alert, oriented, no acute distress
HEENT: sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: marked expiratory wheezes throughout less prominent on
___ AM vs ___ ___, no rales or ronchi
CV: regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSIONS LABS:
================
___ 08:00PM BLOOD WBC-8.7# RBC-4.84 Hgb-14.9 Hct-43.8
MCV-91 MCH-30.8 MCHC-34.0 RDW-12.3 RDWSD-40.5 Plt ___
___ 08:00PM BLOOD WBC-8.7# RBC-4.84 Hgb-14.9 Hct-43.8
MCV-91 MCH-30.8 MCHC-34.0 RDW-12.3 RDWSD-40.5 Plt ___
___ 08:00PM BLOOD Neuts-86.7* Lymphs-6.2* Monos-6.1
Eos-0.0* Baso-0.2 Im ___ AbsNeut-7.52* AbsLymp-0.54*
AbsMono-0.53 AbsEos-0.00* AbsBaso-0.02
___ 08:00PM BLOOD ___ PTT-29.0 ___
___ 08:00PM BLOOD Glucose-99 UreaN-9 Creat-0.7 Na-135 K-4.4
Cl-93* HCO3-31 AnGap-15
___ 08:00PM BLOOD ALT-31 AST-42* AlkPhos-93 TotBili-0.3
___ 03:14AM BLOOD CK(CPK)-58
___ 08:00PM BLOOD cTropnT-<0.01
___ 03:14AM BLOOD CK-MB-2 cTropnT-<0.01
___ 01:42AM BLOOD cTropnT-<0.01
___ 08:00PM BLOOD Albumin-4.8
___ 03:14AM BLOOD Calcium-9.0 Phos-4.5# Mg-2.9*
___ 01:42AM BLOOD Calcium-9.2 Phos-3.5 Mg-2.3
___ 08:00PM BLOOD D-Dimer-242
___ 05:01AM BLOOD Type-ART Rates-/14 pO2-179* pCO2-48*
pH-7.40 calTCO2-31* Base XS-4 Intubat-NOT INTUBA
___ 08:08PM BLOOD Lactate-1.6
___ 05:01AM BLOOD Lactate-1.5
IMAGING AND OTHER STUDIES:
==========================
CXR ___: No acute cardiopulmonary process. COPD.
ECG ___: Sinus rhythm with premature atrial contractions.
Compared to the previous tracing of ___ the P wave voltage
appears to be less. There remainsdelayed R wave transition in
the mid-precordial leads. Other findings are similar to ___.
DISCHARGE LABS:
===================
___ 06:55AM BLOOD WBC-8.0 RBC-3.86* Hgb-11.8* Hct-36.1*
MCV-94 MCH-30.6 MCHC-32.7 RDW-12.3 RDWSD-42.7 Plt ___
___ 06:55AM BLOOD Glucose-114* UreaN-7 Creat-0.7 Na-134
K-3.8 Cl-94* HCO3-30 AnGap-14
___ 06:55AM BLOOD Calcium-9.3 Phos-2.8 Mg-2.1
MICROBIOLOGY:
===============
___ Blood cultures: pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Creon 12 1 CAP PO TID W/MEALS
3. Dronabinol 5 mg PO BID
4. Mirtazapine 45 mg PO QHS
5. Omeprazole 40 mg PO DAILY
6. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H
7. Sertraline 25 mg PO DAILY
8. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
10. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
11. Tiotropium Bromide 1 CAP IH DAILY
12. Atorvastatin 20 mg PO QAM
13. PredniSONE 10 mg PO DAILY
14. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
Discharge Medications:
1. Sulfameth/Trimethoprim DS 1 TAB PO DAILY
For PCP prophylaxis
RX *sulfamethoxazole-trimethoprim 800 mg-160 mg 1 tablet(s) by
mouth daily Disp #*30 Tablet Refills:*1
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheeze
3. Atorvastatin 20 mg PO QAM
4. Nitroglycerin SL 0.4 mg SL Q5MIN:PRN chest pain
5. Tiotropium Bromide 1 CAP IH DAILY
6. Azithromycin 250 mg PO Q24H Duration: 4 Days
Last day ___.
RX *azithromycin 250 mg 1 tablet(s) by mouth daily Disp #*1
Tablet Refills:*0
7. Aspirin 81 mg PO DAILY
8. Creon 12 1 CAP PO TID W/MEALS
9. Dronabinol 5 mg PO BID
10. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
11. Mirtazapine 45 mg PO QHS
12. Omeprazole 40 mg PO DAILY
13. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H
14. Sertraline 25 mg PO DAILY
15. Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
16. PredniSONE 40 mg PO DAILY Duration: 2 Doses
Take 40 mg on ___ and ___ then 20 mg on ___, and ___
then resume 10 mg daily.
Tapered dose - DOWN
RX *prednisone 20 mg 2 tablet(s) by mouth daily Disp #*7 Tablet
Refills:*0
17. PredniSONE 20 mg PO DAILY Duration: 3 Doses
Take 40 mg on ___ and ___ then 20 mg on ___, and ___
then resume 10 mg daily.
Tapered dose - DOWN
18. PredniSONE 10 mg PO DAILY
Take 40 mg on ___ and ___ then 20 mg on ___, and ___
then resume 10 mg daily.
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
===================
COPD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with copd // sob
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
FINDINGS:
Lungs remain hyperinflated, consistent with chronic obstructive pulmonary
disease. No focal consolidation is seen. There is no large pleural effusion
or pneumothorax. The cardiac and mediastinal silhouettes are stable and
unremarkable.
IMPRESSION:
No acute cardiopulmonary process. COPD.
Gender: M
Race: WHITE - EASTERN EUROPEAN
Arrive by WALK IN
Chief complaint: Chest pain, Dyspnea
Diagnosed with CHEST PAIN NOS
temperature: 97.8
heartrate: 121.0
resprate: 36.0
o2sat: 97.0
sbp: 186.0
dbp: 126.0
level of pain: 9
level of acuity: 1.0 | Mr. ___ is a ___ gentleman with COPD on chronic PO
prednisone, alcohol induced chronic pancreatitis w/ pseudocyst
s/p Whipple, and chronic pain presenting with tachypnea and SOB
admitted to the ICU for COPD exacerbation requiring BiPAP. He
was treated for the following issues during this
hospitalization:
ACTIVE ISSUES
==============
# COPD EXACERBATION:
Patient has known COPD, on chronic prednisone 10 mg daily. He is
not on home O2, but reports that he had been on it many years
ago. He was afebrile without concern for infection per CXR and
was treated with azithromycin, prednisone 40 mg, and standing
nebulizers. He was admitted to ICU given need for BIPAP,
although he was only used it intermittently. He was transferred
to the general medicine floor on HD3, where he was quickly
weaned off of oxygen. Plan was to keep patient for one more day
for frequent nebs/monitoring, but patient was very intent on
leaving. His ambulatory O2 sat and O2 sat on room air were both
>90 prior to discharge, and he was able to ambulate with mild
SOB. As such, he was discharged on a prednisone taper,
nebulizers, and azithromycin. For his cough, he was treated
with guaifenesin-codeine and Tessalon Perles.
# CHEST PAIN:
Patient noted to have chest pain in the ED with prior stress
test in ___ negative for coronary disease. Patient did have
nitro prescribed as medication though unclear indication as he
was without known history of cardiovascular disease documented.
EKG was without changes suggestive of ischemia, trops negative
x3, and normal heart rate raised low suspicion for ACS or PE.
Per patient, this chest pain is a chronic pain and he is managed
on a narcotics contract by his PCP.
# PANCREATIC INSUFFICIENCY:
Patient with known pancreatic insufficiency likely secondary to
Whipple and chronic alcohol use. He is on home creon, which was
continued during this hospital stay.
# CHRONIC ABDOMINAL PAIN:
The patient has had chronic abdominal pain since his Whipple
approximately ___ years ago. As above, he has a narcotics
contract with his PCP, the terms of which were followed during
this hospitalization to manage his symptoms.
INACTIVE ISSUES
===============
# GERD:
Continued omeprazole 40 mg PO DAILY
# Insomnia:
Continued Zolpidem Tartrate 5 mg PO QHS:PRN insomnia
# Appetite stimulant:
Dronabinol 5 mg PO BID
# Depression:
He was continued on his home dose of sertraline this admission. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: PLASTIC
Allergies:
Bacitracin / Ampicillin
Attending: ___.
Chief Complaint:
___
Major Surgical or Invasive Procedure:
___ - open splenectomy
___ - L S1 screw, ant column screw
___ - bedside tracheostomy
History of Present Illness:
Ms. ___ is a ___ year old Female who presented to the ___ in
the setting of an MVC. She was initially intubated at the OSH,
and was found on pan-scan imaging to have small bilateral
pneumothoraces, multiple rib fractures, a splenic laceration, L5
transverse process fracture, and pelvic fractures.
Past Medical History:
___:(from old notes and from HCP, needs to be reconfirmed)
-Osteoarthritis
-Depression
-Chronic Back Pain
-HTN
-HLD
-Obesity
-Hyperthyroidism (benign thyroid mass)
-Insulin Dependent DM2
-Hx of osteomyelitis
-Asthma
-? Pulm fibrosis (was o2 dependent at one time and on steroids
per pulm)
Social History:
___
Family History:
noncontributory
Physical Exam:
General: alert and oriented, x3, NAD, awake, oriented x1
Cardiac: RRR, mild tachycardia, sinus rhythm
Respiratory: mildly tachypneic, on trach collar
GI: large left sided incision w/ steri-strips intact, healing
well
GU: foley d/c'd
MSK: moving all extremity, no obvious trauma
Medications on Admission:
lantus 42 qpm, levothyroxine 100', gabapentin 600'', amlodipine
10', metoprolol 25', lexapro 20', mirtazapine 30', aspirin 81',
magnesium oxide 250', hctz 25'
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Polytrauma following MVC
Discharge Condition:
stable
Followup Instructions:
___
Radiology Report
INDICATION: ___ female status post ___ with extensive splenic
laceration.
COMPARISON: CTA torso ___.
PHYSICIANS: Dr. ___ (resident), Dr. ___ (fellow) and Dr.
___ (attending, present and supervising throughout).
ANESTHESIA: The patient arrived to the angiography suite intubated and
sedated. Fentanyl and Versed infusions were maintained throughout the
procedure. 1% lidocaine was administered for local anesthetic.
FLUOROSCOPY: 395 mGy, 32.3 minutes.
CONTRAST: 90 mL Visipaque.
PROCEDURES:
1. Right common femoral artery access.
2. Splenic arteriogram and cone beam CT.
3. Coil embolization of third order and second order branches of the splenic
artery.
4. Proximal splenic artery embolization with a 6mm Amplatzer plug device.
PROCEDURE DETAIL: After discussion of the risks, benefits and alternatives to
the procedure with the patient's next of kin, verbal informed consent was
obtained and witnessed. The patient was brought to the angiography suite and
placed supine on the imaging table. The right groin was prepped and draped in
the usual sterile fashion. A preprocedure timeout and huddle was performed as
per ___ protocol.
Initial scout image demonstrated delayed nephrogram in the right kidney
consistent with impaired excretion of contrast from the prior CTA. Under
fluoroscopic and palpatory guidance, the right common femoral artery was
accessed using local anesthesia and the standard micropuncture technique at
the level of the mid femoral head. A 6 ___ ___ sheath was advanced
over the ___ wire and parked in the mid abdominal aorta. Next, a glide
catheter and Glidewire were advanced through the sheath and used to select the
celiac axis and then advanced further into the splenic artery. The sheath was
then brought further into the splenic artery to secure the celiac ostial
access. A digital subtraction angiogram was performed with cone beam CT
demonstrating multiple abnormalities in the splenic parenchyma consistent with
multiple pseudoaneurysms. There was no definite active extravasation. A
decision was made to further sub-select the branches supplying two largest
pseudoaneurysms in the upper and lower splenic poles. A third order branch
supply the upper pole of the spleen using a ___ Renegade microcatheter and
double-angled Glidewire. After hand injection to confirm the desired
position, three 2 mm x 1 cm Hilal coils were deployed. Injection of contrast
confirmed stasis of flow.
Next, the microcatheter was withdrawn and used to select a second order branch
of the splenic artery supplying the lower pole and supplying multiple large
parenchymal abnormalities. After hand injection of contrast to confirm
position of the microcatheter one 2 mm x 1 cm Hilal coil and two 3 mm x 2 cm
Hilal coils were deployed. There was near-complete stasis of flow.
Approximately 0.5 cc of a gelfoam slurry was injected with resulting stasis of
flow. The microcatheter was withdrawn and the glide catheter exchanged for a 6
___ guiding catheter which was placed in the proximal splenic artery. A 6
mm Amplatzer plug was deployed. Hand injection of contrast following
deployment confirmed absence of antegrade flow to the spleen with reflux into
the celiac axis and common hepatic arteries. The guide catheter and 6 ___
sheath were removed over a wire. Manual pressure was held for 25 minutes for
optimal hemostasis.
The patient tolerated the procedure well without immediate complication.
FINDINGS:
1. Incidental note of a delayed right nephrogram.
2. Multiple splenic parenchymal abnormalities consistent with pseudoaneurysms.
No definite active extravasation.
IMPRESSION:
1. Uncomplicated proximal and selective distal splenic embolization.
2. Delayed right nephrogram consistent with renal insufficiency.
Findings were discussed by phone with Dr. ___ at the completion of the
procedure at approximately 8:20 p.m. on ___.
Radiology Report
INDICATION: Multiple rib fractures.
___ at 533am.
FINDINGS: There is subcutaneous emphysema in the left chest wall. There is a
consolidation in the left mid and lower lung, which likely represents a
combination of hemothorax and atelectasis and contusion from prior injury.
Multiple continuous posterior rib fractures are seen in the left, as seen on
prior CT. ET tube ends 3.4 cm from the carina. The enteric tube ends in the
stomach. No pleural effusion is identified. The right lung is grossly clear.
The mediastinal and hilar contours are within normal limits.
IMPRESSION: Left mid and lower lung opacity likely represents combination of
pleural hemothorax and atelectasis and contusion. Multiple rib fractures on
the left. No pneumothorax is identified.
Radiology Report
INDICATION: Increasing abdominal distention status post MVC. Evaluate for
free air.
COMPARISON: ___ at 5:33 a.m.
FINDINGS: Enteric tube ends in the stomach; however the last side port is
likely above the GE junction. ET tube is stable in position. The left mid
and lower lung opacities are unchanged. The right lung is clear. Left
pleural effusion is unchanged. There is no evidence of free air. No
pneumothorax.
IMPRESSION: No evidence of free air. No significant change compared to
___ at 5:33 a.m. Enteric tube ends in the stomach; however the
last side port is likely above the GE junction. Recommend advancement.
These findings were discussed with Dr. ___ by Dr. ___ at 940am on
___ by phone at time of discovery.
Radiology Report
EXAMINATION: CYSTOGRAM
INDICATION: ___ year old woman with pelvic fracture, concern for bladder
injury, rule out bladder injury.
COMPARISON: CTA torso from ___.
FINDINGS:
Initial AP and oblique scout images prior to administration of contrast show a
Foley catheter within the bladder, a right total hip arthroplasty, and
fractures of the left acetabular column and inferior pubic ramus previously
seen on CT torso.
Intermittent fluoroscopy was performed while approximately 300 cc of
Cysto-Conray water soluble contrast was instilled through the patient's
catheter into the bladder. With a distended bladder, imaging was performed in
AP and oblique projections. The patient's catheter was then reconnected to
the urinary bag, and the patient was able to evacuate the bladder through the
catheter. Post-evacuation images were then obtained.
There is no evidence of contrast extravasation from the bladder. Intermittent
excretion of IV contrast from bilateral ureters were noted during the exam.
IMPRESSION:
No evidence of bladder leak.
Radiology Report
CHEST RADIOGRAPH.
INDICATION: Multiple rib fractures, intubation, evaluation.
COMPARISON: Chest radiograph from ___.
FINDINGS: As compared to the previous radiograph, there is unchanged evidence
of rib fractures. The effusion on the left has substantially decreased.
However, on the right, a new effusion has occurred. As a consequence, the
areas of basal atelectasis have changed accordingly. On the current image,
there is no evidence for the presence of pneumothorax. In the interval, a
right internal jugular vein catheter has been newly introduced. No other
relevant changes.
Radiology Report
INDICATION: New NG tube placement.
COMPARISONS: Chest radiograph from ___ at 5:40.
FINDINGS: An endotracheal tube is in unchanged position, 5.3 cm from the
carina. A right internal jugular sheath is present with the tip in the upper
SVC. An enteric tube courses below the diaphragm with the tip in the stomach.
Since the prior exam, moderate right and small left pleural effusion appear
grossly stable. There is no new opacity or pulmonary edema. There is no
pneumothorax. The cardiomediastinal silhouette is unchanged. Left-sided rib
fractures are again noted.
IMPRESSION: Enteric tube with the tip in the stomach. Otherwise, no
significant change from the prior exam.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Motor vehicle accident, pneumonia.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, no relevant change is seen.
Moderate bilateral pleural effusions. Areas of atelectasis at both lung
bases. Borderline size of the cardiac silhouette with mild fluid overload.
No pneumothorax.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US
INDICATION: ___ year old woman s/p mvc s/p splenectomy, w/pelvic fx, RUE
swelling // RUE DVT?
TECHNIQUE: Grey scale, color and Doppler evaluation was performed on the
right upper extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the subclavian veins
bilaterally.
Normal flow, compression and augmentation is seen in the right internal
jugular, axillary and brachial veins. Normal color flow is seen in the right
basilic vein.
Occlusive thrombus is seen within a segment of the right cephalic vein at the
level of the antecubital fossa. Normal flow and compression is seen within
the cephalic vein in the upper arm.
IMPRESSION:
1. No evidence of deep vein thrombosis.
2. Occlusive thrombus seen within a segment of the right cephalic vein at the
level of the antecubital fossa.
Radiology Report
INDICATION: Polytrauma, status post MVC requiring intubation.
COMPARISON: Chest radiograph dated ___.
TECHNIQUE: Portable semi-erect frontal radiograph of the chest.
FINDINGS: There is improved aeration of the left upper lobe from ___.
Increased retrocardiac opacification and hazy opacification at the left
costophrenic angle likely reflects a pleural effusion with worsening left
lower lobe atelectasis. A small right pleural effusion is also seen. There
is no definitive evidence of pneumothorax on this semi-erect radiograph. The
tip of the endotracheal tube abuts the tracheal wall. An enteric tube and
right internal jugular catheter are unchanged. The cardiomediastinal
silhouette is prominent in part related to low lung volumes and AP technique.
IMPRESSION:
1. Resolved left upper lobe collapse but worsened left lower lobe atelectasis
from ___.
2. Small bilateral pleural effusions, left greater than right.
3. ET tube tip abuts the tracheal wall.
Radiology Report
SINGLE FRONTAL VIEW OF THE CHEST.
REASON FOR EXAM: Hypoxemia.
Comparison is made with prior study performed seven hours earlier.
New increased widespread opacity in the left lung is consistent with left
upper lobe collapse . There is also marked decrease of volume in the left
lower lobe. The amount of pleural effusion cannot be assessed. Improved
opacity in the right lung due to redistribution of a large pleural effusion.
Cardiomediastinum is shifted towards the left. The ET tube, right IJ catheter
tip and NG tube are in unchanged standard positions.
Findings were discussed with Dr. ___ by phone on ___ at 1:50
p.m., two minutes after the discovery of the finding.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Intubation, evaluation for interval change.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, no relevant change is seen.
The monitoring and support devices are constant. Low lung volumes with
retrocardiac atelectasis. The pre-existing blunting of the costophrenic
sinuses is constant. Constant known rib fractures. No pneumothorax.
Radiology Report
STUDY: Pelvis intraoperative study, ___.
CLINICAL HISTORY: Patient with left acetabular fracture ORIF.
FINDINGS: Several fluoroscopic images of the pelvis from the operating room
demonstrate placement of a screw and washer within the left superior pubic
rami. There has also been subsequent placement of a screw and washer
projecting over the left sacroiliac joint. There are no signs for
hardware-related complications. The total intraservice fluoroscopic time was
193.5 seconds. Please refer to the operative note for additional details.
Radiology Report
INDICATION: MVC status post splenectomy and ORIF of the hip, now intubated,
with fever.
COMPARISON: ___.
TECHNIQUE: Portable semi-erect frontal radiograph of the chest.
FINDINGS: The endotracheal tube, enteric tube and right IJ central venous
catheter are unchanged in position. The lung volumes are unchanged.
Retrocardiac opacification is again seen, likely reflecting atelectasis.
There is mild right basilar atelectasis. Blunting of the right costophrenic
angle may reflect small right pleural effusion. The left costophrenic angle
remains visible. There is no significant pneumothorax. The cardiomediastinal
contours are within normal limits and stable. Known rib fractures are
re-demonstrated.
IMPRESSION:
1. Unchanged position of support devices.
2. Persistent low lung volumes and bibasilar atelectasis. Possible small
right pleural effusion.
Radiology Report
PORTABLE CHEST FILM ___ AT 6:06 A.M.
CLINICAL INDICATION: ___ with presumed VAP, evaluate for pneumonia.
Comparison to prior study dated ___ at 1330.
A portable AP upright chest film ___ at 6:06 a.m. is submitted.
IMPRESSION:
1. Endotracheal tube continues to have its tip approximately 5 cm above the
carina. A nasogastric tube is seen coursing below the diaphragm with the tip
just below the esophageal gastric junction. Advancement of the tube by
approximately 5 cm would be recommended to ensure that the side port is
subdiaphragmatic. The cardiac and mediastinal contours are stable. Lung
volumes remain low with improved aeration at the right base but interval
appearance of retrocardiac opacity suggestive of atelectasis, although
pneumonia cannot be entirely excluded. Possible layering left effusion. No
evidence of pulmonary edema although the vasculature is crowded. No
pneumothorax. Results were communicated to the patient's nurse, ___, by
phone on ___ at 11:38 a.m. at the time of discovery.
Radiology Report
INDICATION: New left PICC placement, here to evaluate PICC position.
COMPARISON: Chest radiograph performed earlier the same day at 05:14 a.m.
TECHNIQUE: Portable semi-erect frontal radiograph of the chest.
FINDINGS: There has been interval placement of a left PICC ending at the
confluence of the left brachiocephalic vein and SVC. An endotracheal tube,
enteric tube, and right internal jugular transducer catheter are unchanged.
Aeration of the right lung base is improved from the most recent prior study.
The appearance of the chest is otherwise unchanged from the study performed
earlier the same day with persistent low lung volumes.
IMPRESSION:
1. Left PICC ending at the upper SVC.
2. Improved aeration of the right lung base.
NOTIFICATION: Finding #1 was communicated by Dr. ___ to IV nurse, ___,
via pager at 1:45 p.m. on ___.
Radiology Report
STUDY: AP chest ___.
CLINICAL HISTORY: ___ woman with difficulty weaning off the
respirator. Evaluate for interval change.
FINDINGS: Comparison is made to prior study from ___.
Endotracheal tube, feeding tube and left-sided central line are again seen in
unchanged position. There is cardiomegaly. Several minimally displaced left
lateral rib fractures are seen. A left retrocardiac opacity is seen and the
small left side pleural effusion is present. There is minimal prominence of
the pulmonary interstitial markings without overt pulmonary edema. Overall,
these findings are relatively stable.
Radiology Report
INDICATION: ___ status post splenectomy for splenic laceration.
Spiking fevers and rising white blood cell count. Rule out intra-abdominal
abscess.
COMPARISON: Prior CT scan of ___.
TECHNIQUE: Contiguous helical MDCT images were obtained through the abdomen
and pelvis after the administration of IV contrast. Multiplanar axial,
coronal, and sagittal images were generated.
A TOTAL BODY DLP: 1077.5 mGy-cm.
FINDINGS:
LUNG BASES: There are bilateral small pleural effusions, larger on the right.
Bibasilar airspace opacities are noted, which may represent atelectasis but
superinfection cannot be excluded. There is a residual small right lower lobe
pneumothorax. Calcifications of the coronary arteries and aorta. No
left-sided pneumothorax noted on the provided images. No pericardial
effusion.
CT OF THE ABDOMEN WITH CONTRAST: A gastric bypass with gastrojejunostomy
anastomosis is noted. The patient is status post splenectomy with
postoperative changes at the splenectomy bed. A left abdominal drain with the
tip terminating in the left upper quadrant is seen. There is no
intra-abdominal or pelvic collection noted.
No liver lesion is noted. There is a new, likely dystrophic calcification
along the infero-lateral edge of the liver. No intra- or extra-hepatic
biliary tree dilatation. Curvilinear area of hyperdensity is noted in the
dependent portion of the gallbladder which may represent layering stones or
contrast reflux. Stable 9-mm fatty lesion in the left adrenal gland in
keeping with a myelolipoma. The right kidney and adrenal gland are
unremarkable. There is atrophy of the pancreas which is likely age
appropriate. The appendix is unremarkable as is the small bowel and colon.
An enteric tube is noted which terminates at the most proximal aspect of the
gastric remnant. There is a 41 x 51 cm oval-shaped left adnexal lesion which
may be of ovarian origin. A second oval-shaped structure is noted in the
right adnexal region which may represent the uterus which is slightly deviated
to measures 23 x 36 cm. The right ovary is not well visualized.
The abdominal aorta is of normal caliber with moderate calcified
atherosclerotic disease within the aorta and iliac arteries. There is a left
abdominal drain with the tip terminating in the splenectomy bed.
OSSEOUS STRUCTURES: Redemonstration of the known bilateral rib fractures of
the left, five, six, seven, eight, nine, ten, and twelfth rib and right
seventh rib. Status-post open reduction internal fixation of pelvic ring
fracture with sacroiliac screw, fully threaded, and
retrograde anterior column screw. Stable right hip prosthesis.
IMPRESSION:
1. Status-post splenectomy with post-surgical changes in the splenectomy bed.
2. No intra-abdominal or pelvic collection noted.
3. Small residual right lower lobe pneumothorax.
4. Bilateral small-to-moderate pleural effusions.
5. Indeterminate left adnexal mass for which an elective ultrasound is
recommended when the patient is stabilized.
Radiology Report
INDICATION: Status post MVC with multiple orthopedic injuries, splenic
laceration, and increased white count, evaluate for acalculous cholecystitis.
COMPARISON: CT abdomen and pelvis on ___.
FINDINGS:
The liver is normal in echogenicity. No focal hepatic lesions. No
intrahepatic or extrahepatic biliary duct dilatation. The common bile duct
measures 4 mm. The portal vein is patent with hepatopetal flow. The
gallbladder is only moderately dilated. There is cholelithiasis and on some
images the gallbladder wall appears mildly edematous. No pericholecystic
fluid. No sonographic ___ sign.
A midline well-circumscribed pocket of fluid is consistent with excluded
stomach after gastric bypass, as shows on the prior CT.
IMPRESSION:
Cholelithiasis. On some images the gallbladder wall appears mildly edematous,
but without other signs specific for cholecystitis.
Radiology Report
PORTABLE CHEST X-RAY, ___
COMPARISON: Chest x-ray of one day earlier.
FINDINGS: Nasogastric tube has been exchanged for a feeding tube, terminating
in the proximal stomach. Exam otherwise appears similar to the prior study of
one day earlier, except for apparent slight increase in pleural effusions,
left greater than right.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ year old woman s/p MVA with no initial head trauma with
altered mental status evaluate for intracranial pathology such is bleed or
edema pre
TECHNIQUE: Noncontrast multi sequence, multiplanar brain MRI is performed
utilizing the following sequences: Sagittal T1, axial T2, axial FLAIR, axial
FLAIR propeller, axial T2 GRE, and axial T2 trace.
COMPARISON: Noncontrast head CT dated ___.
FINDINGS:
Some of the sequences are degraded by motion artifact. Within this confines:
There is no infarct, hemorrhage, or mass effect. The ventricles and sulci are
prominent indicative of mild parenchymal volume loss. There are extensive
nonspecific periventricular and subcortical white matter confluent areas of
FLAIR hyperintensity likely sequela of chronic small vessel ischemic disease.
The principal intracranial flow voids are present.
There are bilateral lens implants. There is fluid within the mastoid air cells
bilaterally, left greater than right.
IMPRESSION:
No acute infarct, hemorrhage or mass effect.
Extensive nonspecific white matter abnormalities, likely sequela of chronic
small vessel ischemic disease.
Radiology Report
AP CHEST, 8:27 A.M.
HISTORY: Newly replaced Dobbhoff tube.
IMPRESSION: AP chest compared to ___:
Three serial chest radiographs show initial positioning of the Dobbhoff tube
in the distal right lower lobe bronchial tree, then at the gastroesophageal
junction, finally in the upper stomach. None of the chest radiographs shows
right pneumothorax, or evidence of bleeding in the right lung. Presumed right
pleural effusion is small. Previous consolidation in the right lung laterally
has improved since ___. Left lower lobe, however, is more consolidated
today with greater volume loss, indicating worsening of a component of
atelectasis, despite at least a small left pleural effusion. Followup for
possible complications of the bronchial intubation and possible left lower
lobe pneumonia.
No pneumothorax. Tracheostomy tube in standard placement. Left PIC line ends
in the upper SVC.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Nasogastric tube, Dobbhoff placement.
COMPARISON: ___, 8:27.
FINDINGS: As compared to the previous radiograph, Dobbhoff tube is in
unchanged position. The tip of the tube projects 2-3 cm within the stomach.
The tube has not changed in position since the previous examination. All
other monitoring and support devices are also in constant position. Unchanged
appearance of the heart and the known small left pleural effusion.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Dobbhoff placement.
COMPARISON: ___, 2:27.
FINDINGS: As compared to the previous radiograph, the Dobbhoff catheter
appears to be pulled back. The tip of the catheter is coiled. The last
images of the series show the catheter within the proximal parts of the
stomach. The decision of repositioning the device should be made on the
grounds of clinical criteria.
Radiology Report
AP CHEST, 5:35 A.M., ___
HISTORY: ___ woman after polytrauma with a new Dobbhoff feeding tube.
IMPRESSION: AP chest compared to ___:
Feeding tube with a wire stylet initially placed in the lower esophagus is on
the second image advanced into the upper stomach. Moderate left pleural
effusion changed in distribution but not in overall size. Pulmonary vascular
congestion, more readily assessed in the right lung, has progressed. Heart
size top normal. Tracheostomy tube in standard placement. Left PIC line ends
at the origin of the SVC. No pneumothorax.
Radiology Report
INDICATION: ___ year old woman with dobboff and past gastric bypass. Advanced
tube into the small bowel per ACS recs
FINDINGS:
Patient's existing catheter is found with tip in the distal esophagus/ remnant
proximal stomach. This was exchanged for an 8 ___ ___
catheter as the existing catheter was 12 ___ and the team requested a
bridle. No bridle is available in a ___ size. As a result, the 8 ___
___ was advanced into the stomach.
After repeated attempts, the tip was not able to be advanced past the
gastrojejunostomy and was left with a small amount of slack within the stomach
with hope of passage through peristalsis. This was discussed with the
patient's nurse upon completion of the study who then placed the bridle.
IMPRESSION:
8 ___ ___ catheter left within the stomach. Despite repeated
attempts, unable to be advanced past the gastrojejunostomy.
Please note when ordering this study in the future with instructions to
bridle, only 8 and 10 ___ tubes can be successfully bridled.
Radiology Report
AP CHEST, 6:14 A.M., ___
HISTORY: ___ woman after motor vehicle collision and tracheostomy.
Attempting to wean.
IMPRESSION: AP chest compared to ___ through ___:
Mild pulmonary edema has improved, moderate left pleural effusion has
increased. Mild-to-moderate cardiomegaly stable. Feeding tube ends in the
stomach. Tracheostomy tube in standard placement. Left PICC line ends in the
upper-to-mid SVC. No pneumothorax.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with dobhoff, ? pulled back inadvertantly //
___ year old woman with dobhoff, ? pulled back inadvertantly
TECHNIQUE: Portable chest
COMPARISON: ___
FINDINGS:
Tracheostomy tube and left-sided PICC line are unchanged. There is worsening
appearance of the lungs with increased ill-defined vasculature and increased
alveolar infiltrates left greater than right. There is dense retrocardiac
opacity. The heart is moderately enlarged. There is bilateral pleural
effusions.
IMPRESSION:
Worsened fluid status. An underlying infectious infiltrate can't be excluded
Radiology Report
INDICATION: Trauma. Rib fractures, splenic injury, pelvic fractures on
outside hospital exam.
COMPARISON: CT torso performed subsequently after this exam.
FINDINGS:
PORTABLE AP CHEST: There are at least five contiguous rib fractures on the
left from the fourth to the eighth ribs although several other rib fractures
bilaterally are better evaluated on concurrent CT torso. There is subcutaneous
emphysema in the left chest wall. There is opacity in the left lung, likely a
combination of lung parenchymal contusion and hemothorax. The right lung is
relatively clear, but low in volume. The cardiomediastinal silhouette and
hilar contours are difficult to evaluate given portable technique but grossly
normal. The ET tube terminates approximately 2.5 cm from the carina. Enteric
tube courses through the esophagus and appears to course to the right at the
EG junction and out of view. There is possible small left pneumothorax with
lucency along the left heart border.
PORTABLE AP PELVIS: There are fractures of the superior and inferior pubic
rami on the left with inferior displacement of the medial fracture components.
There is communited left sacral alar fracture. There is no evidence of pubic
symphysis or SI joint diastasis. There is total right hip arthroplasty. The
left hip appears intact.
IMPRESSION:
1. Numerous left rib fractures with left hemothorax and possible left
pneumothorax. Other known right rib fractures and right pneumothorax are
better seen on concurrent CT of the chest.
2. Left superior and inferior pubic rami fractures and comminuted left sacral
alar fracture
Radiology Report
INDICATION: Trauma. Motor vehicle collision with left rib fractures, splenic
laceration, pelvic fractures.
COMPARISON: Outside CT of the torso without contrast the same day.
TECHNIQUE: Contiguous helical MDCT images were obtained through the torso
after administration of Omnipaque IV contrast, followed by additional delayed
images through the torso. Multiplanar axial, coronal, and sagittal images
were generated.
TOTAL BODY DLP: 2237 mGy-cm.
FINDINGS:
OSSEOUS STRUCTURES: There are posterior and lateral displaced fractures of
the left 3, 4, 6, 7, 8, 9, 10 ribs, as well as fractures laterally in the left
second rib, laterally in the left fifth rib, and anteriorly in the left first
rib. There is a lateral second right rib fracture, lateral/anterior right
fourth rib fracture, and lateral right seventh rib fracture.
Left L5 tranverse process fracture is minimally displaced (2A:115). There are
acute fractures of the left inferior pubic ramus (2B:446). There is a
comminuted fracture of the left acetabular column involving the left superior
pubic ramus (2B:427). There is also comminuted fracture of the left sacral
ala (2B:386). There is no evidence of pubic symphysis or SI joint diastasis.
Total right hip prosthesis is incidentally noted.
CT CHEST WITH CONTRAST: Included portions of the thyroid are unremarkable.
There is no supraclavicular, axillary, hilar, or mediastinal lymphadenopathy.
The heart is not enlarged, and there is only trace likely physiologic
pericardial fluid. There are calcifications of the coronary arteries and
aorta. There are very small bilateral pneumothoraces (2A:1). There is a
moderate left hemothorax with atelectasis of the left lower lobe. A small
peripheral area of probable lung contusion is evident in the lingula (2A:3).
Very small right hemothorax is also noted with adjacent atelectasis in the
lower lobe. Subcutaneous emphysema is noted within the left chest wall
adjacent to the fractures.
The thoracic aorta is normal in caliber without intramural hematoma, aneurysm,
or dissection. The great vessels are unremarkable.
CT ABDOMEN WITH CONTRAST: The liver enhances normally without focal lesions,
intra- or extra-hepatic biliary duct dilation. The portal vein is patent.
The gallbladder contains small dependently layering stones. There is
thickening at the fundus of the gallbladder, likely reflecting adenomyomatosis
(2B:319). Fatty lesion in the left adrenal gland is compatible with a
myelolipoma. The pancreas and right adrenal gland are unremarkable. The
kidneys excrete contrast symmetrically without hydronephrosis or worrisome
mass. There are scattered subcentimeter hypodensities. The largest in the
interpolar region of the right kidney measures 1.2 cm with internal density of
15 Hounsfield units, compatible with a simple cyst. Other smaller
hypodensities are too small to characterize but may also be simple cysts. The
ureters are normal throughout their visualized course.
The spleen contains several lacerations, the largest a 3.1-cm laceration
within the upper pole (2B:269). There are several arterially enhancing foci,
most likely reflecting pseudoaneurysms; for example, 1.6 cm focus superiorly
(2A:18) and several smaller scattered foci more inferiorly. The most inferior
focus (2A:40) may have a component of active extravasation, but if present,
this is small. There is small to moderate hemoperitoneum, with a hematoma
seen surrounding the spleen. Additional small volume hemorrhage tracks along
the retroperitoneum on the left along the psoas.
The patient is status post gastric bypass. Enteric tube passes into the
gastric remnant. The excluded portion of the stomach is unremarkable. Small
and large bowel are normal in caliber without evidence of wall thickening or
abnormal enhancement. There is no mesenteric or retroperitoneal
lymphadenopathy and no abdominal wall hernia. No free air is present.
Abdominal aorta is normal in caliber with moderate calcified atherosclerotic
disease within the aorta and iliac arteries.
CT PELVIS WITH CONTRAST: Streak artifact from right total hip arthroplasty
limits evaluation of the lower pelvis. However, within these limitations,
there is small to moderate amount of blood in the pelvis. Two more
well-circumscribed foci in the lower pelvis measuring 4.5 and 3.3 cm also
likely reflect hematomas (2A:157). The rectum and is unremarkable. A foley is
noted in a collapsed bladder. Extraperitoneal hematoma surrounds the left
pubic rami fracture; extraperitoneal bladder rupture is unlikely given the
normal appearance of the bladder on the prior CT.
IMPRESSION:
1. Splenic lacerations (AAST grade 3) with several pseudoaneurysms, the
largest measuring 1.6 cm. The small inferior-most pseudoaneurysm may have a
tiny component of active extravasation.
2. Moderate left hemothorax with small bilateral pneumothoraces.
3. Small left lung contusion at the lingula.
4. Small hemoperitoneum with hemorrhage also in the left retroperitoneum and
pelvis.
5. Comminuted left acetabular column and left inferior pubic ramus fracture.
Comminuted left sacral alar fracture.
6. Fracture of the left L5 transverse process. Numerous left segmental rib
fractures as detailed above and several nonsegmental right rib fractures.
7. Cholelithiasis and adenomyomatosis of the gallbladder fundus.
8. Left adrenal myelolipoma.
These results were communicated to the surgery team immediately at the time of
discovery in person by ___, approximately 3:30 p.m., ___.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: MVC
Diagnosed with SPLEEN PARENCHYMA LACER, FRACTURE OF PUBIS-CLOSED, FX SACRUM/COCCYX-CLOSED, FX LUMBAR VERTEBRA-CLOSE, TRAUM HEMOTHORAX-CLOSED, FX MULT RIBS NOS-CLOSED, MV COLLISION NOS-DRIVER
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Ms. ___ was the restrained driver in an ___, and was intubated
at an outside hospital and transferred to ___. After being
examined in the trauma bay, she was admitted to the ICU. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Vicodin / Seroquel
Attending: ___.
Chief Complaint:
Abdominal pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ year old female with history of multiple GI surgeries, now
presenting with persistent abdominal pain s/p ERCP with stent
placement. She has had recurrent abdominal pain and "issues"
over the past year. She went to ___ for initial
evaluation of abdominal pain and was found to have a UTI. She
had a subsequent evaluation with EGD/ERCP with stent placement.
She was reportedly found to have pancreatitis and treated with
bowel rest. She had minimal improvement during this
hospitalization. She was eventually discharged yesterday but
pain has persisted and she is unable to care for her children at
home, so she is presenting now for further evaluation.
In the ED, initial VS were: 98.2 87 125/85 18 97%. Exam notable
for moderate tenderness to palpation to RUQ. LFTs and lipase
normal with only mild ALT elevation. Given recent stent
placement, CT abd/pelvis done and only showed lymphandenopathy
with stent in place. She was given 1L NS, ondansetron, and
morphine with minimal improvement. With her persistent pain and
intolerance to PO, she is being admitted for pain control and
observation.
On arrival to the floor, pt feels well. She has no complaints
aside from constipation and decreased po intake.
Past Medical History:
- ulcers and gastritis
- congenital abnormalities "heterotaxy syndrome"
- lap band removed due to complications
- cholecystectomy
- pancreatitis
- malrotation corrected age ___
- asplenic (congenital)
- hysterectomy for bleeding, cysts
- pregnancy
Social History:
___
Family History:
noncontributory
Physical Exam:
ADMISSION AND DISCHARGE
VS - 98.0 125/82 99 18 96/RA wt 76.8kg
GENERAL - well-appearing obese female in NAD, comfortable,
appropriate
HEENT - NC/AT, PERRL, EOMI, sclerae anicteric, MMM, OP clear
NECK - supple, no thyromegaly, no JVD, no carotid bruits
LUNGS - CTA bilat, no r/rh/wh, good air movement, resp
unlabored, no accessory muscle use
HEART - PMI non-displaced, RRR, no MRG, nl S1-S2
ABDOMEN - NABS, soft/NT/ND, no masses or HSM, no
rebound/guarding
EXTREMITIES - WWP, no c/c/e, 2+ peripheral pulses (radials, DPs)
SKIN - no rashes or lesions
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ throughout, sensation grossly intact throughout
LABS: see below
Pertinent Results:
ADMISSION AND DISCHARGE LABS
___ 04:30PM BLOOD WBC-11.8* RBC-4.49 Hgb-13.3 Hct-39.8
MCV-89 MCH-29.7 MCHC-33.4 RDW-12.5 Plt ___
___ 04:30PM BLOOD Glucose-92 UreaN-8 Creat-0.7 Na-142 K-3.5
Cl-105 HCO3-26 AnGap-15
___ 04:30PM BLOOD ALT-51* AST-38 AlkPhos-99 TotBili-0.2
___ 06:05AM BLOOD Calcium-9.1 Phos-5.7* Mg-2.0
___ 04:30PM BLOOD Albumin-4.1
U/A - SpecGr 1.020, pH 5.5, Leuk Sm, Bld Neg, Prot Tr, RBC 3,
WBC 5, Bact Few, Yeast None, Epi 1
___ Lipase 40
IMAGING
1. No acute intrapelvic process.
2. Post-operative anatomy compatible with history of heterotaxy
and
malrotation.
3. Several nodular enhancing soft tissue densities at the celiac
axis
measuring up to 1.5 cm in short axis. These may represent lymph
nodes of
unknown significance. In addition, thes could represent an
atypical location
of splenosis. Given the patient's altered anatomy, the celiac
axis is
adjacent to the splenic tail. No normal spleen is visualized.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain
2. Docusate Sodium 100 mg PO BID
3. Clonazepam 1 mg PO BID
4. Adderall XR *NF* (amphetamine-dextroamphetamine) 20 mg Oral
daily
5. Levothyroxine Sodium 75 mcg PO DAILY
6. Venlafaxine XR 150 mg PO DAILY
7. BuPROPion 200 mg PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. Florastor *NF* (saccharomyces boulardii) 250 mg Oral BID
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Oxycodone-Acetaminophen (5mg-325mg) 1 TAB PO Q8H:PRN pain
RX *oxycodone-acetaminophen 5 mg-500 mg 1 capsule(s) by mouth q8
Disp #*21 Capsule Refills:*0
3. Adderall XR *NF* (amphetamine-dextroamphetamine) 20 mg Oral
daily
4. BuPROPion 200 mg PO DAILY
5. Clonazepam 1 mg PO BID
6. Florastor *NF* (saccharomyces boulardii) 250 mg Oral BID
7. Levothyroxine Sodium 75 mcg PO DAILY
8. Pantoprazole 40 mg PO Q12H
9. Venlafaxine XR 150 mg PO DAILY
10. Bisacodyl 10 mg PO DAILY:PRN constipation
RX *bisacodyl 5 mg 2 tablet(s) by mouth daily Disp #*60 Tablet
Refills:*0
11. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth q8 Disp #*90 Tablet
Refills:*0
12. Senna 1 TAB PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a ___ Disp
#*60 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Post procedural abdominal pain
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: ___ woman with history of heterotaxy and repaired
malrotation now status post recent ERCP with abdominal pain.
TECHNIQUE: MDCT data were acquired through the abdomen and pelvis after the
administration of intravenous contrast. Images were displayed in multiple
planes.
COMPARISON: None at this institution
FINDINGS:
Abdomen: The visualized lung bases are clear.
The liver is enhances homogeneously. Attenuation of the liver is low, but
there is no spleen for comparison. The portal and hepatic veins are patent.
There is no intra or extrahepatic biliary dilatation. There is a stent from
the left-sided biliary ducts into the duodenum. Gallbladder is surgically
absent. The anatomic relationships at the porta hepatis are severely
distorted. The pancreas is small and enhances homogeneously. The splenic to
terminates around the celiac axis. The spleen is absent. Mildly enhancing
soft tissue densities are visible at the celiac axis. The largest measures
1.5 x 2.4 cm (601b:037, 2:23). The adrenal glands are normal. The kidneys
enhance symmetrically and excrete contrast promptly.
The stomach, small bowel, and large bowel are normal caliber and wall
thickness. There is a relative paucity of small bowel in the left upper
quadrant, compatible with history of malrotation. There is azygos
continuation of the IVC. In addition, the left renal vein drains into a hemi
azygous vein which courses from the abdomen up into the chest.
Pelvis: The remainder of the bowel is unremarkable. There is no pelvic free
pelvic fluid. The uterus and bladder are within normal limits. There is no
free pelvic fluid. There is no inguinal or pelvic adenopathy.
There are no concerning lytic or sclerotic bone lesions.
IMPRESSION:
1. No acute intrapelvic process.
2. Post-operative anatomy compatible with history of heterotaxy and
malrotation.
3. Several nodular enhancing soft tissue densities at the celiac axis
measuring up to 1.5 cm in short axis. These may represent lymph nodes of
unknown significance. In addition, thes could represent an atypical location
of splenosis. Given the patient's altered anatomy, the celiac axis is
adjacent to the splenic tail. No normal spleen is visualized.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with ABDOMINAL PAIN RUQ, NAUSEA WITH VOMITING
temperature: 98.2
heartrate: 87.0
resprate: 18.0
o2sat: 97.0
sbp: 125.0
dbp: 85.0
level of pain: 10
level of acuity: 3.0 | BRIEF HOSPITAL COURSE + ACTIVE ISSUES
___ year old female with history of multiple abdominal surgeries
and recent ERCP with stent placement, presenting with worsening,
persistent RUQ abdominal pain.
Patient with normal CT scan and reassuring labs. She is
hemodynamically stable and her exam is not concerning for an
acute abdomen. Exam negative for any discomfort. Lipase is
normal. Counseled about gradual relief of pain as pancreatitis
resolves. She was monitored over course of morning and afternoon
of ___ with improving abdominal pain. Was continued on home
medications in-house, and we ensured bowel movement and regular
diet prior to discharge.
INACTIVE ISSUES
# Continued on outpatient psychiatric medications. Medications
reconcilled with pharmacy.
TRANSITIONAL ISSUES
- f/u ERCP in 8 weeks for stent removal |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / latex
Attending: ___.
Chief Complaint:
Pulled G-tube, abdominal distention
Major Surgical or Invasive Procedure:
G-tube placement ___
PICC line placement ___
History of Present Illness:
___ with hx CVAs (relatively nonverbal), HTN, HLD, AFib, G-tube,
and atonic colon with several recent admissions for concern of
obstruction who presented from rehab after pulling out G-tube
and with significant abdominal distention.
Patient has had multiple recent admissions with diagnosis of
atonic colon most recently ___ of this year for distended
abdomen during which time she was decompressed with a rectal
tube and flex sig showed atonic colon thought to be due to
enteric nerve damage in setting of previous CVAs. Her bowel
regimen was increased at that time and she began passing stool
on her own. Patient was noted to have significant abdominal
distention at rehab the day prior to admission but did have a
small BM the day of admission. The same day the patient pulled
her G-tube with ballon inflated. Temporary foley was placed and
patient was brought to ED for evaluation and g-tube replacement.
In the ED, initial vital signs: 98.6 64 148/117 20 100% RA. Labs
were notable for WBC of 2.7, platelets of 123, INR of 1.7 (goal
___. KUB showed colonic dilation to 11cm. Patient was admitted
for g-tube replacement and management of abdominal distention.
VS on transfer 97.9 92 157/101 14 99% RA.
Past Medical History:
History of thromboembolic strokes (L hemiplegia and nonverbal),
seizures, atrial fibrillation, hypertension, hyperlipidemia.
Social History:
___
Family History:
Daughter and son are HCP
Physical Exam:
*Admission Physical*
Vitals: T: 97.9 BP: 152/89 P: 87 R: 32 O2: 100%RA Pain: Unable
to assess
General: Comfortable, frequent mouth movements, attempts to
speak but not understandable
HEENT: MMM, chapped lips, OP clear, sclera anicteric
Neck: Supple, no JVD appreciated, no LAD
CV: Irregularly irregular, mildly tachycardic, no murmurs
appreciated
Lungs: CTAB, unable to listen posteriorly as patient unwilling
to move
Abdomen: normoactive bowel sounds, moderately distended but soft
without tenderness to palpation, tympanic, tube in place at
previous G-tube site
Ext: WWP, 1+ DP pulses bilaterally, no edema
Neuro: Unable to assess as patient nonverbal, makes some words
but not coherent.
Skin: No rashes appreciated
DISCHARGE PHYSICAL:
98.3 124/68 109 18 100% RA
General: confortable, alert
HEENT: MMM, sclera anicteric
CV: irregularly irregular, mildy tachycardic, no m/r/g
Lungs: CTAB
Abd: soft, non-tender to palpation, non-distended, NABS, G-tube
in place
Ext: warm, no edema
Neuro: patient nonverbal
Pertinent Results:
ADMISSION LABS:
___ 10:15AM BLOOD WBC-2.7* RBC-4.41 Hgb-13.7 Hct-40.8
MCV-93 MCH-31.1 MCHC-33.6 RDW-17.8* Plt ___
___ 10:15AM BLOOD Neuts-31* Bands-0 Lymphs-64* Monos-3
Eos-0 Baso-0 Atyps-2* ___ Myelos-0
___ 05:05PM BLOOD ___
___ 10:15AM BLOOD Glucose-108* UreaN-18 Creat-0.7 Na-145
K-3.8 Cl-105 HCO3-28 AnGap-16
___ 08:38PM BLOOD ALT-24 AST-45* CK(CPK)-150 AlkPhos-97
TotBili-0.8
___ 10:15AM BLOOD Calcium-9.2 Phos-2.2* Mg-2.4
BANDEMIA:
___ 05:43AM BLOOD Neuts-34* Bands-0 Lymphs-43* Monos-10
Eos-2 Baso-0 ___ Myelos-1* Blasts-10* NRBC-2*
___ 05:16AM BLOOD Neuts-57 Bands-2 ___ Monos-7 Eos-0
Baso-0 Atyps-3* ___ Myelos-1* Blasts-5* NRBC-1* Other-0
DISCHARGE LABS:
___ 05:35AM BLOOD WBC-3.1* RBC-2.73* Hgb-8.8* Hct-26.2*
MCV-96 MCH-32.3* MCHC-33.7 RDW-18.7* Plt ___
___ 05:35AM BLOOD ___ PTT-40.3* ___
___ 05:35AM BLOOD Glucose-95 UreaN-18 Creat-0.8 Na-142
K-4.2 Cl-109* HCO3-28 AnGap-9
STUDIES:
KUB ___:
IMPRESSION: Prominent colonic distention to a maximum of 11 cm,
increased
compared to prior examination. This is fairly similar in
appearance to some
of the patient's prior examinations including one dated from
___ and
is most likely chronic, secondary to dysmotility
CXR ___:
FINDINGS: Status post G-tube placement. Only a part of the
device is visible
on the current chest x-ray. There are clearly hyperexpanded
parts of the
colon visible both under the left and the right hemidiaphragm.
On the right,
however, there could also be a small amount of post-procedural
free air.
CXR ___:
IMPRESSION: AP chest compared to ___, 8:47 p.m.:
ET tube in standard placement, nasogastric tube passes into
non-distended
stomach. Right internal jugular line ends in the right atrium,
approximately
9 cm below the level of the carina, would need to be withdrawn 5
cm to
reposition it in the low SVC. Opacification in the right upper
lobe has
improved suggesting it was due in large part to atelectasis.
Followup
advised. Moderate cardiomegaly has improved. Left lung is
clear. No
pneumothorax or pleural effusion. The intestines in the upper
abdomen remain
moderately-to-severely distended
EKG ___:
Atrial fibrillation with a rapid ventricular response with
frequent ventricular
premature beats or aberrant conduction. Left ventricular
hypertrophy with
repolarization changes. Inferolateral ST segment changes are
probably due to
left ventricular hypertrophy. Compared to the previous tracing
of ___ the
findings are similar.
CXR ___:
IMPRESSION: Right IJ line has been withdrawn, probably ends in
the upper
atrium since it is still 7 cm below the level of the carina, and
would need to
be further withdrawn 3 cm to reposition it low in the SVC. No
pneumothorax or
pleural effusion. Right upper lobe atelectasis has almost
entirely cleared.
Mild cardiomegaly is stable. ET tube in standard placement.
Upper enteric
drainage tube passes into a non-distended stomach. Intestinal
segments in the
upper abdomen are still moderately-to-severely distended.
CXR ___:
FINDINGS: As compared to the previous radiograph, the sidehole
of the
nasogastric tube is now in the middle to distal parts of the
stomach. The tip
of the device is not included on the image. No evidence of
complications,
notably no pneumothorax. Massive intestinal overdistention,
unchanged to the
prior image. Minimal plate-like atelectasis at the right lung
bases.
Moderate cardiomegaly. Thickening of the minor fissure. The
right internal
jugular vein catheter, the endotracheal tube are in correct
position.
KUB ___:
FINDINGS: Diffuse colonic distension is again demonstrated,
with individual
loops of bowel measuring up to 9 cm in diameter. A moderate
amount of
residual stool is present within the colon, particularly in the
ascending and
distal rectosigmoid regions. Overall similar appearance to
___, though the extent of bowel distention has slightly
decreased since that
time. Similar pattern of colonic distension is present on older
abdominal
radiographs ___, possibly due to a history ___
syndrome.
Nasogastric tube and G-tube overlie the stomach.
KUB ___:
IMPRESSION:
Persistent colonic dilatation, substantially increased, now with
a maximal
dilatation of 14 cm. This is compatible with known
pseudoobstruction, but
volvulus is not excluded in this current study. If clinical
concern for
obstruction persists, a gastrograffin enema or CT may be
considered.
Otherwise, short-term follow-up radiographs are recommended.
The degree of
dilatation may pose a risk of perforation and close follow-up is
suggested.
KUB ___:
IMPRESSION:
Gas throughout the colon largely unchanged since 1 day prior
consistent with
excessive ileus. No evidence of obstruction.
MICRO:
Urine culture ___:
___. >100,000 ORGANISMS/ML..
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
___
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- 16 R
CEFTRIAXONE----------- 2 I
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
PIPERACILLIN/TAZO----- 8 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
Blood cx x4: No growth
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Docusate Sodium (Liquid) 100 mg PO BID
2. LACOSamide 100 mg PO BID
3. Metoprolol Tartrate 25 mg PO TID
4. Glycerin Supps ___AILY constipation
5. Polyethylene Glycol 34 g PO DAILY
6. Atorvastatin 80 mg PO DAILY
7. Ezetimibe 10 mg PO DAILY
8. Omeprazole 20 mg PO DAILY
9. Ramipril 10 mg PO BID
10. Simethicone 80 mg PO TID
11. Warfarin 3.5 mg PO DAILY16
12. Acetaminophen 650 mg PO Q8H
Discharge Medications:
1. Atorvastatin 80 mg PO DAILY
2. Glycerin Supps ___AILY constipation
3. Ramipril 10 mg PO BID
4. Polyethylene Glycol 34 g PO DAILY
5. Ezetimibe 10 mg PO DAILY
6. LACOSamide 100 mg PO BID
7. Simethicone 80 mg PO TID
8. Omeprazole 20 mg PO DAILY
9. Senna 1 TAB PO DAILY
10. Warfarin 3 mg PO DAILY atrial fibrillation
11. Metoprolol Tartrate 50 mg PO TID
12. Acetaminophen 650 mg PO Q6H:PRN pain/fever
13. Docusate Sodium (Liquid) 200 mg PO BID
14. Enoxaparin Sodium 60 mg SC BID Start: ___, First Dose:
Next Routine Administration Time
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary: Abdominal distention to to atony, pulled G-tube, UTI,
atrial fibrillation with aberrancy, respiratory failure
Secondary: CVA, myleoproliferative disorder
Discharge Condition:
Activity Status: Bedbound.
Level of Consciousness: Lethargic but arousable.
Mental Status: Confused, non-verbal.
Followup Instructions:
___
Radiology Report
HISTORY: Colonic dysmotility, presenting after pulling a G-tube which is now
replaced, now with significant abdominal distention.
COMPARISON: ___.
TECHNIQUE: Abdominal radiograph, three views.
FINDINGS: There is prominent dilatation of the large bowel up to roughly 11
cm without noted wall thickening. Small bowel loops are difficult to
evaluate; however, do not appear dilated. There is no evidence of
pneumoperitoneum or pneumatosis, although evaluation is limited given
prominent dilatation of the colon. G-tube projects over the left upper
quadrant.
IMPRESSION: Prominent colonic distention to a maximum of 11 cm, increased
compared to prior examination. This is fairly similar in appearance to some
of the patient's prior examinations including one dated from ___ and
is most likely chronic, secondary to dysmotility.
Radiology Report
CHEST RADIOGRAPH
INDICATION: G-tube placement.
COMPARISON: ___.
FINDINGS: Status post G-tube placement. Only a part of the device is visible
on the current chest x-ray. There are clearly hyperexpanded parts of the
colon visible both under the left and the right hemidiaphragm. On the right,
however, there could also be a small amount of post-procedural free air.
CC7 was called at the time of dictation and observation, 8:46 a.m., on ___. In addition, a wet read was entered into the system.
Low lung volumes. Borderline size of the cardiac silhouette without evidence
of pneumonia or pulmonary edema.
Radiology Report
AP CHEST, 8:47 P.M. ON ___
HISTORY: Clogged G-tube. V-tach. Check ET tube.
IMPRESSION: AP chest compared to ___:
Previous large pneumoperitoneum no longer visible. New opacification in the
right upper lung with volume loss could be largely atelectasis but raises
concern for pneumonia. ET tube is in standard position, with the chin flexed.
Upper enteric drainage tube passes into a non-distended stomach. The gut in
the upper abdomen remains moderately to severely distended. Heart is
moderately enlarged, unchanged, but there is no vascular congestion, edema or
appreciable effusion.
Radiology Report
AP CHEST 11:38 P.M. ON ___
HISTORY: New right IJ line and NG tube.
IMPRESSION: AP chest compared to ___, 8:47 p.m.:
ET tube in standard placement, nasogastric tube passes into non-distended
stomach. Right internal jugular line ends in the right atrium, approximately
9 cm below the level of the carina, would need to be withdrawn 5 cm to
reposition it in the low SVC. Opacification in the right upper lobe has
improved suggesting it was due in large part to atelectasis. Followup
advised. Moderate cardiomegaly has improved. Left lung is clear. No
pneumothorax or pleural effusion. The intestines in the upper abdomen remain
moderately-to-severely distended.
Radiology Report
AP CHEST, 3:34 A.M., ___
HISTORY: Right IJ line partially withdrawn.
IMPRESSION: Right IJ line has been withdrawn, probably ends in the upper
atrium since it is still 7 cm below the level of the carina, and would need to
be further withdrawn 3 cm to reposition it low in the SVC. No pneumothorax or
pleural effusion. Right upper lobe atelectasis has almost entirely cleared.
Mild cardiomegaly is stable. ET tube in standard placement. Upper enteric
drainage tube passes into a non-distended stomach. Intestinal segments in the
upper abdomen are still moderately-to-severely distended.
Radiology Report
CHEST RADIOGRAPH
INDICATION: New nasogastric tube placement.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the sidehole of the
nasogastric tube is now in the middle to distal parts of the stomach. The tip
of the device is not included on the image. No evidence of complications,
notably no pneumothorax. Massive intestinal overdistention, unchanged to the
prior image. Minimal plate-like atelectasis at the right lung bases.
Moderate cardiomegaly. Thickening of the minor fissure. The right internal
jugular vein catheter, the endotracheal tube are in correct position.
Radiology Report
INDICATION: History of a 20 ___ MIC G-tube in place, which fell out, for
replacement.
PHYSICIAN: Dr. ___, the attending radiologist, performed the
procedure.
PROCEDURE:
1. Tube study (injection through existing Foley in place).
2. Replacement with a 20 ___ MIC G-tube.
SEDATION: Moderate sedation was provided by administering dividing doses of
fentanyl throughout the total intraprocedure time of 15 minutes (50 mcg)
during which patient's hemodynamic parameters were continuously monitored by a
trained radiology nurse.
PROCEDURE: Prior to initiation of procedure, written informed consent was
obtained and preprocedure timeout was performed. The site was prepped and
draped in a sterile manner. Contrast injection was performed through the
existing Foley to confirm that the tip was positioned within the stomach.
Next, a 4 ___ dilator and ___ wire advanced alongside the Foley, and
the wire was coiled within the stomach. The Foley balloon was deflated and
the catheter was removed. A Kumpe catheter was advanced into the stomach, and
contrast injection confirmed appropriate location. Over the ___ wire, a
20 ___ MIC G-tube was placed, and the balloon was inflated within the
stomach and pulled back to the ostomy site. The retention disc was advanced,
and the catheter was secured in place. Contrast injection confirmed placement
and the catheter was flushed. The patient tolerated the procedure well and
there were no immediate complications.
FINDINGS: Foley catheter in place within the patent tract, with the tip
positioned in the stomach. Successful exchange for a 20 ___ MIC G-tube.
IMPRESSION: Successful replacement of 20 ___ MIC G-tube.
Radiology Report
PORTABLE ABDOMEN, ___
COMPARISON: ___.
FINDINGS: Diffuse colonic distension is again demonstrated, with individual
loops of bowel measuring up to 9 cm in diameter. A moderate amount of
residual stool is present within the colon, particularly in the ascending and
distal rectosigmoid regions. Overall similar appearance to ___, though the extent of bowel distention has slightly decreased since that
time. Similar pattern of colonic distension is present on older abdominal
radiographs ___, possibly due to a history ___ syndrome.
Nasogastric tube and G-tube overlie the stomach.
Radiology Report
HISTORY: ___ female with colonic distention.
COMPARISON: Abdominal plain film on ___.
FINDINGS:
Supine images through the abdomen demonstrate increased dilatation of large
bowel. Redomonstration of diffuse colonic distention with maximum dimension
measured to be 14 cm; this is considerably more dilated than on prior
examination when dilation measured 7 cm. The orientation of the dilation has
changed slightly as well, now more horizontal. Air is seen within nondilated
loops of small bowel. Re- demonstration of G tube and interval removal of
nasogastric tube.
IMPRESSION:
Persistent colonic dilatation, substantially increased, now with a maximal
dilatation of 14 cm. This is compatible with known pseudoobstruction, but
volvulus is not excluded in this current study. If clinical concern for
obstruction persists, a gastrograffin enema or CT may be considered.
Otherwise, short-term follow-up radiographs are recommended. The degree of
dilatation may pose a risk of perforation and close follow-up is suggested.
Radiology Report
HISTORY: ___ female with colonic distention.
COMPARISON: Abdominal plain film obtained ___.
FINDINGS:
Supine frontal images through the abdomen demonstrate gas filled loops
distended large bowel which appears stable-slightly improved when compared to
prior day. Gas is seen throughout loops of small bowel. No evidence of
obstruction. No free intraperitoneal air identified. Gastric tube noted.
Surgical clips noted in the epigastric region.
IMPRESSION:
Gas throughout the colon largely unchanged since 1 day prior consistent with
excessive ileus. No evidence of obstruction.
Radiology Report
HISTORY: IV access needed for antibiotics.
OPERATORS: Dr. ___ and Dr. ___ resident). The
attending, Dr. ___, was present during key portions of the procedure.
TECHNIQUE: A preprocedure time out was performed per hospital protocol.
Using sterile technique and local anesthesia, the patent right basilic vein
was punctured under direct ultrasound guidance using a micropuncture set.
Hard-copy ultrasound images were obtained before and immediately after
establishing intravenous access. A peel-away sheath was then placed over a
guidewire and a single-lumen PICC measuring 35 cm in length was placed through
the peel-away sheath with its tip positioned in the superior vena cava 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.
IMPRESSION: Uncomplicated ultrasound and fluoroscopically guided single-lumen
PICC via the right basilic vein. The final internal length is 35 cm with its
tip positioned in the low superior vena cava. The line is ready for use.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: GTUBE REPLACEMENT
Diagnosed with FLATUL/ERUCTAT/GAS PAIN
temperature: 98.6
heartrate: 64.0
resprate: 20.0
o2sat: 100.0
sbp: 148.0
dbp: 117.0
level of pain: 13
level of acuity: 3.0 | ___ with hx CVAs (relatively nonverbal), HTN, HLD, AFib, G-tube,
and atonic colon with several recent admissions for concern of
obstruction who presented from rehab after pulling out G-tube
and with significant abdominal distention. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Compazine
Attending: ___.
Chief Complaint:
Surgical Site Infection, UTI
Major Surgical or Invasive Procedure:
JP drain removal
History of Present Illness:
___ year old Female sent from her SNF for concern that her JP
drain fell out the morning of admission. There is concern for a
surgical site infection. In brief she underwent a ___
laminectomy for spinal stenosis in ___ which was complicated
by wound dehiscence and a spinal leak, and was admitted in
___ for debridement and irrigation, with subsequent planned
debridement and paraspinus muscle flaps by PRS recently
(discharged ___ who was discharged with a JP-drain in place
which apparently became discharged the morning, and this
prompted transfer to ___ ED. Of note she also was noted with
a pneumonia at her SNF 2 days prior to transfer for which she
was placed on augmentin. The SNF notes purulent drainage in the
JP drain output.
Initial vitals in the ___ were 97.7, 64, 144/47, 20, 97%2LNC,
and the ED resident notes he was able to express purulent
material from the surgical site, but of course when the ___
consult saw the patient there was none to be expressed (since it
had already been expressed). The patient received IV NS and was
given a dose of Zosyn for concern for a deep surgical wound
infection. The remaining JP drain was removed by the PRS team.
Of note the patient presents with an indwelling foley catheter
from the SNF.
Past Medical History:
- Type 2 Diabetes
- CKD Stage 3
- Primary Hypertension
- HFpEF
- hypothyroidism
- urinary retention
- GERD
- Hx ischemic CVA with question of residual mild aphasia
- Hx L3-L5 hemilaminectomy/foraminotomy and repair of spinal
leak
(___)
- Hx L3 hemilaminectomy and repair of CSF leak with irrigation
and debridement (___)
Social History:
___
Family History:
Mother: ___ Cancer
Father: MI
Physical ___:
ROS:
GEN: - fevers, - Chills, - Weight Loss
EYES: - Photophobia, - Visual Changes
HEENT: - Oral/Gum bleeding
CARDIAC: - Chest Pain, - Palpitations, - Edema
GI: - Nausea, - Vomitting, - Diarhea, - Abdominal Pain, -
Constipation, - Hematochezia
PULM: - Dyspnea, - Cough, - Hemoptysis
HEME: - Bleeding, - Lymphadenopathy
GU: - Dysuria, - hematuria, - Incontinence
SKIN: - Rash
ENDO: - Heat/Cold Intolerance
MSK: - Myalgia, - Arthralgia, - Back Pain
NEURO: - Numbness, - Weakness, - Vertigo, - Headache
Remainder of 10 point ROS negative except as noted
PHYSICAL EXAM:
VSS: 98.2, 188/68, 74, 18, 92%
GEN: NAD
Pain: ___
HEENT: EOMI, MMM, - OP Lesions
PUL: CTA B/L
COR: RRR, S1/S2, - MRG
ABD: NT/ND, +BS, - CVAT
EXT: - CCE
NEURO: CAOx3 although slightly confused [at 1:30am], Non-Focal
DERM: Surgical Site with erythema with sutures in place,
without drainage (see photo in OMR uploaded by ___ team)
Pertinent Results:
ADMISSION LABS:
___ 03:26PM BLOOD WBC-8.0 RBC-2.75* Hgb-7.8* Hct-26.4*
MCV-96 MCH-28.4 MCHC-29.5* RDW-17.4* RDWSD-60.2* Plt ___
___ 03:26PM BLOOD Neuts-69.2 Lymphs-18.1* Monos-8.8 Eos-2.9
Baso-0.5 Im ___ AbsNeut-5.56 AbsLymp-1.45 AbsMono-0.71
AbsEos-0.23 AbsBaso-0.04
___ 03:26PM BLOOD Glucose-81 UreaN-27* Creat-1.6* Na-141
K-4.4 Cl-108 HCO3-23 AnGap-10
___ 07:43PM BLOOD Lactate-0.9
___ 05:38PM URINE Color-Yellow Appear-HAZY* Sp ___
___ 05:38PM URINE Blood-NEG Nitrite-NEG Protein-70*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NORMAL pH-5.5
Leuks-LG*
___ 05:38PM URINE RBC-86* WBC->182* Bacteri-MOD*
Yeast-MANY* Epi-1 TransE-<1
___ 05:38PM URINE CastHy-8*
___ 06:00PM OTHER BODY FLUID FluAPCR-NEG FluBPCR-NEG
___ 7:30 pm BLOOD CULTURE - pending
___ 5:38 pm URINE CULTURE - pending
CHEST (PA & LAT) Study Date of ___ 4:33 ___
IMPRESSION:
Cardiomegaly with pulmonary edema though improved since prior
and persistent bilateral pleural effusions.
CT L-SPINE W/ CONTRAST Study Date of ___ 8:33 ___
IMPRESSION:
1. Status post L3-4 and L4-___s recent
paraspinous muscle flap repair of dehisced lumbar surgical
wound. Expected postsurgical changes are seen within the
midline soft tissues extending from the L1-L5 levels.
Specifically, ill-defined enhancement throughout the surgical
bed may be postsurgical, but early developing phlegmon would be
difficult to exclude. Additionally, a 2.9 cm region of air
within the midline wound at the L1-2 level may also be
postsurgical, although abscess formation would be difficult to
exclude.
2. Sigmoid diverticulosis. Small volume pelvic free fluid
surrounding the
sigmoid colon is nonspecific but limits evaluation for acute
diverticulitis.
3. Bilateral pleural effusions.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
further investigation.
1. Acetaminophen 650 mg PO TID
2. amLODIPine 10 mg PO DAILY
3. Ascorbic Acid ___ mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Cyanocobalamin 1000 mcg PO DAILY
6. Escitalopram Oxalate 10 mg PO DAILY
7. Heparin 5000 UNIT SC BID
8. HydrALAZINE 25 mg PO TID
9. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
10. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
11. Levothyroxine Sodium 75 mcg PO DAILY
12. Metoprolol Tartrate 25 mg PO BID
13. Polyethylene Glycol 17 g PO DAILY
14. Senna 17.2 mg PO BID
15. Tamsulosin 0.8 mg PO QHS
16. Torsemide 20 mg PO DAILY
17. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
18. Vitamin D 1000 UNIT PO DAILY
19. Lidocaine 5% Patch 1 PTCH TD QPM
20. Lisinopril 30 mg PO DAILY
21. Gabapentin 300 mg PO BID
22. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
shortness of breath
23. TraZODone 50 mg PO QHS:PRN insomnia
24. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
Discharge Medications:
1. Glargine 10 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
2. Acetaminophen 650 mg PO TID
3. amLODIPine 10 mg PO DAILY
4. Ascorbic Acid ___ mg PO DAILY
5. Aspirin 81 mg PO DAILY
6. Cyanocobalamin 1000 mcg PO DAILY
7. Escitalopram Oxalate 10 mg PO DAILY
8. Gabapentin 300 mg PO BID
9. Heparin 5000 UNIT SC BID
10. HydrALAZINE 25 mg PO TID
11. Ipratropium-Albuterol Inhalation Spray 1 INH IH Q6H:PRN
shortness of breath
12. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
13. Latanoprost 0.005% Ophth. Soln. 1 DROP BOTH EYES QHS
14. Levothyroxine Sodium 75 mcg PO DAILY
15. Lidocaine 5% Patch 1 PTCH TD QPM
16. Lisinopril 30 mg PO DAILY
17. Metoprolol Tartrate 25 mg PO BID
18. Polyethylene Glycol 17 g PO DAILY
19. Senna 17.2 mg PO BID
20. Tamsulosin 0.8 mg PO QHS
21. Torsemide 20 mg PO DAILY
22. TraMADol 50 mg PO Q6H:PRN Pain - Moderate
23. TraZODone 50 mg PO QHS:PRN insomnia
24. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
___ Diagnosis:
Status post spinal surgery
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: ___ with fever // PNA?
TECHNIQUE: AP and lateral views the chest.
COMPARISON: Chest x-ray from ___.
FINDINGS:
There is persistent pulmonary edema though improved since prior exam. There
are small to moderate pleural effusions, larger on the left. Cardiac
silhouette is enlarged, similar to prior. Azygos fissure again noted. No
acute osseous abnormalities.
IMPRESSION:
Cardiomegaly with pulmonary edema though improved since prior and persistent
bilateral pleural effusions.
Radiology Report
EXAMINATION: CT L-SPINE W/ CONTRAST
INDICATION: ___ with recent JP drainNO_PO contrast // sacral region for
abscess? sacral region for abscess?
TECHNIQUE: Non-contrast helical multidetector CT was performed after the
intravenous administration of mL of Omnipaque contrast agent. Soft tissue
and bone algorithm images were generated. Coronal and sagittal reformations
were then constructed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 15.8 s, 30.3 cm; CTDIvol = 30.3 mGy (Body) DLP =
868.0 mGy-cm.
Total DLP (Body) = 882 mGy-cm.
COMPARISON: CT L-spine ___
FINDINGS:
Status post L3-4 and L4-5 hemilaminectomies and foraminotomies as well as
recent local paraspinous muscle flap repair of dehisced lumbar surgical wound.
Expected postsurgical changes are seen within the midline soft tissues
superficial to the spinous processes extending from the L1-L5 levels. At the
L1-L2 level, there is a 2.9 x 1.0 cm region of air which may be postsurgical.
Ill-defined enhancement throughout the surgical bed is likely postsurgical,
although early developing phlegmon can not be excluded.
Mild right lateral listhesis of L3 on L4 is unchanged. Alignment of the
lumbar spine is otherwise preserved. No acute fractures.
There is moderate sigmoid diverticulosis. Small amount of pelvic free fluid
is nonspecific. Bilateral pleural effusions are partially visualized.
IMPRESSION:
1. Status post L3-4 and L4-5 hemilaminectomies as well as recent paraspinous
muscle flap repair of dehisced lumbar surgical wound. Expected postsurgical
changes are seen within the midline soft tissues extending from the L1-L5
levels. Specifically, ill-defined enhancement throughout the surgical bed may
be postsurgical, but early developing phlegmon would be difficult to exclude.
Additionally, a 2.9 cm region of air within the midline wound at the L1-2
level may also be postsurgical, although abscess formation would be difficult
to exclude.
2. Sigmoid diverticulosis. Small volume pelvic free fluid surrounding the
sigmoid colon is nonspecific but limits evaluation for acute diverticulitis.
3. Bilateral pleural effusions.
Gender: F
Race: AMERICAN INDIAN/ALASKA NATIVE
Arrive by AMBULANCE
Chief complaint: Wound eval
Diagnosed with Pneumonia, unspecified organism
temperature: 97.7
heartrate: 64.0
resprate: 20.0
o2sat: 97.0
sbp: 144.0
dbp: 47.0
level of pain: 0
level of acuity: 3.0 | SUMMARY:
___ yo F PMHx HFpEF, HTN, T2DM, CKD, prior ischemic CVA,
hypothyroidism, and spinal stenosis s/p L3-4/L4-5
hemilaminectomy/ foraminotomy (___) c/b wound dehiscence and
spinal leak requiring debridement, ___ followed by
lumbar wound debridement and muscle flap closure s/p wound vac
placement with JP in ___, who presents from ___ after
JP drain became dislodged. PRS Surgery consulted. JP drain was
removed. There was no concern for surgical site infection per
PRS. Patient will follow-up with Plastic Surgery as an
outpatient. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: ORTHOPAEDICS
Allergies:
Penicillins / Bactrim / Epinephrine / amlodipine / labetalol /
prazosin / hydrochlorothiazide
Attending: ___.
Chief Complaint:
Right femoral neck fracture
Major Surgical or Invasive Procedure:
Right hip hemiarthroplasty ___, ___
History of Present Illness:
___ female medical history of hypertension presents
with the above injury s/p mechanical fall. Patient denies
numbness, tingling, weakness, head strike, LOC, or other
injuries. She is accompanied by her sister who she lives with.
She is reportedly very active and still works. Outside hospital
obtained CT of the head which did not show any acute cerebral
hemorrhage.
Past Medical History:
Hypertension
Hyperlipidemia
Diverticulosis
Depression
Social History:
___
Family History:
Sister -ductal carcinoma in situ
Family history of colon cancer in father and distant cousins.
Father died in ___ because of colon cancer complications, also
had MI
Grandmother and mother with diabetes
Physical Exam:
General: Well-appearing, breathing comfortably
MSK: Right hip with clean and intact dressings with minimal
strikethrough with no surrounding skin changes. Right foot warm
and well perfused with intact sensory and motor function.
Pertinent Results:
___ 07:18AM BLOOD WBC-10.6* RBC-2.70* Hgb-8.2* Hct-25.8*
MCV-96 MCH-30.4 MCHC-31.8* RDW-14.0 RDWSD-48.8* Plt ___
___ 07:18AM BLOOD Glucose-118* UreaN-14 Creat-0.7 Na-143
K-4.2 Cl-109* HCO3-22 AnGap-12
___ 07:18AM BLOOD Calcium-8.2* Mg-2.1
Medications on Admission:
Active Medication list as of ___:
Medications - Prescription
ATENOLOL - Dosage uncertain - (Prescribed by Other Provider)
ATORVASTATIN - atorvastatin 20 mg tablet. tablet(s) by mouth
once
a day - (Prescribed by Other Provider)
CLONIDINE HCL - clonidine HCl 0.2 mg tablet. 1 tablet(s) by
mouth
once a day - (Pt was on 0.3)
FLUOXETINE - fluoxetine 10 mg capsule. capsule(s) by mouth once
a
day - (Prescribed by Other Provider)
HYDROCHLOROTHIAZIDE - hydrochlorothiazide 25 mg tablet. 1
tablet(s) by mouth once a day - (Prescribed by Other Provider)
LABETALOL - labetalol 200 mg tablet. 2 tablet(s) by mouth three
times a day - (Not Taking as Prescribed)
LOSARTAN [COZAAR] - Cozaar 100 mg tablet. tablet(s) by mouth
once
a day - (Prescribed by Other Provider)
NYSTATIN - nystatin 100,000 unit/gram topical powder. apply to
affected area twice daily as needed for yeast - (Not Taking as
Prescribed)
PRAZOSIN - prazosin 1 mg capsule. 1 capsule(s) by mouth twice a
day - (Prescribed by Other Provider)
Medications - OTC
ASPIRIN - aspirin 81 mg chewable tablet. Tablet(s) by mouth once
a day - (Prescribed by Other Provider) (Not Taking as
Prescribed)
CHOLECALCIFEROL (VITAMIN D3) - cholecalciferol (vitamin D3)
2,000
unit capsule. 1 capsule(s) by mouth once a day - (OTC) (Not
Taking as Prescribed)
CYANOCOBALAMIN (VITAMIN B-12) - cyanocobalamin (vit B-12) 1,000
mcg tablet. tablet(s) by mouth once a day - (Prescribed by
Other
Provider)
DOCUSATE SODIUM - docusate sodium 100 mg capsule. Capsule(s) by
mouth once a day - (Prescribed by Other Provider) (Not Taking
as
Prescribed)
MULTIVITAMIN - multivitamin tablet. Tablet(s) by mouth once a
day
- (Prescribed by Other Provider) (Not Taking as Prescribed)
Discharge Medications:
1. Acetaminophen 650 mg PO 5X/DAY
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 30 mg SC DAILY
RX *enoxaparin 30 mg/0.3 mL 30 mg SC daily Disp #*26 Syringe
Refills:*0
4. Ramelteon 8 mg PO QHS:PRN insomnia
Should be given 30 minutes before bedtime
5. Senna 8.6 mg PO BID
6. TraMADol 25 mg PO TID:PRN pain
RX *tramadol 50 mg 0.5 (One half) tablet(s) by mouth every eight
(8) hours Disp #*25 Tablet Refills:*0
7. TraZODone 25 mg PO QHS:PRN insomnia backup
8. Vitamin D ___ UNIT PO DAILY
9. Losartan Potassium 50 mg PO DAILY
Can increase to the home dose after blood pressure monitoring
10. Atenolol 25 mg PO DAILY
11. Atorvastatin 20 mg PO QPM
12. FLUoxetine 10 mg PO DAILY
13. NIFEdipine (Extended Release) 30 mg PO DAILY
14. Pantoprazole 40 mg PO Q24H
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Right femoral neck fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: HIP 1 VIEW
INDICATION: Right hemi fracture
TECHNIQUE: Single AP view of the right hip obtained in the OR without
radiologist present
COMPARISON: Pelvis and right hip radiographs ___
FINDINGS:
The single available image shows interval placement of a right hip
hemiarthroplasty. Alignment appears appropriate on this single projection.
No fracture seen. Please see the operative report for further details.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Leg pain, s/p Fall
Diagnosed with Fracture of unsp part of neck of right femur, init, Fall on same level, unspecified, initial encounter
temperature: 98.1
heartrate: 61.0
resprate: 18.0
o2sat: 95.0
sbp: 194.0
dbp: 64.0
level of pain: 8
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 femoral neck fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for right hip hemiarthroplasty which the
patient tolerated well. For full details of the procedure please
see the separately dictated operative report. The patient was
taken from the OR to the PACU in stable condition and after
satisfactory recovery from anesthesia was transferred to the
floor. The patient was initially given IV fluids and IV pain
medications, and progressed to a regular diet and oral
medications by POD#1. The patient was given ___
antibiotics and anticoagulation per routine. The patient's home
medications were continued throughout this hospitalization. The
patient worked with ___ who determined that discharge to rehab
was appropriate. The ___ hospital course was otherwise
unremarkable.
At the time of discharge the patient's pain was well controlled
with oral medications, incisions were clean/dry/intact, and the
patient was voiding/moving bowels spontaneously. The patient is
weightbearing as tolerated in the 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: F
Service: OBSTETRICS/GYNECOLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ presents to ED with abdominal pain.
She felt sudden onset lower middle abdominal pain around 130pm.
It became significantly worse and was accompanied by nausea and
sweating. She went to urgent care and had rebound tenderness on
exam. Given this she was advised to present to ___. She had
pain in the car ride when going over bumps. She describes it as
"feeling sensitive".
At ___, she had CT scan showing no evidence of appendicitis but
questionable torsion. She then had a PUS which showed a dilated
fallopian tube and complex material with possible torsion.
Recommendation made for OB/GYN consultation.
Now, patient states her pain has improved and is ___. She has
not required pain meds in the ED. She is ambulating without
difficulty. No fevers, chills, emesis. No recent weight loss.
Of note, patient had a similar episode of pain in ___. She
had acute onset pain and discomfort that lasted ___ hours then
spontaneously resolved. That pain episode was accompanied by
nausea but no emesis. She did not seek care as she was on
vacation.
ROS negative except as noted above.
Past Medical History:
POBHx: G4P3
- 1 SAB
- 3 SVD
PGynHx
- menarche at ~age ___ with regular menses prior to IUD -> now
amenorrheic
- contraception: ___ IUD for ___ years total ___ years for one,
new one in place ___ years)
- h/o abnormal pap smears, last normal in ___
- denies h/o STIs
- sexually active w/ ___ male partner, husband
PMH: hypertension
PSH: L hip replacement
Meds: red yeast rice 600mg, glucosamine 500mg, turmeric,
lisinopril, Vitamin D2, fish oil
All: NKDA
Social History:
___
Family History:
Non-contributory
Physical Exam:
Physical Exam on Admission:
98.4, 67, 126/89, 16, 95% RA
Gen: NAD
Lungs: No resp distress
Abd: soft, mild tenderness to palpation in lower abdomen, no
rebound or guarding
SSE: normal external genitalia, cervix with IUD strings visible,
no discharge or blood in vault
SVE: small uterus, + R adnexal tenderness, no adnexal masses
palpated
Physical Exam on Discharge:
24 HR Data (last updated ___ @ 253)
Temp: 98.4 (Tm 98.4), BP: 122/78, HR: 84, RR: 18, O2 sat:
95%, O2 delivery: RA
Fluid Balance (last updated ___ @ 254)
Last 8 hours Total cumulative 0ml
IN: Total 0ml
OUT: Total 0ml, Urine Amt 0ml
Last 24 hours Total cumulative 0ml
IN: Total 0ml
OUT: Total 0ml, Urine Amt 0ml
*one unmeasured void
General: NAD, comfortable
CV: RRR
Lungs: CTAB
Abdomen: soft, non-distended, mild tenderness to palpation,
greatest in right lower quadrant. Marked rebound tenderness,
right>left. No guarding.
Extremities: no edema, no TTP
Pertinent Results:
___ 05:10PM BLOOD WBC-14.6* RBC-4.84 Hgb-15.1 Hct-44.7
MCV-92 MCH-31.2 MCHC-33.8 RDW-11.9 RDWSD-40.2 Plt ___
___ 05:10PM BLOOD Neuts-84.1* Lymphs-7.5* Monos-7.4
Eos-0.4* Baso-0.3 Im ___ AbsNeut-12.26* AbsLymp-1.10*
AbsMono-1.08* AbsEos-0.06 AbsBaso-0.04
___ 01:10PM BLOOD WBC-11.4* RBC-4.14 Hgb-12.9 Hct-38.7
MCV-94 MCH-31.2 MCHC-33.3 RDW-11.8 RDWSD-40.5 Plt ___
___ 01:10PM BLOOD Neuts-77.1* Lymphs-13.7* Monos-7.9
Eos-0.6* Baso-0.3 Im ___ AbsNeut-8.79* AbsLymp-1.56
AbsMono-0.90* AbsEos-0.07 AbsBaso-0.03
___ 05:10PM BLOOD Glucose-105* UreaN-18 Creat-0.9 Na-140
K-4.4 Cl-101 HCO3-28 AnGap-11
___ 05:10PM BLOOD ALT-13 AST-18 AlkPhos-72 TotBili-0.4
___ 05:10PM BLOOD Lipase-25
___ 05:10PM BLOOD Albumin-4.4
___ 05:18PM BLOOD Lactate-1.4
___ 06:10PM URINE Color-Yellow Appear-Clear Sp ___
___ 06:10PM URINE Blood-NEG Nitrite-NEG Protein-TR*
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-6.0 Leuks-SM*
___ 06:10PM URINE RBC-4* WBC-6* Bacteri-FEW* Yeast-NONE
Epi-1
___ 06:10PM URINE Mucous-MOD*
___ 06:10PM URINE Hours-RANDOM
___ 06:10PM URINE UCG-NEGATIVE
___ 5:10 pm BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 12:20 am BLOOD CULTURE
Blood Culture, Routine (Pending): No growth to date.
___ 6:10 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
CT Abdomen/Pelvis (___):
IMPRESSION: Heterogeneous cystic mass in the cul de sac
concerning for adnexal mass or hydrosalpinx. Associated small
volume ascites. Torsion difficult to exclude and pelvic
ultrasound is advised.
U/S Pelvis (___):
IMPRESSION:
1. Findings are concerning with left hydrosalpinx containing
complex material. Currently there is no evidence of torsion
though intermittent torsion not excluded.
2. Mild to moderate free fluid.
U/S Pelvis (___):
IMPRESSION:
1. No substantial change in findings likely reflecting left
hematosalpinx.
2. Unchanged hyperemia of the normal size left ovary. Normal
arterial and
venous flow without evidence of torsion.
3. Moderate volume complex pelvic free fluid.
Medications on Admission:
Lisinopril 10 mg PO DAILY
Discharge Medications:
1. Acetaminophen ___ mg PO Q6H:PRN Pain - Mild/Fever
Reason for PRN duplicate override: Alternating agents for
similar severity
Do not take more than 4000 mg in 24 hours
RX *acetaminophen 500 mg ___ tablet(s) by mouth every six (6)
hours Disp #*60 Tablet Refills:*1
2. Ibuprofen 600 mg PO Q6H:PRN Pain - Mild
take with food. Alternate every three hours with Tylenol for
pain
RX *ibuprofen 600 mg 1 tablet(s) by mouth every six (6) hours
Disp #*60 Tablet Refills:*1
3. Lisinopril 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Hematosalpinx
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: PELVIS, NON-OBSTETRIC
INDICATION: ___ year old woman with dilated left fallopian tube, r/o ovarian
torsion, free fluid// evaluate for torsion, free fluid
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: Pelvic ultrasound ___. CT abdomen and pelvis ___.
FINDINGS:
The uterus is retroverted and measures 8.2 x 3.5 x 5.9 cm. The endometrium is
homogenous and measures 6 mm. An IUD is likely in the appropriate position.
The right ovary measures 1.9 x 2.4 x 1.5 cm. Again seen is a dilated tubular
structure within the left adnexa, demonstrating complex fluid, likely
reflecting hematosalpinx. An adjacent left ovary measures 1.2 x 3.2 x 1.4 cm
and appears hyperemic. Normal arterial and venous flow is demonstrated within
the bilateral ovaries. A moderate amount of complex free fluid has probably
not substantially changed.
IMPRESSION:
1. No substantial change in findings likely reflecting left hematosalpinx.
2. Unchanged hyperemia of the normal size left ovary. Normal arterial and
venous flow without evidence of torsion.
3. Moderate volume complex pelvic free fluid.
NOTIFICATION: The findings were discussed with Dr. ___ by ___,
M.D. on the telephone on ___ at 3:29 pm, 1 minutes after discovery of the
findings.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Lower abdominal pain
Diagnosed with Torsion of left ovary and ovarian pedicle
temperature: 97.3
heartrate: 88.0
resprate: 17.0
o2sat: 100.0
sbp: 126.0
dbp: 81.0
level of pain: 8
level of acuity: 3.0 | Ms. ___ presented to the ED with abdominal pain since the
afternoon of ___. She had CT scan showing no evidence of
appendicitis but questionable torsion. She then had a PUS which
showed a dilated fallopian tube and complex material with
possible torsion. Pain improved to ___ at time of OB/GYN
consult, without requirement for pain medication. Given imaging
reassuring against torsion, plan made for admission for
observation overnight.
The next morning, labs were stable without concern for infection
or bleeding. She remained stable without further pain medication
requirement overnight, so plan was made for discharge home with
outpatient followup. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
worsening abdominal pain and distention
Major Surgical or Invasive Procedure:
Diagnostic/therapeutic paracentesis ___
Diagnostic paracentesis ___
Diagnostic/therapeutic paracentesis ___ with ___
Therapeutic paracentesis ___ with ___
History of Present Illness:
Mr. ___ is a ___ y/o man
with a PMH of alcoholic cirrhosis c/b ascites, esophageal
varices
(s/p banding ___ HCC (s/p TACE), who presents with
abdominal pain.
The abdominal pain is diffuse, intermittent, crampy in nature,
approximately 4 out of 10. It is been associated with
significant
abdominal distention and accumulation of "fluid" in his abdomen.
He denies any associated fevers, nausea, vomiting. He denies any
urinary symptoms. He denies any chest pain or shortness of
breath. He denies any cough, sore throat, runny nose
Notably, admitted to ___ from ___ to ___ for strep
bovis bacteremia and ___ progression s/p TACE, admissions
complicated by tremors and c. diff colitis.
In the ___, initial VS were: 6 97.7 70 101/59 18 98% RA
Exam notable for: Large abdominal distention. Positive fluid
wave. Reducible umbilical hernia present. No CVAT. Minimal
left-sided focal abdominal tenderness. No rebound, no guarding.
Labs showed: Na 133, Cr 2.1, TBili 2.0, INR 1.6 (MELD 24)
Diagnostic paracentesis: 158 WNC, 3% PMNs
Imaging showed:
RUQUS:
1. Cirrhotic liver with large volume ascites and multiple
hypoechoic masses,
as better seen on prior MR.
___. Edematous gallbladder wall likely secondary to chronic liver
disease.
3. The spleen is top-normal in size.
CXR: Final read pending, preliminarily no acute cardiopulmonary
process
Consults: Liver
"Has intermittent tenderness to palpation on exam. Had
diagnostic
paracentesis done in the ___ need to f/u that to evaluate
for SBP. For now, I would recommend empirically treating for SBP
with ceftriaxone and giving albumin 1.5mg/kg. Would also check
blood cultures.
Also has ___. Is getting albumin as per above, so we can see if
the creat improves after albumin infusion. If creat does not
improve, would check urine electrolytes.
As long as LFTs are stable, can admit to ___ under Dr.
___
Patient received:
___ 19:00 IV CefTRIAXone
Transfer VS were: 67 95/58 16 97% RA
On arrival to the floor, patient reports he was experiencing
___
abdominal pain and distension at rehab. His pain has now
improved
and is ___ in severity. His other complaint is cough with
phlegm that has been present for several weeks. Denies fevers,
chills, chest pain, shortness of breath, dysuria, leg swelling.
Past Medical History:
- Alcoholic cirrhosis (complicated by ascites/esophageal varices
s/p banding ___
- Hepatocellular carcinoma (s/p TACE in ___
- Hepatitis C - Weakly positive antibody I n2015; antibody and
viral load were repeated during ___ admission and both were
negative
- Depression
- GERD
Social History:
___
Family History:
Brother- ___ disease, Father- passed away from heart
attack at age ___, no known liver disease or malignancies in
family
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 97.9 97/63 67 16 94Ra
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
MMM
NECK: supple, no LAD, no JVD
HEART: RRR, S1/S2, no murmurs, gallops, or rubs
LUNGS: CTAB, no wheezes, rales, rhonchi, breathing comfortably
without use of accessory muscles
ABDOMEN: nondistended, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: no cyanosis, clubbing, or edema
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
DISCHARGE PHYSICAL EXAM:
VS:24 HR Data (last updated ___ @ 008)
Temp: 98.0 (Tm 98.9), BP: 110/70 (110-128/62-77), HR: 53
(52-56),
RR: 18, O2 sat: 95% (94-98), O2 delivery: ra, Wt: 179.2 lb/81.29
kg
GENERAL: Elderly man sitting up in bed, distended abdomen, NAD
HEENT: AT/NC, EOMI, anicteric sclera, pink conjunctiva,
MMM
HEART: RRR, S1/S2, II/VI holosystolic murmur at LUSB, no gallops
or rubs
LUNGS: Crackles at bilateral bases.Breathing comfortably without
use of accessory muscles.
ABDOMEN: Normoactive bowel sounds. Abdomen distended, somewhat
tense, nontender. Reducible umbilical hernia. No guarding or
rebound.
EXTREMITIES: No cyanosis, clubbing. No peripheral edema.
PULSES: 2+ DP pulses bilaterally
NEURO: A&Ox3, moving all 4 extremities with purpose. No
asterixis
but visible intention tremor.
SKIN: Warm and well perfused, no lesions or eruptions.
Pertinent Results:
ADMISSION LABS:
================
___ 04:25PM BLOOD WBC-4.1 RBC-2.41* Hgb-9.2* Hct-26.8*
MCV-111* MCH-38.2* MCHC-34.3 RDW-16.2* RDWSD-66.1* Plt ___
___ 04:25PM BLOOD Neuts-61.6 ___ Monos-12.8 Eos-2.5
Baso-0.2 Im ___ AbsNeut-2.50# AbsLymp-0.89* AbsMono-0.52
AbsEos-0.10 AbsBaso-0.01
___ 04:25PM BLOOD ___ PTT-37.7* ___
___ 04:25PM BLOOD Glucose-132* UreaN-52* Creat-2.1* Na-133*
K-4.9 Cl-95* HCO3-25 AnGap-13
___ 04:25PM BLOOD ALT-36 AST-58* AlkPhos-194* TotBili-2.0*
___ 04:25PM BLOOD Albumin-3.1* Calcium-8.4 Phos-4.0 Mg-2.4
IMAGING AND STUDIES:
====================
LIVER/GALLBLADDER US ___:
IMPRESSION:
1. Cirrhotic liver with large volume ascites and multiple
hypoechoic masses, as better seen on prior MR.
2. Edematous gallbladder wall likely secondary to chronic liver
disease.
3. The spleen is top-normal in size.
CT ABD/PELV W/O CONT ___:
IMPRESSION:
1. Small amount of hyperdense blood layering in ascites in the
posterior right abdomen, measuring approximately 5.3 x 3.6 x 5.4
cm.
2. Similar volume large ascites, now measures slightly higher
than simple
fluid density, likely due to mixture with blood products.
3. Colonic diverticulosis.
4. Bilateral gynecomastia.
5. Cirrhotic liver morphology with post treatment changes.
DISCHARGE LABS:
===============
___ 05:03AM BLOOD WBC-5.2 RBC-2.76* Hgb-10.3* Hct-29.9*
MCV-108* MCH-37.3* MCHC-34.4 RDW-21.1* RDWSD-82.3* Plt Ct-93*
___ 05:03AM BLOOD Neuts-66.8 ___ Monos-11.5 Eos-1.5
Baso-0.4 Im ___ AbsNeut-3.48 AbsLymp-0.99* AbsMono-0.60
AbsEos-0.08 AbsBaso-0.02
___ 05:03AM BLOOD Plt Ct-93*
___ 05:03AM BLOOD Glucose-114* UreaN-49* Creat-1.8* Na-138
K-5.3* Cl-102 HCO3-24 AnGap-12
___ 05:03AM BLOOD ALT-52* AST-104* LD(LDH)-175 AlkPhos-214*
TotBili-4.6*
___ 05:03AM BLOOD Albumin-3.8 Calcium-8.9 Phos-3.5 Mg-1.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. FoLIC Acid 1 mg PO DAILY
2. Omeprazole 20 mg PO BID
3. Multivitamins 1 TAB PO DAILY
4. Thiamine 100 mg PO DAILY
5. Gabapentin 300 mg PO TID
6. MetroNIDAZOLE 500 mg PO Q8H
7. Ondansetron ODT 8 mg PO Q8H nausea
8. Spironolactone 50 mg PO TID
9. TraMADol 50 mg PO Q4H:PRN Pain - Moderate
10. Lactulose 30 mL PO TID constipation
11. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
12. GuaiFENesin ER 600 mg PO Q12H
13. Fentanyl Patch 50 mcg/h TD Q72H
Discharge Medications:
1. Megestrol Acetate 400 mg PO BID
RX *megestrol 400 mg/10 mL (10 mL) 400 mg by mouth twice a day
Disp #*1 Package Refills:*1
2. Midodrine 15 mg PO TID
RX *midodrine 5 mg 3 tablet(s) by mouth three times per day Disp
#*270 Tablet Refills:*0
3. Gabapentin 300 mg PO BID
RX *gabapentin 300 mg 1 capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
4. Omeprazole 20 mg PO DAILY
RX *omeprazole 20 mg 1 capsule(s) by mouth daily Disp #*30
Capsule Refills:*0
5. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
6. FoLIC Acid 1 mg PO DAILY
RX *folic acid 1 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
7. Lactulose 30 mL PO TID constipation
RX *lactulose 10 gram/15 mL (15 mL) 30 mL by mouth three times
per day Disp #*4 Package Refills:*0
8. Multivitamins 1 TAB PO DAILY
9. Thiamine 100 mg PO DAILY
RX *thiamine HCl (vitamin B1) 100 mg 1 tablet(s) by mouth daily
Disp #*30 Tablet Refills:*0
10. HELD- Spironolactone 50 mg PO TID This medication was held.
Do not restart Spironolactone until discussing with Dr. ___
___ Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Alcoholic cirrhosis
Hepatocellular carcinoma
Post-TACE decompensation of cirrhosis
Acute kidney injury
Hepatorenal syndrome
C difficile infection
Chronic neuropathy
QT Prolongation
Hyponatremia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: LIVER OR GALLBLADDER US (SINGLE ORGAN)
INDICATION: ___ with HCC, developed ascites in 3 days w/ significant
abdominal distention + worsening pain.// PVT?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: MR abdomen ___. Abdominal ultrasound ___ and ___..
FINDINGS:
LIVER: The liver is coarsened and nodular in echotexture. The contour of the
liver is nodular, consistent with cirrhosis. There are multiple hypoechoic
masses within the liver, the largest measuring 2.7 x 2.7 x 2.8 cm, likely
corresponding to the exophytic lesion seen on recent MR. ___ main portal vein
is patent with hepatopetal flow. There is large volume ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 5 mm.
GALLBLADDER: The gallbladder wall is edematous and thickened, consistent with
chronic liver disease. The gallbladder is not distended.
PANCREAS: The pancreas is not well visualized, largely obscured by overlying
bowel gas.
SPLEEN: Normal echogenicity, measuring 13.0 cm.
KIDNEYS: Limited views of the bilateral kidneys show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Cirrhotic liver with large volume ascites and multiple hypoechoic masses,
as better seen on prior MR.
2. Edematous gallbladder wall likely secondary to chronic liver disease.
3. The spleen is top-normal in size.
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: ___ with HCC, ascites, new hypoxia.// New SpO2 93% ISO, ascites.
Hepatic Hydrothorax?
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: Chest radiograph ___ and ___.
FINDINGS:
There is new opacity at the of the right lung base. Opacities in the left
lung base appears minimally improved compared to ___ but is still
more extensive compared to ___. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes are
unremarkable.
IMPRESSION:
Interval progression of probable atelectasis of the right lung base. Left
lung opacity appears improved compared to most recent chest radiograph from ___.
Radiology Report
EXAMINATION: CT ABDOMEN AND PELVIS WITHOUT CONTRAST
INDICATION: ___ year old man with etoh cirrhosis and hcc, u/s showing new
large volume ascites. Also has c diff// assess for bowel distension, abscess,
ascites
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 4.3 s, 57.2 cm; CTDIvol = 20.3 mGy (Body) DLP =
1,159.1 mGy-cm.
Total DLP (Body) = 1,159 mGy-cm.
COMPARISON: CT abdomen and pelvis ___. MRI ___.
FINDINGS:
LOWER CHEST: There is linear left basilar atelectasis. There is severe
coronary artery calcifications. Relative low signal intensity of the blood
pool suggests underlying anemia.
ABDOMEN:
HEPATOBILIARY: Cirrhotic liver morphology. High density lipiodol centered in
segment VIII and V including three discrete lesions in segment VIII are
consistent with post TACE change. Evaluation for additional focal liver
lesions is limited on this non contrast examination. There is large volume
ascites measuring simple density which has increased from ___.
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 symmetric in size. There is a partially exophytic
simple cyst in the right lower pole measuring 1.1 x 1.1 cm. There is no
hydronephrosis.
GASTROINTESTINAL: There is no hiatal hernia. There is no small bowel
obstruction. Oral contrast is seen extending to the proximal colon. No
colonic wall thickening is seen. There is no intra-abdominal free air.
PELVIS: Limited views of the pelvis due to streak artifact. Bladder is
grossly unremarkable. No pelvic sidewall or inguinal adenopathy is seen.
REPRODUCTIVE ORGANS: Prostate contains coarse calcifications but is normal in
size.
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 are multilevel degenerative changes of the lumbar spine most
pronounced at L4-5 where there is vertebral body fusion. Partially imaged
right hip prosthesis noted. No aggressive bony lesions are seen.
SOFT TISSUES: There is an umbilical hernia containing simple fluid.
IMPRESSION:
1. Cirrhotic liver morphology with increasing large volume ascites.
2. Lipiodol in segments VIII and V post recent TACE.
3. No intra-abdominal fluid collections.
4. Unremarkable non-contrast appearance of the small and large bowel.
Radiology Report
INDICATION: ___ year old man with EtOH cirrhosis now with decompensation.
Acutely short of breath.// Intrapulmonary process?
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
IMPRESSION:
Low bilateral lung volumes. New pulmonary vascular congestion without overt
pulmonary edema. Bibasilar atelectasis is noted, right greater than left. No
pleural effusion or pneumothorax. The size of the cardiac silhouette is
within normal limits. Degenerative changes are present around the left
shoulder.
Radiology Report
EXAMINATION: Ultrasound-guided paracentesis
INDICATION: ___ year old man with etoh cirrhosis, hcc, new worsening ascites//
lvp
TECHNIQUE: Ultrasound guided diagnostic and therapeutic paracentesis
COMPARISON: None.
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: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
A 5 ___ catheter was advanced into the largest fluid pocket in the right
lower quadrant and 3 L of clear, straw-colored fluid were removed. Fluid
samples were submitted to the laboratory for cell count, differential, and
culture.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ personally supervised the trainee during the key components of
the procedure and reviewed and agrees with the trainee's findings.
IMPRESSION:
1. Technically successful ultrasound guided diagnostic and therapeutic
paracentesis.
2. 3 L of fluid were removed.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111
INDICATION: ___ year old man with etoh cirrhosis, aggressive HCC// assess for
intracranial mass, acute process
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 4.0 s, 16.0 cm; CTDIvol = 46.7 mGy (Head) DLP =
747.4 mGy-cm.
Total DLP (Head) = 747 mGy-cm.
COMPARISON: None.
FINDINGS:
There is no evidence of 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. There is mild right maxillary sinus mucosal
thickening and minimal patchy ethmoid air cell opacification. 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:
No evidence of an intracranial mass within the limitations of noncontrast CT.
No evidence of an acute intracranial abnormality.
Radiology Report
EXAMINATION: ULTRASOUND-GUIDED PARACENTESIS
INDICATION: ___ year old man with etoh cirrhosis, hcc, new worsening ascites//
Please perform LVP
TECHNIQUE: Ultrasound guided diagnostic and therapeutic paracentesis
COMPARISON: Ultrasound-guided paracentesis dated ___
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a large
amount of ascites. A suitable target in the deepest pocket in the right lower
quadrant was selected for paracentesis.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
A 5 ___ catheter was advanced into the largest fluid pocket in the right
lower quadrant and 3 L of clear yellow fluid were removed. Fluid samples were
submitted to the laboratory for chemistry, cell count, differential, and
culture.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ supervised the trainee during the key components of the
procedure and reviewed and agrees with the trainee's findings.
IMPRESSION:
1. Technically successful ultrasound guided diagnostic and therapeutic
paracentesis.
2. 3 L of fluid were removed.
Radiology Report
EXAMINATION: ULTRASOUND-GUIDED PARACENTESIS
INDICATION: ___ year old man with etoh cirrhosis, large volume ascites, hcc,
___// diagnostic and therapeutic paracentesis
TECHNIQUE: Ultrasound guided diagnostic paracentesis.
COMPARISON: Paracentesis ___.
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a small
amount of ascites. A suitable target in the deepest pocket in the right upper
quadrant was selected for paracentesis.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
A 5 ___ catheter was advanced into the largest fluid pocket in the right
upper quadrant and 20 cc of radial fluid were removed. Fluid samples were
submitted to the laboratory for chemistry, cell count, differential, and
culture.
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 paracentesis.
2. 22 cc of fluid were removed.
Radiology Report
INDICATION: ___ year old man with cirrhosis, now with new oxygen requirement.
Example notable for diffuse crackles and wheezes.// Evaluate for pulmonary
edema
TECHNIQUE: Frontal radiograph of the chest.
COMPARISON: ___.
IMPRESSION:
Increased hazy opacity of bilateral lungs, right greater than left, could
represent worsening moderate pulmonary edema. Infection cannot be excluded.
This could be followed on subsequent exams.
Likely small right pleural effusion. Cardiac silhouette appears unchanged.
Degenerative changes of bilateral shoulders.
Radiology Report
EXAMINATION: Ultrasound paracentesis
INDICATION: ___ year old man with etoh cirrhosis, large volume ascites//
diagnostic and therapeutic paracentesis
TECHNIQUE: Ultrasound guided diagnostic and therapeutic paracentesis
COMPARISON: Ultrasound ___
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: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
A 5 ___ catheter was advanced into the largest fluid pocket in the right
lower quadrant and 2.5 L of serosanguinous fluid were removed. Fluid samples
were submitted to the laboratory for cell count, differential, and culture.
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. 2.5 L of fluid were removed.
Radiology Report
INDICATION: ___ year old man s/p paracentesis on ___, with low hemoglobin,
did not respond to 1U RBC// Evaluate for bleeding? Hematoma? Please page ___
if evidence for active extravasattion
TECHNIQUE: Multidetector CT images of the abdomen and pelvis were acquired
without intravenous contrast. Non-contrast scan has several limitations in
detecting vascular and parenchymal organ abnormalities, including tumor
detection.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 4.2 s, 55.7 cm; CTDIvol = 19.8 mGy (Body) DLP =
1,103.1 mGy-cm.
Total DLP (Body) = 1,103 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: There is mild to moderate bibasilar atelectasis. Otherwise,
visualized lung fields are within normal limits. There is no evidence of
pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates cirrhotic liver morphology with high
density lipiodol centered in segment 8 and 5 with post TACE treatment changes.
There is no evidence of focal lesions within the limitations of an unenhanced
scan. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is within normal limits. There is large volume
ascites, similar to prior volume but now measures slightly higher than simple
fluid density, likely due to mixture with blood products.
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 a stable
sized right renal cyst. Otherwise, there is no evidence of focal renal
lesions within the limitations of an unenhanced scan. There is no
hydronephrosis. There is no nephrolithiasis. There is no perinephric
abnormality.
GASTROINTESTINAL: There is a small amount of hyperdense blood layering in
ascites in the posterior right abdomen. Overall this blood spans approximately
5.3 x 3.6 x 5.4 cm (2:40). 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 and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is partially calcified within normal limits
otherwise. The seminal vesicles are normal.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. There
is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Stable multilevel degenerative changes of the visualized thoracolumbar spine
are noted, including unchanged partial fusion of the L4 and L5 vertebral
bodies. There is a right hip prosthesis.
SOFT TISSUES: There is a small ascites filled umbilical hernia (2:60). There
is bilateral gynecomastia. There is asymmetric soft tissue edema in fat
stranding along the right lower quadrant abdominal subcutaneous tissue, likely
inflammation from recent procedure (2:68).
IMPRESSION:
1. Small amount of hyperdense blood layering in ascites in the posterior right
abdomen, measuring approximately 5.3 x 3.6 x 5.4 cm.
2. Similar volume large ascites, now measures slightly higher than simple
fluid density, likely due to mixture with blood products.
3. Colonic diverticulosis.
4. Bilateral gynecomastia.
5. Cirrhotic liver morphology with post treatment changes.
Radiology Report
EXAMINATION: Ultrasound-guided paracentesis
INDICATION: ___ year old man with ETOH cirrhosis with large volume ascites and
HRS.// paracentesis
TECHNIQUE: Ultrasound guided therapeutic paracentesis
COMPARISON: CT abdomen and pelvis from ___.
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated a large
amount of ascites. A suitable target in the deepest pocket in the right lower
quadrant was selected for paracentesis.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
A 5 ___ catheter was advanced into the largest fluid pocket in the right
lower quadrant and 3 L of bloody fluid were removed.
The patient tolerated the procedure well without immediate complication.
Estimated blood loss was minimal.
Dr. ___ personally supervised the trainee during the key
components of the procedure and reviewed and agrees with the trainee's
findings.
IMPRESSION:
1. Successful therapeutic paracentesis, with the patient being hemodynamically
stable at the end of the procedure.
2. 3 L of serosanguineous fluid were removed. No samples were sent.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abd pain, Abdominal distention, Ascites
Diagnosed with Alcoholic cirrhosis of liver with ascites
temperature: 97.7
heartrate: 70.0
resprate: 18.0
o2sat: 98.0
sbp: 101.0
dbp: 59.0
level of pain: 6
level of acuity: 3.0 | Mr. ___ is a ___ y/o man with a PMH of alcoholic
cirrhosis c/b ascites, esophageal varices (s/p banding
___ HCC (s/p TACE), who presented with abdominal pain,
worsening ascites, ___ consistent with hepatorenal syndrome.
ACTIVE ISSUES
=============
# ACUTE KIDNEY INJURY / Hepatorenal Syndrome:
Creatinine 2.1 on admission from recent discharge Cr 1.1.
Differential included pre-renal in the setting of decreased
intravascular volume given third spacing and poor nutritional
status, as well as poor PO intake, and resumption of diuretics
upon last discharge, ATN (ischemic vs. nephrotoxic), and CIN,
though less likely given lack of recent contrast administration
(though did undergo TACE ___. Patient underwent treatment and
monitoring for hepatorenal syndrome with octreotide and
midodrine, and this diagnosis seemed increasingly likely given
his persistent sodium-avid urine studies and lack of improvement
with daily albumin. Creatinine peaked at 4.5. Nephrology was
consulted for consideration of hemodialysis. There was no urgent
need for HD and question of whether he would tolerate it if
needed given his soft blood pressures. Ultimately he was weaned
off of octreotide. Creatinine overall downtrended and at time of
discharge Cr was 1.8. He was discharged with 15 mg PO TID
midodrine and preferred to not have renal followup. Labs will be
monitored by outpatient hepatologist.
# ALCOHOLIC CIRRHOSIS C/B ASCITES, ESOPHAGEAL VARICES
___ B cirrhosis, with MELD score of 24 on admission.
Complicated by esophageal varices (Banded ___, last EGD
___. Decompensated by mild hyponatremia and worsening
ascites, which were thought related to ischemia post-TACE vs.
progression of HCC. He was continued on Lactulose 30 mL PO TID.
Diuretics were held in setting of acute renal failure.
Management of ascites through therapeutic paracentesis (x3 over
course of hospitalization). Patient will have outpatient
paracentesis after discharge starting ___.
#Goals of care
Discussion held with treatment team, palliative care, patient
and wife regarding goals of care on ___. Patient prioritizes
independence, increased quality of life, and spending time at
home with family. Discussion was held about options of
tubefeeding, hemodialysis and pleurx catheter placement and that
some options may not be best aligned with his goals. Will plan
to continue ongoing discussion outpatient. Patient elected for
DNR/DNI on ___. He has palliative care followup scheduled
outpatient.
#Megaloblastic anemia
#Pancytopenia
#Acute blood loss anemia
Patient with anemia likely multifactorial due to chronic
megaloblatic anemia likely nutritional, with concern for
concurrent acute blood loss anemia in setting of acute Hgb/Hct
drop and CT imaging suggestive of bleed likely ___ paracentesis
on ___. He received 2u pRBCs and Hgb remained stable. Discharge
Hb 10.3.
# Neuropathy
Etiology of paresthesias in distal fingers and toes is unclear,
possibly related to alcohol use. Gabapentin was initially held
given concern for worsening of tremors, however patient felt
that the neuropathy was his most debilitating symptom. Restarted
gabapentin renally dosed, 300 mg BID with some improvement.
Please monitor renal function outpatient and titrate
accordingly.
#QT Prolongation
Patient alarming on tele for a few beats of Vtach/Vfib. Patient
was asymptomatic. EKG showed QT prolonged at 534. Patient was on
standing Zofran, prn Compazine, quetiapine qhs, mirtazapine qhs,
all of which were discontinued.
# ABDOMINAL PAIN:
# NAUSEA:
On admission had acute on chronic abdominal pain, accompanied by
ongoing nausea. Diagnostic paracentesis was not concerning for
SBP. Pain likely multifactorial from large volume ascites and
capsular distension from cirrhosis/HCC. Pain was adequately
managed with PRN Tylenol. Fentanyl patch and Tramadol had been
started in rehab, were discontinued on discharge as they were
not needed.
# TREMOR AND HALLUCINATIONS
The patient developed a new intention tremor and visual
hallucinations during his recent admission. This was thought to
be adverse effect of one of his pain medications (top contenders
were felt to be oxycodone and gabapentin). Neurology saw him on
last admission and agreed with this assessment. Unfortunately,
the tremors have persisted. CT head without contrast showed no
e/o acute intracranial process and gabapentin was restarted
without exacerbation of these symptoms.
CHRONIC ISSUES
==============
# HEPATOCELLULAR CARCINOMA
The patient was diagnosed with hepatocellular carcinoma in
___. Enlargement of previously identified liver lesion
(2.1cm->2.3cm) seen during ___ admission with multiple new
lesions (4 total). He underwent TACE on ___ and will followup
outpatient with hepatology.
# HCV
The patient had a weakly positive (less than 1.50E+01 IU/mL) HCV
viral load in ___, but the patient's last negative HCV antibody
was in ___. HCV antibody and viral load were repeated during
___ admission and both were negative.
# MODERATE MALNUTRITION
Patient presents with moderate malnutrition in the setting of
chronic alcoholic cirrhosis. He continued MVI, Thiamine. Started
megestrol for poor appetite with some improvement.
# DEPRESSION:
Sertraline 50 mg daily was held on discharge on ___ for
unclear reason. Patient was not receiving at rehab. Can consider
restarting.
# GERD:
Decreased omeprazole to 20 mg daily.
# C. DIFF COLITIS:
Diagnosed during ___ admission. The patient received a
course of Flagyl started ___, ultimately a 2 week course from
end date of ceftriaxone (course: ___. Repeat C diff
stool study negative on ___.
CORE MEASURES
=============
# CODE: DNR/DNI
# CONTACT: ___, wife, ___
TRANSITIONAL ISSUES
==================
[ ] Restarted gabapentin renally dosed, 300 mg BID (decreased
from 300 TID). Please monitor renal function outpatient and
titrate accordingly.
[ ] Discharged with 15 mg Midodrine TID.
[ ] Decreased omeprazole to 20 mg daily.
[ ] Started megestrol for poor appetite.
[ ] Held spironolactone on discharge due to worsening renal
function and managing volume with paracentesis.
[ ] DNR form signed upon discharge. Consider filling out MOLST
form at outpatient followup as goals of care are further
elucidated.
[ ] Discharged with ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Falls
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ with past medical history of central-line
associated aortic valve endocarditis (s/p porcine aortic valve
replacement with course c/b periprocedural stroke and residual
left-sided deficits), MI (on aspirin), and gastric lap banding
(___) who presents with two separate episodes of syncope
and pre-syncope.
The patient describes 2 distinct episodes which lead to the
present hospitalization. The first occurred on ___ (5 days prior to presentation) while at work. She
was at desk working when she had total LOC. Patient states that
her coworkers told her that she had passed out but the patient
herself is entirely amnestic to the event. She felt "fine"
immediately after the episode, ate something, and returned to
work for the rest of the day. She denies bowel/bladder
incontinence, tongue biting, or associated chest
pain/palpitations.
The second episode occurred on ___ while at her
mother's house. As she was preparing to leave, the patient
became
acutely dizzy characterized by the sensation that "the room was
spinning." She had the feeling of "falling to the left" and
noted
"dark spots" in her visual field, particularly on the right
(unclear if right eye vs. right visual field). She subsequently
fell to the floor without LOC. Her body "felt limp" and she was
unable to get back up for a few minutes. She again denies
associated chest pain, SOB, incontinence, or other associated
symptoms. The patient then presented to the hospital at the
request of her family.
In the ED, initial vitals were T 98.3 BP 193/100 HR 64 RR 14 O2
100% on RA. Exam was notable for grade III SEM. Neurological
exam
notable for stable mild LLE weakness, LUE weakness, sensory loss
on L leg, ataxia on L side.
Labs notable for a HgB 10.9 (most recent baseline 12.6 in Atrius
records) and WBC 5.3.
Past Medical History:
- Infective endocarditis
- MI
- CVA
- Aortic valve replacement
- S/p gastric banding (___)
Social History:
___
Family History:
Mother: SLE, ___ syndrome, sarcoidosis, MGUS. Had "angina"
in her late ___.
Father: deceased
___ grandmother: CHF, ESRD
Paternal grandmother: Multiple myeloma
___ aunt: ___ disorder
___ aunt: Multiple myeloma (died from complications)
Physical Exam:
=========================
ADMISSION PHYSICAL EXAM
=========================
VITALS: T 98.7 BP 172/113 L Sitting HR 71 RR 18 Sa 100 Ra
GENERAL: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CARDIOVASCULAR: Grade ___ SEM heard best at the left sternal
border. Regular rate and rhythm, normal S1 + S2, no rubs or
gallops
LUNGS: Clear to auscultation bilaterally without wheezes, rales,
rhonchi
ABDOMEN: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
EXTREMITIES: Warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema
NEURO: Mental status - oriented to place, day, date, month year.
Naming intact. Calculations intact. Remote history intact. CNs
II-XII - within normal limits. Motor - Mildly decreased bulk in
the interossei of the left hand compared to left. Orbits around
the left finger. Sensation - Decreased sensation along medial
surface of left palm and left foot. Coordination - FNF intact in
the ___ upper extremities. Decreased speed with rapid fine motor
movements in the left hand compared to the right.
=========================
DISCHARGE PHYSICAL EXAM
=========================
Vitals: 99.0 PO 137 / 71 R Lying 64 18 99 Ra
GENERAL: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, neck supple, JVP not elevated,
CARDIOVASCULAR: Systolic ejection murmur heard best at the left
sternal border. Regular rate and rhythm, normal S1 + S2, no rubs
or
gallops
LUNGS: Clear to auscultation bilaterally
ABDOMEN: Soft, non-tender, non-distended
GU: No foley
EXTREMITIES: Warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema .
NEURO: Mental status - A/O x 3. Moves all four extremities
purposefully. Able to stand unassisted and without
dizziness/lightheadedness.
Pertinent Results:
==================
ADMISSION LABS
==================
___ 05:38AM URINE HOURS-RANDOM
___ 05:30AM URINE HOURS-RANDOM
___ 05:30AM URINE UCG-NEGATIVE
___ 05:30AM URINE COLOR-Straw APPEAR-Hazy* SP ___
___ 05:30AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.0
LEUK-NEG
___ 03:35AM cTropnT-<0.01
___ 03:35AM TSH-2.9
___ 12:25AM COMMENTS-GREEN TOP
___ 12:25AM K+-4.8
___ 11:53PM ___ PTT-30.5 ___
___ 10:10PM GLUCOSE-71 UREA N-15 CREAT-0.8 SODIUM-140
POTASSIUM-6.2* CHLORIDE-103 TOTAL CO2-24 ANION GAP-13
___ 10:10PM estGFR-Using this
___ 10:10PM cTropnT-<0.01
___ 10:10PM CALCIUM-9.2 PHOSPHATE-4.3 MAGNESIUM-2.0
___ 10:10PM WBC-5.3 RBC-4.38 HGB-10.9* HCT-34.7 MCV-79*
MCH-24.9* MCHC-31.4* RDW-18.6* RDWSD-53.5*
___ 10:10PM NEUTS-39.4 ___ MONOS-11.0 EOS-7.4*
BASOS-0.6 IM ___ AbsNeut-2.08# AbsLymp-2.15 AbsMono-0.58
AbsEos-0.39 AbsBaso-0.03
___ 10:10PM PLT COUNT-331
==================
IMAGING
==================
___ CHEST X-RAY
1. Increased haziness of the right lung as compared with the
left likely
relates to foci of right upper lobe ground-glass, better
visualized same-day
CT head and neck, incompletely assessed on that exam. No focal
lung
consolidation, pulmonary edema, or other acute cardiopulmonary
process.
___ ECHOCARDIOGRAM
Conclusions
The left atrial volume index is normal. The estimated right
atrial pressure is ___ mmHg. There is mild symmetric left
ventricular hypertrophy with normal cavity size. There is mild
regional left ventricular systolic dysfunction with hypokinesis
of the distal inferior and lateral walls. The remaining segments
contract normally (biplane LVEF = 52 %). The estimated cardiac
index is high (>4.0L/min/m2). There is no left ventricular
outflow obstruction at rest or with Valsalva. Right ventricular
chamber size and free wall motion are normal. The aortic valve
homograft appears well seated, with normal leaflet motion and
transvalvular gradients. No aortic regurgitation is seen. The
mitral valve leaflets are structurally normal. There is no
mitral valve prolapse. Mild to moderate (___) mitral
regurgitation is seen. The estimated pulmonary artery systolic
pressure is high normal. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with mild regional systolic dysfunction.
Well seated aortic valve bioprosthesis with normal gradient and
no aortic regurgitation. Mild-moderate mitral regurgitation.
Compared with the prior study (images reviewed) of ___,
trace aortic regurgitation is not seen on the current study.
Regional systolic function is similar.
___ CTA HEAD AND CTA NECK (wet read):
1. Patent anterior/posterior circulation, circle of ___, and
major
tributaries.
2. Incidental 1-2 mm left paraclinoid internal carotid
aneurysm/infundibulum
(3:201).
3. Findings suggest sarcoidosis, including
interstitial/perifissural
micronodules in the lung apices and a calcified mediastinal
lymph node (3:4,
03:14).
4. Ground-glass opacity in the right lung apex with ___
morphology may suggest infection. 5 mm and 3 mm right upper lobe
nodules noted incidentally.
5. 5 mm left thyroid nodule which by ACR recommendations does
not require
follow-up unless there is additional clinical concern given size
and patient
age.
==================
DISCHARGE LABS
==================
___ 06:00AM BLOOD WBC-3.9* RBC-4.17 Hgb-10.2* Hct-32.3*
MCV-78* MCH-24.5* MCHC-31.6* RDW-18.3* RDWSD-50.5* Plt ___
___ 06:00AM BLOOD Glucose-87 UreaN-9 Creat-0.7 Na-142 K-3.9
Cl-105 HCO3-25 AnGap-12
___ 03:35AM BLOOD cTropnT-<0.01
___ 06:00AM BLOOD Calcium-8.9 Phos-4.5 Mg-1.9
___ 03:35AM BLOOD TSH-2.9
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Vitamin D 1000 UNIT PO DAILY
3. Cyanocobalamin 1000 mcg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Cyanocobalamin 1000 mcg PO DAILY
3. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES:
- Syncope
SECONDARY DIAGNOSIS:
- Elevated blood pressure without diagnosis of hypertension
- Pulmonary nodules and micronodules
- Thyroid nodule
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: ___ woman presenting with dizziness. Evaluation for
stroke.
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of mL of Omnipaque intravenous contrast material. Three-dimensional
angiographic volume rendered, curved reformatted and segmented images were
generated on a dedicated workstation. This report is based on interpretation
of all of these images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 16.0 s, 16.0 cm; CTDIvol = 50.2 mGy (Head) DLP =
802.7 mGy-cm.
2) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 5.4 mGy (Head) DLP = 2.7
mGy-cm.
3) Stationary Acquisition 5.5 s, 0.5 cm; CTDIvol = 119.8 mGy (Head) DLP =
59.9 mGy-cm.
4) Spiral Acquisition 4.7 s, 37.2 cm; CTDIvol = 30.9 mGy (Head) DLP =
1,148.6 mGy-cm.
Total DLP (Head) = 2,014 mGy-cm.
COMPARISON: None.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There is no evidence of no evidence of infarction, hemorrhage, edema, or mass.
There is evidence of right frontal encephalomalacia. The ventricles are
normal in size and configuration.
There is mucosal thickening of the bilateral ethmoid air cells. The
visualized portion of the remaining paranasal sinuses, mastoid air cells, and
middle ear cavities are clear. The visualized portion of the orbits are
unremarkable.
CTA HEAD:
The vessels of the circle of ___ and their principal intracranial branches
appear normal without dissection, stenosis, or occlusion. There is an
incidentally noted 1-2 mm aneurysm at the left para clinoid internal carotid
(3:201). There is fetal configuration of the right PCA. The dural venous
sinuses are patent.
CTA NECK:
The carotid and vertebral arteries and their major branches appear normal with
no evidence of stenosis or occlusion. There is no evidence of internal carotid
stenosis by NASCET criteria.
OTHER:
There is evidence of interstitial micronodules in the lung apices (3:4), as
well as a calcified mediastinal lymph node (03:14), which may be suggestive of
sarcoidosis. A 5 mm nodule and a 3 mm nodule are incidentally noted within
the right upper lobe. There is also evidence of a ground-glass opacity with
___ morphology at the right apex, which may be suggestive of
infection.
A 5 mm left thyroid nodule is incidentally noted, which does not require
follow-up by ___ guidelines unless there is additional clinical concern given
the size and patient's age.
IMPRESSION:
1. No evidence of hemorrhage or infarction.
2. No evidence of dissection, occlusion, or stenosis. Incidentally noted 1-2
mm aneurysm at the left paraclinoid internal carotid artery.
3. Interstitial micronodules in the lung apices and a calcified mediastinal
lymph node, which may be suggestive of sarcoidosis.
4. 5 mm nodule and 3 mm nodule incidentally noted within the right upper lobe.
Please see ___ society guidelines as outlined below.
5. Incidentally noted 5 mm left thyroid nodule, which does not require
follow-up by ___ guidelines unless there is additional clinical concern given
the size and patient's age.
RECOMMENDATION(S): For incidentally detected multiple solid pulmonary nodules
smaller than 6mm, no CT follow-up is recommended in a low-risk patient, and an
optional CT follow-up in 12 months is recommended in a high-risk patient.
See the ___ ___ Society Guidelines for the Management of Pulmonary
Nodules Incidentally Detected on CT" for comments and reference:
___
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Syncope
Diagnosed with Syncope and collapse
temperature: 98.3
heartrate: 64.0
resprate: 14.0
o2sat: 100.0
sbp: 193.0
dbp: 100.0
level of pain: 0
level of acuity: 2.0 | This patient is a ___ year old female with a past medical history
of a central line associated aortic valve endocarditis (with a
porcine aortic valve replacement complicated by a
___ CVA with left sided deficits), MI (on aspirin),
and gastric lap banding (___) who presents with two
episodes of recent falls.
ACTIVE ISSUES
# Falls/Syncope:
Pt with two syncope-like episodes. One episode occurred a week
prior to arrival (without prodrome and true loss of
consciousness); the second episode seemed to be more vertiginous
in nature, with room-spinning dizziness and weakness that
resolved upon sitting down. Given patient's complicated cardiac
history, she was evaluated for ischemic/arrhythmic etiology of
her falls. Troponins were negative x2, an EKG showed a right
bundle branch block and T wave inversions (stable compared to
previous EKGs). An Echocardiogram was done, without new drop in
EF/wall motion abnormalities/valvular defects since the earlier
study from ___. Overnight telemetry did not show any
arrhythmias. CT head and CTA that did not reveal any acute
processes or issues with cranial perfusion. Possible
contributors to Pt's syncopal/near-syncopal episodes include
transient cardiac arrhythmia (not observed on 24hrs of
telemetry), poor PO intake (Pt hydrating well but not eating
much). She was discharged home with an order placed for an
event monitor (no monitors available at ___ at time of
discharge), and encouraged to follow up with her PCP and primary
cardiologist.
# Elevated blood pressures without diagnosis of hypertension:
Pt with SBP's into the 170-180's while in the ED. These
resolved spontaneously to SBP < 140 on arrival to the floor.
Not started on antihypertensives given no clear diagnosis prior
to arrival.
- f/u pressures in office.
# Incidental pulmonary nodules and
# Pulmonary micronodules:
5mm and 3mm RUL nodules noted incidentally on wet read of CTA
head/neck; also with calcified mediastinal lymph node and
interstitial/perifissural micronodules in the apices, possibly
consistent with sarcoidosis. Per ___ Society Guidelines,
no follow-up recommended in a low-risk patient with low-risk
history. Given the possible consistency with sarcoidosis,
further evaluation with repeat chest CT - or rheumatology
referral - could be considered.
- Consider rheumatology evaluation as outpatient
- Follow up on final read of CTA head/neck
# Incidental thyroid nodule:
Also noted on wet read CTA head/neck. 5mm L thyroid nodule,
which by ___ recommendations does not require follow-up unless
there is additional clinical concern.
- Follow up final read of CTA head/neck.
# Incidental 1-2 mm L paraclinoid internal carotid
artery/aneurysm:
Noted on wet read CTA head/neck.
- Follow up final read CTA head/neck. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Erythromycin Base / Tetracyclines / Augmentin / Zofran / iron
Attending: ___.
Chief Complaint:
Urinary retention
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with hx DM, HTN, Depression, Gastric bypass, and ___
tylenol overdose presents from ___ with oliguria. Per the pt
and her son, on ___ she had a tylenol overdose, for which she
was taken to ___, and found to have a tylenol level of
>400, and DKA. Presumably she was treated with NAC and insulin
gtt. During her stay she was started on HCTZ and cymbalta. She
was discharged on ___ to ___. Since ___ of this week,
the pt felt like she couldn't urinate much, just small trickles
that were cloudy and occasionally pink. She endorsed some
chronic lower back pain, chronic n/v, and new suprapubic pain.
She denied fevers/chills. Her facility was concerned re: urinary
retention and so sent her into the ED.
In the ED, initial vs were: T 96.4 P 67 BP 116/49 R18 O2 sat 97%
RA. Given history thought c/w UTI, the pt was given Bactrim DS
x1.
Cr noted to be 6.0 from 0.7 on d/c from ___ 3.0 on ___
Foley flushed but still no urine draining, US showed collapsed
bladder. Glucose 53, given ___ amp D5. Pt received 3L ns.
On the floor, she was 98.2 120/60 72 18 98%RA. She complained of
some chronic LBP, and increased subprapubic pain with the foley.
She denied taking any non-prescribed medications, denied NSAIDs,
denied current SI.
Past Medical History:
Asthma
HTN
Stroke ___ yrs ago with some residual L sided weakness.
DM
Gastric bypass ___ (leading to chronic diarrhea, vomiting)
Social History:
___
Family History:
NC
Physical Exam:
Admission Physical Exam:
Vitals: 98.2 120/60 72 18 98%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Skin: no rashes
Neuro: non focal
Discharge Physical Exam:
Pertinent Results:
ADMISSION LABS:
___ 04:17PM BLOOD WBC-8.9 RBC-3.74* Hgb-11.1* Hct-31.9*
MCV-85 MCH-29.8 MCHC-34.9 RDW-14.3 Plt ___
___ 04:17PM BLOOD Neuts-64.5 ___ Monos-5.8 Eos-1.9
Baso-0.5
___ 11:04PM BLOOD ___
___ 04:17PM BLOOD Glucose-55* UreaN-51* Creat-6.3* Na-138
K-4.0 Cl-96 HCO3-24 AnGap-22*
Pertinent Labs:
___ 08:32PM URINE Color-Straw Appear-Clear Sp ___
___ 08:32PM URINE Blood-SM Nitrite-NEG Protein-TR
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.0 Leuks-LG
___ 02:26AM URINE RBC-128* WBC->182* Bacteri-MANY
Yeast-NONE Epi-<1
___ 02:26AM URINE bnzodzp-NEG barbitr-NEG opiates-NEG
cocaine-NEG amphetm-NEG mthdone-NEG
Micro:
___ 2:26 am URINE Source: Catheter.
**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.
Piperacillin/tazobactam sensitivity testing available on
request.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ESCHERICHIA COLI
|
AMPICILLIN------------ 4 S
AMPICILLIN/SULBACTAM-- <=2 S
CEFAZOLIN------------- <=4 S
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- <=1 S
CEFTRIAXONE----------- <=1 S
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- <=1 S
Imaging:
Renal ultrasound (___): Normal kidney ultrasound.
Echogenic liver.
Discharge Labs:
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Amlodipine 10 mg PO DAILY
2. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
3. Aspirin 81 mg PO DAILY
4. Clonazepam 0.5 mg PO TID
5. CloniDINE 0.2 mg PO BID
6. Duloxetine 60 mg PO DAILY
7. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
8. GlyBURIDE 2.5 mg PO BID
9. Hydrochlorothiazide 25 mg PO DAILY
10. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO TID:PRN
heartburn
11. MetFORMIN (Glucophage) 1000 mg PO BID
12. Milk of Magnesia 30 mL PO DAILY
13. Metoprolol Tartrate 50 mg PO BID
14. Nicotine Polacrilex 2 mg PO Q1H:PRN smoking
15. OxycoDONE (Immediate Release) 10 mg PO Q6H:PRN pain
16. Omeprazole 20 mg PO DAILY
17. Sertraline 100 mg PO BID
18. Zolpidem Tartrate 10 mg PO HS
Discharge Medications:
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN wheezing
2. Aluminum-Magnesium Hydrox.-Simethicone 30 mL PO TID:PRN
heartburn
3. Amlodipine 10 mg PO DAILY
4. Aspirin 81 mg PO DAILY
5. Clonazepam 0.5 mg PO TID
6. CloniDINE 0.2 mg PO BID
7. Fluticasone-Salmeterol Diskus (100/50) 1 INH IH BID
8. Sertraline 100 mg PO BID
9. Zolpidem Tartrate 10 mg PO HS
10. Metoprolol Tartrate 50 mg PO BID
11. Milk of Magnesia 30 mL PO DAILY
12. Nicotine Polacrilex 2 mg PO Q1H:PRN smoking
13. Omeprazole 20 mg PO DAILY
14. Hydrochlorothiazide 25 mg PO DAILY
15. MetFORMIN (Glucophage) 1000 mg PO BID
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Acute Kidney Injury
Urinary Tract Infection
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Tylenol overdose and increased creatinine.
COMPARISON: None available.
FINDINGS: The right kidney measures 12.4 cm and there is no hydronephrosis,
stone or mass seen. The left kidney measures 10.8 cm and no hydronephrosis,
stone or mass seen. The liver is overall increased in echogenicity.
IMPRESSION: Normal kidney ultrasound. Echogenic liver.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: URINARY RETENTION
Diagnosed with ACUTE KIDNEY FAILURE, UNSPECIFIED
temperature: 96.4
heartrate: 67.0
resprate: 18.0
o2sat: 97.0
sbp: 116.0
dbp: 49.0
level of pain: 7
level of acuity: 2.0 | ___ with DM, HTN, Depression, ___ Tylenol overdose presents
from ___ with oliguria and ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Iodinated Contrast Media - IV Dye
Attending: ___.
Chief Complaint:
Fever, Headaches, Confusion
Major Surgical or Invasive Procedure:
NONE
History of Present Illness:
___ year old gentleman with a history of HTN, DM, lumbar
microdisectomy s/p spinal stimulator, and chronic pain on
narcotics contract presenting with fevers, headaches, and
confusion. Patient reports four days of headache and fever to
102. His headache is frontal, throbbing. He denies neck pain or
stiffness. He reports photophobia and nausea associated. Mild
nonproductive cough as well. He initially presented to ___
___ on ___ with these symptoms. Review of records from
outside hospital indicates patient had negative flu swab,
negative UA. At the OSH, he had a leukocytosis to 16 and was
treated empirically for meningitis/encephalitis with IV
Vancomycin/CTX/Acyclovir. NCHCT did not have any acute
abnormalities. LP was not performed was he had a spinal cord
device implanted. He eventually left AMA. He presented to the
___ on ___ for further management given ongoing symptoms.
-In the ED, initial vitals were: T 98.9 HR 58 BP 97/60 RR 16
SpO2 96% RA
- Exam notable for: Normal mental status, no neck stiffness
- Labs notable for: WBC 12.6, H/H 11.8/33.3, Na 132, Cr 1.0,
lactate 1.6
-No further imaging was performed in the ED
-Patient was given: 1 L IV NS, Azithromycin 500 mg IV, Zofran 4
mg IV, Dilaudid 0.25 mg IV
-No LP was performed in the ED due to implanted spinal cord
device
-Decision was made to admit patient to medicine for further
management
-Vitals prior to transfer: T 99.8 HR 64 BP 133/83 RR 25 SpO2
100% RA
Upon arrival to the floor, the patient was alert and oriented
x3, mentating well and appropriately answering questions. He
denied any neck stiffness. He endorses headaches, nausea, and
productive cough. He denied any chest pain, dyspnea, visual
changes, weakness, or numbness. He was continued on IV
Vanc/CTX/Acyclovir for empiric coverage of meningitis/acyclovir.
He otherwise was continued on his home medications.
Past Medical History:
-Diabetes Mellitus
-Hypertension
-Tobacco Abuse
-Gout
-Insomnia
-Depression
-Chronic Pain/Narcotics Contract
-Lumbar microdiscectomy, ___: facet fusion, ___:
transforaminal lumbar interbody fusion at ___, ___:
Removal of posterior and interbody instrumentation L5-S1,
revision. ___: SCS implant (___).
Social History:
___
Family History:
Mother and Father with high blood pressure. Brothers and one
sister with HTN as well. Grandmother with MI. Grandfather old
age. Mother with breast CA.
Physical Exam:
ADMISSION:
VS T 98.3 BP 141/86 HR 67 RR 18 SpO2 97 RA
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple, no neck stiffness or meningeal signs. Negative
Kernig's and Brudzinski's sign. No cervical lymphadenopathy
CV: RRR. Normal S1+S2, no murmurs, rubs, gallops.
Lungs: R base inspiratory crackles, no wheezing or rhonci
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Alert and oriented x3. Moving all extremities with
purpose, no facial asymmetry, gait deferred.
DISCHARGE:
General: Alert, oriented, no acute distress
Neck: Supple, no neck stiffness or meningeal signs. No cervical
lymphadenopathy
CV: RRR. Normal S1+S2, no murmurs, rubs, gallops.
Lungs: CTAB
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Warm, well perfused, no clubbing, cyanosis or edema
Neuro: CN II-XII intact, sensation grossly intact, ___ strength
all extremities
Pertinent Results:
ADMISSION:
___ 06:47PM BLOOD WBC-12.6* RBC-3.99* Hgb-11.8* Hct-33.3*
MCV-84# MCH-29.6 MCHC-35.4 RDW-14.1 RDWSD-43.2 Plt ___
___ 06:47PM BLOOD Neuts-71.8* Lymphs-15.8* Monos-11.1
Eos-0.2* Baso-0.3 Im ___ AbsNeut-9.02* AbsLymp-1.99
AbsMono-1.40* AbsEos-0.02* AbsBaso-0.04
___ 07:09PM BLOOD ___ PTT-31.7 ___
___ 06:47PM BLOOD Glucose-91 UreaN-8 Creat-1.0 Na-132*
K-3.5 Cl-95* HCO3-23 AnGap-18
___ 06:47PM BLOOD ALT-38 AST-62* AlkPhos-64 TotBili-0.2
___ 06:47PM BLOOD Albumin-3.2* Calcium-8.2* Phos-2.7 Mg-2.2
___ 06:47PM BLOOD Lactate-1.6
DISCHARGE:
___ 08:50AM BLOOD WBC-12.2* RBC-4.06* Hgb-11.9* Hct-34.6*
MCV-85 MCH-29.3 MCHC-34.4 RDW-14.6 RDWSD-45.8 Plt ___
___ 08:50AM BLOOD ___ PTT-31.3 ___
___ 08:50AM BLOOD Glucose-115* UreaN-8 Creat-0.8 Na-140
K-4.3 Cl-106 HCO3-24 AnGap-14
___ 08:50AM BLOOD ALT-66* AST-37 LD(LDH)-251* AlkPhos-68
TotBili-0.2
___ 08:50AM BLOOD Calcium-8.7 Phos-3.2 Mg-2.0
STUDIES:
RUQ US ___:
1. Echogenic liver consistent with steatosis. Other forms of
liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot
be excluded on the basis of this examination.
2. Hepatic cysts.
MICRO:
___ Blood Cultures PENDING
___ CSF Spinal Cx PENDING + ENTEROVIRUS
HSV PCR NEGATIVE
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Trandolapril 2 mg PO BID
2. Pregabalin 300 mg PO TID
3. Mirtazapine 45 mg PO QHS
4. Allopurinol ___ mg PO BID
5. Lidocaine 5% Patch 1 PTCH TD BID:PRN Pain
6. QUEtiapine Fumarate 50 mg PO QAM
7. QUEtiapine Fumarate 100 mg PO QHS
8. MetFORMIN XR (Glucophage XR) 750 mg PO BID
9. CloNIDine 0.1 mg PO BID
10. Baclofen 10 mg PO TID:PRN Pain - Moderate
11. Spironolactone 25 mg PO DAILY
12. Fentanyl Patch 75 mcg/h TD Q72H
13. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
14. Sertraline 50 mg PO DAILY
15. TraZODone 100 mg PO QHS
16. Verapamil SR 180 mg PO Q24H
17. Docusate Sodium 100 mg PO DAILY:PRN constipation
Discharge Medications:
1. Narcan (naloxone) 4 mg/actuation nasal ONCE
TO REVERSE OPIOID OVERDOSE
IF USED CALL ___
RX *naloxone [Narcan] 4 mg/actuation 1 spray intranasal ONCE
Disp #*1 Spray Refills:*0
2. Allopurinol ___ mg PO BID
3. Baclofen 10 mg PO TID:PRN Pain - Moderate
4. CloNIDine 0.1 mg PO BID
5. Docusate Sodium 100 mg PO DAILY:PRN constipation
6. Fentanyl Patch 75 mcg/h TD Q72H
7. Lidocaine 5% Patch 1 PTCH TD BID:PRN Pain
8. MetFORMIN XR (Glucophage XR) 750 mg PO BID
9. Mirtazapine 45 mg PO QHS
10. OxyCODONE (Immediate Release) 5 mg PO Q8H:PRN Pain -
Moderate
11. Pregabalin 300 mg PO TID
12. QUEtiapine Fumarate 50 mg PO QAM
13. QUEtiapine Fumarate 100 mg PO QHS
14. Sertraline 50 mg PO DAILY
15. Spironolactone 25 mg PO DAILY
16. Trandolapril 2 mg PO BID
17. TraZODone 100 mg PO QHS
18. Verapamil SR 180 mg PO Q24H
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Community Acquired Pneumonia
Transaminitis
Secondary:
Hypertension
Diabetes
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 elevated LFTs// biliary pathology, cirrhosis
findings?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: None.
FINDINGS:
LIVER: The liver is diffusely echogenic. The contour of the liver is smooth.
Multiple hepatic cysts are demonstrated. There is no focal liver mass. The
main portal vein is patent with hepatopetal flow. There is no ascites.
BILE DUCTS: There is no intrahepatic biliary dilation. The CHD measures 6 mm.
GALLBLADDER: Gallbladder is contracted.
PANCREAS: The imaged portion of the pancreas appears within normal limits,
without masses or pancreatic ductal dilation, with portions of the pancreatic
tail obscured by overlying bowel gas.
SPLEEN: Normal echogenicity, measuring 11.1 cm.
KIDNEYS: Limited views of the right kidney show no hydronephrosis.
RETROPERITONEUM: The visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. Echogenic liver consistent with steatosis. Other forms of liver disease
including steatohepatitis, hepatic fibrosis, or cirrhosis cannot be excluded
on the basis of this examination.
2. Hepatic cysts.
Gender: M
Race: BLACK/CAPE VERDEAN
Arrive by AMBULANCE
Chief complaint: Confusion, Fever, Headache, Transfer
Diagnosed with Pneumonia, unspecified organism, Headache, Dehydration
temperature: 98.9
heartrate: 58.0
resprate: 16.0
o2sat: 96.0
sbp: 97.0
dbp: 60.0
level of pain: 9
level of acuity: 2.0 | ___ year old gentleman with a history of HTN, DM, lumbar
microdisectomy s/p spinal stimulator, and chronic pain on
narcotics contract who presented with fevers, headaches, and
confusion. Found to have CAP and treated with 5 days of
CTX/Azithromycin. Discharged in stable condition.
# Concern for Meningitis:
The patient presented after leaving AMA from OSH with concern
for meningitis due to headaches, fever, and confusion. He had
been empirically started on Vancomycin, CTX, and acyclovir and
these were continued. His symptoms resolved with the exception
of mild residual headache. He underwent delayed LP which showed
unremarkable cellular composition of CSF. HSV PCR was negative.
Antibiotics were stopped with the exception of CAP treatment
(see below). CSF and blood cultures were pending on discharge
and should be followed-up in the outpatient setting.
# Community Acquired Pneumonia:
Patient presented with fevers and productive cough. He was found
to have a right middle lobe consolidation consistent with CAP.
Treated with 5 days of CTX and Azithromycin (ENDED ___.
Symptoms improved on discharge.
# Transaminitis:
Patient found to have mild to moderate hepatocellular
transaminitis. RUQ US revealed steatosis. This should be further
followed-up in clinic. Consider HCV screening if not already
performed. Recommend repeat LFTs.
# Chronic Pain: Continued home regimen: Quetiapine Fumarate 50
mg PO QAM and 100 mg PO QHS, Pregabalin 300 mg pO TID, Baclofen
10 mg PO TID PRN pain, Lidocaine patch. Narcan script provided.
# Hypertension: Continued home Trandolapril 2 mg PO BID
# Diabetes Mellitus: Patient maintained on inuslin sliding scale
during hospitalization. Discharged on home regimen.
# Gout: Continued home Allopurinol ___ mg PO QDaily
# Insomnia: Continued home Mirtazapine 45 mg PO QHS and
Trazadone 100 mg PO QHS
TRANSITIONAL ISSUES:
- CSF and blood cultures were pending on discharge and should be
followed-up in the outpatient setting.
- Treated with 5 days of CTX and Azithromycin (ENDED ___
for CAP
- Transaminitis should be further followed-up in clinic.
Consider HCV screening if not already performed.
- Recommend repeat LFTs.
- Recommend continued downtitration of opioid regimen as
possible in the outpatient setting
- Patient prescribed naloxone in case of opioid overdose
- Patient on multiple seratonergic medications, please reassess
- Would recommend verification of allopurinol dosage which is
above usual dose
# CODE: Full (confirmed)
# CONTACT: ___ (___) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Oxycodone / Balmex / miconazole / Keflex / SilvaSorb / lidocaine
patch
Attending: ___.
Chief Complaint:
bilateral leg swelling
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ presents for bilateral knee pain after she played
tennis for ___ hours . Pt has some developmental delay and
participates in sports and recently flew to ___ for a tennis
tournament. She felt her both ankles were swollen after the long
plane ride. She also complains of cough which started last
___
for which she took a 8 day course of doxycycline which ended
yesterday.
She ___ shortness of breath, or chest pain or calf
tenderness.
Past Medical History:
PAST MEDICAL HISTORY:
- Peripheral nerve sheath tumor
- Borderline diabetes mellitus
- Hypothyroidism
- Bilateral knee osteoarthritis
- Developmental delay
PAST SURGICAL HISTORY:
- Tympanostomy tubes in ear at the age of ___
- Tonsillectomy at ___ years
- Wide tumor bed excision, right elbow area for intermediate
grade soft tissue sarcoma
Social History:
___
Family History:
Grandfather: colon cancer in grandfather
Father: DM2, CAD
Physical Exam:
General: NAD
VITAL SIGNS:98.2f PO 144 / 79 91 18 98 RA
HEENT: nc/at
CV: RR, NL S1S2 no S3S4 MRG
PULM: CTAB
ABD: BS+, soft,
LIMBS: very minimal non pitting edema. no erythema or rashes.
SKIN: No rashes or skin breakdown
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Benzonatate 100 mg PO TID
2. Gabapentin 600 mg PO TID
3. Levothyroxine Sodium 75 mcg PO DAILY
4. PAZOPanib 600 mg oral DAILY
5. Clindamycin 450 mg PO Q8H
Discharge Medications:
1. Enoxaparin Sodium 100 mg SC Q12H Duration: 3 Months
Start: Today - ___, First Dose: Next Routine Administration
Time
RX *enoxaparin 100 mg/mL 100 mg SC twice daily Disp #*60 Syringe
Refills:*2
2. Benzonatate 100 mg PO TID
3. Gabapentin 600 mg PO TID
4. Levothyroxine Sodium 75 mcg PO DAILY
5. HELD- PAZOPanib 600 mg oral DAILY This medication was held.
Do not restart PAZOPanib until you discuss with your oncologist.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Right posterior Tibial Vein clot
Community acquired pneumonia
Discharge Condition:
Stable
Alert and communicative
Independent
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: History: ___ with dyspnea, metastatic sarcoma // Eval for pulm
edema, acute process
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph from outside hospital dated ___.
CT chest dated ___.
FINDINGS:
A left chest wall Port-A-Cath terminates in the right atrium. Numerous
pulmonary metastatic lesions are seen within the lungs bilaterally. Given the
size and number of these lesions, it is difficult to exclude an underlying
pneumonia. Heart size is normal. The mediastinal and hilar contours are
normal. The pulmonary vasculature is normal. No pleural effusion or
pneumothorax is seen. There are no acute osseous abnormalities.
IMPRESSION:
1. Numerous pulmonary metastatic lesions bilaterally. Given the size and
number of these lesions, it is difficult to exclude an underlying pneumonia.
2. No evidence of pulmonary edema.
Radiology Report
EXAMINATION: BILAT LOWER EXT VEINS
INDICATION: ___ year old woman with sarcoma, bilateral leg swelling, recent
long-distance flight // Eval for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the bilateral lower extremity veins.
COMPARISON: None.
FINDINGS:
There is completely occlusive clot within a right posterior tibial vein.
There is normal compressibility, flow, and augmentation of the bilateral
common femoral, femoral, and popliteal veins. Normal color flow and
compressibility are demonstrated in the left posterior tibial and peroneal
veins. The right peroneal vein was not well visualized.
There is normal respiratory variation in the common femoral veins bilaterally.
No evidence of medial popliteal fossa (___) cyst.
IMPRESSION:
1. Completely occlusive clot within a right posterior tibial vein.
2. Nonvisualized right peroneal vein.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: History: ___ with sarcoma, + dimer // 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) = 397 mGy-cm.
COMPARISON: CT chest dated ___.
FINDINGS:
This examination is limited due to patient's body habitus and motion artifact.
HEART AND VASCULATURE: A Port-A-Cath terminates in the right atrium.
Pulmonary vasculature is well opacified to the segmental level without filling
defect to indicate a pulmonary embolus. The thoracic aorta is normal in
caliber without evidence of dissection or intramural hematoma. The heart,
pericardium, and great vessels are within normal limits. No pericardial
effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: The right peritracheal mediastinal lymph node
measuring 10 mm in short axis is new (series 2, image 26) a paraesophageal
lymph node is stable measuring 12 mm in short axis (series 2, image 79) the
right hilar lymph node conglomerate and has increased in size measuring 3.6 x
2.5 cm on today's examination (series 2, image 55), previously measuring 2.9 x
2.3 cm, and causes mass effect on the right hepatic veins. The left hilar
lymph node conglomerate has also increased in size (series 2, image 57). No
mediastinal mass.
PLEURAL SPACES: No pleural effusion or pneumothorax.
LUNGS/AIRWAYS: Patient is status post right upper lobe resection with
adjacent scarring and pleural thickening, which is stable. There is
increasing thickening of the right chest wall soft tissues, concerning for
metastatic involvement. For instance, a right chest wall nodule measures 2.0
x 1.9 cm on today's examination (series 2, image 30), previously measuring 1.5
x 1.4 cm. There are numerous pulmonary metastatic lesions bilaterally, which
may have also increased in size and distribution. In addition, there are
numerous foci of peribronchial ground-glass opacities and consolidations
within the lower lobes bilaterally, which are new since ___, and
raise concern for multifocal pneumonia. The airways are patent to the level
of the segmental bronchi bilaterally.
BASE OF NECK: The right lobe of the thyroid is atrophic. The remaining
thyroid is within normal limits. Otherwise, visualized portions of the base
of the neck show no abnormality.
ABDOMEN: Included portion of the upper abdomen is unremarkable.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
1. Limited examination due to the patient's body habitus and motion artifact.
2. Within these limitations, no evidence of large central pulmonary embolism.
3. Extensive hilar lymphadenopathy, which has progressed compared to ___. Numerous pulmonary metastatic lesions bilaterally, which seem to have
increased. Right chest wall involvement, which has also progressed.
4. New peribronchial ground-glass opacities and consolidations within the
lower lobes bilaterally, which raise concern for superimposed multifocal
pneumonia in the appropriate clinical setting.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Leg swelling, Transfer
Diagnosed with Pneumonia, unspecified organism
temperature: 98.4
heartrate: 86.0
resprate: 18.0
o2sat: nan
sbp: 141.0
dbp: 75.0
level of pain: 0
level of acuity: 2.0 | ___ is a ___ y F with Malignant peripheral nerve sheath
tumor,
metastatic to the lung despite Pazopanib treatment.
Pt has developmental disability , obesity and T2DM. She
recently had a flight to ___ and despite being active found
herself having leg swelling bilaterally.
US ___ showed R posterior tibial clot. Since it was
symptomatic for pt, decision was made to start pt on Lovenox
1mg\kg bid. Pt tolerated this without complicatinos and was
discharged in a stable condition |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Nausea/Vomiting
Major Surgical or Invasive Procedure:
Paracentesis - ___
G-Tube Replacement - ___
History of Present Illness:
___ PMH of Diarrhea predominant IBS, Oropharyngeal dysphagia
(c/b aspiration now s/p GTube for nutrition), Stage IV
pancreatic cancer (c/b malignant ascites on protocol ___,
presents with vomiting.
As per review of outpatient notes, NP was called by patient's
wife in light of persistent vomiting, that was dark brown, and
was associated with more coughing and white mucus. Reported low
grade fever so was referred to ED.
On arrival to the medical ward, pt and wife provided history.
They noted that he received chemotherapy last week and had 2
asymptomatic days afterward then developed nausea/vomiting which
is similar to how he reacted to prior chemotherapy
administration. Reglan, Zofran, and Compazine was given to good
effect but 1 day later he kept vomiting despite such
medications, and further doses withheld as they wouldn't stay
down. Vomit was noted to be thin/watery/brown without coffee
grounds or bright red blood. He was stooling daily during this
time and passing gas. Denied significant abdominal distension or
pain but noted that he had generalized discomfort when vomiting.
Reported no fevers at home, but temperature was 99 (increased
from baseline of around 97). As a result of vomiting tubefeeds
had been held. Patient also reported increase in chronic cough
with thicker mucus but noted that it is still clear and
breathing was unlabored. On arrival to medical ward patient
reported feeling much improved.
In the ED, initial VS were: 98.0 103 ___ 99% RA. Patient
remained afebrile in ED. CBC with WBC of 2.7, Hgb 7.8, plt 372,
CHEM wnl, lactate wnl, flu negative. CXR with small pleural
effusions but no pneumonia. CT A/P revealed: 1. Pancreatic body
mass with upstream dilation and tail atrophy, similar to prior.
2. Interval increase in now moderate sized right nonhemorrhagic
pleural effusion. 3. No dilated loops of bowel or free air. 4.
Position of the G tube balloon appears slightly retracted and is
not definitively within the stomach lumen; this could be
positioning or incomplete distension of the stomach on this
exam. Correlate with clinical assessment and consider imaging
after injecting G-tube with enteric contrast. 5. 7 x 3.3 cm
collection along the left lateral lobe of the liver with mild
mass effect on the stomach is new or more conspicuous compared
to the prior exam. Multiple other intraperitoneal and pelvic
fluid collections persist, some overall unchanged, others
perhaps slightly smaller. 6. Multiple hepatic hypodensities and
extensive omental caking, consistent with metastases are overall
unchanged. GTube check performed and revealed: Enteric contrast
administered via patient's PEG is noted within the stomach. No
extraluminal contrast identified. ED team performed bedside U/S
and could not identify a tappable pocket of ascites for
diagnostic para. Patient was given IVF and admitted to the
hospital. ___ was consulted and noted that they would change
patient's GTube tomorrow morning.
Past Medical History:
PAST ONCOLOGIC HISTORY:
- ___ CT Abdomen/Pelvis: Within the pancreatic body, there
is a 3cm hypodense mass. The tail is atrophied and the main PD
is dilated in that region. There are multiple scattered
hypodense masses with both lobes of the liver c/w metastases.
Within the R lobe anterior segment, there is a 3cm lesion. In
the posterior segment, there is a 2cm lesion. Most of the other
lesions in both lobes measure between 1-2cm. There is abnormal
soft tissue stranding and nodularity within the omental c/w
carcinomatosis. There is a small amount of free fluid in the
pelvis.
- ___ Pathologic Diagnosis: Liver, targeted needle core
biopsies: Ductal adenocarcinoma, which in the provided clinical
context likely represents metastatic ductal adenocarcinoma of
the pancreas.
- ___ Peritoneal Fluid Cytology: Positive for malignant
cells.
- ___: Right cephalic vein port placement (single-lumen BARD
ClearVUE PowerPort; deemed MRI safe).
- ___: Cycle 1 Protocol ___: A Phase 3,
Randomized, Double-Blind,Placebo-Controlled, Multicenter Study
of PEGylated Recombinant Human Hyaluronidase (PEGPH20) in
Combination with nab-Paclitaxel Plus Gemcitabine Compared with
Placebo Plus nab-Paclitaxel and Gemcitabine in Subjects with
Hyaluronan-High Stage IV Previously Untreated Pancreatic Ductal
Adenocarcinoma
TREATMENT:
- PEGPH20/placebo: ___ mcg/kg IV over ___ minutes (approx.
1mL/min) on day 1, 8, 15 of cycle 2 and beyond.
-Nab-paclitaxel: 125mg/m2 IV over ___ minutes on day 1, 8, 15
of cycle 2 and beyond; administered ___ hours after
PEGPH20/placebo infusion.
- Gemcitabine: 1000mg/m2 IV over 30 minutes on day 1, 8, 15 of
cycle 2 and beyond after nab-paclitaxel infusion.
- Dexamethasone: 8mg PO within 2 hours prior to the beginning of
PEGPH20/placebo infusion AND ___ hours after the completion of
PEGPH20/placebo infusion (at home). This comes from research
supply.
- Enoxaparin: 1mg/kg administered subcutaneously once daily. On
dosing days, enoxaparin will be administered prior to infusion
of study medication by treatment RN and will be administered by
patient at home all other days. This comes from research supply.
- Other pre-medication per provider discretion and ordered in
OMS.
CURRENT TREATMENT SUMMARY:
- ___: C1D1
- ___: Delay C2D1 d/t clinical concern for PNA.
- ___: C2D1, no dose modifications.
- ___: C2D8 Tx HELD due to gr 3 diarrhea, enoxaparin also on
hold
- ___: C3D1 - resume treatment of all 3 drugs
post-hospitalization. No dose modification"
PAST MEDICAL HISTORY:
- s/p R shoulder melanoma (removed in ___
- R hearing loss (spontaneous loss ___ years ago s/p steroid
injections in ear drum with 90% back)
- R hand Dupuytren contracture
- Diarrhea-predominant inflammatory bowel syndrome
- Low back pain with radiculopathy
- Adenomatous polyps
- s/p L IH repair
- s/p remote tonsillectomy
- Stage IV pancreatic cancer c/b malignant ascites
- Oropharyngeal dysphagia c/b aspiration now s/p GTube for
nutrition
- Likely OSA
Social History:
___
Family History:
Mother with alcoholism. Father with prostate CA and adenomatous
polyps, died age ___. MGM with "woman-related" cancer, died age
___. One sister with glioblastoma, died age ___. Her son
(patient's nephew), also with glioblastoma, died <___.
Physical Exam:
========================
Admission Physical Exam:
========================
Vitals: Temp: 98.8, BP: 119/74, HR: 97, RR: 18, O2 sat: 95%, O2
delivery: Ra, Wt: 157.3 lb/71.35 kg
GENERAL: Laying in bed, wife at bedside, appears comfortable,
NAD.
EYES: PERRLA, anicteric.
HEENT: MMM, OP Clear.
NECK: Supple.
LUNGS: CTA b/l, no wheezes/rales/rhonchi.
CV: RRR normal distal perfusion, no edema
ABD: G-tube in LUQ with dressing c/d/I, no tenderness, rebound,
or guarding, normoactive BS, no distension, no flank tenderness.
GENITOURINARY: No foley.
EXT: No deformity, no rash.
SKIN: Warm, dry, no rash.
NEURO: AOx3, fluent speech.
ACCESS: Port in right upper chest, dressing c/d/i.
========================
Discharge Physical Exam:
========================
VS: 98.8 ___ 18 96%RA
General: Chronically ill-appearing gentleman, pleasant, lying in
bed,
in no acute distress.
HEENT: MMM, OP clear of thrush or ulcerations.
CV: RRR, normal s1/s2, no m/r/g.
PULM: CTAB, respirations unlabored but diminished at right base.
ABD: BS+, soft, distended with fluid shift, non-tender to
palpation.
LIMBS: No ___, non-pitting at the ankles.
SKIN: Faint discrete scattered pink macules on back.
NEURO: Speech is clear, thought process logical, linear, future
oriented.
ACCESS: Right chest wall port without erythema.
Pertinent Results:
===============
Admission Labs:
===============
___ 02:38PM BLOOD WBC-2.7* RBC-2.65* Hgb-7.8* Hct-24.8*
MCV-94 MCH-29.4 MCHC-31.5* RDW-18.2* RDWSD-60.6* Plt ___
___ 02:38PM BLOOD Neuts-74.0* ___ Monos-5.1
Eos-0.4* Baso-0.7 NRBC-0.7* Im ___ AbsNeut-2.01
AbsLymp-0.52* AbsMono-0.14* AbsEos-0.01* AbsBaso-0.02
___ 02:38PM BLOOD Glucose-104* UreaN-16 Creat-0.4* Na-135
K-4.4 Cl-99 HCO3-26 AnGap-10
___ 02:45PM BLOOD Lactate-1.1
===============
Discharge Labs:
===============
___ 05:32AM BLOOD WBC-8.1 RBC-3.16* Hgb-9.3* Hct-29.2*
MCV-92 MCH-29.4 MCHC-31.8* RDW-19.1* RDWSD-61.4* Plt ___
___ 04:35AM BLOOD Neuts-67.6 Lymphs-18.7* Monos-9.0
Eos-0.3* Baso-0.3 NRBC-1.3* Im ___ AbsNeut-2.64
AbsLymp-0.73* AbsMono-0.35 AbsEos-0.01* AbsBaso-0.01
___ 05:32AM BLOOD Glucose-122* UreaN-15 Creat-0.4* Na-134*
K-4.6 Cl-98 HCO3-23 AnGap-13
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol Inhaler 2 PUFF IH Q6H:PRN cough
2. Benzonatate 200 mg PO TID:PRN cough
3. Mirtazapine 30 mg PO QHS
4. LOPERamide 2 mg PO Q4H:PRN diarrhea
5. Ondansetron 8 mg PO Q8H:PRN as needed for severe nausea
6. Prochlorperazine ___ mg PO Q6H:PRN nausea r/t chemotherapy
7. Enoxaparin Study Med 80 mg Subcutaneous DAILY
8. Metoclopramide 5 mg PO QID
9. Zenpep (lipase-protease-amylase) 3 tabs oral qmeals
10. LORazepam 0.5-1 mg PO Q6H:PRN nausea, vomiting, anxiety
11. GuaiFENesin ___ mL PO Q6H:PRN cough
12. Dexamethasone 8 mg PO ASDIR
Discharge Medications:
1. Ciprofloxacin HCl 500 mg PO Q12H
RX *ciprofloxacin HCl 500 mg 1 tablet(s) by mouth every twelve
(12) hours Disp #*6 Tablet Refills:*0
2. Albuterol Inhaler 2 PUFF IH Q6H:PRN cough
3. Benzonatate 200 mg PO TID:PRN cough
4. Dexamethasone 8 mg PO ASDIR
5. Enoxaparin Study Med 80 mg Subcutaneous DAILY
6. GuaiFENesin ___ mL PO Q6H:PRN cough
7. LOPERamide 2 mg PO Q4H:PRN diarrhea
8. LORazepam 0.5-1 mg PO Q6H:PRN nausea, vomiting, anxiety
9. Metoclopramide 5 mg PO QID
10. Mirtazapine 30 mg PO QHS
11. Ondansetron 8 mg PO Q8H:PRN as needed for severe nausea
12. Prochlorperazine ___ mg PO Q6H:PRN nausea r/t chemotherapy
13. Zenpep (lipase-protease-amylase) 3 tabs oral qmeals
14.Tube Feeds
Jevity 1.5 at 110 ml/hr over 16 hours. Dispense 1 month supply.
Refills: 11. Free water 150 mL Q4H.
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary Diagnosis:
- Nausea/Vomiting
- Malignant Ascites
- Bacterial Peritonitis
- Diarrhea
- Cough
- Oropharyngeal Dysphagia with Aspiration
- Severe Protein-Calorie Malnutrition
- Metastatic Pancreatic Cancer
- 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
EXAMINATION: Chest radiograph
INDICATION: ___ man with a history of pancreatic cancer who presents
with nausea, vomiting and inability to tolerate po.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest CT dated ___. Chest radiograph dated ___.
FINDINGS:
Slightly low lung volumes. No focal pneumonia, pulmonary edema, or
pneumothorax. Right Port-A-Cath tip ends in the right atrium.
Cardiomediastinal silhouette is unchanged. Pleural effusions are small.
Trace pleural fluid in the minor fissure. Tortuous thoracic aorta. No
evidence of pneumomediastinum or subdiaphragmatic free air.
IMPRESSION:
1. No pneumonia.
2. Small pleural effusions.
Radiology Report
EXAMINATION: CT abdomen and pelvis
INDICATION: ___ man with a history of pancreatic cancer, presenting
with nausea, vomiting, inability to tolerate p.o. Evaluate for small bowel
obstruction. NO_PO contrast.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were
acquired through the abdomen and pelvis following intravenous contrast
administration with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 634 mGy-cm.
COMPARISON: CT abdomen and pelvis and CT chest dated ___.
FINDINGS:
LOWER CHEST: Nonhemorrhagic right pleural effusion is now moderate in size,
larger since the prior exam. Associated homogeneously enhancing relaxation
atelectasis in the right lower lung is mild. A left pleural effusion is trace
and also nonhemorrhagic, overall unchanged from prior. No focal pneumonia in
the partially imaged lower lungs. No evidence of a pericardial effusion.
Coronary artery calcifications are moderate, incompletely imaged. The tip of
a central venous catheter is only partially imaged near the SVC-RA junction.
ABDOMEN:
HEPATOBILIARY: Multiple hepatic hypodensities throughout the liver are
compatible with known metastases, probably overall similar in size to the
prior exam when accounting for differences in measurement technique. No
evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder
is within normal limits.
Multiple large perihepatic fluid collections with fluid attenuation and
enhancing wall persist. 2 closely approximated fluid collections along the
left lateral lobe with mild mass effect on the stomach wall measures 7 x 3.3
cm, new from the prior (series 2, image 27). The largest fluid collection is
bilobed along the anterior surface of the liver. Compared to the prior exam
the inferior lobe of this fluid collection may be slightly smaller, now 16.2 x
9.7 cm on axial images, previously 17.3 x 10.9 cm (series 2, image 71; series
602, image 39). A 5.2 x 1.6 cm fluid collection along the anterior liver
surface is unchanged (series 2, image 20). A 5.3 x 7 cm fluid collection
along the posterior aspect of the liver is also overall unchanged (series 2,
image 25).
PANCREAS: The known hypoattenuating mass in the pancreatic body is difficult
to accurately measure. Severe dilation of the main pancreatic duct with
marked atrophy of the pancreatic tail persists, overall unchanged. The
pancreatic head and uncinate process are within normal limits without main
pancreatic ductal dilation in these regions. Small amount of ascites in the
peripancreatic region is unchanged and of simple attenuation (series 2, image
30).
SPLEEN: The spleen is normal in size and attenuation without evidence of a
focal lesion. A fluid collection with fluid-fluid level of proteinaceous
debris and/or old blood products may be slightly smaller, now measuring 14.3 x
9.9 cm, previously 16.8 x 11.2 cm (series 2, image 22). This fluid collection
exerts mass effect on the spleen.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
No evidence of focal renal lesions or hydronephrosis. No perinephric
abnormality.
GASTROINTESTINAL: The stomach is not markedly distended. The patient has a
G-tube. Position of the G-tube appears slightly retracted relative to the
prior exam however there may still be connect to be with the stomach lumen
(series 2, image 29, 28). Small bowel loops are normal in caliber, wall
thickness, enhancement throughout. The colon and rectum are within normal
limits. The appendix is not seen. No small bowel obstruction. No
pneumoperitoneum.
Caking in the omentum from metastases is probably overall similar to the prior
exam when accounting for differences in measurement technique (series 2, image
44).
An 2.8 x 1.9 cm fluid collection in the mid right abdomen is unchanged (series
2, image 47). A 3.7 x 2.7 cm fluid collection in the right lower quadrant is
unchanged (series 2, image 75).
PELVIS: The urinary bladder is moderately distended and unremarkable. The
distal ureters are unremarkable. An 1.8 x 2.6 cm fluid collection in the
central pelvis is also unchanged (series 2, image 79; series 602, image 39).
REPRODUCTIVE ORGANS: The prostate gland is not enlarged.
LYMPH NODES: No retroperitoneal or mesenteric lymphadenopathy. No pelvic or
inguinal lymphadenopathy. A 6 mm left external iliac lymph node is smaller
from the prior exam (series 2, image 76).
VASCULAR: No abdominal aortic aneurysm. Mild atherosclerotic disease is
noted. The main, left common right portal veins appear patent. The splenic
vein and SMV appear patent.
BONES: No evidence of worrisome osseous lesions or acute fracture. Multilevel
degenerative changes in the spine are similar to the prior exam, moderate to
severe. Mild retrolisthesis of L2 on L3 and L3 on L4 is likely degenerative,
unchanged.
SOFT TISSUES: The patient has a G-tube. No soft tissue gas or fluid
collections in the abdominal or pelvic wall.
IMPRESSION:
1. Pancreatic body mass with upstream dilation and tail atrophy, similar to
prior.
2. Interval increase in now moderate sized right nonhemorrhagic pleural
effusion.
3. No dilated loops of bowel or free air.
4. Position of the G tube balloon appears slightly retracted and is not
definitively within the stomach lumen; this could be positioning or incomplete
distension of the stomach on this exam. Correlate with clinical assessment
and consider imaging after injecting G-tube with enteric contrast.
5. 7 x 3.3 cm collection along the left lateral lobe of the liver with mild
mass effect on the stomach is new or more conspicuous compared to the prior
exam. Multiple other intraperitoneal and pelvic fluid collections persist,
some overall unchanged, others perhaps slightly smaller.
6. Multiple hepatic hypodensities and extensive omental caking, consistent
with metastases are overall unchanged.
RECOMMENDATION(S): Correlate with clinical assessment and consider imaging
radiograph after injecting G-tube with sufficient oral contrast.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 6:33 pm, 20 minutes after discovery
of the findings.
Radiology Report
INDICATION: ___ w/ h/o stage IV pancreatic ca on chemotherapy (third dose of
third cycle finished 5 days prior), history of inguinal hernia repair, p/w n/v
for the past 2 days, inability to tolerate PO, which is a generally dramatic
change from his baseline. No diarrhea (chroniclaly on loperamide to assist
with diarrhea). No fevers. No cough, ST, rhinorrhea. No abd pain, ST, chest
pain. No leg swelling. He has a G-tube for aspiration issues and family has
been providing support through this but patient continues to have emesis.
Several streaks of red in the emesis; on enoxaparin. No illicits x3.
TECHNIQUE: Two abdominal films were obtained, one before one following the
administration of contrast via patient's PEG tube.
COMPARISON: Correlation made to CT scan of the abdomen pelvis from earlier
the same day.
FINDINGS:
Enteric contrast was administered via patient's PEG tube and is seen within
the stomach. There is no extraluminal contrast identified. Excreted contrast
is seen within the renal collecting system and ureters. Degenerative changes
noted in the spine. Nonobstructive bowel gas pattern.
IMPRESSION:
Enteric contrast administered via patient's PEG is noted within the stomach.
No extraluminal contrast identified.
Radiology Report
EXAMINATION: PARACENTESIS DIAGNOSTIC/THERAPEUTIC WITH IMAGING GUIDANCE
INDICATION: ___ year old man with pancreatic ca w/loculated
ascites//therapeutic and dx para please
TECHNIQUE: Ultrasound guided diagnostic and therapeutic paracentesis
COMPARISON: ___
FINDINGS:
Limited grayscale ultrasound imaging of the abdomen demonstrated moderate
loculated ascites. A suitable target in the largest pocket in the right lower
quadrant was selected for paracentesis.
PROCEDURE: The procedure, risks, benefits and alternatives were discussed
with the patient and written informed consent was obtained.
A preprocedure time-out was performed discussing the planned procedure,
confirming the patient's identity with 3 identifiers, and reviewing a
checklist per ___ protocol.
Under ultrasound guidance, an entrance site was selected and the skin was
prepped and draped in the usual sterile fashion. 1% lidocaine was instilled
for local anesthesia.
A 5 ___ catheter was advanced into the largest fluid pocket in the right
lower quadrant and 3.1 L of cloudy brown fluid were removed. Fluid samples
were submitted to the laboratory for cell count, differential, and culture.
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:
-Technically successful ultrasound guided diagnostic and therapeutic
paracentesis.
-3.1 L of fluid were removed.
Radiology Report
INDICATION: ___ year old man with history of stage IV pancreatic cancer on
chemotherapy (3rd dose of ___ cycle finished 5 days prior), N/V x 2 days. Org
placed G-Tube MIC ___ Fr ___ re-admitted on ___ with 2 days N/V,
G-tube check ___. Exchange planned for ___
COMPARISON: Abdominal radiograph ___
TECHNIQUE: OPERATORS: Dr. ___ and Dr.
___ radiologist performed the procedure. Dr. ___
___ supervised the trainee during the key components of the procedure
and has reviewed and agrees with the trainee's findings.
ANESTHESIA: 1% lidocaine was injected in the skin and subcutaneous tissues
overlying the access site.
MEDICATIONS: None
CONTRAST: 35 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 1.1 min, 8 mGy
PROCEDURE: 1. Exchange of a gastrostomy tube.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
patient. The patient was then brought to the angiography suite and placed
supine on the exam table. A pre-procedure time-out was performed per ___
protocol. The upper abdomen and tube site was prepped and draped in the usual
sterile fashion.
A scout image was performed. The existing tube was injected with contrast and
showed opacification of the gastric rugae. A ___ wire was advanced through
the tube into the stomach. The existing tube was then removed using gentle
traction after deflation of the balloon. Given the recent placement of the
gastrostomy tube and lack of issues during tube feeding, a decision was made
to use a 12 ___ MIC for replacement to err on the side of caution and
prevent dehiscence of the fairly immature gastropexy. A 12 ___ gastrostomy
tube was advanced over the wire into the stomach and the balloon was inflated
using contrast diluted in sterile water. Contrast injection confirmed
appropriate position. The retention ring of the tube was secured in place
using 0 silk sutures. Sterile dressing was applied. Patient tolerated the
procedure well and there were no immediate post-procedure complications.
FINDINGS:
1. 12 ___ MIC gastrostomy tube in the stomach. Indwelling gastrostomy tube
balloon under-inflated.
IMPRESSION:
Successful exchange of a gastrostomy tube for a new 12 ___ MIC gastrostomy
tube. The tube is ready to use.
Radiology Report
EXAMINATION: Video oropharyngeal swallow
INDICATION: ___ year old man with pancreatic cancer and silent aspiration.//
Evaluate for aspiration, interval change.
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: 04:57 min.
COMPARISON: None
FINDINGS:
There is penetration with thin and nectar thick consistency liquids. There is
intermittent aspiration with thin liquids.
IMPRESSION:
Intermittent aspiration with thin liquids. Penetration with nectar thick
consistency liquids.
Please note that a detailed description of dynamic swallowing as well as a
summative assessment and recommendations are reported separately in a
standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation
Services).
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Abdominal distention, Vomiting
Diagnosed with Unspecified abdominal pain
temperature: 98.0
heartrate: 103.0
resprate: 18.0
o2sat: 99.0
sbp: 106.0
dbp: 79.0
level of pain: 0
level of acuity: 2.0 | Mr. ___ is a ___ male with a history of
diarrhea-predominant IBS, oropharyngeal dysphagia (c/b
aspiration now s/p G-Tube for nutrition), metastatic pancreatic
cancer (c/b malignant ascites) on protocol ___ who presents
with
nausea/vomiting and recurrent ascites.
# Nausea/Vomiting: Given temporal association to chemotherapy,
this is most likely chemotherapy induced nausea/vomiting, which
was insufficiently treated with PO medications at home.
Alternatively, may be due to mass effect of increased abdominal
fluid collection pushing on stomach. As well could be related to
bolus tube feeds. Obstruction unlikely as CT negative for it.
Much improved now and no further nausea or vomiting. Now
tolerating feeds with standing metoclopramide as needed.
# Diarrhea: Patient with increased diarrhea. Was briefly
constipated on admission but returned to diarrhea after
bisacodyl PR x1. Does have history of diarrhea predominant IBS
but large volume liquid diarrhea with nocturnal component is
suggestive of other etiology. He takes pancreatic enzyme
supplementation at appropriate dose (3 caps w/meals, 1 cap with
snack) so unlikely. At risk for SIBO or bile acid malabsorption.
Per patient, can handle at home with loperamide.
# Malignant Ascites:
# Bacterial Peritonitis: Patient s/p paracentesis on ___ with
PMN count 5,702. Possibly reactive from malignancy, procedures,
G-tube, but PMN count much higher than prior paras. ___ be
secondary from pulled back G-tube. Received CTX, remained
afebrile and stable, discharged on ciprofloxacin to complete 7
days.
# Cough: Patient with increased cough which is unlikely due to
PNA as CXR negative, but could be ___ increased aspiration of
oropharyngeal contents, post-nasal drip, viral process,
increased pleural effusion. Respiratory viral culture negative.
# Oropharyngeal Dysphagia with Aspiration:
# Severe Protein-Calorie Malnutrition: Patient is s/p G-tube and
typically receives Jevity 1.5 (7 cartons daily over 5 feedings)
with reglan to minimize vomiting, and loperamide to minimize
diarrhea. CT in ED had question of malposition of G-Tube but
contrast study showed appropriate filling of contrast in stomach
suggesting was in position however it needs upsizing and there
is still a question of proper location so patient underwent
replacement on ___. Patient was seen by nutrition and had
repeat video swallow which showed continued aspiration and
continued to
recommend NPO as diet. Switched =tube feeds to Jevity 1.5,
cycling over 16
hours which he tolerated.
# Metastatic Pancreatic Cancer: Metastatic to liver and omentum.
He is on clinical trial Protocol ___. Discussed with his
oncologist Dr. ___. Continued enoxaparin 80mg daily (study
drug)
# Anemia: Downtrending likely from IVF/albumin. Also due to bone
marrow suppression from chemotherapy and malignancy. He received
1 unit PRBC on ___.
==================== |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
right eye pain, back pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with history of polysubstance abuse, sciatica, and
psychiatric disorder who presents with chest pain, back pain,
and inability to ambulate s/p fall.
.
The patient states that he got into a fight at a club last
night, and was hit in the right eye with a pistol. He
experienced tearing chest pain that began in his left shoulder,
and radiated to his right hip and across his back. He states
that he was unable to ambulate, and was taken to the hospital in
an ambulence. Of note, the patient states that he used cocaine,
marijuana, and over 1 pint of vodka yesterday. He drinks at
least a pint of vodka daily.
.
In the ED, initial VS: 98.4 103 ___ 99% ra. Labs were
notable for Hct of 28.4 (baseline 36-38), Guaiac was negative.
CT head and sinuses were negative. CT abd without RP bleed. EKG
was reported to be sinus 98, NA/NI, TWF laterally. He received 2
L NS, percocet and 0.5 mg Dilaudid for the chest and back pain.
VS upon transfer 97.8, 84, 18, 125/89, 100%RA.
.
Currently, the patient is complaining of pain in his right eye
and lower back. Back pain is radiating down his right leg. He
states that he did have maroon stools 2 days ago, but has not
had a bowel movement since. No fevers, chills, N/V.
Occasionally has lower abdominal cramping, chronic since gunshot
wound to abdomen.
.
REVIEW OF SYSTEMS: Patient endorses urinary retention. Denies
fever, chills, night sweats, rhinorrhea, congestion, sore
throat, cough, shortness of breath, chest pain, abdominal pain,
nausea, vomiting, diarrhea, constipation, dysuria, hematuria.
Past Medical History:
# Osteonecrosis of L hip, s/p THR at Mt ___ ___
# Polysubstance abuse (EtOH, cocaine and opiates) with repeated
ED visits for pain medications, "inability to walk" and housing
-- numerous OMR notes with suspicion for malingering, narcotics
seeking
# Antisocial disorder. Extensive psych evaluation on ___ when
patient was considered for inpatient psychiatric
hospitalization. Felt to have several features consistent with
psycopathy but did not meet requirements for inpatient
hospitalization. History of aggressive behavior while
hospitalized. Previous incarcerations.
# Bipolar disorder. Unclear history. Patient has not been
medicated.
# Prior MI. In the ___, following cocaine use. Multiple visits
to ED for CP following cocaine use.
# DJD of the spine. Previous reports of sciatica with demands
for pain medication on presentation to ED. He has had LBP and
thigh pain for ___ years. MRI of spine showed degenerative changes
and disc herniation in ___.
# HTN
# mTB as a child. Took medication.
# H/o gunshot wound to abdomen in the ___, s/p ex-lap
Social History:
___
Family History:
Father had extensive alcohol abuse history and gout starting in
his ___. Denies FH of CAD, DM, malignancy.
Physical Exam:
Admission Physical Exam:
VS - Temp 98.1F, BP 131/84, HR 83, R 18, O2-sat 100% RA
GENERAL - Alert, interactive, well-appearing in NAD, laying
comfortably on side
HEENT - right eyelid edematous and closed; eye appears mildly
cloudy and patient with subjective blurred vision; MMM, OP clear
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
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 - obese, NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, non-edematous
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ in upper extremities bilaterally; ___ with giveaway weakness
in ankles bilaterally; otherwise will not participate in motor
exam due to pain; patient states that sensation diminished in
legs bilaterally L>R; decreased sensation in testicular sac;
cremasteric reflex intact bilaterally
.
Discharge Physical Exam:
98.1 ___ ___ 100%RA
GENERAL - Alert, interactive, well-appearing in NAD, laying
comfortably on side
HEENT - right eyelid edematous and closed; MMM, OP clear
NECK - Supple, no thyromegaly, no JVD, no carotid bruits
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 - obese, NABS, soft/NT/ND, no masses or HSM
EXTREMITIES - WWP, non-edematous
NEURO - awake, A&Ox3, CNs II-XII grossly intact, muscle strength
___ in upper extremities bilaterally; 4+/5 with giveaway
weakness in ankles bilaterally - however, on discharge patient
was able to stand and walk comfortably with assistance of cane
Pertinent Results:
Labs:
___ 12:50AM BLOOD WBC-5.2 RBC-3.37*# Hgb-9.7*# Hct-28.4*#
MCV-84 MCH-28.8 MCHC-34.1 RDW-16.2* Plt ___
___ 12:50AM BLOOD Neuts-45.2* ___ Monos-5.7
Eos-6.7* Baso-2.0
___ 06:30PM BLOOD Glucose-102* UreaN-12 Creat-1.1 Na-138
K-4.1 Cl-107 HCO3-24 AnGap-11
___ 06:30PM BLOOD ALT-38 AST-37 AlkPhos-100 TotBili-0.5
___ 06:30PM BLOOD Albumin-3.6 Calcium-8.6 Phos-3.7 Mg-2.1
___ 12:50AM BLOOD Hapto-201*
___ 06:30PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
CT head ___:
1. No acute intracranial process.
2. No evidence of fracture.
.
CT sinus ___:
1. No evidence of fracture.
2. Paranasal sinus disease.
3. Unchanged asymmetric soft tissue in the left piriform sinus,
as noted on ___, to be correlated with direct
visualization.
.
CXR PA/Lateral ___: No acute cardiopulmonary process.
.
Lumbosacral spine X-ray ___: No acute fracture. Stable
degenerative changes.
.
CT abdomen/pelvis w/out contrast ___:
1. No retroperitoneal hematoma.
2. No acute intra-abdominal or intrapelvic process allowing for
non-contrast technique.
.
MRI lumbar spine ___: Stable multifactorial degenerative
changes of the lumbar spine without significant spinal canal
stenosis and multilevel mild-to-moderate neural foraminal
narrowing.
Medications on Admission:
Per discharge summary ___ (patient only able to confirm
seroquel and citalopram)
1. quetiapine 100 mg Tablet Sig: One (1) Tablet PO three times a
day.
2. citalopram 20 mg Tablet Sig: Three (3) Tablet PO DAILY
(Daily).
3. acetaminophen 325 mg Tablet Sig: ___ Tablets PO Q6H (every 6
hours) as needed for pain.
4. ibuprofen 400 mg Tablet Sig: One (1) Tablet PO every six (6)
hours as needed for pain.
5. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily) as
needed for pain: On for 12 hours and off for 12 hours daily.
6. tizanidine 4 mg Tablet Sig: One (1) Tablet PO three times a
day as needed for pain and muscle spasm.
7. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
8. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
9. cyanocobalamin (vitamin B-12) 250 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
Discharge Medications:
1. cyanocobalamin (vitamin B-12) 250 mcg Tablet Sig: One (1)
Tablet PO DAILY (Daily).
2. folic acid 1 mg Tablet Sig: One (1) Tablet PO DAILY (Daily).
3. thiamine HCl 100 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
4. omeprazole 20 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO DAILY (Daily).
5. tizanidine 2 mg Tablet Sig: Two (2) Tablet PO TID (3 times a
day) as needed for pain/muscle spasm.
6. lidocaine 5 %(700 mg/patch) Adhesive Patch, Medicated Sig:
One (1) Adhesive Patch, Medicated Topical DAILY (Daily).
7. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
8. ibuprofen 600 mg Tablet Sig: One (1) Tablet PO Q6H (every 6
hours) as needed for pain.
Discharge Disposition:
Home
Discharge Diagnosis:
Anemia, Back pain, s/p eye trauma
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: Cocaine use with chest pain status post fall with severe low back
pain.
___.
FINDINGS: Frontal and lateral views of the lumbar spine demonstrate five
lumbar-type non-rib-bearing vertebral bodies. There is minimal if any
anterolisthesis of L4 on L5 and retrolisthesis of L5 on S1. Marked disc space
narrowing and endplate sclerosis with anterior spondylosis is present at
L5-S1. Remainder of the lumbar spine demonstrates preservation of disc and
vertebral body height. Mild compression deformity of T12 vertebral body is
unchanged since ___. There is no pubic symphyseal or sacroiliac
diastasis. The patient is status post left total hip arthroplasty.
IMPRESSION: No acute fracture. Stable degenerative changes.
Radiology Report
INDICATION: ___ male with chest pain status post cocaine use, struck
in the face with a pistol.
___.
TECHNIQUE: Contiguous non-contrast axial images were acquired through the
brain with multiplanar reformations.
FINDINGS: There is no intracranial hemorrhage, mass effect, edema, or shift
of normally midline structures. The gray-white matter differentiation is
preserved. Ventricles and sulci appear age appropriate. Suprasellar and
basilar cisterns are patent.
Paranasal sinuses and mastoid air cells are well aerated. There is no
evidence of fracture. Right frontal subgaleal thickening is longstanding.
Globes and orbits are intact.
IMPRESSION:
1. No acute intracranial process.
2. No evidence of fracture.
Radiology Report
INDICATION: ___ male with chest pain after using cocaine.
COMPARISON: Radiograph dated ___ and CT dated ___.
FINDINGS: Frontal and lateral views of the chest demonstrate stable low lung
volumes. Allowing for such, the heart is normal in size. Mild unfolding of
the thoracic aorta is unchanged. The lungs are clear. There is no vascular
congestion, pleural effusion, or pneumothorax.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
INDICATION: ___ male with cocaine use, struck in the face with a
pistol.
COMPARISON: Same-day CT head.
TECHNIQUE: MDCT of the maxillofacial bones was performed without contrast
administration, with multiplanar reformations.
There is no evidence of fracture. The nasal bones, zygomatic arches, lamina
papyracea, anterior clinoid processes, and pterygoid plates are intact. The
mandible appears intact. There is no periapical lucency. There is mucosal
thickening involving the ethmoidal air cells and right maxillary sinus.
Bilateral OMUs are patent. Visualized upper cervical spine demonstrates
moderate multilevel degenerative disease.
Globes appear intact.
There is asymmetric soft tissue in the left piriform sinus, as previously seen
on ___.
IMPRESSION:
1. No evidence of fracture.
2. Paranasal sinus disease.
3. Unchanged asymmetric soft tissue in the left piriform sinus, as noted on
___, to be correlated with direct visualization.
Radiology Report
INDICATION: ___ male with low back pain status post fall with 10
point hematocrit drop. Question retroperitoneal hemorrhage.
___.
TECHNIQUE: MDCT images were acquired from the lung bases through the pubic
symphysis without contrast administration, with multiplanar reformations.
CT ABDOMEN: The lung bases are clear with the exception of dependent
atelectasis. There is no pleural effusion. The heart is normal in size
without pericardial effusion. There is relative hypoattenuation of myocardium
with respect to the blood pool in keeping with anemia.
The liver demonstrates no focal lesion. Non-contrast technique limits
assessment of solid organs. Allowing for such, the gallbladder, spleen,
splenule, pancreas, and adrenal glands appear unremarkable. The kidneys
demonstrate no stone or hydronephrosis. Small and large bowel loops are
normal in caliber. There is no free air or free fluid. The great vessels are
normal in caliber. Tiny mesenteric and retroperitoneal lymph nodes do not
meet size criteria for adenopathy.
CT PELVIS: The bladder, distal ureters, rectum, and prostate appear within
normal limits allowing for streak artifact from a total left hip arthroplasty.
There is anterior tenting of the bladder dome, with a linear structure leading
to a small 7-mm possible urachal cyst (please confirm), likely congenital in
origin and of doubtful clinical significance.
There is no free fluid in the pelvis.
BONE WINDOW: There is a left total hip arthroplasty in appropriate position.
Multilevel moderate degenerative changes are seen. There is grade 1
retrolisthesis of L5 on S1.
IMPRESSION:
1. No retroperitoneal hematoma.
2. No acute intra-abdominal or intrapelvic process allowing for non-contrast
technique.
Radiology Report
INDICATION: ___ patient with known degenerative disc disease,
presenting with progressive decrease of sensation in lower legs. Assessment
for cord compression.
COMPARISON: MR ___ dated ___.
TECHNIQUE: Sagittal STIR, T1 and T2 as well as axial T2 images were obtained
without contrast.
FINDINGS: The lumbar spine has normal lordotic curvature, vertebral body
height and alignment. Besides T1- and T2-hyperintense, STIR-hypointense
lesion in L1, likely meningioma as well as ___ type 2 endplate changes at
L5/S1, the bone marrow signal is unremarkable. The intervertebral discs
demonstrate diffuse loss of height and T2 signal as a manifestation of
degenerative disc disease.
At L3/L4, a diffuse disc bulge is mildly indenting the anterior thecal sac
without causing significant spinal canal stenosis. The left neural foramen is
mildly narrowed due to extending disc material and facet joint arthropathy.
At L4/L5, diffuse disc bulge is indenting the anterior thecal sac without
causing significant spinal canal stenosis. The bilateral neural foramina are
mildly narrowed due to extending disc material and facet joint arthropathy.
At L5/S1, a diffuse disc bulge is indenting the anterior thecal sac. The
bilateral neural foramina are moderately narrowed due to facet joint
arthropathy.
The conus terminates at L2 level. Conus and cauda equina demonstrate normal
morphology and preserved intrinsic T2 signal. The posterior elements
demonstrate multilevel facet joint arthropathy. The paraspinal soft tissues
are unremarkable.
IMPRESSION: Stable multifactorial degenerative changes of the lumbar spine
without significant spinal canal stenosis and multilevel mild-to-moderate
neural foraminal narrowing.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: CHEST PAIN
Diagnosed with ANEMIA NOS, CHEST PAIN NOS, COCAINE ABUSE-UNSPEC
temperature: 98.4
heartrate: 103.0
resprate: 20.0
o2sat: 99.0
sbp: 109.0
dbp: 88.0
level of pain: 10
level of acuity: 2.0 | ___ year old man with antisocial personality disorder admitted
for left eye pain and back pain s/p trauma with blunt object,
found to have diminished lower extremity sensation and
significant hematocrit drop from baseline.
.
# Normocytic anemia: The patient was admitted with a 10 point
hematocrit drop from baseline of 36-38 to 27.1. On admission,
he endorsed 4 episodes of maroon stool prior to admission.
Guaiac in the ED was negative. The patient had several
documented bowel movements during admission, but refused to save
stools to visualize or guaiac. He denied hematemesis or coffee
ground emesis. No evidence of RP bleed on CT. No evidence of
hemolysis on laboratory testing. On day 2 of admission, the
patient began refusing labs, so hematocrit could no longer be
followed. The patient was continued on folate, as he likely has
folate deficiency from chronic alcohol abuse (despite lack of
macrocytosis).
.
# Back pain/Inability to walk: On admission, the patient
endorsed acute inability to walk following trauma to lower back.
He described associated symptoms of decreased lower extremity
sensation bilaterally and urinary retention. He refused to
participate in lower extremity motor exam. He underwent
lumbosacral spine x-ray that was without evidence of fracture.
Given associated symptoms, the patient underwent lumbar spine
MRI that showed chronic degenerative disease (unchanged from
___ with mild chronic multilevel foraminal narrowing, but no
evidence of cord compression. The patient was continued on
tizanidine, acetaminophen, ibuprofen, and a lidocaine patch for
pain. He was not provided narcotics per psychiatry
recommendations. With stable MRI findings, the patient was
discharged to home. On discharge, he was able to stand, dress
himself, and ambulate with a cane. He was recommended to
continue ibuprofen for pain.
.
# Eye trauma: Patient with trauma to right eye from blunt end
of pistol. Right eyelid swollen closed. Appearance unchanged
over the course of admission. The patient was seen by
ophthalmology, who determined that there was no direct trauma to
the eye. He was found to have cotton wool spots from chronic
disease.
.
# Threatening behavior: On admission, the patient endorsed
intent to "kill the people out to get him" when he is
discharged. However, he did not specifically name anyone. He
also endorsed hearing voices, but was unable to report the
gender of the voices or what they were telling him. He demanded
Seroquel and Celexa throughout admission, stating that these
were chronic medications. However, he did not have a primary
provider and had only filled one prescription for short supply
written by the emergency department in the last year. The
patient was seen by psychiatry, who determined the patient has
antisocial personality disorder, and is without indication for
acute psychiatric admission or psychiatric medications. On the
day of discharge, the patient required security supervision, as
he was threatening staff. He was escorted from the building by
security at discharge.
.
# Polysubstance abuse: The patient reported cocaine and
marijuana use prior to admission. He also endorsed drinking a
pint of vodka a day. CIWA scale discontinued on second day of
admission, as patient consistently did not score. He was
continued on thiamine, folate, and B12 throughout admission.
.
# ___: On admission, creatinine elevated to 1.4 from baseline
of 1.1. ___ likely prerenal in the setting of blood loss, as it
resolved with IF fluids in the emergency department. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with a history of recurrent episodes of abdominal pain
and bloating of unclear etiology, presenting with RLQ pain since
yesterday at 8 ___. Patient started having some right flank pain
with sudden onset that radiated to the epigastrium and to the
left abdomen. Had some nausea, but no vomiting. Denies any
fevers
or chills. Has been having some loose stools. In the ED, pelvic
exam was normal, a CTU was performed to evaluate for kidney
stones, and this was negative. It did show an 8 mm appendix.
Surgery is consulted for possible enlarged appendix.
ROS:
(+) per HPI
(-) Denies fevers chills, night sweats, unexplained weight
loss, fatigue/malaise/lethargy, pruritis, jaundice, rashes,
bleeding, easy bruising, dizziness, vertigo, syncope, weakness,
paresthesias, vomiting, hematemesis, bloating, cramping, melena,
BRBPR, dysphagia, chest pain, shortness of breath, cough, edema
Past Medical History:
OCD, trichotillomania, depression, GERD, recurrent episodes of
abdominal pain and bloating of unclear etiology. Normal gastric
emptying study ___, H. pylori ___ s/p treatment, recurrent
vaginitis
Social History:
___
Family History:
Father had CABG
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: 99.6 117 130/80 18 100%
GEN: A&Ox3, 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, minimally tender in all the right
abdomen, not consistent after distraction, no rebound or
guarding, normoactive bowel sounds, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
DISCHARGE PHYSICAL EXAM:
VITALS T99, BP 117/83, HR 90, RR18, 99% RA
GENERAL: well appearing in NAD
HEENT: PERRL, EOMI, MMM, OP clear
NECK: no LAD, supple
LUNGS: CTAB no MRG
HEART: RRR, normal S1 S2, no MRG
ABDOMEN: Soft, +BS, R-side TTP (perumbilical-RUQ, milder TTP
RLQ), negative ___ sign, referred pain to right side with
LLQ and LUQ palpation, no TTP over mcburney's point
EXTREMITIES: No c/c/e
NEUROLOGIC: A+OX3, CN II-XII grossly intact, ___ strength,
normal gait, normal sensation throughout
Pertinent Results:
ADMISSION LABS:
___ 05:45PM BLOOD WBC-9.7 RBC-5.18 Hgb-13.0 Hct-39.4
MCV-76* MCH-25.1* MCHC-32.9 RDW-13.3 Plt ___
___ 05:45PM BLOOD Neuts-76.0* ___ Monos-4.0 Eos-1.2
Baso-0.5
___ 05:45PM BLOOD Glucose-93 UreaN-14 Creat-0.8 Na-138
K-3.9 Cl-104 HCO3-26 AnGap-12
___ 05:45PM BLOOD ALT-16 AST-15 AlkPhos-42 TotBili-0.3
___ 05:45PM BLOOD Albumin-4.6 Iron-24*
___ 05:45PM BLOOD Lipase-33
DISCHARGE LABS:
___ 06:30AM BLOOD WBC-8.0 RBC-4.95 Hgb-12.3 Hct-38.0
MCV-77* MCH-24.8* MCHC-32.3 RDW-13.4 Plt ___
___ 06:30AM BLOOD Glucose-81 UreaN-9 Creat-0.7 Na-140 K-3.6
Cl-107 HCO3-25 AnGap-12
___ 06:30AM BLOOD ALT-9 AST-15 AlkPhos-37 TotBili-0.5
PERTINENT MICRO:
___ 7:21 pm SWAB
-Chlamydia trachomatis, Nucleic Acid Probe, with
Amplification PENDING AT TIME OF DISCHARGE
-NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION
PENDING AT TIME OF DISCHARGE
PERTINENT IMAGING:
CT ABD/PEL ___ NON CON
TECHNIQUE: Multidetector CT through the abdomen and pelvis was
performed
without oral or IV contrast. Patient was scanned in the prone
position and multiplanar reformations were provided.
FINDINGS: The imaged lung bases are clear.
ABDOMEN: The kidneys demonstrate no hydronephrosis or renal
stone. A
hypodensity arising from the lower pole of the left kidney is
incompletely characterized on this single-phase exam though it
is most compatible with a simple cyst, please note this left
renal cyst has been previously characterized on an ultrasound of
the abdomen dated ___.
The liver, spleen, gallbladder, pancreas, and adrenal glands
appear normal on this non-contrast exam. The abdominal aorta is
normal in course and caliber. No significant atherosclerosis is
noted. The retroperitoneal lymph nodes are not enlarged. The
stomach is decompressed. The duodenum appears normal.
PELVIS: Loops of small bowel demonstrate no signs of ileus or
obstruction. The appendix measures up to 8 mm in diameter,
though there is no periappendiceal fat stranding to suggest
acute appendicitis. The colon is unremarkable without signs of
colitis or obstruction. Uterus and adnexal regions appear
normal. The urinary bladder appears unremarkable. No pelvic
free fluid.
BONES: No worrisome lytic or blastic osseous lesion is seen.
IMPRESSION:
1. No hydronephrosis or renal stone.
2. 8 mm appendix which is at the upper limits of normal for
size without
definite signs of acute appendicitis.
___ ABDOMINAL ULTRASOUND
FINDINGS: The liver has normal echotexture and there is no
focal liver
lesion. The main portal vein is patent and displays hepatopetal
flow. The gallbladder is normal and there is no stones. There
is no intra- or
extra-hepatic biliary ductal dilatation and the common bile duct
measures 3 mm. The right kidney measures 11.4 cm and the left
kidney measures 10.8 cm. Both kidneys are normal without
hydronephrosis, mass, or stone. A 4.1 cm simple cyst is noted
in the lower pole of left kidney as seen on prior CT. There is
a lobulation of the left kidney unchanged compared to the prior
ultrasound dated ___. The visualized portions of the
pancreas are normal. The tail of pancreas is not visualized,
likely due to overlying bowel gas. Spleen is normal measuring
10.2 cm. The aorta is of normal caliber throughout. The
visualized portions of the inferior vena cava appear normal.
IMPRESSION: Left renal cyst.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. lactase *NF* 4,500 unit Oral with dairy
2. Omeprazole 20 mg PO DAILY
3. Simethicone 40-80 mg PO QID:PRN bloating
Discharge Medications:
1. Omeprazole 20 mg PO DAILY
2. lactase *NF* 4,500 unit Oral with dairy
3. Simethicone 40-80 mg PO QID:PRN bloating
Discharge Disposition:
Home
Discharge Diagnosis:
Abdominal Pain, etiology unclear
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CT SCAN OF THE ABDOMEN AND PELVIS PERFORMED ON ___
COMPARISON: None.
CLINICAL HISTORY: Right lower quadrant and right CVA tenderness. Assess for
appendicitis or kidney stone.
TECHNIQUE: Multidetector CT through the abdomen and pelvis was performed
without oral or IV contrast. Patient was scanned in the prone position and
multiplanar reformations were provided.
FINDINGS: The imaged lung bases are clear.
ABDOMEN: The kidneys demonstrate no hydronephrosis or renal stone. A
hypodensity arising from the lower pole of the left kidney is incompletely
characterized on this single-phase exam though it is most compatible with a
simple cyst, please note this left renal cyst has been previously
characterized on an ultrasound of the abdomen dated ___.
The liver, spleen, gallbladder, pancreas, and adrenal glands appear normal on
this non-contrast exam. The abdominal aorta is normal in course and caliber.
No significant atherosclerosis is noted. The retroperitoneal lymph nodes are
not enlarged. The stomach is decompressed. The duodenum appears normal.
PELVIS: Loops of small bowel demonstrate no signs of ileus or obstruction.
The appendix measures up to 8 mm in diameter, though there is no
periappendiceal fat stranding to suggest acute appendicitis. The colon is
unremarkable without signs of colitis or obstruction. Uterus and adnexal
regions appear normal. The urinary bladder appears unremarkable. No pelvic
free fluid.
BONES: No worrisome lytic or blastic osseous lesion is seen.
IMPRESSION:
1. No hydronephrosis or renal stone.
2. 8 mm appendix which is at the upper limits of normal for size without
definite signs of acute appendicitis.
Radiology Report
INDICATION: Right-sided abdominal pain of unclear etiology.
TECHNIQUE: Abdominal ultrasound (complete).
COMPARISON: CT abdomen and pelvis ___.
FINDINGS: The liver has normal echotexture and there is no focal liver
lesion. The main portal vein is patent and displays hepatopetal flow. The
gallbladder is normal and there is no stones. There is no intra- or
extra-hepatic biliary ductal dilatation and the common bile duct measures 3
mm. The right kidney measures 11.4 cm and the left kidney measures 10.8 cm.
Both kidneys are normal without hydronephrosis, mass, or stone. A 4.1 cm
simple cyst is noted in the lower pole of left kidney as seen on prior CT.
There is a lobulation of the left kidney unchanged compared to the prior
ultrasound dated ___. The visualized portions of the pancreas are
normal. The tail of pancreas is not visualized, likely due to overlying bowel
gas. Spleen is normal measuring 10.2 cm. The aorta is of normal caliber
throughout. The visualized portions of the inferior vena cava appear normal.
IMPRESSION: Left renal cyst.
Gender: F
Race: HISPANIC OR LATINO
Arrive by WALK IN
Chief complaint: ABD PAIN
Diagnosed with ABDOMINAL PAIN RLQ
temperature: 99.6
heartrate: 117.0
resprate: 18.0
o2sat: 100.0
sbp: 130.0
dbp: 80.0
level of pain: 5
level of acuity: 3.0 | Ms. ___ is a ___ with history trichotillomania, OCD and
chronic abdominal bloating who presented with right-sided
abdominal pain distinct from bloating pains of unclear etiology.
# ABDOMINAL PAIN: Patient with long hx of bloating, but
describes current pain as very different. Pancreatitis,
nephrolithiasis, obstruction, UTI, appendicitis ruled out with
imaging and labs, no ovarian mass on CT or torsion or gallstones
on abdominal-pelvic US. No CMT on pelvic exam and denies recent
sexual activity (husband passed in ___. Functional (gas,
constipation, pre-menstrual cramps) remain on differential as
well as endometriosis. Hx of trichotillomania raises concern for
bezoar/obstruction, but patient passing stool and flatus, no SBO
noted on CT, not distended. Pain was well controlled with
ibuprofen at time of discharge
-Patient instructed to follow with PCP ___ 1 week of
discharge.
# ENLARGED APPENDIX: CT abdomen showed an enlarged appendix with
no signs of inflammation. Patient had no pain over Mc___'s
site, no fevers or leukocytosis. Surgery evaluated the imaging
and did not feel findings were consistent with acute
appendicitis. Most likely normal variant. Patient aware.
# VAGINAL DISCHARGE: likely physiologic.
- GC/Chlamydia PCR were pending at time of 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:
bradycardia and malnutrition
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
Ms. ___ is a ___ year old female with a history of severe
eating disorder, anxiety, and hypothyroidism with a recent
admission for intentional overdose of psychiatric medication now
transferred from ___ for evaluation of SI and failure to
follow their eating disorder protocol as well as medical
clearance for bradycardia.
Patient reports that the SI was a passive fleeting feeling that
she wrote about in her journal and she no longer feels this way.
She reports she was taking good oral intake at ___ but had
declined the tube that they recommended. She would like either
an inpatient psychiatric stay to address her psychiatric
problems or to be transferred back to ___ as soon as
possible. ROS positive only for mild intermittent constipation.
Past Medical History:
PMH
-Anorexia nervosa with purging
-ETOH abuse
-Anxiety
-Depression
-Migraines
-Hypothyroidism?
-Osteopenia
-Born with one kidney
- One grand mal seizure at ___ years old. None since. She used
anti-epileptic (Keppra) for ___ years but has not taken a
medication to prevent seizures since.
Social History:
___
Family History:
Family history of:
- Anxiety: paternal grandfather
- ___: mother and maternal aunt. Mother is a ___.
- One sister cuts herself
- No history of suicide attempts in family
Physical Exam:
ADMISSION PHYSICAL EXAM:
===========================
Vital Signs: T 97.4 PO BP 92 / 64 L Sitting HR48 RR16 SaO2 100RA
General: Very thin young women, Alert, oriented, no acute
distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
neck supple, JVP not elevated, no LAD
CV: Bradycardic and regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, Mild tenderness suprapubic, non-distended, bowel
sounds present, no organomegaly, no rebound or guarding
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, grossly normal sensation and strength of
extremities.
Access: PIV
DISCHARGE PHYSICAL EXAM
=======================
Vitals- 98.1 | 91/59 | 80 | 16 | 100% RA
Weight- 40.3kg from low weight of 38.1 KG on ___
General- cachectic, alert, oriented, no acute distress
HEENT- sclera anicteric, MMM, nicotine lozenge in mouth,
oropharynx clear with good dentition, PERRLA
Neck- thin, supple, JVP not elevated, no LAD
Lungs- clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV- bradycardic with regular rhythm, normal S1 + S2, no murmurs,
rubs, gallops
Abdomen- soft, non-distended, bowel sounds present, mild RLQ
tenderness, no rebound tenderness, no organomegaly
GU- no foley
Ext- 2+ pulses, no clubbing, cyanosis or edema
Neuro- CNs2-12 intact, motor function grossly normal
Pertinent Results:
ADMISSION LABS
==============
___ 03:54PM BLOOD WBC-3.8* RBC-3.94 Hgb-10.4* Hct-33.5*
MCV-85 MCH-26.4 MCHC-31.0* RDW-14.3 RDWSD-44.7 Plt ___
___ 03:54PM BLOOD Glucose-83 UreaN-18 Creat-0.8 Na-140
K-4.2 Cl-101 HCO3-30 AnGap-13
___ 07:25AM BLOOD ALT-19 AST-12 LD(LDH)-129 AlkPhos-66
Amylase-114* TotBili-0.2
___ 07:25AM BLOOD TotProt-5.8* Albumin-3.8 Globuln-2.0
Calcium-9.5 Phos-3.8 Mg-1.7 UricAcd-3.2 Cholest-155
___ 03:54PM BLOOD ASA-NEG Ethanol-NEG Acetmnp-5*
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
Imaging
=======
CXR ___ portable AP: IMPRESSION:
Comparison to ___. The patient is extubated and the
nasogastric tube was removed. Otherwise the chest radiograph is
stable and normal. Normal size of the cardiac silhouette. Mild
scoliosis. No pneumonia, no pulmonary edema, no pleural
effusions.
DISCHARGE LABS
==============
___ 06:50AM BLOOD WBC-3.8* RBC-4.03 Hgb-10.7* Hct-34.1
MCV-85 MCH-26.6 MCHC-31.4* RDW-14.3 RDWSD-42.5 Plt ___
___ 06:50AM BLOOD Glucose-64* UreaN-20 Creat-1.0 Na-137
K-4.0 Cl-98 HCO3-26 AnGap-17
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. LamoTRIgine 150 mg PO BID
2. Levothyroxine Sodium 25 mcg PO DAILY
3. ClonazePAM 0.5 mg PO TID:PRN anxiety
4. FoLIC Acid 1 mg PO DAILY
5. Docusate Sodium 100 mg PO BID
6. Melatin (melatonin) 5 mg oral QPM
7. Polyethylene Glycol 17 g PO BID
8. Multivitamins 1 TAB PO DAILY
9. B Complete (vitamin B complex) oral DAILY
10. Gabapentin 200 mg PO TID
11. Vitamin D Dose is Unknown PO DAILY
12. Calcium Carbonate 500 mg PO Frequency is Unknown
13. OLANZapine 5 mg PO QHS
14. Pedialyte
(electrolytes-dextrose;<br>sodium-potas-chloride-dextrose)
10.6-4.7 mEq/8.5 gram oral TID
15. Gaviscon (Al hyd-Mg tr-alg ac-sod bicarb;<br>aluminum
hydrox-magnesium carb) unknown oral ___
16. Simethicone 40-80 mg PO QID:PRN gas/distention
17. DiphenhydrAMINE 50 mg PO QHS:PRN sleep
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Multivitamins W/minerals 1 TAB PO DAILY
3. Neutra-Phos 2 PKT PO BID
4. Nicotine Lozenge 2 mg PO Q2H:PRN crave
5. Thiamine 100 mg PO DAILY
6. OLANZapine 2.5 mg PO TID W/MEALS
7. ClonazePAM 0.5 mg PO TID:PRN anxiety
8. DiphenhydrAMINE 50 mg PO QHS:PRN sleep
9. FoLIC Acid 1 mg PO DAILY
10. Gabapentin 200 mg PO TID
11. LamoTRIgine 150 mg PO BID
12. Levothyroxine Sodium 25 mcg PO DAILY
13. Melatin (melatonin) 5 mg oral QPM
14. Simethicone 40-80 mg PO QID:PRN gas/distention
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Primary Diagnosis
- Anorexia nervosa
- Malnutrition
- Bradycardia
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 eating disorder // Initial evaluation for
eating disorder protocol. Initial evaluation for eating disorder
protocol.
IMPRESSION:
Comparison to ___. The patient is extubated and the nasogastric
tube was removed. Otherwise the chest radiograph is stable and normal.
Normal size of the cardiac silhouette. Mild scoliosis. No pneumonia, no
pulmonary edema, no pleural effusions.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Anorexia, SI
Diagnosed with Anorexia nervosa, unspecified
temperature: 98.5
heartrate: 52.0
resprate: 14.0
o2sat: 100.0
sbp: 91.0
dbp: 58.0
level of pain: 7
level of acuity: 2.0 | Ms. ___ was admitted for continued weight loss and concern
for bradycardia at ___ Inpatient Eating disorder unit. She
arrived in stable condition, and has remained stable throughout
her admission. She was on the ___ eating disorder protocol and
did not fail any meals. She has gained about 4 lbs during
admission.
# Malnutrition secondary to anorexia nervosa
Ms. ___ was admitted on the eating disorder protocol which
is a multi-team protocol involving nutritionists, physicians,
social workers, psychiatrists, and nursing staff. Though she has
frequently complained about the restrictions and demands of the
protocol, she ultimately cooperated eating all meals in 30
minutes and being observed for one hour following. She has been
given a regimen of supplementation with nutriphos, a
multivitamin with minerals, thiamine, and folate. Basic
electrolytes have been evaluated daily and remained within
normal limits throughout her stay. She has gained weight during
her stay from 67% to 70% of ideal.
Behaviorally, she has been found in the kitchen on several
occasions after being told she could not be there. She attempted
and may have succeed in making caffeinated beverages and
sneaking sugar packets to her room to induce purging. Of note,
despite continuous complaints of hard small stools, no bowel
movements have been observed by nursing staff. Patient continued
to report constipation but none documented, frequently asked for
laxatives. With history of abuse none were given, especially
since she did report some BMs.
#Bradycardia: Initially transferred with concerns about extent
of bradycardia. At baseline, patient has sinus bradycardia at
rest. She was monitored on tele with rates as low as high ___
while sleeping, however during the day rates were ___ at
rest and rose appropriately with exercise. She had no
symptomatic bradycardia.
# Depression
Currently reports depressive symptoms that are likely
multifactorial from malnutrition and possible true depression.
She wants inpatient psychiatry at this time. She endorses
passive suicidal ideation and reports "holding back desires to
harm herself. During her stay she has been started on zyprexa
2.5mg TID with meals in addition to her normal 5mg qhs. QTC ___
was 382. She was not found to need a ___ or to need a 1:1
sitter.
Chronic Problems
================
# Anxiety
- clonazepam PRN
# Insomnia
- Diphenhydramine PRN
# Hypothyroidism
- continue levothyroxine 25mcg daily
# Anemia and leukopenia
Likely secondary to malnutrition, chronic and stable. HGB 10.4
on admission and 10.9 on ___. Leukopenia resolved prior to
discharge at 4.3 on ___
TRANSITIONAL ISSUES
===================
[] Despite gaining weight, she is still severely malnourished.
Additional inpatient treatment is needed with careful monitoring
of her diet and meals as she returns to a healthy weight.
[] She has made repeated attempts to obtain sugar or other
laxative substances. She still needs to be closely monitored at
all times.
[] She continues to endorse significant depressive symptoms
including thoughts of self harm. These might improve with
increased weight, however she has needed and will continue to
need close psychiatric care for both her eating disorder and
depression.
[] She has recently been started on zyprexa 2.5mg TID with meals
in addition to her long standing 5mg QHS. She may additional
dose adjustments. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
amoxicillin / Bactrim / Keflex
Attending: ___.
Chief Complaint:
fever
Major Surgical or Invasive Procedure:
skin punch biopsy
History of Present Illness:
___ female with history of benign
neutropenia, psoriasis and recently diagnosed Crohn's disease
(in
___ of this year) on humira and chronic prednisone who presents
with high grade fevers and new petechial rash x2 days.
Patient has been on a course of Bactrim for cellulitis of right
antecubital fossa. She developed fevers and was seen again 2
days
ago at which time it was thought that she needed a longer course
of antibiotics for her cellulitis. They attempted an I&D but
there was no e/o abscess on exam or ultrasound. Patent was then
discharged with another 10 day course of Bactrim as well as
doxycycline and Keflex. She returns today with persistent high
grade fevers to 102-103 despite round the clock Tylenol. She
also
noted a new petechial rash involving her torso.
She has been on prednisone 10mg daily since ___, prior to that
she was on 40mg daily for several months followed by a slow
taper. She did not receive her shot of Humira on Monnday because
she was told she couldn't get it while being on antibiotics. Her
recent baseline has been about 3 BM's a day without blood in
stool but since missing her shot of Humira she has had on
average
about 6 bloody bowel movements a day.
She denies any shortness of breath, cough, dysuria, joint pains
or joint swelling. She had a mild headache 2 days ago but none
since. She denies any dizziness, photophobia, blurry vision. She
was recently at ___ at the ___ and reports
sunburn and peeling / itchy skin in shoulder and back related to
that. This was before she had started taking the doxycycline.
She
denies any mosquito bites or ticks / tick bites. She denies any
known sick contacts.
She reports history of Benign Neutropenia for which she is
followed by a hematologist at ___. Her most
recent labs are notable for normal white count and neutrophils.
She denies previous history of drug reaction similar to current
presentation. Of the 3 antibiotics started recently, she knows
she has taken Keflex without issue before but doesn't think
she's
ever taken Bactrim before.
ROS: Pertinent positives and negatives as noted in the HPI. All
other systems were reviewed and are negative.
Past Medical History:
PAST MEDICAL/SURGICAL HISTORY:
Benign Neutropenia
Crohn's disease
Psoriasis
Social History:
___
Family History:
FAMILY HISTORY: Reviewed and found to be not relevant to this
illness/reason for hospitalization.
Physical Exam:
DISCHARGE EXAM:
VITALS: Afebrile and vital signs stable (see eFlowsheet)
GENERAL: Alert and in no apparent distress
EYES: Anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Heart regular, no murmur
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 fullness or tenderness to palpation
MSK: Neck supple, moves all extremities, strength grossly full
and symmetric bilaterally in all limbs. However R arm flexion at
elbow limited to pain. With dressing taken down, on the
antecubital fossa there is surrounding 2 cm patch of erythema
around a 1 cm packed wound with scant persistent yellow
drainage.
Proximal suture intact. The erythema is significantly reduced
from admission and retreated from the marked borders, as well as
no edema/induration
PSYCH: pleasant, appropriate affect
NEUROLOGIC:
MENTATION: alert and cooperative. Oriented to person and place
and time.
Pertinent Results:
___ Imaging US EXTREMITY LIMITED SO
IMPRESSION:
Subcutaneous edema and hyperemia without a drainable fluid
collection.
================
___ Pathology Tissue: SKIN, LEVELS X2
Report not finalized.
Assigned Pathologist ___, MD
___ in only.
PATHOLOGY # ___
SKIN, LEVELS X2
================
COMPLETE BLOOD COUNT WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD
Plt Ct
___ 07:40 2.1* 4.05 7.8* 27.0* 67* 19.3* 28.9* 22.2*
48.1* 148*
___ 08:45 2.7* 3.94 7.4* 25.5* 65* 18.8* 29.0* 19.3*
43.6 54*2
RENAL & GLUCOSE Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 06:50 741 7 0.4 142 4.2 ___
ENZYMES & BILIRUBIN ALT AST LD(LDH) CK(CPK) AlkPhos Amylase
TotBili DirBili
___ 04:00 18 25 54 <0.2
HIV SEROLOGY HIV Ab
___ 07:25
___ 07:25 AnaplasmaPhagocytophilum DNA, Qualitative
(see report): negative
___ 04:00 Parvovirus B19 Antibodies (see report) : IgM
negative
___ 04:00 Anaplasma phagocytophilum (human
granulocytic Ehrlichia agent) IgG/IgM PND
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. PredniSONE 10 mg PO DAILY
2. Humira (adalimumab) 40 mg/0.8 mL subcutaneous EVERY 2 WEEKS
Discharge Medications:
1. Acetaminophen 650 mg PO Q4H:PRN Pain - Mild
RX *acetaminophen 325 mg ___ tablet(s) by mouth every 4 hours
Disp #*60 Tablet Refills:*0
2. Doxycycline Hyclate 100 mg PO Q12H Duration: 5 Days
RX *doxycycline hyclate 100 mg 1 capsule(s) by mouth twice a day
Disp #*10 Capsule Refills:*0
3. PredniSONE 10 mg PO DAILY
4. HELD- Humira (adalimumab) 40 mg/0.8 mL subcutaneous EVERY 2
WEEKS This medication was held. Do not restart Humira until
instructed by Dr. ___
5.Outpatient Lab Work
Draw CBC with diff on ___. D70.9. Results forwarded to Dr.
___: ___
Discharge Disposition:
Home
Discharge Diagnosis:
arm abscess and soft tissue skin infection, cellulitis
pancytopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: US EXTREMITY LIMITED SOFT TISSUE RIGHT
INDICATION: ___ year old woman with Crohn's disease with purulence expressed
from punch biopsy by dermatology of erythematous tender plaque in right
antecubital fossa. Reportedly, no abscess seen on bedside ultrasound in ED on
___. Evaluate for abscess collection in right antecubital fossa
TECHNIQUE: Real-time grayscale an color Doppler imaging was performed of the
area of concern over the right antecubital fossa.
COMPARISON: None.
FINDINGS:
Physical examination was notable for packing material in the region of prior
biopsy over the right antecubital fossa with surrounding erythema.
Grayscale and color Doppler ultrasound evaluation of this region demonstrates
diffuse subcutaneous edema and hyperemia. There is no drainable fluid
collection. There is deep posterior acoustic shadowing in the region of the
packing material.
IMPRESSION:
Subcutaneous edema and hyperemia without a drainable fluid collection.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Fever
Diagnosed with Fever, unspecified
temperature: 100.1
heartrate: 115.0
resprate: 14.0
o2sat: 100.0
sbp: 122.0
dbp: 68.0
level of pain: 3
level of acuity: 3.0 | ___ year old lady with history of crohn's disease on adalimumab
who was admitted with pancytopenia and fevers and rash in
context
of travel to ___ and use of Bactrim for 10 days
prior to admission.
#Soft tissue infection/cellulitis/right antecubital fossa arm
abscess
-Underwent bedside biopsy by dermatology which produced 20 cc
purulence
on drainage. Biopsy prelim shows CoNS and no fungus seen or AFB
at time of discharge.
-initially on IV vancomycin, then transitioned to PO
doxycycline on ___ for 10 day course. This was recommended by
ID consult.
-patient will follow up with dermatology on ___ as scheduled.
#Pancytopenia
-Not suspecting tickborne illness. Anaplasma PCR negative.
Parvovirus IgG positive but IgM negative. Parasite smears
negative. Lyme serology negative.
-Heme onc consult suspect thus far that the cytopenias are
largely due to Bactrim bone marrow suppression She did require
1uPRBC on ___. Subsequent daily H/H demonstrates stability in
counts.
-Patient will have repeat CBC drawn a week from discharge for
follow up with her hematologist, Dr. ___.
#Crohn's disease
-Holding off on adalimumab due to
acute infection and neutropenia. Will remain on home
dose of prednisone on discharge.
-She will need to follow up with her primary GI, Dr. ___, on
discharge, to determine future re-introduction of humira as
outpatient.
Ms. ___ is clinically stable for
discharge today. The total time spent today on discharge
planning, counseling and coordination of care today was 35
minutes. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
latex / aspirin
Attending: ___
Chief Complaint:
Dysarthria, unsteady gait
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI:
Mr. ___ is a ___ yo man with hx multiple vascular risk factors
including afib on Coumadin who presents from ___ with
RLE weakness, found to have IPH.
Mr. ___ was watching the football game, and thinks he was last
normal between 1800 and ___. At one point during the game he
stood to walk across the room but almost fell. He was able to
hold onto nearby objects to keep himself from falling. He noted
that he was unable to move his RLE. He states he had no movement
of the limb. He waited between 1 and 2 hours, and then noted he
had significantly more movement in the RLE and was able to walk.
He then presented to ___.
On arrival to ___, his BP was 205/86, which improved
after labetalol 10 mg IV to 120s. He was also given NS at
100/hr.
NCHCT showed IPH and he was transferred to ___ because there
was no neurosurgery available at that hospital.
Of note, on ___, metoprolol XL 25 mg daily was stopped by
PCP
due to pt reported hypotension with HD.
Past Medical History:
- ESRD on HD (___)
- Basal Cell Cancer
- Right Carotid Endarterectomy
- Paroxysmal Atrial Fibrillation, off Coumadin
- DMII
- GERD
- Hypertension
- Hyperlipidemia
- TIA
Social History:
___
Family History:
Mother with hypertension. Father with CAD and MI at age ___.
Physical Exam:
Physical Exam:
VS: T 97.9, HR 75, BP 125/69, RR 16, SpO2 96% RA
General: Sitting up in chair in NAD, appears stated age.
Lungs: breathing comfortably in room air
CV: well-perfused, irregularly irregular rhythm
Resp: Breathing comfortably in room air
Abd: non-distended
Extremities: Brachiocephalic fistula in L forearm; extremities
warm, well-perfused
Neuro:
MS: Awake, alert, oriented to person, place with prompting, date
(looks at wall calendar) and year (unassisted). He has trouble
stating why he is in the hospital. Able to name his 3 sons and
his
home address. Speech is fluent.
CN: PERRL, 3>2 bl; no gaze restriction, no nystagmus, subtle R
ptosis. Tongue protrudes midline. Smile symmetric.
Motor:
RUE: Delt 5, tric 5, bi 5, WE 5, FE ___ FF 5
RLE: IP 5, ham 5, quad 5, TA 5, gastroc 5
LUE: Delt 5, tric 5, bi 5, WE 5, FE ___ FF 5
LLE: IP 5, ham 5, quad 5, TA 5, gastroc 5
Sensory: Grossly intact to light to touch in all extremities.
Reflexes: R Biceps 2, BR trace. L Biceps difficult to assess ___
fistula, L BR 2. B/L patellae and Achilles trace to none. R toe
mute, L
toe up.
Pertinent Results:
___ 06:20AM ALT(SGPT)-20 AST(SGOT)-19 ALK PHOS-80 TOT
BILI-0.9
___ 06:20AM ALBUMIN-4.4 CALCIUM-10.1 PHOSPHATE-5.7*
MAGNESIUM-2.3
___ 06:20AM WBC-6.9 RBC-3.93* HGB-12.3* HCT-39.0* MCV-99*
MCH-31.3 MCHC-31.5* RDW-17.8* RDWSD-65.1*
___ 06:20AM ___ PTT-31.7 ___
___ 11:52PM cTropnT-0.01
___ 11:52PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 11:52PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 11:52PM WBC-7.3 RBC-3.92*# HGB-12.1*# HCT-38.4*#
MCV-98 MCH-30.9 MCHC-31.5* RDW-17.8* RDWSD-64.6*
___ 11:52PM NEUTS-72.4* LYMPHS-17.4* MONOS-7.9 EOS-1.0
BASOS-0.5 IM ___ AbsNeut-5.28 AbsLymp-1.27 AbsMono-0.58
AbsEos-0.07 AbsBaso-0.04
___ 11:52PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-30*
GLUCOSE-150* KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.5*
LEUK-NEG
___ 05:52AM BLOOD ___ PTT-24.4* ___
___ 12:55PM BLOOD Glucose-126* UreaN-42* Creat-7.1*# Na-141
K-4.5 Cl-94* HCO3-27 AnGap-20*
___ 05:52AM BLOOD Glucose-117* UreaN-50* Creat-7.8* Na-139
K-4.0 Cl-94* HCO3-26 AnGap-19*
___ 07:00AM BLOOD Glucose-127* UreaN-51* Creat-8.0* Na-140
K-4.0 Cl-96 HCO3-25 AnGap-19*
___ 07:00AM BLOOD Calcium-10.2 Phos-4.9* Mg-2.1
___ 12:55PM BLOOD WBC-11.7* RBC-3.52* Hgb-11.2* Hct-35.1*
MCV-100* MCH-31.8 MCHC-31.9* RDW-17.9* RDWSD-64.6* Plt Ct-91*
___ 12:55PM BLOOD Neuts-85.9* Lymphs-6.9* Monos-6.2
Eos-0.3* Baso-0.1 Im ___ AbsNeut-10.03*# AbsLymp-0.80*
AbsMono-0.72 AbsEos-0.03* AbsBaso-0.01
___ 07:00AM BLOOD Glucose-127* UreaN-51* Creat-8.0* Na-140
K-4.0 Cl-96 HCO3-25 AnGap-19*
___ 12:26AM URINE Blood-SM* Nitrite-POS* Protein-100*
Glucose-150* Ketone-TR* Bilirub-NEG Urobiln-NEG pH-8.0 Leuks-LG*
___: Urine culture pending
IMAGING:
CT head (OSH) ___: significant for L putamen hemorrahge
CXR ___: no official report available; appears negative for
consolidation or pulmonary edema
MRI Head w/o contrast ___:
IMPRESSION:
1. Unchanged acute left putaminal hematoma, measuring up to 1.4
cm allowing
for differences in imaging modalities. No definite underlying
putaminal
lesion allowing for lack of intravenous contrast.
2. Findings compatible with an old right parietal infarct with
associated
volume loss and gliosis.
3. Confluent white matter chronic small vessel ischemic disease
given the
patient's age
___. Parenchymal involutional changes, likely age-related.
MRI Head w/ and w/o contrast ___:
IMPRESSION:
Hemorrhage centered on left basal ganglia, stable, mild edema.
There is mild hyperemia, typical of early subacute hemorrhage,
no evidence of underlying mass or vascular malformation.
Consider follow-up imaging when hemorrhage resolves, if
indicated.
Chronic infarcts. Severe chronic small vessel ischemic changes.
Advanced
generalized brain parenchymal atrophy.
Fistulogram ___:
IMPRESSION:
Successful balloon angioplasty of mild in stent stenosis due to
intimal
hyperplasia, with no residual stenosis seen post angioplasty.
RECOMMENDATION(S): The fistula may be used for dialysis
immediately.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tamsulosin 0.4 mg PO DAILY
2. Atorvastatin 10 mg PO DAILY
3. Warfarin 5 mg PO DAILY
4. Amiodarone 200 mg PO DAILY
5. Calcitriol 0.5 mcg PO DAILY
6. Calcium Acetate 1334 mg PO TID W/MEALS
7. FoLIC Acid 1 mg PO DAILY
8. sevelamer CARBONATE 800 mg PO TID W/MEALS
9. Viagra (sildenafil) 100 mg oral PRN
Discharge Medications:
1. amLODIPine 5 mg PO DAILY
Take ___ hrs after dialysis on dialysis days.
2. Sulfameth/Trimethoprim DS 1 TAB PO Q24H Duration: 5 Days
To end ___. Give after dialysis on dialysis days.
3. Warfarin 2.5 mg PO Q24H
4. Amiodarone 200 mg PO DAILY
5. Atorvastatin 10 mg PO DAILY
6. Calcitriol 0.5 mcg PO DAILY
7. Calcium Acetate 1334 mg PO TID W/MEALS
8. FoLIC Acid 1 mg PO DAILY
9. sevelamer CARBONATE 800 mg PO TID W/MEALS
10. Tamsulosin 0.4 mg PO DAILY
11. Viagra (sildenafil) 100 mg oral PRN Sexual activity
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Left putamen hemorrhagic stroke
Urinary tract infection
ESRD
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with L putamen IPH, ESRD on HD// Eval for
underlying lesion, microbleeds
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique were then
obtained.
COMPARISON CT head without contrast ___.
FINDINGS:
No significant change in size of the acute left putaminal hematoma, measuring
up to 1.4 cm. There is associated diffusion abnormality and susceptibility on
gradient echo imaging compatible with blood products. There is no definite
underlying putaminal lesion allowing for lack of intravenous contrast. No new
hemorrhage is identified.
Right parietal volume loss and gliosis likely represents sequela of an old
infarct. No evidence of mass effect or midline shift.
Confluent subcortical, deep and periventricular white matter T2/FLAIR
hyperintensity is compatible with chronic small vessel ischemic disease given
the patient's age.
The major intracranial vascular flow voids are maintained. Prominence of
ventricles and cerebral sulci are compatible with age related involutional
changes. The paranasal sinuses, mastoid air cells and orbits are normal.
There is an incompletely evaluated ovoid subcutaneous 1.4 cm T1 hypointense
focus at the posterior midline neck, which is favored to represent a sebaceous
cyst.
IMPRESSION:
1. Unchanged acute left putaminal hematoma, measuring up to 1.4 cm allowing
for differences in imaging modalities. No definite underlying putaminal
lesion allowing for lack of intravenous contrast.
2. Findings compatible with an old right parietal infarct with associated
volume loss and gliosis.
3. Confluent white matter chronic small vessel ischemic disease given the
patient's age
___. Parenchymal involutional changes, likely age-related.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with L putamen hemorrhage// please perform MPRAGE
sequence to evaluate for ?enhancing mass vs. AVM
TECHNIQUE: Sagittal and axial T1 weighted imaging were performed. After
administration of 8 mL of Gadavist intravenous contrast, axial imaging was
performed with gradient echo, FLAIR, diffusion, and T1 technique. Sagittal
MPRAGE imaging was performed and re-formatted in axial and coronal
orientations.
COMPARISON: MRI brain ___ 1144 a.m., head CT ___.
FINDINGS:
Left putamen, adjacent corona radiata acute hemorrhage is again noted with
marked blooming artifact on the gradient echo sequence measuring 10 x 13 mm in
the axial plane. There is mild to moderate surrounding vasogenic edema.
There is surrounding hyperemia, but no obvious underlying mass or vascular
malformation.
Chronic infarct with resultant cystic encephalomalacia involving the right
temporal occipital area.
Hemorrhage products limited usefulness of diffusion-weighted images in the
area of acute hemorrhage. There are no other areas of restricted diffusion to
suggest an acute ischemic infarct. There is large chronic infarct involving
posterior right temporal and adjacent occipital lobe, stable small cortical
infarct right middle frontal gyrus.
Advanced generalized cerebral atrophy with ex vacuo dilatation of the
ventricles. Periventricular T2 and FLAIR hyperintense changes are most likely
secondary to severe small vessel disease. Nonenhancing sebaceous cyst in the
neck subcutaneous soft tissue measuring 13 x 11 mm in the sagittal plane. The
pituitary gland appears normal. The craniocervical junction appears normal.
Absent right vertebral artery flow void, may be from slow flow or occlusion.
There is little flow within right vertebral artery on MP rage images. The
intracranial arteries demonstrate normal T2 flow voids. Mild opacification of
the dependent mastoid air cells. Minimal mucosal thickening involving the
paranasal sinuses. The orbits appear normal.
IMPRESSION:
Hemorrhage centered on left basal ganglia, stable, mild edema. There is mild
hyperemia, typical of early subacute hemorrhage, no evidence of underlying
mass or vascular malformation. Consider follow-up imaging when hemorrhage
resolves, if indicated.
Chronic infarcts. Severe chronic small vessel ischemic changes. Advanced
generalized brain parenchymal atrophy.
Radiology Report
INDICATION: ___ year old man with ESRD on HD admitted for L putamen stroke.//
L brachiocephalic fistulogram- assess for patency due to difficult cannulation
COMPARISON: None.
TECHNIQUE: OPERATORS: Dr. ___ and
Dr. ___ radiologist performed the procedure. Dr. ___
___ supervised the trainee during the key components of the procedure
and has reviewed and agrees with the trainee's findings.
ANESTHESIA: Moderate sedation was provided by administrating divided doses of
37.5mcg of fentanyl and 0 mg of midazolam throughout the total intra-service
time of 55 minutes during which the patient's hemodynamic parameters were
continuously monitored by an independent trained radiology nurse. 1% lidocaine
was injected in the skin and subcutaneous tissues overlying the access site.
MEDICATIONS: None.
CONTRAST: 36 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 6.2 min, 11 mGy
PROCEDURE:
1. Left upper extremity brachiocephalic fistulagram.
2. Axillary, subclavian and super vena cava venography.
3. Balloon angioplasty of the stent complex.
PROCEDURE DETAILS:
Written informed consent was obtained from the patient outlining the risks,
benefits and alternatives to the procedure. The patient was then brought to
the angiography suite and placed supine on the image table with the left upper
extremity abducted and stabilized.
Clinical examination demonstrated a left upper extremity fistula with a good
thrill. Further evaluation by targeted ultrasound demonstrated patency of the
fistula, with good flow. The left upper extremity was prepped and draped in
the usual sterile fashion. A preprocedure timeout and huddle was performed as
per ___ protocol.
Using ultrasound and fluoroscopy, the arterial inflow and outflow stent levels
were identified and the skin was marked with a skin marker. Antegrade
(directed towards the venous outflow) access into the fistula was obtained
using a 21G micropuncture needle. An 0.018 wire was then advanced easily into
the outflow vein under fluoroscopic guidance. A 4.5F micropuncture sheath was
advanced. The inner piece of the sheath and Nitinol wire were removed.
Gentle injection of dilute contrast confirmed intravascular positioning. DSA
was performed, with the fistula noted to be patent, however there was mild
intimal hyperplasia resulting in mild stenosis within the stent complex.
Venography was then performed centrally, demonstrating patency of the axillary
vein, subclavian vein, and superior vena cava. A ___ wire was advanced
through the micropuncture sheath. Exchange was made for a short 7 ___
sheath which was placed over the wire. A 9 mm x 4 cm Conquest balloon was
advanced over the wire. Angioplasty was performed of the proximal aspect of
the stent complex. The balloon was left inflated and DSA was performed,
demonstrating patency of the arterial inflow, without stenosis. Subsequently,
balloon angioplasty was performed progressively distally throughout the stent
complex with the 9 mm balloon, in overlapping fashion to include the entire
stent construct. Completion DSA in antegrade fashion through the 7 ___
sheath demonstrated near complete resolution of the initially noted intimal
hyperplasia with no residual stenosis.
The sheath was then removed and gentle manual pressure was held to assure
hemostasis. The access site was bandaged in sterile fashion. Clinical
examination revealed a satisfactory thrill along the length of the fistula.
There were no immediate complications.
FINDINGS:
1. Patent brachiocephalic fistula with stent complex near the arterial
anastomosis which had mild in stent stenosis due to intimal hyperplasia.
2. Successful balloon angioplasty of the stent construct, with resolution of
in stent stenosis.
3. Satisfactory appearance of the arterial anastomosis. No central venous
stenosis.
IMPRESSION:
Successful balloon angioplasty of mild in stent stenosis due to intimal
hyperplasia, with no residual stenosis seen post angioplasty.
RECOMMENDATION(S): The fistula may be used for dialysis immediately.
Case was discussed with Dr. ___ by telephone on ___ at 10:55 AM.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: ICH, Transfer
Diagnosed with Anesthesia of skin
temperature: 98.4
heartrate: 89.0
resprate: 18.0
o2sat: 98.0
sbp: 120.0
dbp: 70.0
level of pain: 0
level of acuity: 1.0 | Mr. ___ is a ___ yo man with hx multiple vascular risk factors
including afib on Coumadin who presents from ___ with
RLE weakness, found to have L putamen IPH. His exam is notable
for asterixis, inattention, frontal release signs, mild anomia,
R facial droop and mild weakness of the RLE. NCHCT notable for
severe global atrophy, chronic R inferior division R MCA
infarct, vascular calcifications and small (0.6 cc) acute L
putamen IPH. Etiology likely hypertensive given SBP to 200s on
presentation to OSH.
MRI confirmed acute hemorrhage of the L putamen. His symptoms of
weakness resolved completely by the time of discharge. In
consultation with our nephrology colleagues, we controlled his
BP initially on labetolol and transitioned him to once daily
amlodipine prior to discharge. Given his multiple risk factors
for having another stroke (HTN with cerebrovascular disease on
imaging), A-fib, and diabetes, we restarted his Coumadin prior
to discharge with an Aspirin bridge. He was also diagnosed with
a UTI and was discharged to complete a 7-day course of oral
Bactrim.
Transitional issues:
- BP control: He is being discharged on Amlodipine 5mg PO daily.
He should wait until several (___) hours after dialysis to take
his amlodipine on HD days, and ideally try to take as close to
the same time every day as possible. Monitor carefully for
post-dialysis hypotension as this was an issue previously, and
he may require further adjustments of his regimen.
- Anti-coagulation: He is being discharged on Coumadin 2.5mg PO
daily, with an INR goal of ___. This is half his usual dose of
5mg PO daily while he is on Bactrim for his UTI. His Coumadin
will need to be increased again after this course is completed.
He is also taking Aspirin 81mg daily while restarting Coumadin.
This should be discontinued once his Coumadin is therapeutic.
- UTI: He is being discharged on a 7-day course of PO Bactrim
DS, beginning ___, to finish on ___.
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (x) Yes - () No
2. DVT Prophylaxis administered? (x) Yes - () No
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 (verbally or
written)? (x) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (x) Yes - () No
35 minutes were spent on discharge. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
allopurinol / Percocet / doxycycline / Zestril / amoxicillin
Attending: ___
Chief Complaint:
Fever, chills
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ w/ PKD s/p LRRT ___ on tacro/MMF/prednisone, prostate
cancer, htn/hl, presents from ___ with fever/chills, and
shakes.
Pt is from ___, and get his care at ___ normally.
Pt is in town to visit this grandson.
Of note, pt was admitted to ___ in ___ for e
coli urosepsis. He completex ___ x 3 weeks - he did not remember
the name of the ___.
On morning of admission (___), pt reports onset of fever,
chills and rigor. He also noted urinary frequency w/o dysuria or
hematuria. He had clear emesis x 1. He otherwise denies cough,
diarrhea, new skin rash, or abdominal pain.
He presented initially to ___. He was noted to have T
100.8 HR 99, BP 132/84 RR 18 O2 97%RA.
At ___, lactate was 2.2, WBC 3.8. UA was +leuks, neg
nitrite. Tbili 1.36 Per record, UCx and blood cx was drawn.
CTU reportedly showed non-obstructing stone, transplanted
kidney did not show hydronephrosis.
Pt received vanc 1g, zosyn 2.25mg prior to transfer to ___.
In the ___ ED, vitals were: 100.7 ___ 12 94% RA
Labs were notable for: Cr 2.5 (baseline unknown), WBC 2.4 1 10%
bands, Hgb 12.3, lactate 1.3
Patient was given:
___ 00:29 IVF 1000 mL NS 1000 mL
Transplanted kidney ultrasound: Normal on prelim.
On the floor, pt reports feeling better. Though he reports that
he had loose stool x 1 since being in the hospital - he himself
attributed it to ___. On arrival to floor, nursing staff
received report that BCx grew GNB ___.
Past Medical History:
-Recent hospitalization for e. coli sepsis ___ UTI (___)
-PKD s/p LRRT ___: on immunosuppression. Baseline Cr 1.5-2.1
-HTN
-HLD
-GERD
-Gout
-Pre-diabetes
Social History:
___
Family History:
Daughters both with ADPKD
Physical Exam:
ADMISSION
VS: 100.0 89 104/56 15 98% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: Supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, no suprapubic
tenderess bowel sounds present, no organomegaly, no rebound or
guarding
Back: no CVA tenderness.
GU: No foley
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation, 2+ reflexes bilaterally, gait deferred
DISCHARGE:
VS: 97.4, 122/66, 79, 18, 95% on RA
I/O: ___, x2BM
General: NAD
HEENT: Sclera anicteric, EOMI, PERRL, MMM, OP clear
Neck: Supple, no LAD
CV: RRR, (+) S1 + S2, no murmurs/rubs/gallops
Lungs: CTAB b/l, no wheezes, rales, rhonchi
Abdomen: Soft, non-tender, non-distended, no suprapubic
tenderess (+)BS, (+) tip of spleen detected below coastal
margin, no rebound or guarding
BACK: no CVA tenderness.
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: AAOx3
Pertinent Results:
ADMISSION:
___ 11:55PM WBC-2.4* RBC-4.19* HGB-12.3* HCT-36.5* MCV-87
MCH-29.4 MCHC-33.7 RDW-14.0 RDWSD-44.1
___ 11:55PM NEUTS-60 BANDS-10* LYMPHS-11* MONOS-3* EOS-1
BASOS-0 ATYPS-1* METAS-4* MYELOS-10* AbsNeut-1.68 AbsLymp-0.29*
AbsMono-0.07* AbsEos-0.02* AbsBaso-0.00*
___ 11:55PM GLUCOSE-105* UREA N-32* CREAT-2.5* SODIUM-135
POTASSIUM-4.7 CHLORIDE-107 TOTAL CO2-19* ANION GAP-14
___ 12:14AM LACTATE-1.3
___ 06:28AM WBC-1.7* RBC-3.81* HGB-11.2* HCT-33.7* MCV-89
MCH-29.4 MCHC-33.2 RDW-14.0 RDWSD-45.1
___ 06:28AM tacroFK-8.7
___ 06:28AM CALCIUM-8.0* PHOSPHATE-2.3* MAGNESIUM-1.1*
___ 06:28AM HAPTOGLOB-133
___ 06:28AM GLUCOSE-130* UREA N-34* CREAT-2.5* SODIUM-135
POTASSIUM-4.6 CHLORIDE-111* TOTAL CO2-18* ANION GAP-11
___ 06:28AM ALT(SGPT)-20 AST(SGOT)-23 LD(LDH)-207 ALK
PHOS-64 TOT BILI-1.0
___ 06:28AM LIPASE-18
___ 08:30PM ___
INTERIM:
___ 06:10AM BLOOD Glucose-112* UreaN-25* Creat-2.0* Na-135
K-4.7 Cl-107 HCO3-19* AnGap-14
___ 02:50AM BLOOD ALT-14 AST-18 AlkPhos-60 TotBili-0.8
DISCHARGE:
___ 05:40AM BLOOD WBC-5.6# RBC-3.48* Hgb-9.9* Hct-31.0*
MCV-89 MCH-28.4 MCHC-31.9* RDW-14.4 RDWSD-46.5* Plt ___
___ 05:40AM BLOOD ___ PTT-26.7 ___
___ 05:40AM BLOOD Glucose-146* UreaN-21* Creat-1.5* Na-138
K-5.1 Cl-103 HCO3-27 AnGap-13
___ 05:45AM BLOOD ALT-17 AST-19 AlkPhos-161* TotBili-0.8
___ 05:40AM BLOOD Calcium-9.0 Phos-3.4 Mg-1.6
___ 05:40AM BLOOD tacroFK-6.7
IMAGING:
-Renal transplant U/S (___): IMPRESSION: Normal renal
transplant ultrasound.
-Abd U/S (___): IMPRESSION:
1. The patient is status post cholecystectomy.
2. Splenomegaly.
3. No sonographic evidence of abscess or other intraabdominal
infectious
source.
-CXR (___): IMPRESSION: There no prior chest radiographs
available for review. Lungs clear. Heart size normal. No
pleural abnormality.
-MRI abdomen w/o contrast (___): IMPRESSION:
1. Innumerable cysts in the liver and left kidney, as well as
several small cysts in the pancreas, in keeping with the history
of polycystic kidney disease. Many of them have hemorrhagic or
proteinaceous material, though none have overtly concerning
features or evidence of an obvious infection on this limited
noncontrast exam.
2. Status post right nephrectomy. No abnormality in the
surgical bed.
3. Splenomegaly.
-MRI Head w/o contrast (___): IMPRESSION:
1. No evidence for parenchymal abnormalities on noncontrast MRI.
No
extra-axial collection. No evidence for meningitis on FLAIR
images; however, CSF studies would be more sensitive for
meningitis.
2. Paranasal sinus abnormalities and trace fluid in bilateral
mastoid air
cells may be secondary to prolonged supine positioning in the
inpatient
setting. However, please correlate clinically whether there may
be associated infectious symptoms.
-CXR (___): IMPRESSION: There is a new left-sided PICC line
with tip in the mid SVC. There is no pneumothorax. The lungs
are clear.
-TTE (___): IMPRESSION: Normal biventricular cavity size and
systolic function. No 2D echocardiographic evidence of
endocarditis.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Tacrolimus 4 mg PO QAM
2. Tacrolimus 3 mg PO QPM
3. Mycophenolate Mofetil 750 mg PO BID
4. PredniSONE 5 mg PO DAILY
5. NexIUM (esomeprazole magnesium) 40 mg oral BID
6. Losartan Potassium 50 mg PO QHS
7. Metoprolol Tartrate 12.5 mg PO BID
8. Colchicine 0.6 mg PO DAILY
9. Januvia (sitaGLIPtin) 25 mg oral DAILY
10. ezetimibe-simvastatin ___ mg oral DAILY
11. Tamsulosin 0.4 mg PO QHS
12. Cinacalcet 30 mg PO DAILY
13. Aspirin 81 mg PO DAILY
14. Calcium 500 + D (calcium carbonate-vitamin D3) 500
mg(1,250mg) -200 unit oral DAILY
15. Sulfameth/Trimethoprim SS 1 TAB PO 3X/WEEK (___)
16. Zolpidem Tartrate 10 mg PO QHS
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Colchicine 0.6 mg PO DAILY
3. Metoprolol Tartrate 12.5 mg PO BID
4. PredniSONE 5 mg PO DAILY
5. Tamsulosin 0.4 mg PO QHS
6. Atovaquone Suspension 1500 mg PO DAILY
RX *atovaquone 750 mg/5 mL 1500 mg by mouth daily Refills:*0
7. CeftriaXONE 2 gm IV Q24H
RX *ceftriaxone in dextrose,iso-os 2 gram/50 mL 2 gm IV q24h
Disp #*23 Intravenous Bag Refills:*0
8. Zolpidem Tartrate 10 mg PO QHS
9. ezetimibe-simvastatin ___ mg oral DAILY
10. Januvia (sitaGLIPtin) 25 mg oral DAILY
11. Losartan Potassium 50 mg PO QHS
12. NexIUM (esomeprazole magnesium) 40 mg oral BID
13. Mycophenolate Mofetil 500 mg PO BID
RX *mycophenolate mofetil 500 mg one tablet(s) by mouth twice a
day Disp #*60 Tablet Refills:*0
14. Tacrolimus 1.5 mg PO Q12H
RX *tacrolimus 1 mg one capsule(s) by mouth daily Disp #*60
Capsule Refills:*0
RX *tacrolimus 0.5 mg one capsule(s) by mouth twice a day Disp
#*60 Capsule Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
PRIMARY DIAGNOSES:
Sepsis
Gram-negative rod bacteremia
Acute kidney injury
Neutropenia
SECONDARY DIAGNOSES:
Autosomal dominant polycystic kidney disease
Status-post kidney transplant (___)
Hypertension
Hyperlipidemia
Prostate cancer
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION:
___ year old man with 49cm left arm DL power PICC. ___ ___ // 49cm left
arm DL power PICC. ___ ___ Contact name: ___: ___
TECHNIQUE: Chest single view
COMPARISON: ___.
IMPRESSION:
There is a new left-sided PICC line with tip in the mid SVC. There is no
pneumothorax. The lungs are clear.
Radiology Report
EXAMINATION: RENAL TRANSPLANT U.S.
INDICATION: History: ___ with report of kidney stone, ? normal flow and
appearance of transplanted kidney // ? abnormality in transplanted kidney
TECHNIQUE: Grey scale as well as color and spectral Doppler ultrasound images
of the renal transplant were obtained.
COMPARISON: CT from ___
FINDINGS:
The right iliac fossa transplant renal morphology is normal. Specifically,
the cortex is of normal thickness and echogenicity, pyramids are normal, there
is no urothelial thickening, and renal sinus fat is normal. There is no
hydronephrosis and no perinephric fluid collection.
The resistive index of intrarenal arteries ranges from 0.67 to 0.74, within
the normal range. The main renal artery shows a normal waveform, with prompt
systolic upstroke and continuous antegrade diastolic flow, with peak systolic
velocity of 60 cm/second. Vascularity is symmetric throughout transplant. The
transplant renal vein is patent and shows normal waveform.
IMPRESSION:
Normal renal transplant ultrasound.
Radiology Report
EXAMINATION: ABDOMEN US (COMPLETE STUDY)
INDICATION: ___ year old man with hx. of renal transplant in ___ presenting
with sepsis with ___ blood culture bottles positive for GNRs. // Please
evaluate for intraabdominal process. Please evaluate for acute cholecystitis.
TECHNIQUE: Grey scale and color Doppler ultrasound images of the abdomen were
obtained.
COMPARISON: CT urogram dated ___
FINDINGS:
LIVER: The hepatic parenchyma appears within normal limits. The contour of the
liver is smooth. Innumerable anechoic cysts are seen throughout the liver
parenchyma. The main portal vein is patent with hepatopetal flow. There is no
ascites.
BILE DUCTS: The CBD measures 6 mm proximally and 8 mm more distally, most
likely related to prior cholecystectomy. No definite mass or stone is
identified.
GALLBLADDER: The patient is status post cholecystectomy.
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: The spleen is enlarged measuring 16 cm. A small adjacent splenule is
noted measuring 1.3 x 1.5 x 1.3 cm.
KIDNEYS: The right kidney is surgically absent. The left kidney measures 22
cm. Innumerable cysts are seen within the left kidney, consistent with the
patient's diagnosis of polycystic kidney disease.
RETROPERITONEUM: Visualized portions of aorta and IVC are within normal
limits.
IMPRESSION:
1. The patient is status post cholecystectomy.
2. Splenomegaly.
3. No sonographic evidence of abscess or other intraabdominal infectious
source.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old man with septic shock, unclear source // Eval for
cardiopulmonary process Eval for cardiopulmonary process
IMPRESSION:
There no prior chest radiographs available for review. Lungs clear. Heart
size normal. No pleural abnormality.
Radiology Report
EXAMINATION: MRI of the Abdomen
INDICATION: History of polycystic kidney disease, presenting with gram
negative bacteremia of unclear source. Evaluate for liver or kidney
infection.
TECHNIQUE: T1- and T2-weighted multiplanar images of the abdomen were
acquired in a 1.5 T magnet.
Intravenous contrast: None, given the patient's acute kidney injury.
COMPARISON: Abdominal ultrasound from ___. CT of the abdomen and
pelvis from ___.
FINDINGS:
Lower Thorax: There are small bilateral pleural effusions. Within the
limitations of MRI, the lung bases are otherwise clear. The base of the heart
is normal in size. There is no pericardial effusion.
Liver: The liver is normal in shape and contour without morphologic features
of cirrhosis. There are innumerable cysts in the liver, some of which are
intrinsically hyperintense on the precontrast T1 weighted images, suggesting
proteinaceous or hemorrhagic contents. Within the limitations of this
noncontrast exam, none have overtly concerning features. The largest cyst in
the right lobe is 39 x 38 mm (15, 21), and has layering proteinaceous debris
or hemorrhage. The largest cyst in the left lobe is 45 x 46 mm (15, 22), and
is simple. There is no obvious evidence of infection, such as a thickened rim
or surrounding parenchyma abnormalities, in any of the cysts.
Biliary: There is no intrahepatic biliary duct dilation. The common bile duct
measures 7 mm, which is mildly prominent for a patient of this age. It tapers
smoothly to the ampulla without evidence of a mass or choledocholithiasis.
The gallbladder is not visualized, and presumed to be surgically absent.
Pancreas: The pancreatic parenchyma is normal in signal there is no duct
dilation or solid mass. A few tiny subcentimeter cysts are noted.
Spleen: The spleen is enlarged, measuring 16.6 cm. There are no focal
lesions.
Adrenal Glands: The bilateral adrenal glands are normal.
Kidneys: The right kidney is surgically absent. There is no abnormality in
the gallbladder fossa. The left kidney is enlarged, and completely replaced
by cysts. No normal parenchyma is identified. The majority of the cysts have
some intrinsic hyperintensity on the precontrast T1 weighted images,
suggesting proteinaceous or hemorrhagic debris. The debris is layering within
many of the cysts. There are no obviously concerning features, though the
exam is limited by the lack of intravenous contrast. None are significantly
thick rimmed or have the appearance of an infected cyst. Note, the
transplanted kidney is not included in the field of view on this abdominal
MRI.
Gastrointestinal Tract: The stomach and small bowel are normal in course and
caliber. There is no evidence of obstruction. The imaged portions of the
large bowel are normal. There is no ascites.
Lymph Nodes: There is no periportal, retroperitoneal, or mesenteric
lymphadenopathy.
Vasculature: The abdominal aorta is normal in caliber without evidence of an
aneurysm. There is moderate atherosclerotic plaque.
Osseous and Soft Tissue Structures: There are no concerning osseous lesions.
Mild multilevel degenerative changes are noted throughout the spine.
Postsurgical changes are noted in the anterior abdominal wall. There is no
evidence of a hernia or fluid collection. The soft tissues are otherwise
unremarkable.
IMPRESSION:
1. Innumerable cysts in the liver and left kidney, as well as several small
cysts in the pancreas, in keeping with the history of polycystic kidney
disease. Many of them have hemorrhagic or proteinaceous material, though none
have overtly concerning features or evidence of an obvious infection on this
limited noncontrast exam.
2. Status post right nephrectomy. No abnormality in the surgical bed.
3. Splenomegaly.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST PORT
INDICATION: ___ year old man with persistent gram-negative rod bacteremia and
headache concerning for intracranial process. Evaluate for abscess or other
intracranial process.
TECHNIQUE: Sagittal T1 weighted, and axial T2 weighted, FLAIR, gradient echo,
and diffusion-weighted images of the brain were obtained. Intravenous
contrast was withheld due to poor renal function.
COMPARISON: None.
FINDINGS:
Diffusion weighted and gradient echo images are mildly limited by motion
artifact. T2 weighted and FLAIR images were successfully repeated with motion
reducing technique.
There is no evidence for edema, mass effect, abnormal diffusion, blood
products, or other signal abnormalities in the brain parenchyma. FLAIR images
demonstrate no signal abnormality in the sulci to suggest meningitis. There
is no extra-axial collection. Ventricles, sulci, and basal cisterns are
normal in size. Cerebellar tonsils are normally positioned. Major
intravascular flow voids are grossly preserved.
There is moderate mucosal thickening and trace aerosolized secretions in the
left maxillary sinus. There is mucosal thickening in left greater than right
ethmoid air cells with complete opacification of the left anterior ethmoid air
cell. There is mild mucosal thickening in the right maxillary and left
sphenoid sinuses. There is trace fluid in bilateral mastoid air cells.
IMPRESSION:
1. No evidence for parenchymal abnormalities on noncontrast MRI. No
extra-axial collection. No evidence for meningitis on FLAIR images; however,
CSF studies would be more sensitive for meningitis.
2. Paranasal sinus abnormalities and trace fluid in bilateral mastoid air
cells may be secondary to prolonged supine positioning in the inpatient
setting. However, please correlate clinically whether there may be associated
infectious symptoms.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever
Diagnosed with Urinary tract infection, site not specified
temperature: 100.7
heartrate: 106.0
resprate: 12.0
o2sat: 94.0
sbp: 91.0
dbp: 51.0
level of pain: 1
level of acuity: 2.0 | ___ PMHx PKD s/p LRRT ___ on tacro/MMF/prednisone, prostate
cancer, HTN/HLD, presenting with sepsis and GNB bacteremia
thought to be ___ infected intraabdominal cyst vs UTI.
# Severe Sepsis: following transfer from OSH, blood cultures at
OSH were notable for ___ bottles with (+) GNR. Initial concern
was for urinary source, given patient's recent admission for E.
coli UTI and bacteremia and concern for increased urinary
frequency. However urinalysis was unrevealing for infection,
given only 1WBC, negative nitrites, and trace leukocytes.
Infectious work-up was initiated, including blood, urine, stool,
and viral studies. He was initially hemodynamically unstable and
received a x1 dose of amikacin and aggressive IVF resuscitation.
With continued IVF, his blood pressure stabilized. Due to
ongoing fevers, he was transitioned from Zosyn to cefepime.
Blood cultures were repeated with fevers and were (+) for GNRs
x3 days, urine culture was negative. Due to persistence of
bacteremia and concern for poor source control, Infectious
Disease was consulted. In the setting of PKD, a MRI abdomen was
performed to assess for infected cysts which was unrevealing.
Due to patient's headaches, an MRI brain was performed which was
negative for intracranial process. An echo was obtained which
showed no vegetation. Following speciation of blood cultures and
improved stability of the patient, he was transitioned from
cefepime to CTX. Blood cultures after ___ were notable for no
growth. A PICC was placed to allow for completion a x4 week
course of antibiotics.
# ___ on CKD in the setting of PKD s/p LRRT (___): Cr 2.5 on
arrival, baseline creatinine 1.5 - 2.1. In addition, patient was
noted to have low urine output. A renal transplant ultrasound
was obtained which was normal. He received aggressive IVF
resuscitation and his MMF was held in the setting of sepsis. His
urine was spun and was notable for mild ATN. CMV was checked and
no viral load was detected. Urine BK was negative. He was
continued on tacrolimus and prednisone for immunosuppression.
Due to leukopenia (discussed below) his Bactrim ppx was held and
he was transitioned to dapsone. His creatinine was trended and
continued to improve; discharged with creatinine of 1.5. His MMF
was restarted day prior to discharge at a dose of 500mg BID;
outpatient provider should ___ as appropriate.
# Leukopenia/Neutropenia: during admission, patient was noted to
be neutropenic. Concern for marrow suppression in the setting of
persistent bacteremia vs EtOH use given patient reported daily
EtOH use vs splenic sequestration given splenomegaly on
exam/imaging vs medication-induced. His home bactrim was held
and he was transitioned to atovaquone for PCP ___. Heme-Onc was
consulted who recommended treatment with G-CSF, with resultant
resolution of his neutropenia. Of note, patient's imaging was
concerning for new splenomegaly; he should be monitored closely
and repeat imaging considered.
# HTN: on admission, his home anti-hypertensives were in setting
of sepsis. They were restarted in the hospital after his sepsis
resolved.
# HLD: he was continued on his home ezetimibe/simvastatin.
# Question of pre-diabetes: he was monitored on the insulin
sliding scale while in house and did not require insulin.
# GERD: he was continued on his home omeprazole
# Gout: his home colchicine was originally held in the setting
of ___ this was restarted prior to discharge
Transitional Issues:
[] D1 of clear blood cultures ___ plan for 4 week course of
CTX 2gm IV q24hr (last day ___
[] Given neutropenia, Bactrim was stopped and patient was
started on Dapsone 1500mg qd for PJP ppx
[] Tacrolimus trough was elevated on admission; discharged on
dose of 1.5mg BID. Plan to recheck level on ___
[] MMF was held on admission ___ sepsis; restarted at dose of
500mg BID, please ___ to home dose if needed (750mg BID)
[] Cinalcet was held ___ hypocalcemia during admission; please
continue to monitor
[] Physical exam and abd MRI notable for splenomegaly (measured
at 16.6 cm, no focal lesions) with previous obtained imaging
reports without mention of splenomegaly, please continue to
monitor
Code: FULL
Contact: ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Motrin / Sulfa (Sulfonamide Antibiotics) / Nsaids / lisinopril /
egg / iodine
Attending: ___.
Chief Complaint:
___ w/ COPD, T2DM, prior cellulitis presents with 2 weeks of
drainage from RLE lesions.
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Two weeks prior to admission, Ms. ___ was in her usual state
and had noticed wide-based blisters developing on her right
lower extremity (RLE). While she was using a washcloth on her
right leg, she noted the removal of skin from a blister with
immediate drainage of clear fluid. Given her body habitus, she
cannot directly visualize her lower extremities. However, she
noted continued leakage based on the wetness on her clothes. She
believes the leakage rate increased over time, and 4 days prior
to admission noted the leakage of milky white fluid from the
lesions. That day, she was seen by her PCP who believed the
lesions to be venous stasis ulcers. She denies fevers and
endorses feeling chilly. On ___ she presented to the
___ ED due to concern about possible cellulitis.
She denies interaction with cats or dogs, any recent trauma,
gardening, and exposure to freshwater.
#Review of Systems:
(+) per HPI and chronic intermittent headache, vision changes,
dyspnea on exertion, periumbilical abdominal pain, constipation.
(-) fever, night sweats, sore throat, cough, shortness of
breath at rest, chest pain, nausea, vomiting, diarrhea,
hematochezia, dysuria.
Past Medical History:
SLEEP APNEA, nonadherent to BIPAP at home due to nosebleeds
Asthma with chronic obstructive pulmonary disease (COPD), on 3L
NC at home
DM (diabetes mellitus), type 2 with neurological complications
ANEMIA
Hypertension, essential
DEPRESSIVE DISORDER
ANXIETY STATES, UNSPEC
VITAMIN D DEFIC, UNSPEC
CROHN'S DISEASE
Fibromyalgia
Cellulitis ___ years ago, hospitalized at ___ for rx)
MRSA ___ (documented at ___)
Social History:
___
Family History:
-Mother: ___, leukemia
-Father: ___, cancer not specified
-Brother: ___, lung cancer with metastases
-Sister: ___ cancer
-Niece: lung cancer
Physical Exam:
==================
EXAM ON ADMISSION
==================
Vitals- T 98.3 HR 90 BP 166/51 RR 18 SaO2 95%(3L)
General: Woman with large body habitus laying in bed.
CV: RRR, mild systolic murmur
Lungs: CTAB
Abdomen: Bowel sounds present, protuberant, nontender
GU: no foley
Ext: Pitting edema throughout lower extremities up to the knee.
RLE: 3 1x1 cm contiguous areas of apparent granulation
tissue w/ serous drainage w/ a single 0.5x0.5 cm area of similar
appearance just proximal. These areas are raised compared to
surrounding skin and tender to palpation. Just medial to these
is a raised, tense lesion that appears as though it could be a
precursor lesion. Surrounding all of these is mild induration,
erythema, and warmth. In addition, there is deeper pigmentation
of the distal extremity along with an area of hypopigmentation
on the medial heel.
LLE: Dry and scaly, with a few isolated areas of deeper
pigmentation.
Neuro: AOx3, responsive to questions and commands, moves all 4
extremities at will. Diminished sensation to light touch on
plantar aspects bilaterally.
Skin: see above
==================
EXAM ON DISCHARGE
==================
Vitals- Tmax 98.7, Tcurr 98.5, HR 80, BP 158/62, RR 20, SaO2
96%(BiPAP)
General: Woman with large body habitus sitting in her power
chair.
CV: RRR, mild systolic murmur
Lungs: CTAB
Abdomen: Bowel sounds present, protuberant, nontender
GU: no foley
Ext: Pitting edema throughout lower extremities up to the knee.
RLE: Under dressing, there are 3 1x1 cm contiguous areas of
apparent granulation tissue (was purulent yesterday) w/ a single
0.5x0.5 cm area of similar appearance just proximal. These areas
are tender to palpation. Interval decrease in the surrounding
induration, erythema, and warmth. In addition, there is deeper
pigmentation of the distal extremity along with an area of
hypopigmentation on the medial heel that is erythematous.
LLE: Dry and scaly, with a few isolated areas of deeper
pigmentation.
Neuro: AOx3, responsive to questions and commands, moves all 4
extremities at will. Diminished sensation to light touch on
plantar aspects bilaterally.
Skin: see above
Pertinent Results:
LABS AT ADMISSION:
___ 01:50PM BLOOD WBC-9.4 RBC-4.02 Hgb-10.9* Hct-36.9
MCV-92 MCH-27.1 MCHC-29.5* RDW-14.2 RDWSD-47.8* Plt ___
___ 01:50PM BLOOD Neuts-71.1* Lymphs-17.0* Monos-6.8
Eos-4.3 Baso-0.4 Im ___ AbsNeut-6.69* AbsLymp-1.60
AbsMono-0.64 AbsEos-0.40 AbsBaso-0.04
___ 01:50PM BLOOD Glucose-134* UreaN-16 Creat-0.9 Na-142
K-4.7 Cl-103 HCO3-32 AnGap-12
___ 01:50PM BLOOD Calcium-10.6* Phos-3.6 Mg-1.8
___ 06:30AM BLOOD CRP-10.2*
___ 02:58PM BLOOD Lactate-1.4
IMAGING:
X-ray right tib/fib ___:
No radiographic evidence for osteomyelitis. Diffuse soft tissue
swelling.
Right lower extremity ultrasound ___:
Extremely limited examination secondary to patient's known right
lower extremity cellulitis. No evidence of deep venous
thrombosis in the right lower extremity veins.
LABS PRIOR TO DISCHARGE:
___ 07:00AM BLOOD WBC-9.7 RBC-3.98 Hgb-10.7* Hct-37.0
MCV-93 MCH-26.9 MCHC-28.9* RDW-14.2 RDWSD-48.2* Plt ___
___ 07:00AM BLOOD Glucose-178* UreaN-11 Creat-0.6 Na-140
K-4.4 Cl-100 HCO3-32 AnGap-12
___ 06:30AM BLOOD Calcium-9.8 Phos-3.5 Mg-1.6
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. irbesartan 150 mg oral BID
2. Montelukast 10 mg PO DAILY
3. Morphine Sulfate ___ 30 mg PO Q8H:PRN pain
4. NPH 33 Units Breakfast
NPH 36 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Potassium Chloride 20 mEq PO BID
6. TraMADOL (Ultram) 50 mg PO TID:PRN pain
7. Baclofen 20 mg PO TID
8. HydrOXYzine 10 mg PO DAILY:PRN very itchy
9. Fluticasone Propionate 110mcg 4 PUFF IH BID
10. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
11. Fluticasone Propionate NASAL 1 SPRY NU BID
12. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea
13. Aspirin 81 mg PO DAILY
14. Ascorbic Acid ___ mg PO DAILY
Discharge Medications:
The Preadmission Medication list is accurate and complete.
1. irbesartan 150 mg oral BID
2. Montelukast 10 mg PO DAILY
3. Morphine Sulfate ___ 30 mg PO Q8H:PRN pain
4. NPH 33 Units Breakfast
NPH 36 Units Bedtime
Insulin SC Sliding Scale using HUM Insulin
5. Potassium Chloride 20 mEq PO BID
6. TraMADOL (Ultram) 50 mg PO TID:PRN pain
7. Baclofen 20 mg PO TID
8. HydrOXYzine 10 mg PO DAILY:PRN very itchy
9. Fluticasone Propionate 110mcg 4 PUFF IH BID
10. Albuterol Inhaler 2 PUFF IH Q4H:PRN dyspnea
11. Fluticasone Propionate NASAL 1 SPRY NU BID
12. Albuterol 0.083% Neb Soln 1 NEB IH Q4H:PRN dyspnea
13. Aspirin 81 mg PO DAILY
14. Ascorbic Acid ___ mg PO DAILY
15. Clindamycin 450 mg PO Q6H Until ___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Cellulitis
Venous stasis dermatitis
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: History: ___ with chronic right lower extremity wounds with
purulent drainage.
TECHNIQUE: Two views of the right tibia and fibula
COMPARISON: None.
FINDINGS:
No acute fracture or focal lytic or sclerotic osseous abnormality is
identified. No cortical destruction or periosteal new bone formation is
visualized. Imaged aspect of the right knee and right ankle demonstrate no
gross dislocation. There is diffuse soft tissue swelling without radiopaque
foreign body or subcutaneous gas.
IMPRESSION:
No radiographic evidence for osteomyelitis. Diffuse soft tissue swelling.
Radiology Report
EXAMINATION: VENOUS DUP EXT UNI (MAP/DVT) RIGHT
INDICATION: ___ year old woman with RLE cellulitis // Evaluate for DVT
TECHNIQUE: Grey scale, color, and spectral Doppler evaluation was performed
on the right lower extremity veins.
COMPARISON: Lower extremity DVT examination from ___.
FINDINGS:
Extremely limited examination secondary to patient's known right lower
extremity cellulitis. There is normal compressibility, flow and augmentation
of the rightcommon femoral, femoral, and popliteal veins. Normal color flow is
demonstrated in the posterior tibial and peroneal veins.
There is normal respiratory variation in the common femoral veins bilaterally.
IMPRESSION:
Extremely limited examination secondary to patient's known right lower
extremity cellulitis. No evidence of deep venous thrombosis in the rightlower
extremity veins.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Wound eval
Diagnosed with Cellulitis of right lower limb
temperature: 97.6
heartrate: 95.0
resprate: 18.0
o2sat: 98.0
sbp: 151.0
dbp: 61.0
level of pain: 5
level of acuity: 3.0 | Ms. ___ is a ___ with T2DM, COPD, and prior cellulitis who
presents with RLE lesions most consistent with cellulitis ___
venous stasis dermatitis. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
referral for abnormal labs
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ with hx of chronic anemia (Hct 30) who p/w fatigue and
palpitations x 3 months. She has also been having nonradiating,
exertional chest pain, ___ in intensity. She went to outpt
provider and was found to have Hct 18 and referred here for
further evaluation. She denies hemoptysis, hematemesis,
hematochezia, melena. She was guiac negative in the ED. She
does however endorse heavy periods, sometimes requiring ___ pads
per day. She denies sob, f/c, night sweats, rash, abd pain.
In the ED, her initial VS 98 80 122/52 15 100%. Labs remarkable
for H/H 4.9/17.5, RDW 21.9, MCV 60, Plat 302, INR 0.8, Cre 3.4
(baseline 1.2), Fe 15 and ferritin 4.1. EKG demonstrates NSR
with no st-t wave abnormality. CXR demonstrates cardiomegaly.
UA was not obtained. She was typed and screened. PIVs were
placed. She was transfuse 2U PRBCs. She was guiac negative.
On arrival to the MICU, her VS were afebrile 74 150/83 200% RA.
REVIEW OF SYSTEMS:
Otherwise negative in detail
Past Medical History:
Chronic anemia
Chronic kidney disease
Social History:
___
Family History:
No family hx of anemia or renal failure
Physical Exam:
Admission exam:
Vitals: 74 150/83 100% RA.
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, JVP not elevated, no LAD
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, otherwise grossly nonfocal
Discharge exam:
AVSS
anicteric
rr, nl rate (occasional PVC)
CTAB
abdomen soft, nontender, nondistended
Pertinent Results:
___ 08:27PM BLOOD WBC-5.1 RBC-2.87* Hgb-4.9* Hct-17.5*
MCV-61* MCH-17.2* MCHC-28.2* RDW-21.9* Plt ___
___ 02:18AM BLOOD WBC-6.8 RBC-3.36* Hgb-6.6*# Hct-23.1*#
MCV-69*# MCH-19.7*# MCHC-28.7* RDW-24.5* Plt ___
___ 06:25AM BLOOD WBC-4.6 RBC-3.48* Hgb-7.4* Hct-24.2*
MCV-70* MCH-21.4* MCHC-30.8* RDW-24.9* Plt ___
___ 08:27PM BLOOD Hypochr-3+ Anisocy-3+ Poiklo-2+
Macrocy-1+ Microcy-3+ Polychr-OCCASIONAL Ovalocy-2+ Schisto-1+
Tear Dr-1+ Envelop-OCCASIONAL Ellipto-1+
___ 02:18AM BLOOD ___ PTT-30.9 ___
___ 02:18AM BLOOD Ret Man-.9
___ 08:27PM BLOOD Glucose-128* UreaN-50* Creat-3.4*# Na-137
K-4.8 Cl-104 HCO3-23 AnGap-15
___ 06:25AM BLOOD Glucose-80 UreaN-46* Creat-3.4* Na-139
K-4.1 Cl-108 HCO3-23 AnGap-12
___ 08:27PM BLOOD ALT-25 AST-20 LD(LDH)-208 AlkPhos-56
TotBili-0.1
___ 06:25AM BLOOD Calcium-8.4 Phos-4.6* Mg-1.9
___ 11:00AM BLOOD Iron-15*
___ 02:18AM BLOOD VitB12-553 Folate-11.6
___ 08:27PM BLOOD Hapto-72
___ 11:00AM BLOOD calTIBC-386 Ferritn-4.1* TRF-297
___ 02:18AM BLOOD %HbA1c-5.2 eAG-103
___ 11:00AM BLOOD TSH-3.0
___ 11:00AM BLOOD Free T4-1.0
___ 12:00AM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-7.0 Leuks-NEG
___ 12:00AM URINE RBC-0 WBC-1 Bacteri-FEW Yeast-NONE Epi-<1
___ 12:03AM URINE Hours-RANDOM Creat-32 Na-62 K-23 Cl-57
TotProt-91 Prot/Cr-2.8*
Renal ultrasound: 1. Echogenic kidneys, compatible with chronic
renal disease. 2. 1.2 cm right upper pole renal cyst contains a
single thin septation. No dedicated followp necessary. 3. No
splenomegaly.
Medications on Admission:
___ Herbs
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*60 Tablet Refills:*0
2. Ferrous Gluconate 325 mg PO TID
RX *ferrous gluconate 325 mg (36 mg iron) 1 tablet(s) by mouth
three times per day Disp #*90 Tablet Refills:*3
3. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice per day Disp
#*60 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Chronic kidney disease
iron deficiency anemia
symptomatic anemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___.
COMPARISON: None.
CLINICAL HISTORY: Severe anemia and chest pain. Assess for acute
intrathoracic process.
FINDINGS: Portable AP upright chest radiograph was obtained. The heart is
mildly enlarged and there is mild pulmonary edema. No large effusions are
seen and there is no pneumothorax. Mediastinal contour is normal. There is
mild hilar congestion. Bony structures are intact.
IMPRESSION: Cardiomegaly with mild edema.
Radiology Report
HISTORY: Renal insufficiency.
TECHNIQUE: Ultrasonography of the kidneys and bladder.
COMPARISON: None available.
FINDINGS:
The right and left kidneys measure 8.6 and 8.5 cm, respectively, and are
echogenic, denoting chronic kidney disease. Within the upper pole of the
right kidney is a 1.1 x 1.2 x 0.9 cm cyst containing a single thin septation.
A 9 x 8 x 9 mm simple cyst resides within the lower pole of the right kidney.
There is no stone or hydronephrosis. The bladder appears normal. The spleen
is not enlarged, measuring 9.9 cm.
IMPRESSION:
1. Echogenic kidneys, compatible with chronic renal disease.
2. 1.2 cm right upper pole renal cyst contains a single thin septation. No
dedicated followp necessary.
3. No splenomegaly.
Gender: F
Race: ASIAN - CHINESE
Arrive by WALK IN
Chief complaint: PALLOR/ANEMIA
Diagnosed with ANEMIA NOS, ACUTE KIDNEY FAILURE, UNSPECIFIED
temperature: 98.0
heartrate: 80.0
resprate: 15.0
o2sat: 100.0
sbp: 122.0
dbp: 52.0
level of pain: 13
level of acuity: 3.0 | ___ with hx of chronic anemia (Hct 30) who p/w several months of
feeling dizzy and tachycardic as well as new onset CP, now with
acute on chronic anemia and chronic renal failure.
# Iron deficiency anemia, beta thalassemia, menorrhagia: This is
consistent with severe iron deficient anemia. Her CKD may also
contribute. She was treated with 2u PRBC with improvement of her
tachycardia, chest pain and shortness of breath. She continued
to feel palpitations. She was started on ferrous gluconate TID
(has not tolerated ferrous sulfate in the past due to pruritis).
She did not have any side effects. She was treated with colace
and senna as well. She will need to follow up with her PCP to
get repeat lab draws. She will follow up with nephrology where
she may require epo injections.
# Chronic kidney disease stage IV: Based on GFR she is nearly
stage V. Nephrology was consulted and think this is chronic
renal failure. She has protein in her urine but was not started
on an ACE inhibitor due to dizziness. She should be started on
one in the near future if she tolerates. She will follow up with
nephrology. This appointment will be scheduled by the nephrology
department with an interpreter and she will be contacted about
the appointment.
# Palpitations: Likely due to PVCs as seen on EKG. No evidence
of arrhythmia. Possibly exacerbated by anemia. She will need
further monitoring as an outpatient.
# Menorrhagia: She should receive further evaluation as an
outpatient to determine if further management is necessary.
Of note, she was warned not to take any more ___ herbs.
TRANSITIONAL ISSUES
- f/u pcp for labs and symptoms evaluation
- f/u nephrology for evaluation and treatment of CKD
- consider ACEi and epo (epo after iron repletion) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Cough
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ man with h/o Down syndrome who presents with cough for one
week and concern for PNA on CXR.
Per patients group leader, patient is minimally communicative at
baseline, but has had cough for approximately 1 week. He thinks
it may have been productive at first, but now appears to be dry.
His group leader denies associated symptoms including fever or
noticable shortness of breath. No one else in his group home is
sick, and patient is without recent hospitalization or abx
therapy. After group activities today, he developed a large
coughing fit and was incontinent of urine and refused to get up
off the floor, prompting the trip to the ED.
Initial VS in the ED: T 99.0, HR 100, BP 105/p, RR 20. Patient
triggered for O2 sat of 86% on room air. Initial labs were
notable for lactate 3.3, Cr 1.3, BUN 25, and leukocytosis to
12.2 with 95% N. Patient was given 750mg levofloxacin and 1L NS
prior to being admitted to medicine for furhter management. VS
prior to transfer: Temperature 99.4 °F (37.4 °C). Pulse 77.
Respiratory Rate 22. Blood Pressure 105/. O2 Saturation 98. O2
Flow ___ np. Pain Level 0.
On the floor, patient appears well. He intermittently nods yes
or no to questions, but appears very shy. He denies pain at this
time.
Past Medical History:
None
Social History:
___
Family History:
No significant family history of recurrent pulmonary infections.
Physical Exam:
Physical Exam on admission:
Vitals: T: 98.2 BP: 96/70 P:72 R:18 18 O2:96%RA
General: Alert, well appearing middle aged man with featurs of
Down syndrome. Interacts with examiner, but only intermittenty
nods yes or no. Unable to assess orientation.
HEENT: Sclera anicteric, dry MM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Nonlabored on RA. Crackles at bases bilaterally, R>L.
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: Moves all extremities, symetric face. Tongue midline.
Pertinent Results:
___ 06:05PM BLOOD WBC-12.2*# RBC-4.34* Hgb-14.3 Hct-42.3
MCV-97 MCH-33.0* MCHC-33.9 RDW-13.4 Plt ___
___ 06:00AM BLOOD WBC-24.2*# RBC-3.69* Hgb-12.0* Hct-35.4*
MCV-96 MCH-32.4* MCHC-33.8 RDW-13.9 Plt ___
___ 06:00AM BLOOD WBC-21.6* RBC-3.71* Hgb-12.2* Hct-36.6*
MCV-99* MCH-32.8* MCHC-33.2 RDW-13.5 Plt ___
___ 06:05PM BLOOD Neuts-94.7* Lymphs-4.0* Monos-0.8*
Eos-0.1 Baso-0.5
___ 06:00AM BLOOD Neuts-93.9* Lymphs-4.2* Monos-1.8* Eos-0
Baso-0.1
___ 06:05PM BLOOD Glucose-114* UreaN-25* Creat-1.3* Na-139
K-4.1 Cl-101 HCO3-27 AnGap-15
___ 06:00AM BLOOD Glucose-93 UreaN-24* Creat-1.2 Na-138
K-4.2 Cl-103 HCO3-27 AnGap-12
___ 06:00AM BLOOD Glucose-106* UreaN-20 Creat-1.4* Na-137
K-4.2 Cl-104 HCO3-28 AnGap-9
___ 06:05PM BLOOD Calcium-8.8 Phos-1.7* Mg-1.9
___ 06:00AM BLOOD Calcium-8.2* Phos-2.5* Mg-2.0
___ 06:07PM BLOOD Lactate-3.3*
___ 08:26AM BLOOD Lactate-1.4
HISTORY: ___ man with pneumonia. Question changes.
COMPARISON: ___.
FINDINGS: Lung volumes are low, somewhat accentuating pulmonary
vascular
markings. Bibasilar opacities present in the prior radiograph
are still
apparent, although substantially less so. The upper lungs
appear clear.
Cardiomediastinal silhouette and hilar contours appear normal.
IMPRESSION: Resolving opacities in the lower lung.
The study and the report were reviewed by the staff radiologist.
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
___.
CLINICAL HISTORY: Hypoxia, assess for pneumonia.
FINDINGS: Single AP upright portable chest radiograph was obtained
demonstrating lower lung airspace opacities which are concerning for
pneumonia. Small effusions would be difficult to exclude. Heart size is
difficult to assess but appears grossly unchanged. No pneumothorax is seen.
Bony structure is intact.
IMPRESSION: Opacities in the lower lungs concerning for pneumonia.
Radiology Report
HISTORY: ___ man with pneumonia. Question changes.
COMPARISON: ___.
FINDINGS: Lung volumes are low, somewhat accentuating pulmonary vascular
markings. Bibasilar opacities present in the prior radiograph are still
apparent, although substantially less so. The upper lungs appear clear.
Cardiomediastinal silhouette and hilar contours appear normal.
IMPRESSION: Resolving opacities in the lower lung.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: COUGH
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 99.0
heartrate: 100.0
resprate: 20.0
o2sat: 86.0
sbp: nan
dbp: nan
level of pain: 13
level of acuity: 1.0 | ___ Male with down's syndrome with pneumonia.
# Cough: Likely PNA given CXR findings. Patient also hypoxic at
triage, but appears comfortable with normal O2 sat currently on
RA. Lactate mildly elevated at 3.3, decreased to 1.4 the
following morning after fluids. Given 750 Levo in the ED, and
continued daily on the floor. Will send home with 5 days of
levo. Repeat chest xray showed resolving opacities. Pt sent
home afebrile with O2 sats >90 on RA. Has appt for PCP follow
up.
# Incontinence: Not normally incontinent of urine. Likely due to
coughing fit and acute illness. UA was negative.
# Down syndrome: Will continue home meds for now including bowel
reg and Paxil.
# FEN: 500cc bolus, replete electrolytes, regular diet
# Prophylaxis: boots, bowel regimen
# Access: peripherals
# Code: Full (confirmed)
# Communication: Patient's Sister (HCP) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Cc: arm pain, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
This is a ___ with history of psychiatric illness (?ADHD,
anxiety, bipolar disorder) recently admitted and discharged from
___ who re-presents with disorientation. She reported to
the emergency department that she lost her medications. She
complains that her backpack was stolen and she is also concerned
her charger was stolen when she was in the emergency department.
In terms of her breathing, she reports a longstanding history of
asthma and COPD. She does not report her breathing has gotten
significantly worse recently. She does have both a Combivent and
pro-air inhaler which she reports she uses. She reports she uses
the albuterol inhaler every 4hours. She does not report
shortness of breath currently. She continues to smoke ___
packs/day. She complains of ongoing right arm pain due to her
fracture.
In the emergency department, given concern for COPD the patient
was given Solumedrol 125mg IV and Azithromcyin. In addition to
albuterol nebs and admitted to the floor for ongoing management.
She is initially was cooperative and spoke with me. She then
walked off of the floor and light a cigarrete in the elevator. A
code purple was called. The patient was placed in a wheelchair
and went back to her room. She yelled at security and attempted
to kick and punch the security guard. She was given 5mg IM
Haldol and 2mg IM Ativan and continued to ask for her personal
belongings. She also asked to speak with psychiatry because she
is here for a psychiatric reason. She ultimately was
redirectable and remained in her room.
ROS: Could not be obtained due to patient cooperation.
Past Medical History:
___
Fractured R arm prior to ___ Admission
Asthma and ?COPD
PAST PSYCHIATRIC HISTORY: Per psychiatry consult note.
"- Sx: ADHD and "fucking anxiety"; adds "I have 101 diagnoses
under the fucking sun;" Prior hospitalizations for Bipolar
Disorder, but denies this diagnosis.
- Hospitalizations: "Plenty" - Most recently in ___
(couple months ago); reports she was hospitalized for Bipolar
Disorder (but denies this diagnosis)
- Current treaters and treatment: Dr. ___ saw 1 month
ago); in ___
- Medication and ECT trials: Responds yes to trials of all
medications I list, including: Lithium, Risperidone, Zyprexa,
"Antidepressants."
- Self-injury/Suicide attempts: Denies
- Harm to others: Current HI toward multiple people.
- Access to weapons: Responds "I wish""
Social History:
Per OMR:
SUBSTANCE ABUSE HISTORY:
- EtOH: "Once in great while"
- Illicits: Denies
- Tobacco: 1- 2 packs/day
SOCIAL HISTORY: ___
Family History:
refuses to answer
Physical Exam:
Vitals:
T: 98.7 BP: 115/77 P:111 R:20 O2:96RA
Disheveled female laying in bed, speaking in full sentences
HEENT: MMM
Lungs: Faint crackles in all lung fields, no wheezes or ronchi
___: RRR S1 S2 Present
Abdomen: Soft, NT, ND, no rebound or guarding
Ext: No edema, some skin excoriations
Psych: Tangential, disorganized. Repeats belief that Kid ___
stole something from her.
Neuro: Moving all extremities. Good Grip strength in right and
left hands. Limited ROM of right shoulder due to pain.
Pertinent Results:
___ 08:37PM URINE HOURS-RANDOM
___ 08:37PM URINE UCG-NEGATIVE
___ 08:37PM URINE UHOLD-HOLD
___ 08:37PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 08:37PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 08:37PM URINE BLOOD-SM NITRITE-NEG PROTEIN-NEG
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-7.5
LEUK-LG
___ 08:37PM URINE RBC-1 WBC-6* BACTERIA-FEW YEAST-NONE
EPI-1
___ 12:15AM BLOOD WBC-8.1 RBC-3.91 Hgb-11.1* Hct-34.7
MCV-89 MCH-28.4 MCHC-32.0 RDW-13.6 RDWSD-44.3 Plt ___
___ 06:45AM BLOOD Glucose-87 UreaN-7 Creat-0.6 Na-142 K-3.8
Cl-109* HCO3-25 AnGap-12
___ 12:15AM BLOOD ALT-17 AST-21 AlkPhos-111* TotBili-0.2
CXR: ___
IMPRESSION:
1. Bilateral streaky and patchy opacities likely represent
atelectasis, but in the appropriate clinical setting, patchy
retrocardiac opacity could represent very early pneumonia.
2. Compression deformity of L1 is age-indeterminate.
Right arm ___
FINDINGS:
Comminuted fracture of the proximal right humerus is re-
demonstrated with
possible slight increase in displacement, and with evidence of
early callus formation. The space between the humeral head and
the right acromion appears somewhat widened which may be due to
underlying joint effusion.
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of
breath/wheezing
2. Amphetamine-Dextroamphetamine 30 mg PO DAILY
3. Ipratropium-Albuterol Inhalation Spray 1 INH IH QID:PRN
worsening shortness of breath/wheezing
4. TraZODone 50-100 mg PO QHS:PRN insomnia
5. ARIPiprazole 15 mg PO DAILY
6. OxyCODONE--Acetaminophen (5mg-325mg) 2 TAB PO Q6H:PRN Pain -
Severe
7. ClonazePAM 1 mg PO TID:PRN worsening anxiety
8. ClonazePAM 0.5 mg PO TID:PRN worsening anxiety
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN Pain - Mild
RX *acetaminophen [8 HOUR PAIN RELIEVER] 650 mg 1 tablet(s) by
mouth every 6 hours Disp #*30 Tablet Refills:*0
2. Ibuprofen 400 mg PO Q8H:PRN Pain - Moderate
RX *ibuprofen 800 mg 1 tablet(s) by mouth every 6 hours Disp
#*30 Tablet Refills:*0
3. OxyCODONE (Immediate Release) 10 mg PO Q6H:PRN Pain - Severe
RX *oxycodone 5 mg ___ tablet(s) by mouth every 6 hours Disp
#*30 Tablet Refills:*0
4. ARIPiprazole 20 mg PO DAILY
RX *aripiprazole [Abilify] 20 mg 1 tablet(s) by mouth daily Disp
#*14 Tablet Refills:*0
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN shortness of
breath/wheezing
6. ClonazePAM 1 mg PO TID:PRN worsening anxiety
7. Ipratropium-Albuterol Inhalation Spray 1 INH IH QID:PRN
worsening shortness of breath/wheezing
8. TraZODone 50-100 mg PO QHS:PRN insomnia
9. HELD- Amphetamine-Dextroamphetamine 30 mg PO DAILY This
medication was held. Do not restart
Amphetamine-Dextroamphetamine until advised by your psychiatrist
10. HELD- ClonazePAM 0.5 mg PO TID:PRN worsening anxiety This
medication was held. Do not restart ClonazePAM until advised by
your psychiatrist
11. HELD- ClonazePAM 0.5 mg PO TID:PRN worsening anxiety This
medication was held. Do not restart ClonazePAM until advised by
your psychiatrist
Discharge Disposition:
Home
Discharge Diagnosis:
Schizoaffective disorder
COPD without acute exacerbation
R humerus fracture
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with hx R humeral fracture // Eval for interval
healing
TECHNIQUE: Three views of the right shoulder
COMPARISON: ___
FINDINGS:
Comminuted fracture of the proximal right humerus is re- demonstrated with
possible slight increase in displacement, and with evidence of early callus
formation. The space between the humeral head and the right acromion appears
somewhat widened which may be due to underlying joint effusion.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with productive cough (would cancel the prior
pa/ lateral one but not available as option) // r/o pneumonia
COMPARISON: CTA chest and chest radiographs ___
FINDINGS:
AP upright and lateral views of the chest provided.
There are streaky bibasilar opacities and patchy retrocardiac opacity. There
is mild pulmonary vascular congestion and a trace left pleural effusion.
There is no pneumothorax. The cardiomediastinal silhouette is normal.
Compression deformity of T11 appears similar to ___. Compression
deformity of L1 is age-indeterminate. No free air below the right
hemidiaphragm is seen. Surgical clips are again seen in the right upper
quadrant.
IMPRESSION:
1. Bilateral streaky and patchy opacities likely represent atelectasis, but in
the appropriate clinical setting, patchy retrocardiac opacity could represent
very early pneumonia.
2. Compression deformity of L1 is age-indeterminate.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Dyspnea, SI
Diagnosed with Schizoaffective disorder, unspecified, Encounter for issue of repeat prescription
temperature: 98.6
heartrate: 100.0
resprate: 18.0
o2sat: 100.0
sbp: 120.0
dbp: 80.0
level of pain: 10
level of acuity: 3.0 | This is a ___ with history of psychiatric disease who presented
with disorganized thinking. She was seen by psychiatry who
recommended inpatient psychiatric admission. She was
subsequently admitted to medicine for management of COPD
exacerbation.
#Chronic COPD without exacerbation
The patient was noted to have wheezing in the emergency
department and was treated for a COPD exacerbation with
Solumedrol and Azithromycin. Her lung exam was without wheezing
on admission to the medical floor, she was able to speak in full
sentences, she was afebrile and not short of breath on
ambulation making both COPD and Pneumonia unlikely. The patient
was monitored for a number of days in the ___ medical
setting on her home inhalers with good control of her
respiratory symptoms. Smoking cessation was advised.
#Schizoaffective disorder with decompensation.
The patient presented with delusions and disorganization after
her medications were stolen. She was seen by psychiatry who
placed a ___ and recommended inpatient admission. The
patient was intermittently agitated, requiring IM Haldol 5mg
IM/Ativan 2mg IV/Cogentin 1mg and a security sitter. She
continued to be agitated requiring a security sitter and doses
of the above medications. Attempts were made to place her in an
inpatient psych facility but no beds were available for several
days. She was continually evaluated by psych daily until it was
felt that she was no longer a harm to herself or others and
close to her baseline on ___. Her home abilify was
increased from 15 to 20 mg and she received an injection of
long-acting abilify prior to discharge. Arrangements with the
SW at ___ to assist pt in finding psychiatrist locally.
#Right humerus fracture
Missed outpatient follow up. Discussed with orthopedics who
reviewed X-ray. Patient can begin ROM. She should remain
non-weight bearing but can begin pendulum swings and follow up
in clinic after discharge. pain was managed with ibuprofen,
acetaminophen and oxycodone. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Aspirin / Naprosyn / Lithium / Cephalexin / Neurontin
Attending: ___.
Chief Complaint:
Nausea, vomiting, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ F w/ hx BRCA mutation, endometrial ca s/p TAH/
chemo/radiation, large bowel obstruction, radiation enteritis
p/w acute onset b/l lower abd pain and nausea/ emesis starting
at 1700 last night.
She has been in usual state of health when she developed crampy
abdominal pain followed by nausea and 20+ episodes of bilious
vomiting. Reports feeling constipated with ___ episodes of small
BRBPR. (She reports inserting her finger into her rectum to try
to relieve the constipation but there was only blood.) Had soft
and firm stool today w/ bright red blood. Reports subjective
fevers and chills, no CP/SOB/vaginal bleeding. Denies recent
illness, no recent travel, strange ingestions, or sick contacts.
In the ED, initial vital signs were: T100 ___ 22 100%
RA Labs were notable for leukocytosis to 17.5. ALT 82, AST72,
AP 145, Hct 49.1. Lactate of 3.0 down to 2.5 with hydration. UA
without evidence of infection.
Guaiaic was performed which was +, no melena, no impaction
noted.
Patient was given Ativan, tylenol, zofran 4 mg x 2, dilaudid 1mg
and morphine 5 mg iv x 1.
Studies performed include ct abd/pelvis which showed no evidence
of bowel obstruction, chronic radiation fibrosis of the sigmoid
and rectum. Hepatic steatosis. Also had KUB which showed no
evidence of obstruction and no free air.
Vitals on transfer: 99.1 95 149/94 18 99% RA
Upon arrival to the floor, the patient reports ___ sharp
left-sided chest pain since this AM. Brought on by respiration,
reproducible, non-radiating. No associated
SOB/palpitations/diaphoresis.
Past Medical History:
PAST MEDICAL HISTORY:
# Breast cancer
# BRCA-1 mutation carrier
# Prophylactic bilateral salpingo-oophorectomy
# Endometrial cancer
-- Stage IIIc serous adenocarcinoma of the uterus
-- s/p chemotherapy, radiation
# Psychiatric history (per OMR)
- pt denies bipolar diagnosis but has been on lithium in the
past
PAST SURGICAL HISTORY:
# Total abdominal hysterectomy
# Omentectomy
# Pelvic and para-aortic lymphadenectomy
# Prophylactic bilateral salpingo-oophorectomy
Social History:
___
Family History:
# Twin sister -- died of breast cancer at age ___
Multiple family members with breast cancer, BRCA-1 mutation.
Physical Exam:
Admission Physical Exam:
Vitals- 98.8 102/65 74 18 97 RA
General: NAD, resting comfortably in bed
HEENT: PERRL, EOMI, nares clear, MMM
Neck: No cervical/supraclavicular LAD
CV: RRR, normal S1, S2, no m/g/r, no JVP
Lungs: CTAB
Abdomen: +BS, soft, tender to palpation and with rebound,
lower>upper quadrants, some increased tympany, +guarding, no
rigidity
GU: foley in place
Ext: Pulses 2+ DP bilaterally
Neuro: CN ___ intact, moving all extrem
Skin: WWP
Discharge Physical Exam:
Vitals- Tm 98.5 Tc 98 BP 123/78 74 18 97 RA
General: NAD, resting comfortably in bed
HEENT: PERRL, EOMI, nares clear, MMM
CV: RRR, normal S1, S2, no m/g/r, no JVP
Lungs: CTAB
Abdomen: +BS, soft, distended, tender to palpation and with
rebound, lower>upper quadrants, some increased tympany,
+guarding, no rigidity. Slightly improved from yesterday and
somewhat distractable.
GU: foley in place
Ext: Pulses 2+ DP bilaterally, no edema
Neuro: CN ___ intact, moving all extrem
Skin: WWP
Pertinent Results:
Admission Labs:
___ 01:32AM BLOOD WBC-17.5*# RBC-5.55*# Hgb-16.4*#
Hct-49.1*# MCV-88 MCH-29.5 MCHC-33.4 RDW-14.0 Plt ___
___ 01:32AM BLOOD Neuts-89.8* Lymphs-6.9* Monos-2.5 Eos-0.5
Baso-0.3
___ 01:32AM BLOOD ___ PTT-26.5 ___
___ 01:32AM BLOOD Glucose-167* UreaN-24* Creat-0.9 Na-138
K-4.1 Cl-98 HCO3-21* AnGap-23*
___ 01:32AM BLOOD ALT-82* AST-72* AlkPhos-145* TotBili-0.6
___ 01:32AM BLOOD Lipase-39
___ 01:32AM BLOOD Albumin-4.6 Calcium-10.4* Phos-4.0 Mg-1.9
___ 01:36AM BLOOD ___ Temp-37.8
___ 01:36AM BLOOD Lactate-3.0*
Pertinent Labs:
___ 05:31AM BLOOD Lactate-2.5*
___ 09:16PM BLOOD WBC-8.7 RBC-3.82* Hgb-11.6* Hct-34.6*
MCV-91 MCH-30.4 MCHC-33.6 RDW-14.0 Plt ___
___ 06:50PM BLOOD CK-MB-3 cTropnT-<0.01
___ 01:32AM BLOOD cTropnT-<0.01
Discharge Labs:
___ 08:00AM BLOOD WBC-6.9 RBC-3.73* Hgb-11.3* Hct-33.3*
MCV-89 MCH-30.2 MCHC-33.8 RDW-14.0 Plt ___
___ 08:00AM BLOOD Glucose-91 UreaN-11 Creat-0.6 Na-141
K-3.5 Cl-109* HCO3-24 AnGap-12
___ 08:00AM BLOOD ALT-43* AST-30 LD(LDH)-190 AlkPhos-81
TotBili-0.3
___ 08:00AM BLOOD Calcium-8.3* Phos-2.1*# Mg-1.8
Imaging:
- CXR ___: No acute cardiopulmonary abnormalities
- ECG ___: Sinus rhythm. Possible inferior myocardial infarction
of indeterminate age.
Non-specific repolarization abnormalities. Compared to the
previous tracing of ___ there is no diagnostic change.
- KUB ___: No evidence of obstruction. No free air.
- CT ABD+Pelvis w/con ___: No evidence of bowel obstruction.
Chronic radiation fibrosis of the sigmoid and rectum.
Hepatic steatosis.
Micro:
- Blood cx x 2: Pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ClonazePAM 1 mg PO BID
2. CloniDINE 0.3 mg PO TID
3. Methadone 20 mg PO QAM
4. Methadone 10 mg PO QPM
5. QUEtiapine Fumarate 50 mg PO QHS
6. BuPROPion (Sustained Release) 150 mg PO QAM
7. Docusate Sodium 100 mg PO BID
8. Milk of Magnesia 30 mL PO Q6H:PRN constipation
Discharge Medications:
1. BuPROPion (Sustained Release) 150 mg PO QAM
2. ClonazePAM 1 mg PO BID
3. Docusate Sodium 100 mg PO BID
4. Methadone 20 mg PO QAM
5. Methadone 10 mg PO QPM
6. QUEtiapine Fumarate 50 mg PO QHS
7. Milk of Magnesia 30 mL PO Q6H:PRN constipation
8. Calcium Carbonate 500 mg PO QID:PRN indigestion
RX *calcium carbonate 500 mg calcium (1,250 mg) 1 tablet(s) by
mouth four times a day Disp #*30 Tablet Refills:*0
9. Ondansetron 4 mg PO Q8H:PRN nausea
RX *ondansetron 4 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*10 Tablet Refills:*0
10. CloniDINE 0.3 mg PO TID
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSIS:
viral gastroenteritis
SECONDARY DIAGNOSIS:
radiation enteritis
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: History: ___ with abd pain // eval for air fluid levels, free
air
TECHNIQUE: Supine and upright views of the abdomen.
COMPARISON: CT abdomen pelvis on ___.
FINDINGS:
Multiple clips are seen in the abdomen. There is seen throughout the small
and large bowel without evidence of dilation or air-fluid levels. No free
air.
IMPRESSION:
No evidence of obstruction. No free air.
Radiology Report
INDICATION: +PO contrast; History: ___ with hx bowel obstruction p/w acute
onset abd pain+PO contrast // r/o obstruction, radiation colitis
TECHNIQUE: MDCT axial images were acquired through abdomen and pelvis
following intravenous contrast administration with split bolus technique.
Coronal and sagittal reformations were performed and submitted to PACS for
review.
Oral contrast was administered.
DOSE: DLP: 493mGy-cm.
IV Contrast: 130 mL Omnipaque injected at a rate of 2 cc/sec
COMPARISON: CT abdomen pelvis on ___.
FINDINGS:
LOWER CHEST:
2 mm right lower lobe pulmonary nodule is unchanged since ___. The
visualized heart and pericardium are unremarkable.
ABDOMEN:
HEPATOBILIARY: The liver is decreased in attenuation consistent with fatty
infiltration. No focal lesions are identified.. The gallbladder is within
normal limits, without stones or gallbladder wall thickening.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout.
A 9 mm hypodensity in the spleen is unchanged. ADRENALS: The adrenal glands
are normal bilaterally.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of stones or hydronephrosis. A 1.2 cm right renal cyst
and another subcentimeter hypodensity is unchanged..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. Multiple surgical clips are again seen in the
mesentery, omentum and retroperitoneum. No free air. The ascending, transverse
and descending colon are unremarkable with normal wall thickness and stool
burden. The sigmoid the and rectum are diffusely narrowed in caliber as seen
on prior exam compatible with chronic radiation changes. No adjacent fat
stranding. Appendix contains air, has normal caliber without evidence of fat
stranding.
RETROPERITONEUM: There is no evidence of retroperitoneal and mesenteric
lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. There is no 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: Reproductive organs are within normal limits
BONES AND SOFT TISSUES:
There is no evidence of worrisome lesions. Abdominal and pelvic wall is within
normal limits.
IMPRESSION:
No evidence of bowel obstruction. Chronic radiation fibrosis of the sigmoid
and rectum.
Hepatic steatosis.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with left sided inspiratory chest pain,
elevated WBC count // ? pneumonia
TECHNIQUE: Chest PA and lateral
FINDINGS:
Cardiomediastinal contours are normal. The lungs are clear with some minimal
areas of scarring/ atelectasis at the bases. There is no pneumothorax or
pleural effusion. The osseous structures are unremarkable
IMPRESSION:
No acute cardiopulmonary abnormalities
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with RECTAL & ANAL HEMORRHAGE, ABDOMINAL PAIN GENERALIZED
temperature: 100.0
heartrate: 107.0
resprate: 22.0
o2sat: 100.0
sbp: 156.0
dbp: 102.0
level of pain: 10
level of acuity: 2.0 | ___ y/o F with hx of radiation enteritis presenting with acute
onset nausea, vomiting, and crampy abdominal pain. Reports BRBPR
which she has had in the past. CT scan shows radiation enteritis
without obstruction. Believed to have viral gastroenteritis on
top of chronic radiation enteritis.
On day of admission pt complained of ___ chest pain, sharp,
pleuritic, reproducible, non-radiating with no
SOB/diaphoresis/palpitations. EKG similar to previous. Later
that day pt had episode of hypotension to 72 systolic,
asymptomatic, that prompted 2L fluid bolus, trops x 2
(negative), stat H/H (decrease from previous hemoconcentration
but recheck stable), and CXR (normal). This episode was
attributed to hypotension. Pt had not received any IVF since
admission so maintenance fluids were continued and blood
pressure responded appropriately.
On last day of admission patient complained of the medical team
not giving her meds as prescribed (her reported 300 mg colace
BID was changed to 200 mg BID and her home 0.3 mg clonidine TID
was held after hypotensive episode- pt was normotensive at the
time). Pt had taken home clonazepam and clonidine in the ED when
first admitted and was asking nursing for opiates for a headache
despite being on methadone. Her neuro exam was non-focal. Pt
eventually left AMA, despite counseling from medicine team, but
beforehand was informed to make f/u appointment with PCP and
discuss GI f/u. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: SURGERY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Fever, abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ M recently admitted to ___ surgery service on for
management of a cystic duct stump leak following lap CCY at an
OSH presents with abd pain and low grade temperatures. Pt and
wife report pain has been present for 3 days. Continuous, dull,
associated with nausea but no emesis. Pt is tolerating PO but
has had a decreased appetite. Some associated chills and fevers
to
102 at home.
During recent admission pt has an ___ guided drain placed in his
biloma. He had already had one in place from the OSH. He also
underwent ERCP and is s/p sphincterotomy and stent placement. He
was discharged to home on a 6 day course of C/F which he
finished.
Past Medical History:
PMH: Hyperchoelsterolemia, colon CA, asthma, depression, chronic
UTI, Afib
PSH: Lap CCY, pacemaker, colectomy, ?additional abdominal
surgery
___: Seroquel XR 100mg PO QHS, Cymbalta 30mg PO QHS, Digoxin
125mcg', Methylphenidate 10mg BID, Simvastatin 40mg', Albuterol
Inh 2puffs Q2h PRN, APAP 650 Q4h PRN, Maalox''''prn, vicodin
___ q4h, miralax 1tbsp daily, Coumadin
Social History:
___
Family History:
NC
Physical Exam:
On Admission:
VS:98.1 87 127/100 18 95%
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, TTP in all four quadrant with guarding,
no rebound, normoactive bowel sounds, no palpable masses
Ext: No ___ edema, ___ warm and well perfused
On Discharge:
VS:
GEN: NAD
CV: RRR, no m/r/g
PULM: CTAB
ABD: Soft, NT/ND, RUQ old pigtail site with occlusive dressing
and c/d/i
Extr: Warm, no c/c/e
Pertinent Results:
___ 10:05AM BLOOD WBC-9.7 RBC-3.94* Hgb-11.7* Hct-36.3*
MCV-92 MCH-29.6 MCHC-32.1 RDW-13.1 Plt ___
___ 10:05AM BLOOD Glucose-220* UreaN-11 Creat-0.7 Na-138
K-4.7 Cl-103 HCO3-24 AnGap-16
___ BLOOD CULTURES: Pending
___ LIVER US:
IMPRESSION:
1. Pain with scanning along the surgical drain over the mid
abdomen/periumbilical region. No fluid collection is identified
along this
drain to suggest abscess formation, however.
2. Likely interval resolution of the previously seen biloma in
the
gallbladder resection bed with a pigtail catheter remaining in
place.
3. Stable liver cyst.
___ ABD CT:
IMPRESSION:
1. Interval decrease in size of the fluid collection within the
gallbladder resection bed compared to CT from ___,
although the collection has not completely drained. The pigtail
catheter is seen along the edge of the collection and
correlation with catheter output is recommended to ensure proper
positioning.
2. Likely subcapsular 6.5 cm collection along the inferior
aspect of the
right hepatic lobe appears more organized on the current study,
now with a
thick surrounding rind.
3. Reactive changes, without evidence of abscess formation,
along the distal portion of the surgical drain that ends near
the hepatic flexure. Of note, this drain does not end within
either of the intra-abdominal collections
Medications on Admission:
Seroquel XR 50 PO QHS, Cymbalta 30mg PO QHS, Digoxin 125mcg',
Methylphenidate 10mg am and noon PRN pt request, Simvastatin
40mg', Albuterol Inh 2puffs Q2h PRN, APAP 650 Q4h PRN,
Maalox''''prn, vicodin ___ q4h, miralax 1tbsp daily, Coumadin
5' ___ and 2.5 rest
Discharge Medications:
1. acetaminophen 325 mg Tablet Sig: Two (2) Tablet PO Q6H (every
6 hours) as needed for pain.
2. docusate sodium 100 mg Capsule Sig: One (1) Capsule PO BID (2
times a day) as needed for constipation.
3. duloxetine 30 mg Capsule, Delayed Release(E.C.) Sig: One (1)
Capsule, Delayed Release(E.C.) PO QHS (once a day (at bedtime)).
4. digoxin 125 mcg Tablet Sig: One (1) Tablet PO DAILY (Daily).
5. simvastatin 40 mg Tablet Sig: One (1) Tablet PO DAILY
(Daily).
6. methylphenidate 10 mg Tablet Sig: One (1) Tablet PO AM AND
NOON, PRN () as needed for patient request.
7. Seroquel XR 50 mg Tablet Extended Release 24 hr Sig: One (1)
Tablet Extended Release 24 hr PO at bedtime.
8. amoxicillin-pot clavulanate 875-125 mg Tablet Sig: One (1)
Tablet PO Q12H (every 12 hours) for 13 days.
Disp:*26 Tablet(s)* Refills:*0*
9. Coumadin 5 mg Tablet Sig: One (1) Tablet PO ___.
10. Coumadin 2.5 mg Tablet Sig: One (1) Tablet PO
TUE/WED/FRI/SAT/SUN: please continue to check your INR as
scheduled.
Discharge Disposition:
Home
Discharge Diagnosis:
Cystic duct stump leak and biloma
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: Stump leak, status post cholecystectomy. Assess for biloma.
COMPARISON: The liver/gallbladder ultrasound from ___.
FINDINGS: A pigtail catheter ends within the region of the previously seen
biloma within the gallbladder resection bed. There is no definite remaining
fluid collection within this area. A cyst within the left lobe of the liver
is stable in appearance. The liver echogenicity and echotexture are grossly
normal. There is no intrahepatic biliary duct dilatation. The portal vein is
patent. The spleen is normal in size, measuring 10.2 cm. Scanning along the
surgical tube within the right mid abdomen/periumbilical region elicited
significant discomfort. No fluid collection was seen along the tube, however.
IMPRESSION:
1. Pain with scanning along the surgical drain over the mid
abdomen/periumbilical region. No fluid collection is identified along this
drain to suggest abscess formation, however.
2. Likely interval resolution of the previously seen biloma in the
gallbladder resection bed with a pigtail catheter remaining in place.
3. Stable liver cyst.
Radiology Report
INDICATION: Prior biloma with ___ drains in place. Patient with abdominal
tenderness. Please evaluate for inflammation around prior biloma.
TECHNIQUE: MDCT axial images were acquired from the lung bases to the lesser
trochanters following administration of both oral and intravenous contrast
material. Multiplanar reformations were performed.
COMPARISON: Reference CT abdomen from ___, reference CT abdomen
from ___.
ABDOMEN CT: The visualized portions of the lung bases are clear. Pacer leads
are seen within the right atrium and right ventricle.
As seen on prior CT from ___, there are scattered liver cysts,
measuring up to 3.7 cm in the left hepatic lobe (2:12), not significantly
changed in size. There is no intrahepatic biliary duct dilatation. The
portal vein is patent. The patient is status post cholecystectomy. A pigtail
catheter is seen within the gallbladder resection bed along the edge of a
small gallbladder fossa fluid collection, markedly decreased in size compared
to ___, now measuring 5.9 x 1.6 cm in its greatest axial
dimension, compared to 10.2 x 3.4 cm previously. Small foci of air within
this collection likely relate to the presence of the pigtail catheter. A
second likely subcapsular collection is seen along the inferior right hepatic
lobe (2:27). This collection was seen previously on CT from ___, although appears to be more organized on the present study with a new
thick surrounding rind. The overall size of this collection does not appear
appreciably changed. A biliary stent is noted extending down the common duct
and into the second portion of the duodenum.
The spleen, pancreas, and adrenal glands are unremarkable. Scattered
bilateral renal hypodensities are not significantly changed in size or number,
at least one of which is a simple cyst and others of which are too small to
characterize. The kidneys are otherwise unremarkable. The stomach, small
bowel, and colon are unremarkable. There is no significant quantity of free
fluid in the abdomen. No free air is noted. There are no pathologically
enlarged abdominal lymph nodes. A surgical drain enters the right mid
abdomen, loops within the pelvis and then ends near the hepatic flexure.
There is reactive change along the distal catheter with associated fat
stranding (60___:22) although no associated fluid collection is seen.
PELVIS CT: The bladder and prostate are grossly unremarkable. There is no
free fluid in the pelvis. No pathologically enlarged pelvic lymph nodes are
seen.
BONE WINDOW: No suspicious lytic or blastic lesions are identified. Mild
multilevel degenerative changes of the thoracolumbar spine are noted.
IMPRESSION:
1. Interval decrease in size of the fluid collection within the gallbladder
resection bed compared to CT from ___, although the collection
has not completely drained. The pigtail catheter is seen along the edge of
the collection and correlation with catheter output is recommended to ensure
proper positioning.
2. Likely subcapsular 6.5 cm collection along the inferior aspect of the
right hepatic lobe appears more organized on the current study, now with a
thick surrounding rind.
3. Reactive changes, without evidence of abscess formation, along the distal
portion of the surgical drain that ends near the hepatic flexure. Of note,
this drain does not end within either of the intra-abdominal collections.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: ABD PAIN, FEVERS
Diagnosed with OTHER SPEC COMPL S/P SURGERY, ACCIDENT NOS
temperature: 98.1
heartrate: 87.0
resprate: 18.0
o2sat: 95.0
sbp: 127.0
dbp: 100.0
level of pain: 4
level of acuity: 3.0 | The patient with history of cystic duct stump leak and biloma
s/p percutaneous drainage was admitted to the General Surgical
Service with increased abdominal pain and fever. The patient
completed the course with Cipro/Flagyl at home. On admission,
the patient underwent abdominal CT, which demonstrated interval
decrease in size of the fluid collection within the gallbladder
and new undrainable right hepatic lobe fluid collection. The
patient was started on IV Unasyn, IV fluids and his Coumadin was
held. The patient was hemodynamically stable.
On HD # 2, patient was afebrile with stable vital signs, his
abdominal pain resolved. On HD # 3, patient was advanced to
regular diet with good tolerance, IV fluid were discontinued and
antibiotics were changed to PO Augmentin. Patient's percutaneous
drain was removed and he was restarted on home dose of Coumadin.
.
During this hospitalization, the patient ambulated early and
frequently, was adherent with respiratory toilet and incentive
spirrometry, and actively participated in the plan of care. The
patient received subcutaneous heparin and venodyne boots were
used during this stay. The patient's blood sugar was monitored
regularly throughout the stay; sliding scale insulin was
administered when indicated. Labwork was routinely followed;
electrolytes were repleted when indicated.
.
At the time of discharge, the patient was doing well, afebrile
with stable vital signs. The patient was tolerating a regular
diet, ambulating, voiding without assistance, and pain was well
controlled. The patient received discharge teaching and
follow-up instructions with understanding verbalized and
agreement with the discharge plan. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Ventricular Fibrillation arrest
Major Surgical or Invasive Procedure:
- ___ - Cardiac catheterization
- ___ - 1. Simple extraction, teeth numbers 30 and 29. 2.
Surgical extraction, tooth number 19.
- ___ - CABG X 4 (LIMA-> LAD, SVG-> OM1, OM2, R PDA)
History of Present Illness:
Mr. ___ is a ___ year-old gentleman with a PMH of
hyperlipidemia and obesity, now admitted s/p VF arrest.
Per ED records, patient had a cardiac arrest at a gas station;
an ambulence was at the same gas station and initiated CPR. When
EMS arrived, they continued CPR and delivered two
defibrillations, as well as epinephrine with return of
spontaneous circulation. Amiodarone was also administered.
At ___, he was started on norepineprine and given
IVF x6L. Cooling protocol was initiated there. There,
non-contrast head CT, CTA torso and CT neck were all
unremarkable. There was no evidence of PE. BY report, EKG at
OSH also showed STEMI, but the EKG did not come with patient's
records to ___. He was transported to ___ by MedFlight,
which was uneventful.
On arrival to the ___ ED at 10:45 am, initial EKG showed NSR
with NA/NI, and no ST depressions/elevations, but
anterior/inferior Q waves. Groin CVL and a-lines were placed.
Norepinephrine was started at 0.15 mcg/kg/min, and was weaned
down to 0.05 mcg/kg/min. The ___ post-arrest team continued
cooling (at 11:30 am), which was presumably started at OSH.
Patient was taken to the lab, where he underwent left heart
cardiac cath via RRA ___. He was found to have a
left-dominant system with severe RCA and LAD disease (LAD 80%
___, LCx 50-60% ___, RCA 80% ___ with normal flow. No
PCI was done. Hemodynamics showed LV 80/___, aorta 80/___.
He was given heparin IV, diltiazem IV bolus and nitroglycerine
IV bolus during the case. Patient was brought to the cath lab
with plan for continued cooling, and reassessment for PCI vs.
CABG after rewarming is complete.
Of note, for the past ___ years, the patient has had multiple
episodes of chest pain for which he has gone to the ED and has
been evaluated. As per his wife, for the past 2 weeks he has
noted intermittant increased chest pressure along with increased
shortness of breath. Today, she notes that he likely had to do
heavy lifting for his ___ job.
On arrival to the CCU, the patient was on assist control
ventilator support, HR 63 and BP 107/82. Cardiac surgery
consulted for coronary bypass evaluation.
Past Medical History:
1. CARDIAC RISK FACTORS: HLD since age ___, has a history of
being on Lipitor and Crestor but stopped for the past year b/c
he was concerned about myalgias
2. CARDIAC HISTORY: none
3. OTHER PAST MEDICAL HISTORY:
BPH- has a history of not tolerating flomax
Restless leg syndrome
GERD
dyslipidemia
Past surgical history: TURP w/vasectomy ___ years ago
Social History:
___
Family History:
Brother ___ years younger)- ACD, multiple episodes of Vfib, EF
___
Father- h/o stroke, passed away from MI
Mother- ___, CHF, pacemaker
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals: HR 63 BP 107/82
General: intubated
HEENT: NCAT
Neck: difficult to assess JVD
CV: distant heart sounds, no murmurs appreciated
Lungs: course breath sounds anteriorly
Abdomen: nondistended
GU: foley in place
Ext: no edema in lower extremities bilaterally
Neuro: intubated and sedated, unable to assess
Pulses: dopplerable DPs
DISCHARGE PHYSICAL EXAM (********** please update on
___
Pulse:96 Resp:14 O2 sat:99/4L
B/P ___
Height:5'9" Weight:86.4 kgs
General:
Skin: Dry [x] intact [x]
HEENT: PERRLA [x] EOMI [x]
Neck: Supple [x] Full ROM [x]
Chest: Lungs clear bilaterally [x]
Heart: RRR [x] Irregular [] Murmur [x] gradeI/VI SEM
Abdomen: Soft [x] non-distended [x] non-tender [x] bowel sounds
+[x]
Extremities: Warm [x], well-perfused [] Edema [x]
Varicosities: None [x]
Neuro: Grossly intact [x]
Pulses:
Femoral Right:1+ Left:1+
DP Right:1+ Left:1+
___ Right:1+ Left:1+
Radial Right:1+ Left:1+
Carotid Bruit Right:- Left:-
Pertinent Results:
ADMISSION LABS
___ 11:22AM BLOOD WBC-13.8* RBC-4.39* Hgb-13.9* Hct-41.6
MCV-95 MCH-31.6 MCHC-33.4 RDW-13.1 Plt ___
___ 02:48PM BLOOD Neuts-89.0* Lymphs-5.8* Monos-4.4 Eos-0.4
Baso-0.3
___ 11:22AM BLOOD ___ PTT-49.5* ___
___ 11:22AM BLOOD Plt ___
___ 11:22AM BLOOD UreaN-17 Creat-1.1
___ 11:22AM BLOOD ALT-99* AST-102* AlkPhos-43 TotBili-0.8
___ 11:22AM BLOOD Lipase-26
___ 11:22AM BLOOD cTropnT-0.40*
___ 11:22AM BLOOD Albumin-3.0*
___ 11:22AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 11:15AM BLOOD Type-ART Tidal V-500 PEEP-5 FiO2-60
pO2-55* pCO2-62* pH-7.03* calTCO2-18* Base XS--15 -ASSIST/CON
Intubat-INTUBATED
___ 11:29AM BLOOD Glucose-278* Lactate-3.8* Na-142 K-4.7
Cl-115* calHCO3-14*
___ 01:15PM BLOOD Hgb-13.5* calcHCT-41 O2 Sat-89 COHgb-0
___ 11:29AM BLOOD freeCa-0.93*
___ CXR (AP portable): ET tube is present, 3.5 cm
above the carina. An enteric tube is present with tip
coursing towards the stomach but not captured on the
film. An esophageal temperature probe is also noted.
Moderate cardiomegaly is present. The mediastinal and
hilar contours are unremarkable. Bilateral pleural
effusions are likely. There is no large pneumothorax.
Diffuse hazy opacification of all lung fields is
consistent with pulmonary edema.
IMPRESSION: Satisfactory positioning of ET tube. No
obvious pneumothorax.
___ CARDIAC CATH:
Hemodynamic Measurements (mmHg):
Baseline
Site ___ ___ End Mean A Wave V Wave HR
___
Findings:
ESTIMATED blood loss: 2 cc
Hemodynamics (see above):
Coronary angiography: left dominant
LMCA: normal
LAD: proximal 80% disease just after S1; normal flow
LCX: large dominant vessel; proximal 50-60% disease
RCA: small nondominant vessel with proximal/mid disease to 80%;
normal flow
Assessment & Recommendations
1. Severe RCA and LAD disease with normal flow
2. Elevated LVEDP
3. No PCI at this time; can consider stenting of LAD if regains
consciousness.
4. Continue cooling
5. Cardiac echo
TTE ___
Left ventricular wall thicknesses are normal. The left
ventricular cavity is moderately dilated. LV systolic function
appears depressed. A left ventricular mass/thrombus cannot be
excluded. Right ventricular chamber size is normal with
depressed free wall contractility. There is no aortic valve
stenosis. An eccentric, posteriorly directed jet of at least
moderate (2+) mitral regurgitation is seen. The pulmonary artery
systolic pressure could not be determined. There is no
pericardial effusion.
IMPRESSION: Moderately dilated left ventricle with severely
depressed global left ventricular systolic function. Depressed
right ventricular systolic function. At least moderate mitral
regurgitation in the setting of tethering of the inferolateral
left ventricular segments is seen. Indeterminate pulmonary
artery systolic pressure.
Compared to the previous study of ___ (images reviewed),
the left ventricle has minimally increased in size (previously
5.9 cm). Mild aortic root and ascending aortic dilation were
previously seen, but not reassessed on today's study.
TTE ___
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. There is severe global left ventricular
hypokinesis (LVEF = ___ with relatively better wall motion
in the basal inferolateral wall. No masses or thrombi are seen
in the left ventricle. Right ventricular chamber size is mildly
dilated with mild free wall motion hypokinesis.. The aortic root
and ascending aorta is mildly dilated. The aortic valve leaflets
(3) are mildly thickened but aortic stenosis is not present. The
mitral valve is abnormal. Moderate to severe (3+) mitral
regurgitation is seen with posteriorly directed jet likely from
tethered posterios mitral leaflet. Moderate [2+] tricuspid
regurgitation is seen. There is moderate pulmonary artery
systolic hypertension. There is a trivial/physiologic
pericardial effusion with no signs of tamponade.
Compared with the prior study (images reviewed) of ___
findings are similar with better visualization of the left
ventricular apex which shows no thrombus. The severity of mitral
regurgitation may be increased. The severity of tricuspid
regurgitation is increased. Pulmonary artery systolic
hypertension is moderate in severity (not estimated on prior
study).
TTE ___
The left atrium is moderately dilated. Left ventricular wall
thicknesses are normal. The left ventricular cavity is
moderately dilated. Overall left ventricular systolic function
is severely depressed (LVEF = 20 %) with regional variation.
Right ventricular chamber size and free wall motion are normal.
The aortic valve leaflets (3) appear structurally normal with
good leaflet excursion and no aortic stenosis or aortic
regurgitation. The mitral valve leaflets are structurally
normal. Moderate (2+) mitral regurgitation is seen. The
end-diastolic pulmonic regurgitation velocity is increased
suggesting pulmonary artery diastolic hypertension. There is no
pericardial effusion.
Compared with the prior study (images reviewed) of ___,
the mitral regurgitation is reduced. Left ventricular
contractile function is slightly
Thallium Viability Study ___
IMPRESSION:
1. Probably normal resting myocardial perfusion. Inferior wall
defect most likely due to soft tissue attenuation.
These results indicate that there is extensive myocardial
viability in all
coronary artery territories.
Teeth X-ray ___
FINDINGS: Multiple missing teeth, the remaining teeth show
other fillings or severe defects. One fractured tooth is seen
in region IV. There is no
convincing evidence of a periarticular osteolysis or granuloma.
Medications on Admission:
NONE
Discharge Medications:
1. Amiodarone 400 mg PO BID
Take 200mg twice daily for 30 days then starting ___ take
200mg daily thereafter.
RX *amiodarone 200 mg 1 tablet(s) by mouth Twice daily for 30
days then switch to once daily on ___ Disp #*60 Tablet
Refills:*2
2. Aspirin EC 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth
Daily Disp #*90 Tablet Refills:*4
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth Twice
daily Disp #*60 Capsule Refills:*0
4. Oxycodone-Acetaminophen (5mg-325mg) ___ TAB PO Q4H:PRN pain
RX *oxycodone-acetaminophen 5 mg-325 mg 1 tablet(s) by mouth
Every ___ hours Disp #*50 Tablet Refills:*0
5. Warfarin 2 mg PO DAILY16
RX *warfarin [Coumadin] 2 mg As instructed tablet(s) by mouth
Daily Disp #*40 Tablet Refills:*2
6. Metoprolol Tartrate 25 mg PO BID
RX *metoprolol tartrate 25 mg 1 tablet(s) by mouth Twice daily
Disp #*60 Tablet Refills:*2
7. Losartan Potassium 50 mg PO DAILY
RX *losartan 50 mg 1 tablet(s) by mouth Daily Disp #*30 Tablet
Refills:*2
8. Ranitidine 150 mg PO BID Duration: 30 Days
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth Twice daily Disp
#*60 Tablet Refills:*0
9. Tucks Hemorrhoidal Oint 1% ___ID
RX *pramoxine-mineral oil-zinc [Tucks] 1 %-12.5 % 1 Ointment(s)
rectally four times a day Disp #*1 Tube Refills:*2
10. Atorvastatin 10 mg PO HS
RX *atorvastatin 10 mg 1 tablet(s) by mouth at bedtime Disp #*30
Tablet Refills:*2
11. Furosemide 40 mg PO DAILY Duration: 7 Days
RX *furosemide 40 mg 1 tablet(s) by mouth Daily in AM Disp #*7
Tablet Refills:*0
12. Potassium Chloride 20 mEq PO DAILY Duration: 7 Days
RX *potassium chloride 20 mEq 1 Tablet by mouth Daily in AM Disp
#*7 Tablet Refills:*0
Discharge Disposition:
Extended Care
Discharge Diagnosis:
Ventricular fibrillation arrest in the setting of 3 vessel
coronary disease
Hyperlipidemia since age ___ (has a history of being on Lipitor
and Crestor but stopped for the past year b/c he was concerned
about myalgias)
Benign Prostatic Hyperplasia
Restless leg syndrome
Gastroesophageal Reflux Disease
Asthma (in his ___
Tinnitus
Cardiomyopathy
Postoperative, paroxysmal Atrial Fibrillation
Discharge Condition:
Alert and oriented x3 nonfocal
Ambulating with steady gait
Incisional pain managed with
Incisions:
Sternal - healing well, no erythema or drainage
Leg Left - healing well, no erythema or drainage.
Edema 2+
Followup Instructions:
___
Radiology Report
INDICATION: V-fib arrest, evaluate ET tube placement and pneumothorax.
COMPARISON: CT torso ___.
FINDINGS: ET tube is present 3.5 cm above the carina. An enteric tube is
present with tip coursing towards the stomach but not captured on the film.
An esophageal temperature probe is also noted. The cardiomediastinal and
hilar contours are unremarkable. Bilateral pleural effusions are not
excluded. There is no pneumothorax. Diffuse hazy opacification of all lung
fields is consistent with pulmonary edema.
IMPRESSION: Satisfactory positioning of ET tube. Pulmonary edema. No
pneumothorax.
Radiology Report
PORTABLE CHEST ___
COMPARISON: Radiograph of earlier the same date.
FINDINGS: Support and monitoring devices are unchanged in position. Interval
slight decrease in width of mediastinal vascular pedicle, accompanied by
improvement in extent of pulmonary edema and reduction in size of right
pleural effusion. Left effusion has apparently resolved. Prominent lucency
adjacent to left heart border and diaphragm could potentially represent a
basilar pneumothorax on this supine view. Lateral decubitus radiograph may be
helpful to exclude a left pneumothorax.
Radiology Report
PORTABLE CHEST FILM ___ AT 820
INDICATION: ___ with VF arrest, now with cooling protocol line and
intubation.
Comparison is made to prior study of ___ at 1454.
A portable supine chest film ___ at 820 is submitted.
IMPRESSION:
1. Support and monitoring devices are in satisfactory position. There is
improving mild pulmonary and interstitial edema. In addition, there is
retrocardiac opacity with probable associated layering left effusion which
likely reflects patchy atelectasis and is slightly worse when compared to the
prior study. No large pneumothorax is seen, although the sensitivity to
detect a pneumothorax is diminished given supine technique. Overall, cardiac
and mediastinal contours are unchanged.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Intubation, evaluation.
COMPARISON: ___.
FINDINGS: As compared to the previous radiograph, the position of the
endotracheal tube, the esophageal device and the feeding tube are unchanged.
Moderate cardiomegaly persists. Increasing atelectasis in the retrocardiac
lung areas. Likely presence of a small left pleural effusion. Minimal fluid
overload. No other parenchymal changes.
Radiology Report
HISTORY: Male with coronary artery disease, status post cardiac arrest.
Assess for pneumonia and effusion.
TECHNIQUE: Single portable frontal chest radiograph.
COMPARISON: Chest radiographs, ___, and
___.
FINDINGS: Interval removal of ET tube and NG tube with mild improvement in
lung volumes. Mild increase in pulmonary edema with mildly enlarged heart size
and new bilateral perihilar haze. Minimal left lower lobe atelectasis with
interval decrease in left pleural effusion. No pneumothorax, new focal
opacity or right pleural effusion. No bony abnormality.
IMPRESSION:
1. Interval increase in mild pulmonary edema.
2. Minimal improvement in lung volumes.
Radiology Report
INDICATION: CABG.
COMPARISON: No comparison available at the time of dictation.
FINDINGS: Multiple missing teeth, the remaining teeth show other fillings or
severe defects. One fractured tooth is seen in region IV. There is no
convincing evidence of a periarticular osteolysis or granuloma.
Radiology Report
CHEST RADIOGRAPH
INDICATION: Status post CABG, evaluation.
COMPARISON: Preoperative chest x-ray from ___.
FINDINGS: As compared to the previous radiograph, the patient has undergone
CABG. All monitoring and support devices, including the Swan-Ganz catheter
and the left-sided chest tube are in correct position. Normal postoperative
appearance of the thorax, with normal-sized cardiac silhouette. No larger
pleural effusions and no pneumothorax. No pulmonary edema.
Radiology Report
HISTORY: CABG, for pre-discharge evaluation.
FINDINGS: In comparison with study of ___, all of the monitoring and support
devices have been removed. There is no convincing evidence of a residual
pneumothorax. Blunting of both costophrenic angles, more prominent on the
left, is consistent with pleural fluid. Some volume loss is noted in the left
lower lung. No evidence of vascular congestion or acute focal pneumonia.
Gender: M
Race: WHITE
Arrive by HELICOPTER
Chief complaint: S/P V FIB ARREST
Diagnosed with VENTRICULAR FIBRILLATION, CARDIAC ARREST
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | ___ year old male past medical history only significant for
hyperlipidemia who was admitted on ___ following ventricular
fibrillation arrest.
Given the lenght of his inpatient stay, his preoperative course
will be divided into systems.
# VF arrest: Patient had a witnessed VF arrest while at a gas
station that happened to have an ambulance there at the same
time. CPR was started immediately. On presentation to ___,
cardiac cath was performed demonstrating severe RCA and LAD
disease and moderate LCX disease with normal flow. None of the
lesions were intervened upon. TTE was performed which
demonstrated mild symmetric left ventricular hypertrophy with
mild left ventricular cavity dilation and severely depressed
biventricular systolic function (LVEF ___ with 2+ mitral
regurgitation. LV thrombus was unable to be ruled out, and
patient was started on heparin. Pt's Vfib was thought most
likely to be due to global ischemia in the setting of three
vessel disease. Non-ischemic causes such as electrolyte
abnormality, a hereditary channelopathy or old MI scar
initiating a focus of arrhythmia were also considered in the
differential. Post cardiac catheterization, patient was cooled
per cooling protocol and rewarmed. On being rewarmed, patient
was found to be neurologically intact, and was extubated.
Repeat TTE demonstrated severe global left ventricular
hypokinesis (LVEF = ___ with relatively better wall motion
in the basal inferolateral wall. No masses or thrombi are seen
in the left ventricle. Pt was also noted to have possibly
worsened mitral regurgitation. While in the CCU, patient was
loaded with amiodarone given his vfib arrest of unclear
etiology, and continued on amiodarone PO. He was also treated
with aspirin 325 mg daily, metoprolol tartrate 25 mg q6 hours,
and captopril 3.125 mg q8 hours. Heparin gtt was started due to
concern for possible LV thrombus on initial TTE. On transfer to
the floor, pt's captopril was discontinued and lisinopril 5 mg
daily was started. In addition, metoprolol was titrated to
metoprolol XL 125 mg daily. Atorvastatin was started at 10 mg
daily given pt's known history of myalgias with other statins.
Lisinopril was changed to Losartan 25 mg daily after pt
developed a cough. On the floor, pt underwent a thallium
viability study which showed extensive myocardial viability in
all coronary artery territories. In addition, TTE ___
demonstrated continued LV dysfuncttion with LVEF = 20% and
improved MR from previous study. It was determined that pt would
undergo CABG with cardiac surgery. As part of pre-op work up,
pt underwent extraction of 3 teeth (19, 29, 30) with extensive
decay.
# CAD: As discussed above, cath on arrival showed severe RCA and
LAD disease with normal flow. No PCI were performed, and
further interventions held off while undergoing cooling. Seen
by cardiac surgery and underwent CABG x4 with Dr. ___ on
___. Atorvastatin was initially held during the cooling and
low dose atorvastatin at 10 mg daily was started once patient
was transferred to the floor. Aspirin was started while
hospitalized.
# Heart Failure: Initial TTE post-arrest demonstrated severe
systolic diyfunction with and EF ___ and 2+ mitral
regurgitation. Repeat echo demonstrated severe global left
ventricular hypokinesis (LVEF = ___ with relatively better
wall motion in the basal inferolateral wall. No masses or
thrombi are seen in the left ventricle. Pt was also noted to
have possibly worsened mitral regurgitation. Pt was started on
an ACEi and metoprolol as described above, and lasix 40 mg
daily. Lasix was changed to 20 mg daily, and the ACEi was
changed to losartan after pt developed a cough. Post-CABG, he
was followed by Dr. ___ recommended that he be discharged
home with Life Vest for 3 months.
# Superficial thrombophlebitis: On the floor, pt developed a
superficial thrombophlebitis of his right forearm. Pt was
already anticoagulated with heparin as described above, and warm
compresses combined with elevation were instituted which were
effective. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
joint pains
Major Surgical or Invasive Procedure:
skin biopsy ___
History of Present Illness:
Primary Care Physician: ___. MD
.
___ with new dx of nodular vasculitis is here with upper and
lower extremity pain not relieved by morphine or ibuprofen at
home. He has been undergoing W/U as outpt for fevers x 5 weeks.
He then developed pain and stiffness in his hands, wrists,
elbows, ankles and feet then developed small tender erythematous
subcutaneous nodules over his upper and lower extremities. ID
saw pt and felt this was not infectious. He was seen by Rheum
and had nodule biopsy which revealed nodular vasculitis. Plan
was to start IV steroids next week but b/c of pain pt came to
the ER. Extensive work up revealed elevated ESR, WBC count, and
LFTs. Pt reports abdominal CT and MRI of lower extremities was
WNL. At this point in time pt is in so much pain he lays on the
couch all day long and needs to use a wheelchair to get to the
bathroom.
.
ROS: some dry mouth "I think this is from the AC" denies cough,
hemoptysis, dysuria, hematuria, headache, n/v/d, chest pain,
palpitations, shortness of breath, no rashes, no nausea
vomittign diarrhea, no dry eyes, no vision changes
.
In the ED, initial vital signs were 98.9, 133, 105/91, 18, 100%.
WBC 13K, CRP 163, ALT 124, AST 58, Alk P ___. Exam was notable
for multiple SQ nodules in extremities and diffuse joint
tenderness. Triggered for HR of 130's. 2 L IVF, 2 mg IV
morphine, 30 mg IV ketorolac. Improved to 120's. Patient was
given 2 L NS, 3 mg dilaudid and ketorolac.
.
Past Medical History:
none
Social History:
___
Family History:
Paternal great grandmother had RA.
Family history is negative for systemic lupus erythematosus,
inflammatory myopathy, systemic sclerosis, Sjogren's syndrome,
psoriasis or inflammatory bowel disease.
Prostate CA in the family, grandparents with CAD, DM and HTN.
Physical Exam:
ADMISSION EXAM:
VS: 98.9 133 ___ 100
General: sitting in bed, appears to be in pain, difficulty using
his iphone
HEENT: EOMI, tongue with no thrush
CV: tachycardia 120s, normal S1 S2, no murmers
Lungs: clear to auscultation b/l
Abdomen: soft non tender no organomegaly
Neuro: could not assess stregnth bc of pain
Skin: many dime sized pink papules on arms, hands, legs, feet
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema.
MSK: Warmth, redness of the MCP/PIP joints in hands and feet
bilaterally. nodules are also on hands and feet. No digit
swelling of fingers or toes bilaterally. Tender wrists, elbows
and feet and ankles. Decrease ROM due to pain. Shoulders,
elbows, wrists, hands: no deformity, erythema, they are warm,
tender, very limited ROM from pain. Knee, ankles, feet, toes:
no deformity, there is warmth, tenderness, very limited ROM
.
DISCHARGE EXAM:
99.6 18 100%RA HR range 91-112
.
Exam unchanged though he had fewer subcutaneous nodules and was
able to move his extremities without as much pain, but still
with pain
.
Pertinent Results:
ADMISSION LABS
.
___ 03:50PM BLOOD WBC-13.4* RBC-4.49* Hgb-11.7* Hct-35.1*
MCV-78* MCH-26.0* MCHC-33.3 RDW-16.1* Plt ___
___ 03:50PM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-2+ Polychr-1+ Ovalocy-1+ Tear Dr-1+
___ 03:50PM BLOOD Plt Smr-VERY HIGH Plt ___
___ 03:50PM BLOOD Glucose-113* UreaN-19 Creat-0.8 Na-135
K-4.7 Cl-97 HCO3-23 AnGap-20
___ 03:50PM BLOOD ALT-124* AST-58* CK(CPK)-21* AlkPhos-289*
TotBili-0.9
___ 07:45AM BLOOD Calcium-9.0 Phos-3.8 Mg-2.0 Iron-25*
___ 07:45AM BLOOD calTIBC-286 Hapto-316* Ferritn-312
TRF-220
___ 07:45AM BLOOD HBsAg-PND HBsAb-PND HBcAb-PND IgM HBc-PND
___ 03:50PM BLOOD CRP-163.8*
___ 04:06PM BLOOD Lactate-1.9
.
DISCHARGE LABS:
___ 09:11AM BLOOD Plt ___
___ 07:45AM BLOOD Ret Aut-3.5*
___ 05:35AM BLOOD Glucose-94 UreaN-16 Creat-0.7 Na-135
K-4.3 Cl-98 HCO3-27 AnGap-14
___ 09:11AM BLOOD ALT-87* AST-39 AlkPhos-209* TotBili-0.7
___ 05:35AM BLOOD Calcium-9.1 Phos-5.3* Mg-2.2
___ 09:11AM BLOOD WBC-8.9 RBC-3.57* Hgb-9.1* Hct-27.9*
MCV-78* MCH-25.3* MCHC-32.4 RDW-15.9* Plt ___
___ 09:11AM BLOOD Hypochr-1+ Anisocy-NORMAL
Poiklo-OCCASIONAL Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL
Spheroc-OCCASIONAL Ovalocy-OCCASIONAL
.
___ cxr
FINDINGS: AP portable upright chest radiograph provided. The
lungs are well expanded and clear. No signs of pneumonia or
effusion. No pneumothorax is seen. The cardiomediastinal
silhouette is normal. Bony structures are intact.
IMPRESSION: No acute abnormalities.
.
___ echo
EF 65%
The left atrium is normal in size. No atrial septal defect is
seen by 2D or color Doppler. The estimated right atrial pressure
is ___ mmHg. Left ventricular wall thickness, cavity size and
regional/global systolic function are normal (LVEF >55%). There
is no ventricular septal defect. Interventricular septal motion
is normal. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. No masses or vegetations are
seen on the aortic valve. The mitral valve appears structurally
normal with trivial mitral regurgitation. There is no mitral
valve prolapse. No mass or vegetation is seen on the mitral
valve. The estimated pulmonary artery systolic pressure is
normal. No vegetation/mass is seen on the pulmonic valve. There
is no pericardial effusion.
.
___ RUQ u/s
FINDINGS:
The liver echogenicity and echotexture are normal. No focal
liver lesions are identified. There is no intra or extrahepatic
biliary duct dilatation, with the common duct measuring 3 mm.
The portal vein is patent, with normal hepatopetal flow. The
gallbladder is normal. The kidneys are normal in size, with the
right kidney measuring 11.7 cm and the left kidney measuring
10.6 cm. There is no hydronephrosis, focal renal mass, or
calculus. The pancreas is unremarkable. The spleen is normal
in size, measuring 11.8 cm. The abdominal aorta is normal in
caliber. Limited assessment of the IVC is unremarkable. There
is no free fluid in the abdomen.
IMPRESSION:
Normal abdominal ultrasound.
.
___ Skin Biopsy (___)
Skin, right upper arm, biopsy (A-C):
Extensive deep dermal and subcutaneous hemorrhage with early
organization and associated acute and chronic inflammation, see
note.
Note: Definitive vasculitis is not seen; elastic stain
evaluated. Special stains for organisms (PAS, Gram, ___, AFB,
GMS) are negative. The differential diagnosis includes a
bleeding diathesis. Although evidence of nodular vasculitis is
not identified, a deeper biopsy may be of benefit if clinical
suspicion persists. Studies for evaluation of coagulopathy are
recommended if clinically warranted.
.
.
___ Review of outpt skin biopsy (originally bx done ___
as outpt)
Skin, "right incisional forearm, biopsy" (___,
___, ___, 7 slides):
Septal and lobular panniculitis with vasculitis, see note.
Note: Sections show acute, chronic, and granulomatous septal and
lobular inflammation with septal thickening and fibrosis.
Prominent vasculitis of the subcutaneous vessels with fibrinoid
necrosis and focal thromboses is seen. Special stains for fungus
and mycobacteria (GMS, PAS and ___ performed at the outside
institution and reviewed at ___
are negative. The findings are suggestive of erythema
induratum/nodular vasculitis in the appropriate clinical
setting. A less likely consideration is polyarteritis nodosa,
although the degree of panniculitic inflammation and the pattern
would be unusual. Clinicopathologic correlation is recommended.
.
.
Pertinent Labs:
___ 07:45AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE IgM HBc-NEGATIVE
___ 07:45AM BLOOD HCV Ab-NEGATIVE
___ 07:10AM BLOOD HIV Ab-NEGATIVE
___ BLOOD HISTOPLASMA Ag-NEGATIVE
___ 12:27PM BLOOD LYME DISEASE ANTIBODY,
IMMUNOBLOT-NEGATIVE
___ 07:10AM BLOOD QUANTIFERON-TB GOLD-NEGATIVE
___ 05:35AM BLOOD HISTOPLASMA ANTIBODY (BY CF AND
ID)-NEGATIVE
___ 05:35AM BLOOD COCCIDIOIDES ANTIBODY, COMPLEMENT
FIXATION AND IMMUNODIFFUSION-NEGATIVE
___ 05:35AM BLOOD PARACOCCIDIOIDES ___
ANTIBODY-NEGATIVE
___ 05:35AM BLOOD BLASTOMYCOSIS ANTIBODY (BY CF AND
ID)-NEGATIVE
___ 05:35AM BLOOD B-GLUCAN-NEGATIVE
___ 10:15AM BLOOD EBV PCR, QUANTITATIVE, WHOLE
BLOOD-NEGATIVE
___ 10:15AM BLOOD PARVOVIRUS B19 DNA-NOT DETECTED
___ 10:15AM BLOOD PARVOVIRUS B19 ANTIBODIES (IGG &
IGM)-NEGATIVE
___ BLOOD HCV VIRAL LOAD-NOT DETECTED
___ BLOOD ASO SCREEN-NEGATIVE
___ BLOOD LYME DISEASE-EIA EQUIVOCAL
___ BLOOD CMV VIRAL LOAD-NOT DETECTED
___ Blood Culture - no growth
___ Blood Culture #1 - no growth
___ Blood Culture #2 - no growth
___ Blood Culture #3 - no growth
___ Blood Culture #1 - no growth
___ Blood Culture #2 - Gram-positive cocci in clusters
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ibuprofen 400 mg PO Q6H
2. Morphine Sulfate ___ 15 mg PO Q8H:PRN pain
Discharge Medications:
1. Ibuprofen 800 mg PO Q8H
RX *ibuprofen 800 mg 1 tablet(s) by mouth every eight (8) hours
Disp #*90 Tablet Refills:*0
2. Polyethylene Glycol 17 g PO DAILY:PRN constipation
RX *polyethylene glycol 3350 [___] 17 gram 1 packet by mouth
daily Disp #*30 Packet Refills:*0
3. Senna 1 TAB PO BID
RX *sennosides [senna] 8.6 mg 1 capsule by mouth daily Disp #*30
Capsule Refills:*0
4. OxycoDONE (Immediate Release) 15 mg PO Q4H:PRN pain
RX *oxycodone 15 mg 1 tablet(s) by mouth every four (4) hours
Disp #*30 Tablet Refills:*0
5. 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
6. OxyCODONE SR (OxyconTIN) 20 mg PO Q12H
RX *oxycodone 20 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*28 Tablet Refills:*0
RX *oxycodone [OxyContin] 20 mg 1 tablet extended release 12
hr(s) by mouth twice a day Disp #*30 Tablet Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
1. Painful subcutaneous nodules, arthralgias
2. Anemia
Discharge Condition:
Mental Status: Clear and coherent.
Followup Instructions:
___
Radiology Report
HISTORY: 6 week history of fevers and painful subcutaneous nodules. Also
with elevated LFTs. Evaluate hepatic tree for evidence of aneurysms or signs
of vasculitis.
COMPARISON: None.
FINDINGS:
The liver echogenicity and echotexture are normal. No focal liver lesions are
identified. There is no intra or extrahepatic biliary duct dilatation, with
the common duct measuring 3 mm. The portal vein is patent, with normal
hepatopetal flow. The gallbladder is normal. The kidneys are normal in size,
with the right kidney measuring 11.7 cm and the left kidney measuring 10.6 cm.
There is no hydronephrosis, focal renal mass, or calculus. The pancreas is
unremarkable. The spleen is normal in size, measuring 11.8 cm. The abdominal
aorta is normal in caliber. Limited assessment of the IVC is unremarkable.
There is no free fluid in the abdomen.
IMPRESSION:
Normal abdominal ultrasound.
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: None.
CLINICAL HISTORY: Tachycardia, question pneumonia.
FINDINGS: AP portable upright chest radiograph provided. The lungs are well
expanded and clear. No signs of pneumonia or effusion. No pneumothorax is
seen. The cardiomediastinal silhouette is normal. Bony structures are
intact.
IMPRESSION: No acute abnormalities.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: EXTREMITY PAIN
Diagnosed with JOINT PAIN-MULT JTS, ERYTHEMA NODOSUM
temperature: 98.9
heartrate: 133.0
resprate: 18.0
o2sat: 100.0
sbp: 105.0
dbp: 91.0
level of pain: 5
level of acuity: 1.0 | ___ with 6 wks of myalgias/arthralgias, 15 lb weight loss, and
tender subcutaneous nodules on all extremities has started
workup for rheum vs ID vaculitis vs erythema nodosum was
admitted for pain control and further workup.
.
#fever/arthralgias/subcutaneous nodules, likely c/w NODULAR
VASCULITIS: Pt had already undergone extensive outpt w/u, with
skin biopsy most c/w nodular vasculitis with plan to initiate
systemic steroids. However, due to severe pain, pt presented to
the hospital for pain control. Rheum, ID and Derm Consults were
involved in his care. The following workup has been done: Smear
negative for parasites, Lyme antibody negative, Erhlichia
IgG/IgM negative, CMV neg, Anaplasma IgG/IgM negative, Quant
gold neg, Blood culture negative x 2, Hep panel neg, HCV neg,
HIV neg, ASO neg. ___ neg, ANCA neg, normal SPEP, normal
Complement levels, antiphospholipid Ab neg, cryoglobulin neg.
Further infectious w/u at ___ was done to r/o fungal
infection, which was negative. He had one positive blood
culture from ___ which grew GRAM POSITIVE COCCI IN CLUSTERS,
however, another set from the same day was negative for growth,
and he had 4 more additional sets of blood cultures, so the
positive blood culture was felt to represent contaminant. He
had a TTE that did not show evidence of vegetations / infective
endocarditis.
He underwent repeat skin biopsy at ___, with dermatopathology
result showed: lots of hemorrhage, c/w acute and chronic
inflammation, but otherwise non-diagnostic. HIs outpt path
slides were obtained and were reviewed by ___ Pathology, and
based on their review, the findings are c/w nodular vasculitis.
Pending return of Quantaferon gold, if TB is ruled out,
Rheumatology Consult plans to coordinate with his outpt
Rheumatologist and recommend the initiation of systemic steroids
for treatment of nodular vasculitis.
.
#Sinus tachycardia: HR iniitally in the 120s and before d/c in
the low 100s. Tachycardia felt to likely be related to pain and
improved with pain control.
.
#Microcytic anemia: Ht ___ MVC 78 then after IVF was
___ anemia with iron low at 25, TIBC 286 ferritin
312. Haptoglobin and LDH both WNL, not suggestive of hemolysis.
Guaiac negative. On d/c Ht was 27..
.
#Elevated LFTs: ALT 124, AST 58 Alk P ___, then started trending
down and on day before d/c AST 39 ALT 87 Alk P ___. Per pt he
has frequently had elevated LFTs whenever he is sick even in
college. It is possible that either infections of systemic
inflammation could explain this. RUQ u/s was unremarkable. Hep
C serology was negative. Hep B serologies were c/w prior
immunization.
.
.
TRANSITIONAL ISSUES
[]per rheum, they will discuss w/ outpatient rheum the plan to
be started on prednisone assuming quant gold neg |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Latex / Vicodin / Food Extracts / Bactrim / Iodinated Contrast
Media - IV Dye / dapsone / diazepam / raltegravir / Truvada
Attending: ___.
Chief Complaint:
Joint pain
Major Surgical or Invasive Procedure:
SURGICAL WASHOUT OF L ELBOW, L WRIST, R KNEE ___
History of Present Illness:
___ hx HIV (last CD4 ___, last VL undetectable in
___ and extensive joint history including b/l steroid wrist
injection for chronic carpal tunnel on ___ and right knee
arthritis w/ tap and steroid injection on ___ presents with ___
days fevers, chills, night sweats, and exquisite tenderness
worst in left wrist but notable in numerous PIP, DIP, MCP (left
___ digit worst), ?L elbow, right knee (though the latter is
improving since ___. The left wrist pain has gotten worse
since injection (which have helped in the past). Her right knee
feels "tense."
At At___, labs drawn ___ as below:
- PENDING: ___ prev negative ___
- uric acid 2.9
- RF<30
- CRP 141
- ESR 90
Right knee tap showed 33K cells, gram stain with 4 PMNs but no
organisms.
No new sexual partners and ___ w/i marriage (20+ years),
though per records does have history of gonoccocal proctitis a
few years ago. No ocular symptoms.
Bilateral steroid injections of hands for carpal tunnel
___.
Knee tap of 81cc fluid + steroid injection ___.
In the ED, initial vitals were: 100.6 97 144/92 18 100% RA
- Exam notable for:
Left wrist with erythema, edema, warm to touch, more swollen
than right wrist. Tender per pt. All MCP tender, majority of
PIP/DIP as well, left ___ PIP most visibly swollen. Pt yells out
when most of these are touched. Also endorsing tenderness of
right elbow though this has full ROM. Right knee also tender w/o
frank erythema, edema, no ballottment. No restriction on ROM.
- Labs notable for:
WBC 8.7
Joint fluid with ___ WBC's, 79% PMN's and no crystals (GST
PND)
- Imaging was notable for: none obtained
- Orthopedics, Hand surgery were consulted:
-Please process synovial fluids for analysis.
-Please elevate LUE as much as possible with IV pole.
-Suggest NSAIDS.
-NPO at midnight, please.
-will plan for serial examinations.
-please obtain hand and wrist films
-Advise rheumatologic workup as well
- Patient was given:
Vanc/CTX
Tylenol ___ mg
Oxycodone 5
Dilaudid 0.5 IV x 2
- Vitals prior to transfer: 100.2 86 140/86 18 99% RA
Upon arrival to the floor, patient reports severe debilitation
in her L arm and hand. The pain has been getting worse and
worse. She can barely use her L arm now. Endorses some
occasional night sweats over the past month. Otherwise, denies
fevers at home, weight changes, diarrhea, dysuria, abdominal
pain, cough.
Past Medical History:
Past Medical History: Includes HIV positive, latent TB,
hepatitis, gastroesophageal reflux, obstructive sleep apnea,
knee pain, plantar fasciitis, thalassemia, G6PD deficiency,
___ syndrome, laryngeal reflux, allergic rhinitis, herpes,
thenar atrophy, hyperlipidemia.
Past Surgical History: Status post tubal, status post carpal
tunnel. Sleeve gastrectomy ___ at ___
Social History:
___
Family History:
Dad with DM, HTN
Mom with DM, HTN, CAD
Physical Exam:
ADMISSION:
Vital Signs: 98.2 124/81 88 18 100 Ra
General: Alert, oriented, no acute distress
HEENT: Sclerae anicteric, MMM, oropharynx clear, EOMI, PERRL.
Neck: Supple. JVP not elevated. no LAD
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: No foley
Ext: slightly edematous and fluctuant R knee, L hand wrist
elbow; all exquisitely TTP with limited ROM
Neuro: CNII-XII intact
DISCHARGE:
General: Alert, oriented, no acute distress
CV: Regular rate and rhythm. Normal S1+S2, no murmurs, rubs,
gallops.
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: Soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
Ext: Right knee incision clean without discharge, LUE wrapped
c/d/I, intact movement and circulation distally
Neuro: Grossly intact
Pertinent Results:
ADMISSION:
___ 10:07PM BLOOD WBC-8.7 RBC-3.78* Hgb-11.5 Hct-35.1
MCV-93 MCH-30.4 MCHC-32.8 RDW-11.6 RDWSD-39.7 Plt ___
___ 10:07PM BLOOD Neuts-60.3 ___ Monos-10.7
Eos-0.5* Baso-0.7 Im ___ AbsNeut-5.26 AbsLymp-2.38
AbsMono-0.93* AbsEos-0.04 AbsBaso-0.06
___ 07:10AM BLOOD ___ PTT-29.3 ___
___ 07:10AM BLOOD WBC-8.6 Lymph-21 Abs ___ CD3%-71
Abs CD3-1290 CD4%-44 Abs CD4-787 CD8%-27 Abs CD8-491 CD4/CD8-1.6
___ 10:07PM BLOOD Glucose-132* UreaN-13 Creat-0.5 Na-137
K-5.2* Cl-104 HCO3-22 AnGap-16
___ 07:10AM BLOOD Calcium-9.9 Phos-2.7 Mg-2.1 UricAcd-2.0*
NOTABLE LABS:
___ 07:10AM BLOOD WBC-8.6 Lymph-21 Abs ___ CD3%-71
Abs CD3-1290 CD4%-44 Abs CD4-787 CD8%-27 Abs CD8-491 CD4/CD8-1.6
___ 07:30AM BLOOD Ret Aut-1.6 Abs Ret-0.04
___ 07:30AM BLOOD calTIBC-179* Hapto-290* Ferritn-356*
TRF-138*
___ 07:35AM BLOOD HBsAg-Negative HBsAb-Positive
HBcAb-Negative HAV Ab-Positive
___ 07:35AM BLOOD ANCA-NEGATIVE B
___ 07:35AM BLOOD ___ CRP-172.5*
___ 07:35AM BLOOD PEP-NO SPECIFI
___ 07:35AM BLOOD C3-158 C4-20
___ 07:35AM BLOOD HCV Ab-Negative
___ 07:10AM BLOOD HIV1 VL-NOT DETECT
DISCHARGE:
___ 07:25AM BLOOD WBC-5.7 RBC-3.02* Hgb-9.4* Hct-28.2*
MCV-93 MCH-31.1 MCHC-33.3 RDW-14.0 RDWSD-47.6* Plt ___
___ 07:25AM BLOOD Glucose-81 UreaN-21* Creat-2.0* Na-141
K-4.7 Cl-106 HCO3-22 AnGap-18
___ 07:25AM BLOOD ALT-61* AST-35 LD(LDH)-217 AlkPhos-160*
TotBili-0.5
___ 07:25AM BLOOD Calcium-9.9 Phos-4.0 Mg-2.0
___ 07:25AM BLOOD ___
STUDIES:
___ TTE:
The left atrial volume index is normal. The estimated right
atrial pressure is ___ mmHg. Left ventricular wall thickness,
cavity size and regional/global systolic function are normal
(LVEF >55%). Right ventricular chamber size and free wall motion
are normal. The diameters of aorta at the sinus, ascending and
arch levels are normal. The aortic valve leaflets (3) appear
structurally normal with good leaflet excursion and no aortic
stenosis or aortic regurgitation. The mitral valve appears
structurally normal with trivial mitral regurgitation. No mass
or vegetation is seen on the mitral valve. The estimated
pulmonary artery systolic pressure is normal. No vegetation/mass
is seen on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: No vegetations or clinically-significant regurgitant
valvular disease seen (excellent-quality study). Normal global
and regional biventricular systolic function.
Compared with the prior study (images reviewed) of ___, the
findings are similar.
Renal US ___:
Limited evaluation of the left kidney. However, no
hydronephrosis
bilaterally.
MICRO:
NEISSERIA GONORRHOEAE (GC), NUCLEIC ACID PROBE, WITH
AMPLIFICATION
(Final ___:
NEISSERIA GONORRHOEAE.
Positive by PANTHER System, APTIMA COMBO 2 Assay.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Epzicom (abacavir-lamivudine) 600-300 mg oral DAILY
2. Etravirine 400 mg PO DAILY
3. Cyanocobalamin 500 mcg PO DAILY
4. Cetirizine 10 mg PO DAILY
5. Vitamin D ___ UNIT PO DAILY
6. Multivitamins 1 TAB PO DAILY
7. Ranitidine 300 mg PO QHS
Discharge Medications:
1. Abacavir Sulfate 600 mg PO DAILY
RX *abacavir 300 mg 2 tablet(s) by mouth once a day Disp #*60
Tablet Refills:*0
2. Acetaminophen 1000 mg PO Q8H:PRN Pain - Mild
RX *acetaminophen 500 mg 2 tablet(s) by mouth three times a day
Disp #*100 Tablet Refills:*0
3. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*0
4. Doxycycline Hyclate 100 mg PO Q12H
END ___
RX *doxycycline hyclate 100 mg 1 tablet(s) by mouth twice a day
Disp #*12 Tablet Refills:*0
5. LaMIVudine 150 mg PO DAILY
RX *lamivudine [Epivir] 150 mg 1 tablet(s) by mouth once a day
Disp #*30 Tablet Refills:*0
6. Ondansetron 4 mg PO Q8H:PRN nausea Duration: 10 Days
RX *ondansetron HCl 4 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*12 Tablet Refills:*0
7. Polyethylene Glycol 17 g PO DAILY
Please stop taking when regular bowel movements.
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 powder(s) by
mouth once a day Disp #*14 Packet Refills:*0
8. Senna 8.6 mg PO BID constipation
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice a day Disp
#*60 Tablet Refills:*0
9. Ranitidine 150 mg PO QHS
RX *ranitidine HCl 150 mg 1 tablet(s) by mouth at bedtime Disp
#*30 Tablet Refills:*0
10. Cetirizine 10 mg PO DAILY
11. Cyanocobalamin 500 mcg PO DAILY
12. Etravirine 400 mg PO DAILY
13. Multivitamins 1 TAB PO DAILY
14. Vitamin D ___ UNIT PO DAILY
15. HELD- Epzicom (abacavir-lamivudine) 600-300 mg oral DAILY
This medication was held. Do not restart Epzicom until YOUR
DOCTOR TELLS YOU TO
16.CRUTCHES
ICD-10 CODE: ___.80
EXPECTED LENGTH: 13 MONTHS
PROGNOSIS: GOOD
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Primary:
Septic Arthritis due to gonorrhea
Acute Kidney Injury
Vaginal Bleeding
Secondary:
HIV
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: DX HAND AND WRIST
INDICATION: ___ year old woman with severe L wrist pain, joint tap shows WBC
of 145k// acute process acute process
acute process
TECHNIQUE: Frontal, oblique, and lateral view radiographs of the left hand.
COMPARISON: None
FINDINGS:
Fine osseous detail is obscured by the overlying cast. There is pronounced
soft tissue swelling extending from the base of the proximal phalanx to the
wrist and distal forearm. Within the limitations of the study, there is no
evidence of acute fracture or dislocation, significant degenerative changes,
bony erosions or periostitis, nor suspicious lytic or sclerotic lesions. No
soft tissue calcification or radio-opaque foreign bodies are detected.
IMPRESSION:
1. Pronounced soft tissue swelling extending from the base of the proximal
phalanx to the distal forearm without acute bony abnormality or osseous
erosions makes osteomyelitis less likely. However, fine osseous detail is
obscured by the overlying cast.
Radiology Report
EXAMINATION: RENAL U.S.
INDICATION: ___ year old woman with acute ___ s/p joint washout//
hydronephrosis?
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: None.
FINDINGS:
The right kidney measures 12.8 cm. The left kidney measures 11.4 cm.
Evaluation of the left kidney is limited due to poor acoustic window. There
is no hydronephrosis bilaterally. There is no mass or stones in the right
kidney. Normal cortical echogenicity and corticomedullary differentiation are
seen bilaterally.
The bladder was completely collapsed.
IMPRESSION:
Limited evaluation of the left kidney. However, no hydronephrosis
bilaterally.
Gender: F
Race: BLACK/CARIBBEAN ISLAND
Arrive by WALK IN
Chief complaint: Body pain
Diagnosed with Fever, unspecified
temperature: 100.6
heartrate: 97.0
resprate: 18.0
o2sat: 100.0
sbp: 144.0
dbp: 92.0
level of pain: 10
level of acuity: 3.0 | ___ with history of HIV, bilateral carpal tunnel syndrome, and
OA of knee who presents with oligoarthritis. She was found to
have septic arthritis due to gonorrhea and treated with surgical
washouts and doxycycline. Hospital course complicated by acute
renal failure of unclear etiology which improved prior to
discharge. Also found to have vaginal bleeding.
#Gonococcal Arthritis:
The patient presented with fever and severe joint pain. She had
tap of R knee prior to ED presentation which showed ___ WBC.
Tap of left wrist with ___ WBC, which was thought to be
concerning for septic arthritis. She was continued on
Vancomycin/CTX. The patient went for surgical washout of left
elbow, left wrist, and right knee with purulent fluid in the OR.
Her clinic knee culture subsequently grew rare staph which was
thought to be contaminant. Urine gonorrhea came back positive
which was likely cause of septic arthritis. The patient was
continued on CTX for gonococcal arthritis, which was
subsequently narrowed to doxycycline due to concern for AIN (see
below). The patient should continue a 2 week course of
doxycycline (___). She received one-time dose of 1g
azithromycin. Joint fluid cultures were pending at discharge and
should be followed-up in the clinic. She should follow-up with
___ clinic, orthopedic surgery, and hand surgery after discharge.
She was discharged on Tylenol for pain. Her partner was notified
with intent to seek partner treatment with his provider.
#Acute renal failure:
The patient's course was complicated by acute renal failure,
with creatinine peaking at 5.6 from baseline ~0.6. Unclear
etiology of this ___ but creatinine trended towards normal prior
to discharge. It should be noted that WBC casts were seen in the
urine, so the patient's CTX was changed to doxycycline due to
concern for AIN. This may have contributed to the cause.
Discharge Cr 2.0. Recommend repeat Cr and BMP in clinic.
Medications adjusted for renal failure should be re-adjusted
when creatinine returns to normal: ranitidine and lamivudine.
#Vaginal Bleeding:
The patient was found to have slowly downtrending Hb in the
setting of vaginal bleeding between periods. She remained
hemodynamically stable. She received 2U of pRBCs during
hospitalization for Hb 7.1 with slow downtrend. Her Hb was
subsequently stable and her bleeding stopped. UHCG negative. She
should follow-up in clinic with OB/GYN for further workup and
consideration of ultrasound and endometrial biopsy. She should
also have repeat CBC in clinic.
#HIV: Continued abacavir 600, lamivudine (dose adjusted for
renal dysfunction to 150 daily), and etravirine 400. CD4: 787.
HIV VL: NOT DETECTABLE.
#GERD: Continued ranitidine
#History of sleeve gastrectomy: Vit D, MV, B12
TRANSITIONAL ISSUES:
- Continue a 2 week course of doxycycline (___).
- She received one-time dose of 1g azithromycin.
- Joint fluid cultures were pending at discharge and should be
followed-up in the clinic.
- She should follow-up with ___ clinic, orthopedic surgery, and
hand surgery after discharge.
- She was discharged on Tylenol for pain and miralax for
constipation.
- Her partner was notified with intent to seek partner treatment
with his provider.
- Recommend repeat Cr and BMP in clinic. WHEN CREATININE RETURNS
TO NORMAL WILL NEED DOSES OF RANITIDINE AND LAMIVUDINE INCREASED
TO HOME-DOSE.
- Medications adjusted for renal failure should be re-adjusted
when creatinine returns to normal: ranitidine and lamivudine.
- She should follow-up with OB/GYN for continued workup of
vaginal bleeding between periods.
- Recommend repeat CBC in clinic for slow vaginal bleeding.
- Discharged with limited PO Zofran for nausea likely due to
doxycycline
# DISCHARGE CR: 2.0
# CODE: Full (confirmed)
# CONTACT: ___: ___ Daughter (*please note patient
does not want updates to go to anyone else besides her daughter) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Penicillins
Attending: ___.
Chief Complaint:
Chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ year old male with hx remote paroxysmal afib presenting as
transfer from OSH with c/o cough, n/diarrhea, and chest pain.
Patient reports onset of cough/congestion 4d ago. Cough
productive of green sputum. Had progressive fatigue, and
yesterday had 6 episodes watery diarrhea with nonbloody emesis
x1. Denies fevers/chills although did not take temp at home, no
recent travel or sick contacts
Yesterday evening then developed sharp left sided chest pain,
left sided, ___, also involving left shoulder. Pain lasted
about 10mins and went away on its own, denies associated
aggravating or releiving factors.
He presented to ___ where initial EKG showed STE in I, avL.
Patient received nitro/morphine x1 with improvement in chest
pain, however became bradycardic to the ___ with SBP 73/44,
received 0.5mg atropine. Also received ASA 325, ceftriaxone,
lovenox ___, toradol and 1L IVF. Plan was for PCI but this
was aborted after reviewing subsequent EKGs.
Also ceftriaxone x1 and 2L IVF. Trop/MB neg x2, WBC @ 15.3 with
52% bands. He was transferred to our ED for further eval.
In the ED, initial vitals: 99 87 126/68 18 96% 3L, Tm 104.9.
Iniital labs notable for chem-7 with bicarb 21, Bun/Cr ___
(baseline 1.0). CBC with plt 134, INR 1.3, lactate 2.5. trop
neg, LFTs WNL. Patient was given tylenol, vanc/levofloxacin,
oseltamivir and toradol x1, and 2L IVF. CXR was done with
evidence of bibasilar opacities concerning for rapidly
developing pneumonia vs. alveolar hemorrhage.
On arrival to the MICU, patient has no complaints. Says he is
feeling a little better. Denies dyspnea, chest pain, abdominal
pain, no further episodes emesis or diarrhea since yesterday.
Denies hemoptysis.
Past Medical History:
Low back pain
Disc disorder of lumbar region
PROSTATITIS, UNSPEC
H/O SCC left forehead ___
Atopic Dermatitis
paroxysmal atrial fibrillation - noticed on ETT in ___,
asymptomatic
Social History:
___
Family History:
Unknown/adopted
Physical Exam:
Admission Physical Exam:
========================
Vitals- T: 98.4 BP: 106/64 hr 87 94% 4L
General- awake, alert, NAD
HEENT- EOMI, PERRLA, OMM no lesions
Neck- supple JVP mildly elevated at 30deg to under mandible
CV- RRR, split s2 more prominent during inhalation, no murmurs
Lungs- rhonchi bilaterally with fair air movement, + egophany
LLB
Abdomen- mildly distended/hypertympanic, no r/g/r, +BS
GU- no foley
Ext- WWP no c/c/e
Neuro- CN II-XII intact, strength ___ in UE and ___ b/l
Dishcarge Physical Exam:
=========================
Vitals - 97.9, 126/88, HR 72, 18, 97% on RA
General- awake, alert, NAD
HEENT- EOMI, PERRLA, OMM no lesions
Neck- supple JVP mildly elevated at 30deg to under mandible
CV- RRR, split s2 more prominent during inhalation, no murmurs
Lungs- CTAB, improved egophany LLB
Abdomen- mildly distended/hypertympanic, no r/g/r, +BS
GU- no foley
Ext- WWP no c/c/e
Neuro- CN II-XII intact, strength ___ in UE and ___ b/l
Pertinent Results:
ADMISSION LABS
===============
___ 05:05AM BLOOD WBC-6.8 RBC-4.95 Hgb-15.3 Hct-46.1 MCV-93
MCH-30.9 MCHC-33.2 RDW-12.5 Plt ___
___ 05:05AM BLOOD ___ PTT-36.9* ___
___ 05:05AM BLOOD Glucose-127* UreaN-26* Creat-1.4* Na-137
K-4.0 Cl-101 HCO3-21* AnGap-19
___ 05:05AM BLOOD Albumin-3.9
___ 05:25AM BLOOD Lactate-2.5*
DISCHARGE LABS
===============
___ 05:40AM BLOOD WBC-8.4 RBC-3.55* Hgb-11.0* Hct-32.9*
MCV-93 MCH-30.9 MCHC-33.4 RDW-12.9 Plt ___
___ 05:40AM BLOOD Glucose-91 UreaN-10 Creat-0.9 Na-145
K-3.4 Cl-106 HCO3-27 AnGap-15
___ 05:40AM BLOOD Calcium-7.4* Phos-3.3# Mg-1.9
IMAGING
=======
TTE: Normal global and regional biventricular systolic
function. No diastolic dysfunction, pulmonary hypertension or
pathologic valvular abnormality seen. No pericardial effusion.
CXR:
Short interval development of bibasilar opacities, which are
concerning for a rapidly developing pneumonia versus alveolar
hemorrhage.
CT CHEST W/CONTRAST (___): 1. Bilateral pleural effusions,
moderate on the left side without evidence of empyema. 2.
Multifocal airspace disease which is predominant at the lung
bases and is likely in keeping with multifocal pneumonia.
Multiple mediastinal and hilar reactive lymph nodes are noted.
3. Incidental finding of a 6 mm non-obstructing stone in the
upper pole of the left kidney.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 1000 mg PO Q6H:PRN pain
2. Docusate Sodium 200 mg PO BID
RX *docusate sodium [Colace] 100 mg 1 capsule(s) by mouth twice
a day Disp #*60 Capsule Refills:*0
3. Guaifenesin ___ mL PO Q6H:PRN cough
RX *guaifenesin 100 mg/5 mL 5 mL by mouth every 6 hours Disp #*1
Bottle Refills:*0
4. Levofloxacin 750 mg PO DAILY
RX *levofloxacin 750 mg 1 tablet(s) by mouth daily Disp #*4
Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
Primary: Pneumonia
Secondary: Ileus
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Cough and tachypnea.
COMPARISON: Comparison is made with chest radiographs from ___.
FINDINGS:
PA and lateral images of the chest. There has been interval development of
bibasilar opacities, which are concerning for a rapidly developing pneumonia
versus alveolar hemorrhage. There appears to be a small left pleural
effusion. There is no right pleural effusion or pneumothorax. The
cardiomediastinal silhouette is unremarkable.
IMPRESSION:
Short interval development of bibasilar opacities, which are concerning for a
rapidly developing pneumonia versus alveolar hemorrhage.
Radiology Report
AP CHEST, 7:27 A.M., ___.
HISTORY: ___ man with rapidly developing basilar opacities.
IMPRESSION: AP chest compared to ___:
Large scale consolidation in both lower lungs developed between ___, most likely severe pneumonia or pulmonary hemorrhage. Aspiration is most
likely scenario. Mild-to-moderate cardiomegaly unchanged. Pulmonary vascular
congestion is probably a function of volume resuscitation. Small left pleural
effusion is larger, small right pleural effusion, presumed. No pneumothorax.
Radiology Report
INDICATION: ___ year old man with pneumonia and distended abdomen, evaluate
for intra-abdominal process
TECHNIQUE: Single portable supine radiograph of the abdomen and pelvis was
obtained.
COMPARISON: None available.
FINDINGS:
There is mild gaseous distension of loops of small and large bowel with air
seen within the rectum. No definite intraperitoneal free air is identified.
Right basilar opacities partially imaged and better characterized on chest
radiograph from the same day.
IMPRESSION:
Mild gaseous distention of loops of small and large bowel with air seen within
the rectum. No evidence of obstruction.
Radiology Report
PORTABLE CHEST FILM ___ AT 7:34.
CLINICAL INDICATION: ___ with pneumonia, here for followup.
Comparison to ___ at 7:27.
A portable AP upright chest film ___ at 7:34 is submitted.
IMPRESSION:
There is persistent opacification within the left lower lobe and to a somewhat
lesser extent at the right lung base. These findings would be consistent with
aspiration or pneumonia. The heart remains enlarged. No pulmonary edema.
Probable small layering left effusion. No evidence of pneumothorax. Marked
thoracolumbar curvature.
Radiology Report
INDICATION: ___ man with history of pneumonia and bacteremia.
Evaluate for empyema.
COMPARISON: No prior CT scan is available for comparison. Prior chest x-rays
of ___ and ___ available for review.
TECHNIQUE: Axial helical MDCT images were obtained of the chest after the
administration of IV contrast. Multiplanar reformats were generated in the
coronal and sagittal planes.
DLP: 323 mGy-cm
FINDINGS: There are bilateral pleural effusions, moderate on the left and
small on the right. Loculated fluid is seen along the left major fissure.
There is no enhancement of the pleural cavity to suggest an empyema. There is
no pericardial effusion.
The vessels of the mediastinum are patent. The main pulmonary artery is
borderline in size, measuring 32 mm. There are multiple enlarged and prominent
hilar and mediastinal lymph nodes. There is a 1 cm right paratracheal lymph
node (series 3, image 19) and bilateral hilar lymph nodes measuring 9 mm on
the right (series 3, image 26) and 9 mm on the left (series 3, image 28).
These are likely reactive in nature. The trachea and proximal segmental
bronchi are patent. There are bilateral patchy airspace and ground-glass
opacities which are more predominant at the bases and most likely represent
multifocal pneumonia and associated atelectasis. There is no pneumothorax.
There is a non-obstructing 6 mm stone in the upper pole of the left kidney.
The remainder of the visualized portion of the abdomen is unremarkable.
No suspicious bony lesions. Dextroconvex thoracolumbar scoliosis. 14 mm
rounded hyperdensity in the soft tissues of the back in the midline which may
represent a sebaceous cyst (6b;115).
IMPRESSION:
1. Bilateral pleural effusions, moderate on the left side without evidence of
empyema.
2. Multifocal airspace disease which is predominant at the lung bases and is
likely in keeping with multifocal pneumonia. Multiple mediastinal and hilar
reactive lymph nodes are noted.
3. Incidental finding of a 6 mm non-obstructing stone in the upper pole of
the left kidney.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED
temperature: 99.0
heartrate: 87.0
resprate: 18.0
o2sat: 96.0
sbp: 126.0
dbp: 68.0
level of pain: 0
level of acuity: 3.0 | BRIEF SUMMARY STATEMENT: Mr. ___ is a ___ year old male with
no significant medical history presenting as transfer from OSH
with c/o cough, n/d/diarrhea, and chest pain found to have fever
and hypoxia. On further work-up, pt. was found to have a
multifocal pneumonia. Culture data was unrevealing. Pt. was
placed on antibiotics and continued to improve. His O2
requirement resolved and he was discharged with close follow-up.
ACTIVE ISSUES
=============
# Sepsis and Community Acquired Pneumonia: Mr. ___
presented with tachycardia, temp to 104, and multifocal
opacities seen on CXR. He was started on ceftriaxone and
levofloxacin in accordance to ___ guidelines for community
acquired pneumonia. Respiratory viral panel negative,
legionella negative, strep pneumo antigen negative, and cultures
were unrevealing. Pt. grew GPCs in clusters in blood ___
bottles) which raised concern for possible MRSA bacteremia from
MRSA pneumonia. Pt. has negative MRSA swab and without known
MRSA risk factors. TTE was negative for evidence of
endocarditis and surveillance blood cultures were negative.
Oxygen requirement had resolved by day 2 of admission and he was
transferred to the floor. He was transitioned to levofloxacin
to complete his course of antibiotics.
# Chest Pain: Pt. complained of left sided sharp chest pain
made worse with coughing and deep breathing. Most likely
pleuritic chest pain from underlying inflammatory pleuritis from
pneumonia. Cardiac enzymes neg x2 making cardiac ischemia less
likely. No ischemic changes or other notable changes seen on
ECG. TTE done on ___ and was grossly normal with LVEF 60-65%.
# Abdominal Distension: Initially, pt. presented with diarrhea,
CDiff negative. Continued to complain of abdominal distension.
KUB showed multiple air filled loops of bowel without air fluid
levels consistent with possible ileus. Pt. continued to
complain of minimal flatus, abdominal distension made worse with
consuming POs, and minimal BMs. Slowly, he began to tolerate PO
intake. At time of discharge, pt. was tolerating full liquids
without issue. He was encouraged to advance his diet as
tolerated.
# Anemia: Patient with downtrending Hct throughout this
admission. Initial and repeat DIC labs returned negative. Most
likely etiology ___ bone marrow suppression due to acute illness
with possible suppression ___ medication effect. No signs of
active bleeding.
# ___: Pt. with evidence ___ on admission. Likely pre-renal
etiology in the setting of pneumonia and sepsis. With IVF, pt's
creatinine returned to baseline and ___ resolved.
CHRONIC ISSUES
==============
# BPH: Stable. Continued on flomax
TRANSITIONAL ISSUES
===================
# Antibiotics: Pt. should continue levofloxacin for an
additional 4 days to complete a 10 day course. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfa (Sulfonamide Antibiotics) / Novocain / Lidocaine /
Penicillins / Fentanyl / Morphine / Codeine / Motrin
Attending: ___.
Chief Complaint:
nausea, polyuria, polydipsia
Major Surgical or Invasive Procedure:
PATIENT LEFT AMA. She did not wait for her paperwork, but was
given a prescription for Metformin and instructed to follow up
with her PCP.
History of Present Illness:
___ with a PMH of HepC, arthritis on a narcotics contract, and
multiple admission for ___ who presents with four days of
malaise, fatigue, polyuria, and polydipsia. She called EMS and
was found to have a FSBG >500 by EMS and brought into the ED.
The patient is a poor historian, but notes subjective fevers,
chills, cough, dysuria, and genital rash. She denied a history
of diabetes or insulin use. She states that she eats
significant amounts of sugar in the form of Koolaid, ice cream,
and cookies.
In the ED, initial vitals were: 98.7 78 155/97 16 94% RA
Her glucose was >1000 and and AG of 26. She was given 10U of
insulin and 3L of IV fluids. Her AG fell to 16 and her
fingerstick fell to 513.
On the floor, the patient arrived stating she felt much improved
compared to when she had come in the ED. She expressed a desire
to use diet and oral medications to control her diabetes rather
than insulin, even acutely here while recovering.
Review of systems:
(+) Per HPI
(-) Denies headache, sinus tenderness, rhinorrhea or congestion.
Denies shortness of breath. Denies chest pain or tightness,
palpitations. Denies nausea, vomiting, diarrhea, constipation or
abdominal pain. Denies arthralgias or myalgias.
Past Medical History:
- seen by neurology for HA, sleep walking, possible long fiber
neuropathy
- chronic lower back pain
- arthritis, on narcotics, has history of requesting early
refills
- HTN
- HL
- HepC
- GERD
- Depression
- H/o viral labryinthitis with persistent vertigo
- H/o MRSA PNA
- H/o
- S/p bilateral carpal tunnel release ___
Social History:
___
Family History:
Sister with CAD in her ___.
Physical Exam:
ADMISSION:
Vitals: 97.7 149/91 66 70 99% RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL
Neck: supple, no LAD
CV: Regular rate and rhythm, normal S1 + S2, II/VI SEM best at
LUSB
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly, no rebound or guarding
GU: no foley, white film surrounding labia
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CNII-XII intact, ___ strength upper/lower extremities,
grossly normal sensation
DISCHARGE EXAM:
Patient left AMA.
Pertinent Results:
ADMISSION LABS:
___ 09:56PM URINE COLOR-Straw APPEAR-Clear SP ___
___ 09:56PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-10 BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 09:56PM URINE RBC-4* WBC-3 BACTERIA-FEW YEAST-RARE
EPI-1
___ 09:56PM URINE MUCOUS-RARE
___ 03:15PM GLUCOSE-388* UREA N-10 CREAT-0.9 SODIUM-139
POTASSIUM-3.9 CHLORIDE-102 TOTAL CO2-25 ANION GAP-16
___ 03:15PM CALCIUM-10.3 PHOSPHATE-2.3* MAGNESIUM-2.2
___ 03:15PM OSMOLAL-302
___ 09:52AM ___ PO2-46* PCO2-49* PH-7.34* TOTAL
CO2-28 BASE XS-0 COMMENTS-PERIPHERAL
___ 09:52AM GLUCOSE-GREATER TH LACTATE-2.0 NA+-137 K+-4.0
CL--98 TCO2-25
___ 09:52AM O2 SAT-73
___ 09:45AM GLUCOSE-693* UREA N-12 CREAT-0.9 SODIUM-136
POTASSIUM-4.0 CHLORIDE-99 TOTAL CO2-25 ANION GAP-16
___ 09:45AM CALCIUM-9.8 PHOSPHATE-3.4 MAGNESIUM-2.1
___ 08:45AM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 07:13AM GLUCOSE->500 LACTATE-3.0* NA+-130* K+-4.3
CL--88* TCO2-24
___ 07:00AM GLUCOSE-1021* UREA N-15 CREAT-1.1 SODIUM-127*
POTASSIUM-4.6 CHLORIDE-83* TOTAL CO2-23 ANION GAP-26*
___ 07:00AM cTropnT-<0.01
___ 07:00AM WBC-9.6# RBC-5.03 HGB-16.2* HCT-52.0*
MCV-104* MCH-32.3* MCHC-31.2 RDW-12.7
___ 07:00AM NEUTS-75.7* ___ MONOS-3.2 EOS-0.8
BASOS-0.9
___ 07:00AM PLT COUNT-247
STUDIES:
___ CXR - no acute process
DISCHARGE LABS:
___ 07:15AM BLOOD WBC-6.3 RBC-4.45 Hgb-14.6 Hct-44.5
MCV-100* MCH-32.8* MCHC-32.8 RDW-13.0 Plt ___
___ 07:15AM BLOOD Glucose-384* UreaN-9 Creat-0.7 Na-135
K-4.1 Cl-102 HCO3-24 AnGap-13
___ 07:15AM BLOOD Calcium-9.8 Phos-1.7* Mg-2.0
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. OxycoDONE (Immediate Release) 15 mg PO Q6H:PRN pain
2. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
3. Atenolol 25 mg PO DAILY
4. Amlodipine 10 mg PO DAILY
5. Simvastatin 10 mg PO DAILY
6. Vitamin D 1000 UNIT PO DAILY
7. Omeprazole 20 mg PO DAILY
8. Acetaminophen 500 mg PO Q6H:PRN pain
9. Gabapentin 600 mg PO TID
10. Meclizine 25 mg PO Q8H:PRN vertigo
Discharge Medications:
1. MetFORMIN (Glucophage) 500 mg PO BID
RX *metformin 500 mg 1 tablet(s) by mouth twice a day Disp #*30
Tablet Refills:*0
2. Acetaminophen 500 mg PO Q6H:PRN pain
3. Amlodipine 10 mg PO DAILY
4. Atenolol 25 mg PO DAILY
5. Gabapentin 600 mg PO TID
6. Meclizine 25 mg PO Q8H:PRN vertigo
7. Omeprazole 20 mg PO DAILY
8. OxycoDONE (Immediate Release) 15 mg PO Q6H:PRN pain
9. OxyCODONE SR (OxyconTIN) 10 mg PO Q12H
10. Vitamin D 1000 UNIT PO DAILY
11. Simvastatin 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
primary diagnosis:
hyperglycemia
secondary diagnosis:
chronic pain, opiate use
vaginal yeast infection
Discharge Condition:
PATIENT LEFT AMA. She did not wait for her paperwork, but was
given a prescription for Metformin and instructed to follow up
with her PCP.
Followup Instructions:
___
Radiology Report
HISTORY: Cough and fever. Assess for pneumonia.
COMPARISON: ___.
FINDINGS: 2 views were obtained of the chest. The lungs are clear. There is
no pneumothorax or pleural effusion aside from trace fluid on the minor
fissure. Heart and mediastinal contours are unremarkable.
IMPRESSION: No acute intrathoracic process. Trace fluid on the minor fissure.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: HYPERGLYCEMIA
Diagnosed with NIDDM UNCONTROLLED
temperature: 98.7
heartrate: 78.0
resprate: 16.0
o2sat: 94.0
sbp: 155.0
dbp: 97.0
level of pain: 13
level of acuity: 3.0 | # Hyperglycemia - appeared HHS > DKA and was treated with SC
insulin and 4L of IV fluids to good effect in ED and
normalization of her serum osms. Her K and Phos were repleted.
A search for infectious causes of her presentation including UA
and CXR was unrevealing and the patient was afebrile. On
admission the patient was refusing further insulin. She
repeatedly stated she wished to manage her blood sugars with
diet and oral medications. She understood that this was a
dangerous therapy for her acute condition and that there were
risks including death. She was started on metformin 500 BID and
her sugars on the floor ranged between 300 to 400. She left
against medical advice with a prescription for oral metformin
and stated that she would follow up with her PCP. She
understood the risks of leaving and that she may have to return
in an ambulance or die as a result. An A1c was pending at
discharge.
# thick vaginal discharge - treated empirically with one dose of
fluconazole
# HTN - continued home amlodipine and atenolol
# HL - held simvastatin due to increased risk of rhabdo with
fluc
# Chronic pain - continued gabapentin, oxycodone, oxycontin.
Doses and refills confirmed with ___.
# Vertigo - continued home meclizine
# GERD - continued home omeprazole |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Motrin / aspirin
Attending: ___
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ female past medical history significant for smoking,
COPD presented to the emergency department with a 3-day history
of worsening of shortness of breath with exertion as well as
intermittent lower extremity edema. Patient states that she has
for the past few months had dyspnea walking up stairs, but no
associated chest pain. Patient denies any fevers, chills but
endorses significant coughing with some green/brown sputum the
past few days. Patient states that this feels consistent with
her
prior COPD episodes but feels worse. If she attempts to ambulate
for father than a few steps, she has a coughing fit and feels
like she cannot breath. No lightheadedness or falls.
Last TTE ___ with normal EF
Spirometry ___ FEV1/FVC 65%, ___ 92%
In the ED:
- Initial vital signs were notable for:
T98 HR96 BP130/66 RR16 O2-95
- Exam notable for:
GA: Comfortable
HEENT: No scleral icterus
Cardiovascular: Normal S1, S2, regular rate and rhythm, no
murmurs/rubs/gallops, 2+ peripheral pulses bilaterally
Pulmonary: Rhonchi
Abdominal: Soft, nontender, nondistended, no masses
Extremities: No lower leg edema
Integumentary: No rashes noted
- Labs were notable for:
FluAPCR: Negative
FluBPCR: Negative
BNP 292
- Studies performed include: CXR w volume overload
- Patient was given:
___ 18:44 PO PredniSONE 50 mg
___ 18:44 IH Ipratropium-Albuterol Neb 1 NEB
___ 18:48 IH Ipratropium-Albuterol Neb 1 NEB
___ 22:41 IV Azithromycin
___ 00:27 NEB Ipratropium-Albuterol Neb 1 NEB
___ 05:06 NEB Ipratropium-Albuterol Neb 1 NEB
___ 08:28 PO/NG PredniSONE 50 mg
- Consults: none
Vitals on transfer: T98 HR76 BP131/80 RR16 ___
Upon arrival to the floor, patient confirms the above history.
Respiratory decline has been going on for several months but she
cannot identify clear trigger. Initially had trouble going up
steps in her house, now also gets out of breath going down steps
or walking on flat ground. She is unable to sleep flat because
she "chokes" and needs to sit up. Denies chest pain or pressure
at any time. No hemoptysis. Lives alone with her cat, no one
around her are recent illnesses.
REVIEW OF SYSTEMS: Complete ROS obtained and is otherwise
negative.
Past Medical History:
- Nephrolithiasis with 4mm left UPJ stone in ___
- COPD
- Asthma
- Tubal pregnancy
- Seizure disorder
- Allergic rhinitis
- GERD
- Overweight
- Sciatica
- Stress incontinence
- Active smoking
- Depression with psychotic features, multiple prior suicide
attempts
- Bipolar disorder
- History of pneumothorax
- Pulmonary nodule
- Chronic back pain
Social History:
___
Family History:
Heart disease, diabetes in multiple family members (MGM, ___.
MI
in PGM. Father with lung cancer.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VITALS: 24 HR Data (last updated ___ @ 1129)
Temp: 97.2 (Tm 98.1), BP: 94/50 (94-118/50-73), HR: 69 (69-74),
RR: 16, O2 sat: 97%, O2 delivery: 2L, Wt: 249.12 lb/113.0 kg
GEN: Overnweight, sitting up in NAD, coughing frequently,
speaking in full sentences
HEENT: Sclera anicteric and without injection. MMM.
NECK: Large, unable to visualize JVD but limited ___ habitus.
CARDIAC: rrr, no mrg but difficult exam given coughing
LUNGS: difficult exam as patient coughing w deep breaths.
diffuse
wheezing, rhonchi in upper lobes, crackles in bilateral lower
fields. normal WOB on 2L NC
ABDOMEN: obese, non-tender, non-distended, no rebound/guarding
EXTREMITIES: warm, 1+ pitting edema bilateral, no cyanosis
NEUROLOGIC: AOx3, CN2-12 intact. ___ strength throughout.
DISCHARGE PHYSICAL EXAM:
24 HR Data (last updated ___ @ 753)
Temp: 97.7 (Tm 98.5), BP: 124/78 (120-134/57-84), HR: 66
(66-80), RR: 20 (___), O2 sat: 96% (94-98), O2 delivery: 2L,
Wt: 236.1 lb/107.09 kg
GEN: Overweight, NAD, coughing intermittently, speaking in full
sentences
HEENT: Sclera anicteric and without injection. MMM.
NECK: supple, no LVD
CARDIAC: rrr, no mrg but difficult exam given coughing
LUNGS: diffuse wheezing, rhonchi in upper lobes, crackles in
bilateral lower fields. normal WOB on 2L NC
ABDOMEN: obese, non-tender, non-distended, no rebound/guarding
EXTREMITIES: warm, no cyanosis, trace edema
NEUROLOGIC: AOx3, CN2-12 intact grossly, moving all extremities
with purpose
Pertinent Results:
ADMISSION LABS:
===============
___ 06:54PM BLOOD WBC-8.2 RBC-4.65 Hgb-13.9 Hct-42.2 MCV-91
MCH-29.9 MCHC-32.9 RDW-13.4 RDWSD-44.7 Plt ___
___ 06:54PM BLOOD ___ PTT-25.7 ___
___ 06:54PM BLOOD Glucose-96 UreaN-13 Creat-0.9 Na-141
K-4.3 Cl-107 HCO3-24 AnGap-10
___ 06:54PM BLOOD proBNP-292*
___ 06:54PM BLOOD cTropnT-<0.01
___ 11:35PM BLOOD cTropnT-<0.01
___ 05:40AM BLOOD Calcium-8.9 Phos-3.3 Mg-2.2
___ fluAPCR, fluBPCR - negative
DISCHARGE LABS:
===============
___ 08:15AM BLOOD Glucose-97 UreaN-19 Creat-0.8 Na-141
K-4.2 Cl-105 HCO3-26 AnGap-10
___ 08:15AM BLOOD Calcium-9.0 Phos-3.6 Mg-2.0
MICRO:
======
none
IMAGING:
========
___ CTA CHEST:
There is no thoracic aortic dissection or aneurysm. There is
mild scattered
noncalcified atherosclerotic plaque throughout the thoracic
aorta.
The pulmonary arteries are well opacified to the subsegmental
level, with no
evidence of filling defect to indicate the presence of pulmonary
embolism.
The main and right pulmonary arteries are normal in caliber, and
there is no
evidence of right heart strain. Heart size is normal. There is
no
pericardial effusion.
The visualized inferior aspect of the thyroid gland appears
unremarkable.
There is no supraclavicular or axillary lymphadenopathy.
Borderline right
paratracheal lymph nodes measuring up to 10 mm in short axis are
stable.
There is no hilar lymphadenopathy.
There is no pleural effusion.
There is mild paraseptal emphysema, most pronounced in the
bilateral upper
lobes. A 4 mm left fissural nodule likely represents a lymph
node (series
301, image 94). A 6 mm paramediastinal nodular density in the
left upper lobe
(series 2, image 37) is also stable. There is mild diffuse
peripheral
reticulation. There is no consolidation. There is mild linear
subsegmental
atelectasis and/or scarring in the bilateral lung bases. The
airways are
patent to the subsegmental level.
This study is not tailored for subdiaphragmatic evaluation.
Visualized upper
abdominal structures are unremarkable. There is a small hiatal
hernia.
There is no suspicious osseous lesion. There are mild
multilevel endplate
degenerative changes of the thoracic spine.
IMPRESSION:
1. No evidence of pulmonary embolism or acute pulmonary
parenchymal process.
___ TTE:
The left atrial volume index is normal. The right atrium is
mildly enlarged. There is mild symmetric left ventricular
hypertrophy with a normal cavity size. There is normal regional
and global left ventricular systolic function. Quantitative
biplane left ventricular ejection fraction is 71 %. There is no
resting left ventricular outflow tract gradient. Normal right
ventricular cavity size with normal free wall motion. The aortic
sinus diameter is normal for gender with normal ascending aorta
diameter for gender. The aortic arch diameter is normal with a
mildly dilated descending aorta. There is no evidence for an
aortic arch coarctation. The aortic valve leaflets (3) appear
structurally normal. There is no aortic valve stenosis. There is
no aortic regurgitation. The mitral valve leaflets appear
structurally normal with no mitral valve prolapse. There is
trivial mitral regurgitation. The tricuspid valve leaflets
appear structurally normal. There is physiologic tricuspid
regurgitation. The estimated pulmonary artery systolic pressure
is normal. There is no pericardial effusion.
IMPRESSION: Suboptimal image quality. Mild symmetric left
ventricular hypertrophy with normal cavity size and
regional/global biventricular systolic function. No valvular
pathology or pathologic flow identified. Normal pulmonary artery
systolic pressure.
___ CXR:
Persistent mild pulmonary edema.
___ CXR:
Top-normal heart size with increased interstitial opacity
suggestive of
interstitial pulmonary edema.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
2. ClonazePAM 0.5 mg PO DAILY:PRN panic attack
3. Aspirin 81 mg PO DAILY
4. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
5. Cetirizine 10 mg PO DAILY
6. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
GERD
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY
8. TraZODone 50-100 mg PO Frequency is Unknown unknown
9. HydrOXYzine 50 mg PO Q6H:PRN anxiety
10. Omeprazole 20 mg PO DAILY
11. diclofenac sodium 1 % topical QID:PRN
Discharge Medications:
1. Azithromycin 250 mg PO DAILY Duration: 4 Doses
RX *azithromycin 250 mg 1 tablet(s) by mouth once a day Disp #*1
Tablet Refills:*0
2. Nicotine Patch 14 mg/day TD DAILY
RX *nicotine [Nicoderm CQ] 14 mg/24 hour apply one 14mg/24hr
daily transdermal patch once a day Disp #*30 Patch Refills:*0
3. PredniSONE 40 mg PO DAILY Duration: 3 Doses
RX *prednisone 20 mg 2 tablet(s) by mouth once a day Disp #*2
Tablet Refills:*0
4. TraZODone 50-100 mg PO QHS:PRN unknown
5. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
GERD
6. Aspirin 81 mg PO DAILY
7. Cetirizine 10 mg PO DAILY
8. ClonazePAM 0.5 mg PO DAILY:PRN panic attack
9. diclofenac sodium 1 % topical QID:PRN pain
10. Fluticasone Propionate NASAL 2 SPRY NU DAILY
11. Fluticasone-Salmeterol Diskus (500/50) 1 INH IH BID
12. HydrOXYzine 50 mg PO Q6H:PRN anxiety
13. Omeprazole 20 mg PO DAILY
14. ProAir HFA (albuterol sulfate) 90 mcg/actuation inhalation
Q4H:PRN
15.Outpatient Physical Therapy
ICD10 H81.10 benign paroxysmal vertigo, unspecified ear
Please perform vestibular physical therapy
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses:
Acute hypoxemic respiratory failure
COPD exacerbation
Pulmonary edema
Secondary diagnosis:
Benign paroxysmal positional vertigo
Panic attacks
GERD
Tobacco abuse
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: ___ year old woman with COPD admitted with worsening SOB/DOE and
being treated for COPD exacerbation. Pulm edema of unclear etiology was noted
on prior imaging.// Interval change of pulmonary edema?
TECHNIQUE: Chest PA and lateral
COMPARISON: Radiograph of the chest performed on ___.
FINDINGS:
Mild cardiomegaly is unchanged compared to the prior exam. Mild pulmonary
edema is unchanged. No large pleural effusion or pneumothorax. Visualized
osseous structures are grossly unremarkable.
IMPRESSION:
Persistent mild pulmonary edema.
Radiology Report
EXAMINATION: CTA CHEST
INDICATION: ___ woman w hx COPD (last PFTs "normal" per ___ note
___, ongoing smoker, presented w acute on chronic SOB and DOE, symptoms and
findings concerning for both COPD exacerbation as well as potential congestive
heart failure. However, PE is in differential given new O2 requirement and
worsening SOB, in setting of recent ankle injury. // evidence of PE?
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 2.5 s, 32.7 cm; CTDIvol = 23.2 mGy (Body) DLP = 758.4
mGy-cm.
2) Stationary Acquisition 0.6 s, 0.5 cm; CTDIvol = 2.7 mGy (Body) DLP = 1.3
mGy-cm.
3) Stationary Acquisition 3.6 s, 0.5 cm; CTDIvol = 16.1 mGy (Body) DLP =
8.1 mGy-cm.
Total DLP (Body) = 768 mGy-cm.
COMPARISON: CT from ___.
FINDINGS:
There is no thoracic aortic dissection or aneurysm. There is mild scattered
noncalcified atherosclerotic plaque throughout the thoracic aorta.
The pulmonary arteries are well opacified to the subsegmental level, with no
evidence of filling defect to indicate the presence of pulmonary embolism.
The main and right pulmonary arteries are normal in caliber, and there is no
evidence of right heart strain. Heart size is normal. There is no
pericardial effusion.
The visualized inferior aspect of the thyroid gland appears unremarkable.
There is no supraclavicular or axillary lymphadenopathy. Borderline right
paratracheal lymph nodes measuring up to 10 mm in short axis are stable.
There is no hilar lymphadenopathy.
There is no pleural effusion.
There is mild paraseptal emphysema, most pronounced in the bilateral upper
lobes. A 4 mm left fissural nodule likely represents a lymph node (series
301, image 94). A 6 mm paramediastinal nodular density in the left upper lobe
(series 2, image 37) is also stable. There is mild diffuse peripheral
reticulation. There is no consolidation. There is mild linear subsegmental
atelectasis and/or scarring in the bilateral lung bases. The airways are
patent to the subsegmental level.
This study is not tailored for subdiaphragmatic evaluation. Visualized upper
abdominal structures are unremarkable. There is a small hiatal hernia.
There is no suspicious osseous lesion. There are mild multilevel endplate
degenerative changes of the thoracic spine.
IMPRESSION:
1. No evidence of pulmonary embolism or acute pulmonary parenchymal process.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Dyspnea
Diagnosed with Chronic obstructive pulmonary disease w (acute) exacerbation
temperature: 98.0
heartrate: 96.0
resprate: 16.0
o2sat: 95.0
sbp: 130.0
dbp: 66.0
level of pain: 6
level of acuity: 2.0 | ___ woman w hx COPD (last PFTs "normal" per ___ pulm note
___, ongoing smoker, presented w acute on chronic SOB and DOE,
symptoms and findings concerning for both COPD exacerbation as
well as potential congestive heart failure. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Right facial droop, headache, and chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
At work, around 9:45 am, the patient reported the acute onset of
a headache, along with chest pain and a right facial droop. The
headache came on suddenly and remained in the front of his head.
He experienced nausea, but no vomiting, photophobia, or vision
changes. The chest pain was located substernally and was sharp.
The patient reported that it felt "like food was stuck in my
throat". The pain did not radiate and was constant. He felt
that the right side of his face had drooped, but was not sure if
it involved his forehead. He was able to comprehend speech but
was non-fluent. He knew what he wanted to say and thought he
was speaking clearly, but others noted that his speech was
slurred but could be understood. A friend drove him home where
his wife was returning from work, at which time she noted his
right face was drooping. She activated EMS for transport to
___ ED for further evaluation. On arrival, his symptoms per
the wife and clinical evaluation by the ED were gone (around
1200hrs).
Per the patient and his wife's report, the patient has had a
number of episodes similar to this in the past years with the
most recent in ___ specifically, the facial weakness on the
right side. He did not seek medical attention for these
episodes, except for the first one that occured in ___.
On neuro ROS, the pt denied loss of vision, blurred vision,
diplopia, dysphagia, lightheadedness, vertigo, tinnitus or
hearing difficulty. Denied difficulties producing or
comprehending speech. Denied focal weakness, numbness,
parasthesiae. No bowel or bladder incontinence or retention.
Denied difficulty with gait.
On general review of systems, the pt denied recent fever or
chills. No night sweats or recent weight loss or gain. Denied
cough. Denied palpitations. Denied nausea, vomiting, diarrhea,
constipation or abdominal pain. No recent change in bowel or
bladder habits. No dysuria. Denied arthralgias or myalgias.
Denied rash.
Past Medical History:
- Multiple reported TIA's in the past few years (reported by
patient, evaluation was at ___)
- Hepatitis C
- Peripheral Artery Disease
- COPD/Asthma
- Hyperlipidemia
- Hypertension
- Elevated blood sugars ___ A1c% was >7%)
- Active Tobacco Abuse
- Obesity
Social History:
___
Family History:
- Per patient no history of cardiovascular disease, or stroke
- Several relatives with lupus, including death of ___ year old
son.
Physical Exam:
ADMISSION PHYSICAL EXAM
Vitals:
Pain=7, T=98.3F, HR=56, BP=150/68, RR=16, SaO2=96% RA , Glucose
99
General: Awake, cooperative, NAD.
HEENT: NC/AT
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, pulses palpated
Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
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. Attentive, had good knowledge of current events.
There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm, both directly and consentually; brisk
bilaterally. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch, pinprick in all
distributions, and ___ strength noted bilateral in masseter
VII: Right facial droop with good activation, facial musculature
symmetric and ___ strength in upper and lower distributions,
bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline, and is equal ___ strength
bilaterally as evidenced by tongue-in-cheek testing.
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ ___ 5 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
- Plantar response was flexor bilaterally.
- Pectoralis Jerk was absent, and Crossed Adductors are absent.
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: Did not assess
==========================================
DISCHARGE PHYSICAL EXAM
T=98.1F, HR=49-55, BP=135-157/67-88, RR=20, SaO2=94-96% RA ,
Glucose: 76-113
General: Awake, alert, oriented x3. Slightly frustrated by exam
and having to repeat answers to questions.
HEENT: NC/AT, MMM
Neck: Supple, no carotid bruits appreciated. No nuchal rigidity
Pulmonary: CTABL, no rhonchi, rales, or wheezes
Cardiac: RRR, no murmurs
Abdomen: soft, nontender, nondistended
Extremities: no edema, WWP
Skin: no rashes or lesions noted
Neurologic:
-Mental Status: Alert, oriented x 3. Able to relate history
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. Attentive, had good knowledge of current events.
There was no evidence of apraxia or neglect.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 4 to 2mm, both directly and consentually; brisk
bilaterally. VFF to confrontation.
III, IV, VI: EOMI without nystagmus. Normal saccades.
V: Facial sensation intact to light touch, pinprick in all
distributions, and ___ strength noted bilateral in masseter
VII: Slight face asymmetry but with good activation, facial
musculature
symmetric and ___ strength in upper and lower distributions,
bilaterally
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline
-Motor: Normal bulk, tone throughout. No pronator drift
bilaterally. No adventitious movements, such as tremor, noted.
No
asterixis noted.
Delt Bic Tri WrE FFl FE IO IP Quad Ham TA ___
L ___ ___ ___ 5 5 5 5 5
R ___ ___ ___ 5 5 5 5 5
-DTRs:
Bi Tri ___ Pat Ach
L 2 2 2 2 2
R 2 2 2 2 2
- Plantar response was flexor bilaterally.
-Sensory: No deficits to light touch, pinprick, cold sensation,
vibratory sense, proprioception throughout. No extinction to
DSS.
-Coordination: No intention tremor, no dysdiadochokinesia noted.
No dysmetria on FNF or HKS bilaterally.
-Gait: normal gait but some difficulty with tandem gait
Pertinent Results:
___ 01:00PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG mthdone-NEG
___ 12:18PM GLUCOSE-103 LACTATE-1.2 NA+-140 K+-4.2
CL--101 TCO2-25
___ 12:11PM GLUCOSE-105* UREA N-13 CREAT-0.9 SODIUM-140
POTASSIUM-4.2 CHLORIDE-104 TOTAL CO2-25 ANION GAP-15
___ 12:11PM ALT(SGPT)-66* AST(SGOT)-63* ALK PHOS-86 TOT
BILI-0.5
___ 12:11PM cTropnT-<0.01
___ 12:11PM ALBUMIN-4.0 CALCIUM-9.2 PHOSPHATE-3.7
MAGNESIUM-2.2
___ 12:11PM ASA-NEG ETHANOL-NEG ACETMNPHN-NEG
bnzodzpn-NEG barbitrt-NEG tricyclic-NEG
___ 12:11PM WBC-11.4*# RBC-6.94* HGB-17.0 HCT-51.8
MCV-75* MCH-24.5* MCHC-32.8 RDW-15.7*
___ 12:11PM PLT COUNT-247
___ 12:11PM ___ PTT-35.2 ___
CT: No acute intracranial process. Please note, MRI is more
sensitive for
detecting acute ischemia. No thrombosis, aneurysm or dissection
within the principal arteries of the head and neck.
MRI: No acute infarct. Extensive supratentorial white matter
signal abnormalities, nonspecific but likely sequela of chronic
small vessel ischemic disease in a patient of this age.
Echo: Biatrial enlargement. Mild symmetric left ventricular
hypertrophy with normal global and regional biventricular
systolic function. Mildly dilated ascending aorta. No ASD/PFO
demonstrasted on saline contrast injection
CXR: Bibasilar opacities are likely atelectasis with low lung
volumes, however, pneumonia could be considered in the correct
clinical setting. Mild pulmonary edema.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Aspirin 81 mg PO DAILY
2. Ipratropium Bromide MDI 2 PUFF IH QID
3. Amlodipine 10 mg PO DAILY
4. Viagra (sildenafil) 100 mg oral 1 tablet(s)
5. Albuterol Inhaler 2 PUFF IH Q4H:PRN cough
6. Atenolol 100 mg PO DAILY
7. Hydrochlorothiazide 25 mg PO DAILY
8. Nicotine Patch 21 mg TD DAILY
9. Pravastatin 10 mg PO DAILY
Discharge Medications:
1. Aspirin 81 mg PO DAILY
2. Atenolol 100 mg PO DAILY
3. Ipratropium Bromide MDI 2 PUFF IH QID
4. Nicotine Patch 21 mg TD DAILY
5. Viagra (sildenafil) 100 mg oral 1 tablet(s)
6. Hydrochlorothiazide 25 mg PO DAILY
7. Amlodipine 10 mg PO DAILY
8. Azithromycin 250 mg PO Q24H Duration: 4 Days
RX *clarithromycin 250 mg 1 tablet(s) by mouth once a day Disp
#*3 Tablet Refills:*0
9. Albuterol Inhaler 2 PUFF IH Q4H:PRN cough
10. Pravastatin 10 mg PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
1. Right facial droop and difficulty with language concerning
for stroke.
2. Stroke work up
3. Alcohol dependency
4. Tobacco dependency
5. Hypertension
6. Hyperlipidemia
7. Headache
8. Diabetes
9. Obesity
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK
INDICATION: Right facial droop and slurred speech. Evaluate for intra
cerebral hemorrhage or CVA.
TECHNIQUE: Contiguous axial images were obtained through the brain without
contrast material. Subsequently, rapid axial imaging was performed from the
aortic arch through the brain during infusion of Omnipaque intravenous
contrast material. Three-dimensional angiographic Images were generated.
DOSE: DLP: 2360.74 mGy-cm
COMPARISON: None.
FINDINGS:
NONENHANCED HEAD CT: There is no acute hemorrhage, edema or shift of the
normally midline structures. The ventricles and sulci are of normal size and
configuration for age. Confluent, periventricular white matter hypodensities,
while nonspecific, are presumably sequela of chronic small vessel ischemic
disease. Otherwise, the gray-white matter differentiation is preserved and
there is no evidence for an acute, vascular territorial infarction. The basal
cisterns are patent.
There is no fracture. The included paranasal sinuses and mastoid air cells are
well-aerated. The lenses and globes are unremarkable.
HEAD AND NECK CTA: The carotid and vertebral arteries and their major branches
are patent with no evidence of stenoses. The distal cervical internal carotid
arteries measure 5.5 mm in diameter on the left and 5.4 mm in diameter on the
right. There is no evidence of aneurysm formation or other vascular
abnormality.
The lung apices are clear. The known hilar lymphadenopathy was not fully
imaged. The thyroid is unchanged from the thyroid ultrasound of ___. The bones are unremarkable.
IMPRESSION:
1. No acute intracranial process. Please note, MRI is more sensitive for
detecting acute ischemia.
2. No thrombosis, aneurysm or dissection within the principal arteries of the
head and neck.
3. This report is provided without 3D and curved reformats. When these
images are available, and if additional information is obtained, then an
addendum may be given to this report.
Radiology Report
INDICATION: Chest pain. Evaluate for pneumonia.
TECHNIQUE: Bedside frontal chest radiograph.
COMPARISON: Chest radiograph ___ and chest CT ___.
FINDINGS:
The lung volumes are low, resulting in crowding of bronchovascular structures.
Bibasilar opacities are likely atelectasis, however, pneumonia could be
considered in the correct clinical setting. There is no pleural effusion or
pneumothorax. Bilateral hilar lymphadenopathy is unchanged. Heart is mildly
enlarged but unchanged. There is mild pulmonary edema.
IMPRESSION:
1. Bibasilar opacities are likely atelectasis with low lung volumes, however,
pneumonia could be considered in the correct clinical setting.
2. Mild pulmonary edema.
Radiology Report
EXAMINATION: MR HEAD W/O CONTRAST
INDICATION: ___ year old man with transient right facial droop. Evaluate for
ischemia.
TECHNIQUE: Sagittal T1 weighted imaging was performed. Axial imaging was
performed with gradient echo, FLAIR, diffusion, and T2 technique.
COMPARISON: CTA head and neck ___.
FINDINGS:
There is no evidence of acute infarction, edema, mass effect, or blood
products. There are numerous foci of patchy and confluent T2/FLAIR
hyperintensity in the subcortical, deep, and periventricular white matter.
These are nonspecific but commonly seen due to severe chronic small vessel
ischemic disease. The ventricles and sulci are normal in size for age.
There is mild mucosal thickening of the frontal and ethmoid sinuses. There is
scattered fluid in the right mastoid air cells.
IMPRESSION:
1. No acute infarct.
2. Extensive supratentorial white matter signal abnormalities, nonspecific
but likely sequela of chronic small vessel ischemic disease in a patient of
this age.
Gender: M
Race: BLACK/AFRICAN AMERICAN
Arrive by WALK IN
Chief complaint: Chest pain, R FACIAL DROOP
Diagnosed with TRANS CEREB ISCHEMIA NOS
temperature: 98.3
heartrate: 56.0
resprate: 16.0
o2sat: 96.0
sbp: 150.0
dbp: 68.0
level of pain: 7
level of acuity: 1.0 | Mr. ___ is a ___ year old male with multiple cerebrovascular
risk factors including hypertension, hyperlipidemia, diabetes,
obesity and smoking presenting with multiple episodes of right
facial droop and dysarthria concerning for TIA v. new ischemia
v. migraine. On initial examination, the patient demonstrated
right facial droop with good activation. Otherwise his
sensorimotor examination was unremarkable. He was admitted to
rule out stroke, rule out MI, and to asses for stroke risk
factors.
# NEURO: In the Emergency department, a CT/CTA Head/Neck showed
no thrombosis, aneurysm or dissection within the principal
arteries of the head and neck, but did show atherosclerosis.
MRI showed "No intracranial hemorrhage or acute infarct.
Numerous foci of patchy and confluent FLAIR hyperintensity in
the white matter, nonspecific but consistent with severe chronic
small vessel ischemic disease". Mr. ___ stroke risk factors
were assesed with fasting lipid panel and HbA1c (see labs
section for details). During his hospitalization, home
pravastatin 10mg daily was increased to atorvastatin 40mg daily
and home aspirin was increased from 81mg daily to 325mg daily.
At discharge, both medications were returned to ___
medications and doses. Mr. ___ was seen by physical therapy
and speech pathology. He was assesed to be back at his baseline
with resolution of the facial droop and no residual symptoms.
He was determined to have a complex migraine as the cause of his
symptoms.
# ___: EKG and troponin-T x1 normal. Echo: "Mild symmetric left
ventricular hypertrophy with a normal LVEF and biatrial
enlargement. Mildly dilated ascending aorta. No ASD/PFO
demonstrasted on saline contrast injection." He was monitored on
telemetry and no concerning findings were recorded. His home
dose of atenolol was halved from 100mg to 50mg daily to allow
his blood pressure to autoregulate. His more norvasc was held
during his hospitalization. Both medications were returned to
home doses at discharge.
# PULM: Chest radiograph from the emergency department revealed
possible pneumonia vs COPD flare. Mr. ___ was started on
azithromycin 250mg for a five day course. He was also provided
with his home dose of atrovent and albuterol.
# ENDO: HbA1c result was pending at the time of discharge.
Blood sugars were monitored with finger sticks QID and Insulin
sliding scale with a goal of normoglycemia.
# Toxic/Metabolic: Slight transaminitis (ALT 66, AST 63),
consistent with HCV history.
# ID: UA negative for UTI. Chest radiograph concerning for PNA
and patient was started on azithromycin x 5day . |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
Oxycodone
Attending: ___.
Chief Complaint:
Patient without Chief Complaint, per ED consult has history of
behavioral changes and sleep disturbances
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ is a ___ year-old man with history of history
?afib/WPW on A/C, HTN, CHF, cirrhosis/EtOH, and 2wks ago wide
exision of sarcoma resection bed (RLE). He was in his USOH until
he underwent skin grafting on his RLE last ___. Following
this, he has been complaining frequently of pain in that
leg/ankle, and while taking several sedating medications, he
developed drowsiness and mild behavioral changes.
.
His behavior was normal until ___ morning. At that time,
his wife noticed that he was falling asleep at the breakfast
table. He said he wanted to walk downstairs to put up his leg
and watch TV. She argued against this (due to concern for
falling on the stairs given his drowsy state and gait
instability since the surgeries), but he went anyway. He had to
catch himself on the wall near the bottom few stairs and sat on
the staircase while she helped him up (no fall/trauma). He
watched TV and dozed in his chair. His daughter says that he
looked "fine" in the afternoon when she visited. His wife said
that he would close his eyes and keep talking or mumbling
sometimes, and that all his extremities would twitch or jerk
briefly when he closed his eyes sometimes (I witnessed this in
the ED room, see below). That night (___), he went to bed early,
around 7:30pm, which is very out of character for him. His
daughter checked on him, and he told her, "I'm fine, I just need
rest." His wife says he arose at least 6x during the night to
use his bedside urine container. This morning, he told his wife
that he was speaking with his sister (in ___ on the phone,
but there was no one there and no phone. She called the
orthopedics office to discuss -- nurse there recommended 911,
ED.
.
His wife and ___ say that he has no history of stroke or
seizure. Never, at any time, was his speech slurred or garbled.
Never was his comprehension abnormal. He never complained of
weakness or numbness. A couple days ago, he mentioned blurry
vision to his wife, in passing, but this resolved. No sustained
or rhythmic jerking movements at any time.
.
His wife says he was prescribed a bottle of 40 tabs of oxycodone
5mg (q4h PRN). This was adequate for pain control for the first
week, but this past ___, he said 5mg q4hrs was not cutting it
for his pain. She says it is unusual for him to want to take
medications of any kind. ___, she spoke with a nurse from
the orthopedist's office, who suggested increasing to two tabs
(10mg q4hrs). She gave him 10mg ___ night around 11pm. He
got another 5mg and 5mg ___ morning and afternoon (none ___
evening), and the last dose of oxycodone was 5mg yesterday
morning with breakfast (___). A visiting nurse
suggested stopping the oxycodone at that point (started Tylenol)
due to behavioral changes, as described above.
In addition to the oxycodone, he was prescribed Ambien, which he
took for a week after the skin grafting, then stopped this past
___ due to concern for sedating side-effects. Since that time
(the past four nights), he has been taking 50mg of Benadryl
every night. Also, his wife and daughter say that he stopped
drinking on ___ (since the surgery). Prior to that, he drank
___ beers
and a "nip" of ___ whiskey every night. The wife
says he usually hides his EtOH intake from her, but they do not
think he had anything to drink this past week. The daughter said
his food intake is good (eggs, fruit, and milk every morning),
but his fluid intake is poor. He was BIBA to our ED. NAD. VS and
routine lab studies unremarkable (other than irreg HR in the
___, c/w h/o afib). He was given Tylenol ___ for leg pain
and surgery consult saw
him, said he was OK for follow-up and dressing changes as
previously planned (See OMR note). We were consulted with the
question "is this Neurologic?"
Review of Systems: <negative except as above> On neuro ROS, the
pt denies headache, loss of vision, diplopia, dysarthria,
dysphagia, lightheadedness, vertigo, tinnitus or hearing
difficulty. Denies difficulties producing or
comprehending speech. Denies focal weakness (just related to
RLE ankle/leg pain), numbness, parasthesiae. No bowel or bladder
incontinence or retention. Denies difficulty with gait other
than recent post-op basline. 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. + poor sleep (wife says he snores and
should have sleep study)
Past Medical History:
1. sarcoma RLE s/p excision and 2wks ago (late ___ an
elective wide excision of the tumor bed (wound healing well per
surgery note here in ED today.
2. atrial fibrillation on chronic A/C (warfarin ....)
3. status post ablation for ___ syndrome in
___
4. congestive heart failure
5. cirrhosis
6. hemochromatosis diagnosed two to ___ years ago
7. hypertension
8. GERD
9. "asthma"
10. depression
11. hypothyroidism
12. int hemorrhoids
Social History:
___
Family History:
Significant for alcoholism. He has a brother who has
hepatocellular carcinoma and there is a history of breast cancer
in both his mother and a sister.
Physical Exam:
Vital signs @ED triage:
T 99.2F
HR 99-->77,irreg
BP 144/77
RR 14
___ 95% RA
General: Awake, cooperative, NAD. Sleeping on arrival, awakens
to
verbal request.
HEENT: Normocephalic and atraumatic. No scleral icterus. Mucous
membranes are moist. No lesions noted in oropharynx.
Neck: Obese neck. Supple. No bruits. No lymphadenopathy.
Mallampati IV airway.
Pulmonary: Lungs CTA. Non-labored breathing.
Cardiac: RRR, no loud M/R/G appreciated in ED core.
Abdomen: Soft, non-tender, and non-distended.
Extremities: Stasis changes above dressing/wrap RLE near and
including ankle. Mildly tender. LLE minimal stasis changes; no
___. WWP feet/toes.
*****************
Neurologic examination:
Mental Status:
Oriented to ___. Said date was the ___ and it was
___. Knew he was in ___ ED. Mildly confused, interrupts
with questions and jokes. *Moderately inattentive -- can do
DOWfw
and bw. Can do MOYfw, but repeats fw when repeatedly asked to do
bw. Speech was not dysarthric. Language is fluent with intact
repetition and comprehension, normal prosody, and normal affect.
There were no paraphasic errors. Able to read (raise your right
hand -- yet does not follow the command) and write (how is the
weather today?) without difficulty. Naming is intact. Able to
follow both midline and appendicular commands. Memory -
registers
3 objects and recalls ___ (out of order, with difficulty) at 4
minutes. Good knowledge of recent and current events, discussed
upcoming election. Calculation was intact (answers seven
quarters
in $1.75, with difficulty). There was no evidence of apraxia,
although ?utilization (used finger to brush teeth, hand to brush
hair). Mild left-right confusion, but worked his way through
instruction to tough left ear with right hand. Luria sequencing
was good. Cube 3D copying impaired (draws three
square/rectanglular shapes, no 3D features). Frontal release
signs are: Not present (no glabellar, no grasp, no palmar-mental
reflex).
* Line-bisection task -- bisected lines appropriately, at
center,
but he left uncrossed all the lines to the left of center, and
did not seem to notice when I asked repeatedly if anything was
missing or if any lines were left uncrossed.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL, 3.5 to 2mm and brisk. No anisocoria. Visual fields
are
grossly full, [although initially it seemed that he might be
neglecting or missing part of the Left superior quadrant].
III, IV, VI: EOMs full and conjugate; no nystagmus.
V: Facial sensation intact and subjectively symmetric to light
touch and pin V1-V2-V3.
VII: No ptosis, no flattening of either nasolabial fold. Normal,
symmetric facial elevation with smile. Brow elevation is
symmetric. Eye closure is strong and symmetric.
VIII: Hearing intact bilaterally.
IX, X: Palate elevates symmetrically with phonation.
XI: ___ equal strength in trapezii bilaterally.
XII: Tongue protrusion is midline.
-Motor:
No drift. No asterixis. Mild, low-amplitude high-frequency
postural tremor. Normal muscle bulk and tone; no flaccidity,
hypertonicity, or spasticity noted.
Delt Bic Tri WE FE dIO/ADM | IP ___ ___ ___
L ___ ___ 5 5 5 5 5 5
R ___ ___ 5 5 5 5 4+ 5
-Sensory:
* patient reports patchy "40%" deficit of pinprick in left arm
and hand, sparing most but not all finger tips.
Otherwise, there are no gross deficits to light touch, pinprick,
cold sensation, or vibratory sensation in any extremity. Joint
position sense is grossly normal in both lower extremities
(great
toes). Eyes-closed Finger-to-nose testing revealed no
proprioceptive deficit (did not miss nose). No extinction.
-Reflexes (left; right):
Biceps (++;++)
Triceps (++;++)
Brachioradialis (+;+)
Quadriceps / patellar -- cannot assess, as pt does not relax leg
when about to strike.
___ / achilles (0;0)
Plantar response appears flexor bilaterally, but contaminated by
strong tickle response.
-Coordination:
Finger-nose-finger testing and heel-knee-shin testing with no
dysmetria or intention tremor. No dysdiadochokinesia noted on
rapid-alternating movements.
-Gait:
Stands without difficulty. Gait is slightly antalgic (c/o left
foot/ankle pain). Good initiation. Narrow-base. Turns quickly.
Able to walk on toes (pain, stopped quickly). Romberg absent,
slight wobble.
Pertinent Results:
LABS ON ADMISSION:
___ 08:58AM BLOOD WBC-7.3# RBC-3.85* Hgb-11.7* Hct-36.7*
MCV-95 MCH-30.5 MCHC-31.9 RDW-13.2 Plt ___
___ 08:58AM BLOOD Neuts-77.3* Lymphs-14.8* Monos-6.4
Eos-1.1 Baso-0.4
___ 11:26AM BLOOD ___ PTT-31.9 ___
___ 08:58AM BLOOD Glucose-111* UreaN-26* Creat-1.1 Na-139
K-4.9 Cl-101 HCO3-30 AnGap-13
___ 08:58AM BLOOD ALT-16 AST-22 AlkPhos-96 TotBili-0.4
___ 08:58AM BLOOD Lipase-28
___ 08:58AM BLOOD Albumin-3.7
___ 08:58AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
.
CARDIAC ENZYMES:
___ 06:35AM BLOOD CK-MB-1 cTropnT-<0.01STROKE RISK FACTORS:
.
STROKE RISK FACTOR ASSESSMENT:
___ 06:35AM BLOOD Triglyc-68 HDL-33 CHOL/HD-4.9 LDLcalc-114
___ 06:35AM BLOOD TSH-1.0
___ CT Head:
No evidence of acute intracranial process. No fracture
identified.
.
___ CXR:
No acute cardiopulmonary process. Mild cardiomegaly.
.
___ MRI/MRA:
FINDINGS: MRI OF THE BRAIN:
There is no evidence of intracranial hemorrhage, mass, mass
effect or shifting
of the normally midline structures. The ventricles and sulci are
prominent,
likely age related and involutional in nature. On FLAIR and T2,
few scattered
foci of high signal intensity are identified in the subcortical
white matter
and periventricular regions, which are nonspecific and may
reflect chronic
microvascular ischemic disease. No diffusion abnormalities are
detected to
suggest acute or subacute ischemic changes. There is no evidence
of abnormal
enhancement. The orbits are grossly unremarkable, the paranasal
sinuses and
mastoid air cells are clear.
IMPRESSION: Slightly prominent ventricles and sulci, likely age
related and
involutional in nature.
Few scattered areas of high signal intensity are demonstrated on
T2 and FLAIR
sequences, distributed in the subcortical white matter and
periventricular
regions, which are nonspecific and may reflect chronic
microvascular ischemic
disease. No diffusion abnormalities or areas with abnormal
enhancement are
identified.
MRA OF THE HEAD:
There is evidence of vascular flow in both internal carotid
arteries as well
as the vertebrobasilar system, no flow stenotic lesions or
aneurysms larger
than 2 mm in size are seen. The anterior, middle and posterior
cerebral
arteries are grossly unremarkable. Both vertebral arteries and
the basilar
artery are patent.
IMPRESSION: Essentially normal MRA of the head with no evidence
of flow
stenotic lesions or aneurysms.
MRA OF THE NECK:
The origin of the supra-aortic vessels appears normal, the
common carotid
arteries are patent and the bifurcations are widely patent with
no stenotic
lesions. Both vertebral arteries are patent and appear
unremarkable as well
as the visualized intracranial structures.
IMPRESSION: Normal MRA of the neck with no evidence of flow
stenotic lesions
or major vascular abnormalities.
.
ECG:
Atrial fibrillation. No significant change compared with
previous tracing
of ___.
Read by: ___.
Intervals Axes
Rate PR QRS QT/QTc P QRS T
99 0 92 362/430 0 27 18
.
LABS AT DISCHARGE:
___ 06:35AM BLOOD WBC-7.5 RBC-3.75* Hgb-11.7* Hct-37.0*
MCV-99* MCH-31.3 MCHC-31.8 RDW-13.8 Plt ___
___ 06:35AM BLOOD Glucose-97 UreaN-18 Creat-0.9 Na-140
K-4.2 Cl-101 HCO3-30 AnGap-13
___ 06:35AM BLOOD ALT-16 AST-24 AlkPhos-95 TotBili-0.5
Radiology Report
INDICATION: Altered mental status, evaluate for hemorrhage.
COMPARISON: CT head on ___.
TECHNIQUE: Contiguous axial images were obtained through the brain. No
contrast was administered. Coronal and sagittal reformations were performed.
FINDINGS: There is no evidence of hemorrhage, edema, mass, mass effect, or
acute territorial infarction. Ventricles and sulci are normal in size and
configuration for the patient's age. The gray-white differentiation is
preserved. The visualized paranasal sinuses and mastoid air cells are well
aerated. There is no fracture identified.
IMPRESSION: No evidence of acute intracranial process. No fracture
identified.
Radiology Report
INDICATION: Altered mental status, evaluate for pneumonia.
COMPARISON: CT chest on ___.
FINDINGS: PA and lateral views of the chest. There is mild cardiomegaly.
The cardiomediastinal and hilar contours are normal. The lungs are clear.
There is no evidence of pleural effusion or pneumothorax.
IMPRESSION: No acute cardiopulmonary process. Mild cardiomegaly.
Radiology Report
STUDY: MRI and MRA of the brain and MRA of the neck.
CLINICAL INDICATION: ___ man with history of recent induced delirium,
subtle right parietal signs on clinical exam of uncertain chronicity (left
visual neglect). Evaluate for small right parietal lesion.
COMPARISON: Prior head CT dated ___ and ___.
TECHNIQUE: MRI of the brain.
Pre-contrast axial and sagittal T1-weighted images were obtained, axial FLAIR,
axial T2, axial magnetic susceptibility and axial diffusion-weighted
sequences. The T1-weighted images were repeated after the administration of
gadolinium contrast in axial T1, sagittal MP-RAGE and multiplanar
reconstructions were provided.
MRA OF THE HEAD:
3D time-of-flight arteriography of the head was obtained, multiple axial
source images and maximum intensity projection images were reviewed.
MRA OF THE NECK:
Bolus tracking technique sequences were obtained after the intravenous
administration of gadolinium contrast, coronal reformations and multiple
maximum intensity projection images of the neck vessels were reviewed.
FINDINGS: MRI OF THE BRAIN:
There is no evidence of intracranial hemorrhage, mass, mass effect or shifting
of the normally midline structures. The ventricles and sulci are prominent,
likely age related and involutional in nature. On FLAIR and T2, few scattered
foci of high signal intensity are identified in the subcortical white matter
and periventricular regions, which are nonspecific and may reflect chronic
microvascular ischemic disease. No diffusion abnormalities are detected to
suggest acute or subacute ischemic changes. There is no evidence of abnormal
enhancement. The orbits are grossly unremarkable, the paranasal sinuses and
mastoid air cells are clear.
IMPRESSION: Slightly prominent ventricles and sulci, likely age related and
involutional in nature.
Few scattered areas of high signal intensity are demonstrated on T2 and FLAIR
sequences, distributed in the subcortical white matter and periventricular
regions, which are nonspecific and may reflect chronic microvascular ischemic
disease. No diffusion abnormalities or areas with abnormal enhancement are
identified.
MRA OF THE HEAD:
There is evidence of vascular flow in both internal carotid arteries as well
as the vertebrobasilar system, no flow stenotic lesions or aneurysms larger
than 2 mm in size are seen. The anterior, middle and posterior cerebral
arteries are grossly unremarkable. Both vertebral arteries and the basilar
artery are patent.
IMPRESSION: Essentially normal MRA of the head with no evidence of flow
stenotic lesions or aneurysms.
MRA OF THE NECK:
The origin of the supra-aortic vessels appears normal, the common carotid
arteries are patent and the bifurcations are widely patent with no stenotic
lesions. Both vertebral arteries are patent and appear unremarkable as well
as the visualized intracranial structures.
IMPRESSION: Normal MRA of the neck with no evidence of flow stenotic lesions
or major vascular abnormalities.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: HALLUCINATIONS
Diagnosed with ALTERED MENTAL STATUS
temperature: 99.2
heartrate: 77.0
resprate: 14.0
o2sat: 95.0
sbp: 144.0
dbp: 77.0
level of pain: 0
level of acuity: 3.0 | Mr. ___ is a ___ year-old right/left-handed man with a past
medical history including Afib/WPW on A/C, HTN, CHF,
cirrhosis/EtOH, 2wks ago wide exision of sarcoma resection bed
(RLE) with multiple recent psychoactive and sedating medications
(Ambien, Oxycodone, Benadryl) who presented to the ___ with
behavioral issues and sleep disturbances. He was admitted to
the stroke service from ___ to ___.
.
On initial evaluation his neurologic examination was not
remarkable for any gross
sensory or motor deficits. Likewise, there are no speech or
language or visual deficits by history or on exam. HOWEVER, the
exam did reveal a few unexpected findings -- First, was a subtle
sensory loss in the LEFT arm (patchy pinprickassymetry); Second,
there may be a subtle LEFT neglect (line bisection neglected on
the left side; VF testing intermittently abnormal on the left);
Third, he had a constructional/visual-spatial deficit manifest
as inability to copy a cube. These subtle deficits all localize
to a potential Right-parietal (cortical) deficit; the lack of
motor findings implied that any such lesion avoids the frontal
(precentral) motor cortex. Of note patient had several risk
factors for stroke
(primarily afib, but also HTN, age, positive smoking history).
.
A CT of the head showed no evidence of hemorrhage, masses, or
obvious signs of ischemia. There did not appear to be evidence
of stenosis, dissection, or aneurysm on angiography. As the
patient's symptoms were considered concerning for stroke, an MRI
of the brain was performed. The study revealed no signs of
acute ischmic stroke.
.
The patient most likely had an issue with polypharmacy which
accounted for his presentation. We recommended to stop taking
oxycodone, ambine, benadryll.
For his atrial fibrillation, the patient continued his home
medications and anticoagulation without any issues. He was
monitored on continuous telemetry without any significant
events.
. |
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 leg pain
Major Surgical or Invasive Procedure:
IM nail insertion left tibia.
History of Present Illness:
This is a ___ year-old woman in her USOH until this afternoon
when she sutained a mechanical fall from a chair. She was
transferred from an OSH with a splint in place.She denies
headstrike and LOC. She also denies, neck or chest pain. She
presented to ___ ED with films demonstrating a tibia shaft
fracture.
Past Medical History:
Hysterectomy, Depression, Anxiety
Social History:
___
Family History:
Non-contributory
Physical Exam:
Vitals: 99, 98.5, 71, 93/51, 18, 99%RA
Gen: NAD, A and O X3
CV: RRR, no m/r/g
Pulm: CTAB
LLE: Aircast boot in place. Exposed toes +flex/extend, SITL,
WWP, cap refill ,2sec.
Pertinent Results:
___ 07:40AM BLOOD ___-44
___ 07:40AM BLOOD 25VitD-PND
Medications on Admission:
Escitalipram 20 mg QD
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
2. Docusate Sodium 100 mg PO BID
3. Enoxaparin Sodium 40 mg SC DAILY Duration: 28 Days
4. Escitalopram Oxalate 20 mg PO DAILY
5. Methocarbamol 750 mg PO QID:PRN muscls spasm
Please take 1 tablet up to 4 times daily only as needed for
muscle spasm.
6. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN Pain
7. Senna 1 TAB PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Left tibial shaft fracture
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - requires assistance or aid (walker
or cane).
Followup Instructions:
___
Radiology Report
CHEST RADIOGRAPH PERFORMED ON ___
COMPARISON: None.
CLINICAL HISTORY: Tibia and fibula fractures, preop assessment.
FINDINGS: AP upright and lateral views of the chest are provided. The lungs
are hyperinflated, though clear. Patient is rotated to her left. No effusion
or pneumothorax. No focal consolidation or signs of pulmonary edema.
Cardiomediastinal silhouette is normal. Bony structures are intact.
IMPRESSION: Hyperinflated lungs without superimposed acute pathology.
Radiology Report
HISTORY: Postreduction films.
COMPARISON: Comparison is made to radiographs from the left tibia and fibula
from outside hospital (___) from 5 hours prior.
FINDINGS: 4 views of the left tibia and fibula demonstrate unchanged alignment
of the obliquely oriented and displaced fracture through the proximal tibial
shaft with angulation and posterior displacement of the proximal fracture
fragment. Additionally, there is a minimally displaced segmental fracture
through the proximal fibula (neck and ___ shaft). An overlying splint is in
place. There is no evidence of joint effusion at the knee.
IMPRESSION: Unchanged alignment of displaced proximal tibial shaft fracture.
Minimally displcated segmental fracture of the proximal fibula.
Radiology Report
HISTORY: Left Tib/fib ORIF in OR
COMPARISON: Radiograph ___.
A total of 201 intraoperative images demonstrate a fracture in the proximal
shaft of the tibia and segmental fibular fractures. Images obtained during
placement of an IM nail with interlocking screws through the tibial fracture.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: TIB FIB FX
Diagnosed with FX SHAFT TIBIA-CLOSED, FALL FROM CHAIR OR BED
temperature: 98.7
heartrate: 74.0
resprate: 16.0
o2sat: 100.0
sbp: 127.0
dbp: 70.0
level of pain: 4
level of acuity: 3.0 | The patient presented to the emergency department and was
evaluated by the orthopedic surgery team. The patient was found
to have a left tibial shaft fracture and was admitted to the
orthopedic surgery service. The patient was taken to the
operating room on ___ for left tibia IM nail insertion, 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 PWB 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:
=======================================================
HMED ADMISSION NOTE
Date of admission: ___
=======================================================
PCP: ___. ___
CC: ___
Major ___ or Invasive Procedure:
None
History of Present Illness:
HISTORY OF PRESENT ILLNESS:
___ is a ___ yo ___ speaking man with h/o BPH with
urinary retention c/b recurrent UTIs and dementia who presents
with fevers, and confusion x 1 day.
This is his third admission for identical symptoms within the
last 2 months.
___ is unable to provide history given mental status so
history obtained from his daughter who is his primary care
taker.
Per daughter, patient has been fine, at his baseline mental and
functional status all week until yesterday. In fact, yesterday
morning he walked with a walker, ate breakast as he typically
does and was doing well. She returned from her afternoon walk
and found him laying in his bed, confused, not answer questions
and shivering. He also had abdominal distension and pain with
palpation of his abdomen. She took his temperature and it was
101, she gave him 500mg PO Tylenol and watched him, he was no
better and mounted another fever 4 hours later for which she
gave him another 650mg tylenol. He had an "extra large" bowel
movement and his abdomen pain resolved but by morning he was
still shivering and confused so she brought him to the ED.
In the ED, initial vitals were 98.5 91 73/47 19 99% RA. Labs
were notable for marked leukocytosis, acute renal failure and
elevated lactate. UA was grossly positive and CXR showing
atelectasis. CT showing dilated sigmoid colon concerning for
Ogilve. He was started on IV Vanc and Cefepime for possible UTI
and/or pneumonia and admitted to medicine.
Of note, this presentation is identical to his last two
admissions. During prior admissions he was found to have a UTI,
the first time treated with zosyn
and he was transitioned to macrobid to complete a ___fter Cx returned E.Coli with significant resistance pattern.
Last admissions his Cx returned positive for resistant
Klebsiella and he was discharged to continue IV Meropenem.
Regarding his BPH history, patient has had multiple admissions
(4x in ___, 4x in ___ at ___ for UTI, urosepsis, or
pyelonephritis. He has been evaluated by urology as inpatient
for complicated foley placement and their complications as well
as outpatient for voiding trial. He was started initially on
macrobid for UTI ppx but now is on Fosfomycin QWeekly.
On the floor, patient is confused, unable to communicate and
appears to br shivering. Daughter is at the bedside and provides
history. She reports his abdomen is much softer than before and
he is no longer having abdominal pain and this is his baseline
abdominal exam.
Review of systems: Unable due to mental status
Past Medical History:
1. BPH.
2. Hyperlipidemia.
3. Dementia, A+Ox1 at baseline
4. Acute cholecystitis ___
5. UTI, recurrent, prior pyelonephritis
Social History:
___
Family History:
Unspecified coagulopathy in one of his daughters, otherwise
none.
Physical Exam:
Admission PHYSICAL EXAM:
Vitals: 100.1 PO 96 / 59 87 24 97 RA
Pain Scale: Unable
General: Patient appears acutely ill, he is confused, unable to
communicate but makes eye contact, he is noticeably shivering
and makes incoherent noises, mumbling.
HEENT: Dry MM
Neck: supple, JVP low, no LAD appreciated
Lungs: Reduced air movement bilaterally though patient cannot
follow commands. Bibasilar faint rales.
CV: Regular rate and rhythm, S1 and S2 clear and of good
quality, ___ systolic murmur at ___ most prominently
Abdomen: Distended but soft, non-tender to palpation, no rebound
or guarding, hypoactive bowel sounds, tympanic to percussion
Ext: Warm, well perfused, full distal pulses, no clubbing,
cyanosis or edema
Neuro: Unable to communicate, non-verbal, mumbling
Discharge physical exam:
97.9 PO 103 / 50 L Lying 68 16 98 RA
Gen: Sitting in chair, NAD, interactive
HEENT: MMM
Cardiovascular: RRR ___ systolic murmur at apex.
Pulmonary: Lung fields clear to auscultation throughout
Gastroinestinal: Soft, distended, +BS, no TTP, no guarding or
rebound.
MSK: No edema, warm well perfused.
Neurological: Alert, interactive, face symmetric, moving all
extremities
Pertinent Results:
Admission Labs
___ 01:18PM BLOOD WBC-38.1*# RBC-3.44* Hgb-9.9* Hct-31.8*
MCV-92 MCH-28.8 MCHC-31.1* RDW-16.7* RDWSD-57.0* Plt ___
___ 01:18PM BLOOD ___ PTT-25.8 ___
___ 01:18PM BLOOD Glucose-110* UreaN-20 Creat-1.3* Na-137
K-4.6 Cl-95* HCO3-22 AnGap-25*
___ 01:18PM BLOOD ALT-16 AST-33 AlkPhos-109 TotBili-0.4
___ 01:18PM BLOOD Lipase-25
___ 07:15PM BLOOD cTropnT-0.07*
___ 01:18PM BLOOD cTropnT-0.02*
___ 01:18PM BLOOD Albumin-4.3
___ 01:39PM BLOOD Lactate-2.8*
___ 01:37PM BLOOD Lactate-3.1*
Imaging:
CT Head: No acute intracranial process.
CT A/P:
1. Multiple dilated fluid and air-filled loops of small and
large bowel. The sigmoid is markedly dilated compared to ___, but there is no transition point to suggest an
obstruction. No bowel wall thickening. Again this may reflect
___ syndrome.
2. Other incidental findings include cholelithiasis and
prostatomegaly
CXR PA/LAT:
1. Patchy opacification at the medial lung bases bilaterally may
reflect atelectasis, however an underlying pneumonia cannot be
excluded.
2. Lucency under the right hemidiaphragm may be related to
distended bowel loops. This can be resolved on the pending
abdominal CT
Prior Results:
MICROBIOLOGY
URINE CULTURE (Final ___:
KLEBSIELLA PNEUMONIAE. >100,000 CFU/mL.
_________________________________________________________
KLEBSIELLA PNEUMONIAE
|
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- <=1 S
CEFTAZIDIME----------- =>64 R
CEFTRIAXONE----------- 32 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- 128 R
PIPERACILLIN/TAZO----- =>128 R
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
URINE CULTURE (Final ___:
ESCHERICHIA COLI. >100,000 CFU/mL
ESCHERICHIA COLI
|
AMPICILLIN------------ =>32 R
AMPICILLIN/SULBACTAM-- =>32 R
CEFAZOLIN------------- =>64 R
CEFEPIME-------------- R
CEFTAZIDIME----------- 4 S
CEFTRIAXONE----------- 16 R
CIPROFLOXACIN--------- =>4 R
GENTAMICIN------------ <=1 S
MEROPENEM-------------<=0.25 S
NITROFURANTOIN-------- <=16 S
PIPERACILLIN/TAZO----- <=4 S
TOBRAMYCIN------------ <=1 S
TRIMETHOPRIM/SULFA---- =>16 R
IMAGING
==============
CT HEAD ___:
No acute intracranial process.
CT TORSO ___:
1. No evidence of acute intra-abdominal or pelvic abnormality.
Persistent
dilation of the sigmoid colon without bowel obstruction.
2. Cholelithiasis and common bowel duct dilation, unchanged
since the prior study.
3. Thickened bladder wall may be secondary to chronic bladder
outlet
obstruction in the setting of a severely enlarged prostate.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Bisacodyl ___AILY constipation
2. Docusate Sodium 100 mg PO BID
3. Polyethylene Glycol 17 g PO DAILY
4. Senna 17.2 mg PO BID
5. Simethicone 40-80 mg PO TID:PRN gas pain
6. Simvastatin 20 mg PO QPM
7. Tamsulosin 0.8 mg PO QHS
8. TraZODone 25 mg PO QHS
9. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP DAILY:PRN
itch
10. Fosfomycin Tromethamine 3 g PO 1X/WEEK (MO)
11. Finasteride 5 mg PO DAILY
Discharge Medications:
1. ertapenem 1 gram injection DAILY Duration: 3 Days
Continue through ___
RX *ertapenem [Invanz] 1 gram 1 g IV daily Disp #*3 Vial
Refills:*0
2. Fosfomycin Tromethamine 4 g PO EVERY 10 DAYS
3. Bisacodyl ___AILY constipation
4. Docusate Sodium 100 mg PO BID
5. Finasteride 5 mg PO DAILY
6. Polyethylene Glycol 17 g PO DAILY
7. Senna 17.2 mg PO BID
8. Simethicone 40-80 mg PO TID:PRN gas pain
9. Simvastatin 20 mg PO QPM
10. Tamsulosin 0.8 mg PO QHS
11. TraZODone 25 mg PO QHS
12. Triamcinolone Acetonide 0.1% Ointment 1 Appl TP DAILY:PRN
itch
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Urosepsis
Discharge Condition:
Mental Status: Confused - always.
Level of Consciousness: Alert and interactive.
Activity Status: Bedbound.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with cough, eval for pnacough, eval for pnaabd
swelling, eval for intrabdominal infectionconfusion, eval for bleed in head//
cough, eval for pnaabd swelling, eval for intrabdominal infectionconfusion,
eval for bleed in head
TECHNIQUE: Single AP radiograph of the chest.
COMPARISON: Chest radiograph dated ___.
FINDINGS:
Low lung volumes. Left infrahilar consolidation is probably atelectasis
rather than pneumonia because of leftward mediastinal shift and depression of
the left hilus indicating volume loss. No pulmonary edema or consolidation
elsewhere. Moderate cardiomegaly. No pleural abnormality. Lucency under the
right hemidiaphragm is probably due to distended bowel loops rather than
pneumo peritoneum.
IMPRESSION:
1. Bilateral medial lung base atelectasis or pneumonia.
2. Lucency under the right hemidiaphragm may be related to distended bowel
loops. The possibility of pneumoperitoneum will be resolved on the pending
abdominal CT.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST
INDICATION: History: ___ with cough, eval for pnacough, eval for pnaabd
swelling, eval for intrabdominal infectionconfusion, eval for bleed in head//
cough, eval for pnaabd swelling, eval for intrabdominal infectionconfusion,
eval for bleed in head
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast. Coronal and sagittal reformations as well as bone algorithm
reconstructions were provided and reviewed.
DOSE: Total DLP (Head) = 714 mGy-cm.
COMPARISON: Head CT dated ___.
FINDINGS:
There is no evidence of acute territory infarction,hemorrhage,edema,or mass
effect. Subcortical, deep, and periventricular white matter hypodensities are
nonspecific, but likely represent chronic microvascular ischemic disease.
There is prominence of the ventricles and sulci suggestive of involutional
changes.
There is no evidence of acute fracture. Mild mucosal thickening within the
right sphenoid sinus. Otherwise, the visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear.
IMPRESSION:
No acute intracranial process.
Radiology Report
EXAMINATION: CT abdomen and pelvis with IV contrast.
INDICATION: ___ with cough, eval for pnacough, eval for pnaabd swelling,
eval for intrabdominal infection.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was not administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Total DLP (Body) = 624 mGy-cm.
COMPARISON: CT abdomen and pelvis dated ___.
FINDINGS:
LOWER CHEST: Dependent atelectasis at the lung bases bilaterally. No focal
consolidations. No pleural or pericardial effusion. Cardiomegaly. Dense
aortic valvular calcifications are visualized.
ABDOMEN:
HEPATOBILIARY: Subcentimeter hypodensity within the right lobe is too small to
characterize, but likely represents a simple cyst or biliary hamartoma (series
2, image 22). Otherwise, the liver demonstrates homogenous attenuation
throughout. There is no evidence of solid lesions. There is no evidence of
intrahepatic dilatation. The common bile duct is prominent, but tapers
distally, unchanged compared to prior. Multiple stones are seen within the
decompressed gallbladder (series 2, image 32).
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: Multiple hypodensities are seen within the kidneys bilaterally, some
of which are too small to characterize, others are consistent with simple
cysts, and with intermediate density (series 2, image 33), likely represent
proteinaceous cysts, unchanged compared to prior. Otherwise, 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: Small hiatal hernia. The stomach is unremarkable. Again
seen are multiple dilated fluid and air-filled loops of small and large bowel.
The sigmoid is markedly dilated in comparison to ___ measuring up
to 13.6 cm (series 2, image 52). There is no transition point to suggest an
obstruction, and there is air and fluid within the rectum. There is no bowel
wall thickening. The bowel wall enhances normally throughout. The appendix
is not visualized.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate is enlarged measuring 5.5 x 5.3 cm.
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: Multiple chronic appearing left posterior rib fractures are visualized.
Moderate levoscoliosis of the lumbar spine. Bilateral pars defects with grade
1 anterolisthesis of L5 on S1 is unchanged. There is no evidence of worrisome
osseous lesions or acute fracture.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
IMPRESSION:
1. Multiple dilated fluid and air-filled loops of small and large bowel. The
sigmoid is markedly dilated compared to ___, but there is no
transition point to suggest an obstruction. No bowel wall thickening. Again
this may reflect ___ syndrome.
2. Other incidental findings include cholelithiasis and prostatomegaly.
Gender: M
Race: BLACK/CARIBBEAN ISLAND
Arrive by WALK IN
Chief complaint: Altered mental status, Hypotension
Diagnosed with Tubulo-interstitial nephritis, not spcf as acute or chronic
temperature: 98.5
heartrate: 91.0
resprate: 19.0
o2sat: 99.0
sbp: 73.0
dbp: 47.0
level of pain: 0
level of acuity: 1.0 | ASSESSMENT AND PLAN:
___ with history of BPH, HLD, dementia (alert and oriented x 1
at baseline), BPH with urinary retention and recurrent urinary
tract infections, who presents with confusion and abdominal pain
with positive urinalysis all consistent with recurrent sepsis
from UTI including MDR GNR (susceptible to penems) similar to
two recent hospitalizations.
# Sepsis, severe, without shock:
# Bacterial Urinary tract infection:
# Acute Renal Failure
Profound leukocytosis with neutrophilia and bands, with fever to
101, hypotension and elevated lactate, acute renal failure and
source clearly UTI. Patient has history of multi-drug resistant
urinary tract infections, last two cultures only overlap with
Meropenem sensitivity. Patient has underlying BPH and retention
which is likely contributing to increased risk of recurrent
UTI's. He initially received Cefepime in ED, however, his most
recent urine culture was resistant to Cefepime. ARF and lactic
acidosis both related to hypovolumia and sepsis most likely. He
was evaluated by ID who knew him well. They agreed with
Meropenem. His urine culture grew MDR Klebseilla sensitive to
penems. In house, he was treated with Meropenem. He had a
midline placed. He received and test dose of Ertapenem and
tolerated this well. He will complete a 7 day course of
Ertapenem (starting: ___. Per ID, reasonable to continue
fosfomycin 4g PO q10d. Unfortunately, given his BPH as noted
below, these UTIs will likely recur. The family is aware of
this.
# Acute Metabolic Encephalopathy:
# Dementia:
Patient has baseline dementia and is alert and oriented x 1, can
ambulate with aid of walker and can use a cup to drink but needs
assist to eat, can communicate and answer questions generally.
Presents altered, non-responsive to questions, unable to follow
commands consistent with. Encephalopathy was most likely
toxic-metabolic related to sepsis. CT head negative for acute
intracranial process. His mental status improved by to baseline
upon treatment.
# BPH/Urinary Retention:
Chronic history with prior admission requiring foley catheters,
difficult placements and urology following. No foley placed
during this admission. However, BPH is likely the underlying
trigger for his recurrent UTI. He was continued on Tamsulosin
and Finasteride.
# Sigmoid Distention: Concern for Ogilve
This is a chronic problem with several prior CT Torso performed
in the ED showing similar findings of "persistent dilation of
the sigmoid colon without bowel
obstruction." This CT is showing more dilatation than the prior
CT and again concern for ___ syndrome. His
abdominal exam, however, is completely benign, soft, non-tender,
no peritoneal signs and he had a large BM last evening. Given
increased dilation and notable leukocytosis, ACS was consulted
to opine on possibility of toxic megacolon. However, his C. diff
was negative and ACS thought this was acute worsening of
___ and no further intervention was needed. His exam
remained benign and he continued to pass gas and have bowel
movements.
# Elevated Troponin:
Likely demand related in setting of sepsis. During prior
admissions for similar symptoms he developed ST Depressions in
V4-5 on admission EKG with a similar Trop elevation of 0.05 with
MB 3. Not a candidate for cath or anticoagulation anyway, highly
unlikely to be acute plaque rupture
# Hypokalemia: had mild hypokalemia during his stay, which
corrected with oral repletion and had resolved as of discharge.
Should have a repeat BMP early next week to follow up on this |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
azithromycin / Dilaudid / morphine / Zofran (as hydrochloride)
Attending: ___.
Chief Complaint:
Diarrhea
Major Surgical or Invasive Procedure:
EGD/colonoscopy with biopsy ___
History of Present Illness:
Ms. ___ is a ___ woman who presents after leaving ___
___ AMA this morning for further evaluation and
treatment of lower abdominal pain and diarrhea.
Patient reports having ongoing diarrhea and abdominal pain now
for the past 8 weeks. Her diarrhea was as frequent as ___ a day
in the beginning, mostly during the day. At times she would have
incontinence of stool. On ___, she presented to the ED for
these symptoms and was prescribed a week of Flagyl, which she
says made the diarrhea and pain worse. During this time she had
blood stools as well. She then presented to the ED again and was
admitted. She had a colonoscopy by Dr. ___ at ___ and
pathology returned for colitis with skip lesions, concerning for
Crohn's disease vs c.diff. Repeat c.diff studies were negative.
She was discharged. She represented to ___ on ___ with
persistent diarrhea and abdominal pain and fevers to 102. She
was started on solumedrol 40mg q8h per GI recommendations
yesterday. She was planned to have an upper GI series but it was
rescheduled and she became unsatisfied with her care there and
thus left AMA.
She continues to have ___ lower abdominal pain, mouth ulcers
and diarrhea. Denies fever/chills at this time and denies blood
in stool. Denies stools being dark or tarry. Reports
odynophagia. Denies reflux, chest pain, shortness of breath.
Reports hemorrhoids and rectal pain.
She has had several similar episodes of abdominal pain and
diarrhea over the last ___ years. She has had episodes of
abdominal pain and diarrhea lasting as long as a week. They
occur monthly or so. She was originally diagnosed with Celiac's
disease although never had any blood work or biopsy. She has
lost 17 pounds since end of ___. She also has had
increases in her mouth ulcers. Initially started with ___ ulcers
8 weeks ago but then increased significantly. She endorses knee
and angle swelling and pain as well. She denies any hip pain.
She also has a rash on her thighs that she describes as
appearing like pimples but then scabs over.
In the ED, initial vital signs were: 98.3 88 134/83 16 100%RA
- Exam was notable for: ulcers noted on uvula, gums and roof of
mouth, all hemostatic, mildly tender to palpation in LLQ and
RLQ, LLQ>RLQ
- Labs were notable for: wbc 15.1, plts 428
- The patient was given: IV morphine
- Consults: none
Vitals prior to transfer were: 97.6 66 120/90 18 100% RA
Upon arrival to the floor, patient feeling well. Continues to
have some abdominal pain and diarrhea. Sores in her mouth are
very painful as well.
Past Medical History:
asthma
? Celiac disease
Social History:
___
Family History:
- UC: mother
- paternal grandmother: celiac's disease
- maternal grandmother: colon cancer
- significant diverticulitis in family.
Physical Exam:
ON ADMISSION
VITALS: 98.5 124/82 66 18 100% RA
GENERAL: Pleasant, well-appearing, in no apparent distress.
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, multiple small ulcers of the hard
palate and posterior oropharynx, and uvula, multiple ulcers also
of the gums of her lower teeth
NECK: Supple, no LAD, no thyromegaly, JVP flat.
CARDIAC: RRR, 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. There is very minimal edema of the ankles but they are
tender to palpation. They is no palpable effusion of the knees.
SKIN: There are scattered acne-like small lesions on an
erythematous base of the left thigh, right thigh, and upper back
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
ON DISCHARGE
VITALS: 97.9 123/90 45 18 98% RA
GENERAL: Pleasant female in no acute distress, AAOx3
HEENT - normocephalic, atraumatic, no conjunctival pallor or
scleral icterus, PERRLA, EOMI, small ulcers on posterior
oropharynx
NECK: Supple, no LAD, no thyromegaly, JVP flat.
CARDIAC: RRR, normal S1/S2, no murmurs rubs or gallops.
PULMONARY: Clear to auscultation bilaterally over anterior
chest.
ABDOMEN: Normal bowel sounds, soft, non-tender, non-distended,
no organomegaly.
EXTREMITIES: Warm, well-perfused, no cyanosis, clubbing or
edema. Ankles TTP. They is no palpable effusion of the knees.
SKIN: There are almost healed, scattered acne-like small lesions
on an erythematous base of the inner thighs
NEUROLOGIC: A&Ox3, CN II-XII grossly normal, normal sensation,
with strength ___ throughout.
Pertinent Results:
ON ADMISSION
======================================
___ 03:22PM URINE MUCOUS-RARE
___ 03:22PM URINE RBC-1 WBC-1 BACTERIA-NONE YEAST-NONE
EPI-3
___ 03:22PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.5
LEUK-NEG
___ 03:22PM URINE COLOR-Yellow APPEAR-Clear SP ___
___ 03:22PM URINE UCG-NEGATIVE
___ 06:15PM PLT COUNT-428*
___ 06:15PM NEUTS-81.8* LYMPHS-10.8* MONOS-6.6 EOS-0.0*
BASOS-0.3 IM ___ AbsNeut-12.33* AbsLymp-1.63 AbsMono-0.99*
AbsEos-0.00* AbsBaso-0.05
___ 06:15PM WBC-15.1* RBC-4.65 HGB-13.8 HCT-43.3 MCV-93
MCH-29.7 MCHC-31.9* RDW-12.9 RDWSD-43.5
___ 06:15PM ALBUMIN-3.8
___ 06:15PM ALT(SGPT)-14 AST(SGOT)-24 ALK PHOS-67 TOT
BILI-0.2
___ 06:15PM GLUCOSE-122* UREA N-10 CREAT-0.6 SODIUM-139
POTASSIUM-4.7 CHLORIDE-105 TOTAL CO2-22 ANION GAP-17
CRP
___ 06:08AM BLOOD CRP-148.2*
___ 05:59AM BLOOD CRP-67.9*
MICRO
====================
__________________________________________________________
___ 12:19 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
FECAL CULTURE (Pending):
CAMPYLOBACTER CULTURE (Pending):
__________________________________________________________
___ 9:30 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
__________________________________________________________
___ 3:05 pm BLOOD CULTURE Source: Venipuncture.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 6:11 am BLOOD CULTURE 1 OF 2.
Blood Culture, Routine (Pending):
__________________________________________________________
___ 8:08 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
CYCLOSPORA STAIN (Final ___: NO CYCLOSPORA SEEN.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
__________________________________________________________
___ 7:55 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
Time Taken Not Noted Log-In Date/Time: ___ 1:42 pm
THROAT CULTURE
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Pending):
__________________________________________________________
___ 9:44 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 3:22 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
Log-In Date/Time: ___ 1:42 pm
THROAT CULTURE
VIRAL CULTURE: R/O HERPES SIMPLEX VIRUS (Preliminary):
No Herpes simplex (HSV) virus isolated.
___ 8:08 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
CYCLOSPORA STAIN (Final ___: NO CYCLOSPORA SEEN.
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Illumigene DNA
amplification assay.
(Reference Range-Negative).
FECAL CULTURE (Final ___: NO SALMONELLA OR SHIGELLA
FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
OVA + PARASITES (Final ___:
NO OVA AND PARASITES SEEN.
This test does not reliably detect Cryptosporidium,
Cyclospora or
Microsporidium. While most cases of Giardia are detected
by routine
O+P, the Giardia antigen test may enhance detection when
organisms
are rare.
FECAL CULTURE - R/O VIBRIO (Final ___: NO VIBRIO
FOUND.
FECAL CULTURE - R/O YERSINIA (Final ___: NO YERSINIA
FOUND.
FECAL CULTURE - R/O E.COLI 0157:H7 (Final ___:
NO E.COLI 0157:H7 FOUND.
Cryptosporidium/Giardia (DFA) (Final ___:
NO CRYPTOSPORIDIUM OR GIARDIA SEEN.
___ 6:11 am BLOOD CULTURE 2 sets.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 9:30 pm URINE Source: ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
GRAM POSITIVE BACTERIA. 10,000-100,000 ORGANISMS/ML..
Alpha hemolytic colonies consistent with alpha
streptococcus or
Lactobacillus sp.
___ 12:19 pm STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
FECAL CULTURE (Final ___:
NO SALMONELLA OR SHIGELLA FOUND.
NO ENTERIC GRAM NEGATIVE RODS FOUND.
CAMPYLOBACTER CULTURE (Final ___: NO CAMPYLOBACTER
FOUND.
___ 6:05 am Immunology (CMV)
**FINAL REPORT ___
CMV Viral Load (Final ___:
CMV DNA not detected.
Performed by Cobas Ampliprep / Cobas Taqman CMV Test.
Linear range of quantification: 137 IU/mL - 9,100,000
IU/mL.
Limit of detection 91 IU/mL.
This test has been verified for use in the ___ patient
population.
SACCHAROMYCES CEREVISIAE ANTIBODY PANEL
Test Result Reference
Range/Units
S CEREVISIAE AB (IGA) 10.2 <=20.0 U
Reference range(s):
Negative : <=20.0
Equivocal: 20.1 - 24.9
Positive: >=25.0
Test Result Reference
Range/Units
S CEREVISIAE AB (IGG) 7.7 <=20.0 U
QUANTIFERON-TB GOLD
Test Result Reference
Range/Units
QUANTIFERON(R)-TB GOLD NEGATIVE NEGATIVE
Negative test result. M. tuberculosis complex
infection unlikely.
Test Result Reference
Range/Units
NIL 0.04 IU/mL
MITOGEN-NIL 0.91 IU/mL
TB-NIL <0.00 IU/mL
Test Result Reference
Range/Units
SOURCE Whole Blood
EBV DNA, QN PCR <200 <200 copies/mL
IMAGING:
MR ENTEROGRAPHY ___:
Along the cecum and ascending colon there is apparent wall
thickening and
hyperemia, however this may be secondary to nondistended bowel.
The remainder
the visualized loops of large and small bowel are within normal
limits with no
definite areas of wall thickening, or hyperemia identified. No
extra
intestinal manifestations of inflammatory bowel disease such as
fibro fatty
proliferation, mesenteric lymphadenopathy or engorgement of the
vasa recta.
No fluid collections.
MRI OF THE ABDOMEN AND PELVIS WITH AND WITHOUT IV CONTRAST:
Visualized liver, biliary tree, gallbladder, spleen, adrenal
glands, and
kidneys are within normal limits.
Visualized bladder is unremarkable. Uterus and adnexa are
within normal
limits.
No lymphadenopathy is seen within the abdomen or pelvis.
No aneurysmal dilatation of the abdominal aorta.
No acute or worrisome osseous lesions.
IMPRESSION:
No definite MR features of inflammatory bowel disease. Apparent
wall
thickening and hyperemia of the cecum and ascending colon may be
secondary to
nondistended bowel. No extra intestinal manifestations of
inflammatory bowel
disease. No fluid collections.
PATHOLOGY:
SURGICAL PATHOLOGY REPORT - Revised
REVISED A: Immunohistochemical stain results:
- H. pylori immunohistochemical stain (performed on part 1) is
negative, with satisfactory control.
- CMV immunohistochemical stains (performed on parts ___ are
negative, with satisfactory control.
PATHOLOGIC DIAGNOSIS:
Gastrointestinal mucosal biopsies, five:
1. Stomach:
- Antral mucosa with mild edema and minimal chronic
inflammation, non-specific.
- Immunohistochemical stain results for H. pylori will be issued
in a revised report.
2. Duodenum:
- Duodenal mucosa with intact villous architecture and rare foci
of mildly increased intraepithelial
lymphocytes.
Note: The findings are mild and non-specific, but raise the
possibility of a drug effect, infection, or
celiac disease. Further correlation with clinical and serologic
findings is recommended.
3. Ascending colon/cecum:
___
Department of Pathology Patient: ___ 2 of 3
- Focal severely active colitis with ulceration. See note.
- Immunohistochemical stain results for CMV will be issued in a
revised report.
4. Transverse colon:
- Focal mildly active colitis. See note.
- Immunohistochemical stain results for CMV will be issued in a
revised report.
5. Rectum:
- Mildly active colitis. See note.
- Immunohistochemical stain results for H. pylori will be issued
in a revised report
Radiology Report
EXAMINATION: MR ___
INDICATION: ___ year old woman with crohns, needs MRE to eval // eval crohns
Colonoscopy performed ___ for rectal bleeding and diarrhea
demonstrated inflammatory changes of the rectum and entire colon covering a
non contiguous fashion, with biopsy results revealing increased inflammatory
cells within the rectum, sigmoid and descending colon. No evidence of C diff
colitis.
TECHNIQUE: T1 and T2-weighted multiplanar images of the abdomen and pelvis
were acquired within a 1.5 T magnet, including 3D dynamic sequences performed
prior to, during, and following the administration of 0.1 mmol/kg of Gadavist
intravenous contrast (6 cc). Oral contrast consisted of 900 mL of VoLumen. 1.0
mg of Glucagon was administered IM to reduce bowel peristalsis.
COMPARISON: None.
FINDINGS:
MR ENTEROGRAPHY:
Along the cecum and ascending colon there is apparent wall thickening and
hyperemia, however this may be secondary to nondistended bowel. The remainder
the visualized loops of large and small bowel are within normal limits with no
definite areas of wall thickening, or hyperemia identified. No extra
intestinal manifestations of inflammatory bowel disease such as fibro fatty
proliferation, mesenteric lymphadenopathy or engorgement of the vasa recta.
No fluid collections.
MRI OF THE ABDOMEN AND PELVIS WITH AND WITHOUT IV CONTRAST:
Visualized liver, biliary tree, gallbladder, spleen, adrenal glands, and
kidneys are within normal limits.
Visualized bladder is unremarkable. Uterus and adnexa are within normal
limits.
No lymphadenopathy is seen within the abdomen or pelvis.
No aneurysmal dilatation of the abdominal aorta.
No acute or worrisome osseous lesions.
IMPRESSION:
No definite MR features of inflammatory bowel disease. Apparent wall
thickening and hyperemia of the cecum and ascending colon may be secondary to
nondistended bowel. No extra intestinal manifestations of inflammatory bowel
disease. No fluid collections.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Abd pain
Diagnosed with Unspecified abdominal pain, Diarrhea, unspecified
temperature: 98.3
heartrate: 88.0
resprate: 16.0
o2sat: 100.0
sbp: 134.0
dbp: 83.0
level of pain: 8
level of acuity: 3.0 | Ms. ___ is a ___ woman with h/o recently diagnosed Crohn's
disease who presents after leaving ___ AMA
for further evaluation and treatment of lower abdominal pain and
diarrhea.
# Abdominal pain, diarrhea:
# Severe malnutrition:
Possibly IBD however per GI, pathology results atypical for
Crohn's disease. Patient also with significant other IBD-related
symptoms such as oral ulcers, lower extremity arthritis, and
skin manifestations which could be consistent with Behcet's
disease though she does not meet clinical criteria for
diagnosis. Her stool studies were largely unrevealing and
serologies for parasites were pending at time of discharge. Her
symptoms improved and CRP downtrended to 6 after IV
methylprednisolone x 4 days (___). She was
tolerating a low-residue diet by day prior to discharge. She was
transitioned to PO prednisone 40mg daily on ___ with plan
for prolonged steroid course and ___. She was started on
calcium/vitamin D supplementation, a PPI, and Bactrim for PCP
___.
TRANSITIONAL ISSUES
====================================
-Patient had PPD placement and quantiferon in house which were
negative
-Patient was discharged on prednisone ___ with calcium/vitamin
D, PPI, and Bactrim for PCP prophylaxis
___: 40mg x1 week, 30mg x1 week, 20mg x1 week, 10mg x1 week,
5mg x1 week, then stop.
-Patient was started on escitalopram for anxiety, which was
exacerbated by steroids. She was also given a small amount of
lorazepam in case of panic attacks, which she has had in the
past prior to this hospitalization.
-Patient to continue low residue diet
-Patient to F/U with GI at ___
-Patient will require outpatient hepatitis B vaccine
-Patient reports she was previously misdiagnosed with Celiac
disease; please discuss at GI followup whether she can resume
gluten in her diet
-Entamoeba histolytica, Yersinia enterocolitica, Schistosoma,
and Strongyloides antibodies were pending at the time of
discharge
-Final HSV culture from swabs of oral ulcers were pending at
time of discharge (prelim negative) |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Naprosyn / Lisinopril / mirtazapine
Attending: ___.
Chief Complaint:
abdominal discomofort and malaise
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a pleasant ___ year-old woman with a history of HTN,
spinal stenosis, vertigo, and anxiety who presents with a week
of general malaise and low-grade fevers found to have new L
upper lung opacity concerning for infection. Per the patient,
she began feeling unwell last ___ with nausea, abdominal
discomfort, decreased PO intake, dizziness and measured
temperatures to ___ F. She describes the dizziness as
occuring when walking and worse with sudden movement but not
present if she is sitting/lying still.
On ___, she saw an NP at her PCP's office where she was
afebrile with T 93 but hypertensive BP 180/70. The nurse was
concerned for "labyrinthitis and possibly due to otitis
externa," for which she was prescribed topical Cortisporin drops
and low-dose meclizine. She did not pick up the ear drops, but
started taking meclizine, which she thought worsened her
dizziness and subsequently discontinued. This morning, she woke
up and attempted to drink a cup of coffee, which gave her
significant nausea and abdominal discomfort and prompted her to
come to ___ ED.
ROS is positive for a dry cough that started around the time of
her abdominal discomfort. She has also had a change in bowel
habits - she typically has hard stools and takes daily metamucil
and two stool softeners, but this past week she has had fewer
bowel movements in the setting of PO intake followed by looser
stools today. Notably negative for change in diet, sick
contacts, F/C/CP/SOB, night sweats, weight loss/gain, headache,
sinus tenderness, rhinorrhea,arthralgias or myalgias.
In ___ ED, vital signs were 97.9 90 156/59 16 98% RA. Chem7
and CBC were unremarkable, and EKG was consistent with prior.
CT Abd/Pelvis did not find any acute pathology to explain the
patient's symptoms, but CXR showed new L upper lobe opacity
concerning for infection. She was administered ceftriaxone
azithromycin for possible pneumonia and admittion to Medicine.
On arrival to the floor, patient's vitals were 98.8 143/51 85 18
97%RA. She was able to tolerate a small meal, and had a small
loose bowel movement without any abdominal pain or nausea.
Past Medical History:
hypertension
sarcoidosis
iron deficiency anemia
spinal stenosis
stress incontinence
depression
chronic rhinitis
diverticulosis
SBO ___
Hpylori positive treated in ___
Social History:
___
Family History:
Hypertension in many family members
Sister and niece with DM Type 2
Sister with ___
Both children have thyroid disease
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals: T: 98.9 BP: 143/51 P: 81 R: 18 O2: 97%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII, motor, and sensory grossly intact.
DISCHARGE PHYSICAL EXAM:
Vitals: T: 98.5 BP: 132/66 P: 77 R: 20 O2: 95%RA
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, JVP not elevated, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no rebound tenderness or guarding, no organomegaly
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema
Neuro: CN II-XII, motor, and sensory grossly intact.
Pertinent Results:
ADMISSION LABS:
___ 07:40AM BLOOD Neuts-59.5 ___ Monos-7.3 Eos-1.4
Baso-0.9
___ 07:40AM BLOOD Glucose-96 UreaN-20 Creat-0.6 Na-140
K-4.1 Cl-105 HCO3-28 AnGap-11
___ 08:54AM BLOOD Lactate-0.9
DISCHARGE LABS:
___ 04:25AM BLOOD WBC-2.6* RBC-3.53* Hgb-10.9* Hct-34.5*
MCV-98 MCH-30.9 MCHC-31.6 RDW-13.1 Plt ___
___ 04:25AM BLOOD Glucose-88 UreaN-13 Creat-0.5 Na-140
K-4.7 Cl-104 HCO3-33* AnGap-8
STUDIES:
___ CT abdomen and pelvis: No acute pathology to explain pts
symtoms. Degenerative changes of the thoracolumbar spine with
deformity of T11 vertebral body of indeterminate chronicity.
desc colon and sigmoid diverticulosis without evidence of
diverticulitis. Mildly prominent panc duct, similar to
decreased since ___.
___ CXR: 1. No acute focal consolidation. 2. 7-mm rounded
opacity in the left upper lung new since 2 days prior and may
be focus of infection; attention to this region on follow up
imaging.
MICROBIOLOGY:
___ Legionella Urinary Antigen -FINAL
___ Blood Culture x2-PENDING
___ C. difficile DNA amplification assay - Positive
___ FECAL CULTURE, CAMPYLOBACTER CULTURE, OVA + PARASITES -
pending
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Fluticasone Propionate NASAL 2 SPRY NU BID
2. Gabapentin 300 mg PO QHS
3. Losartan Potassium 100 mg PO DAILY
4. Acetaminophen 1000 mg PO Q8H:PRN pain
5. Citracal + D Maximum *NF* (calcium citrate-vitamin D3)
315-250 mg-unit Oral BID
6. Docusate Sodium Dose is Unknown PO BID
7. Multivitamins 1 TAB PO DAILY
8. Polyethylene Glycol 17 g PO DAILY
9. Psyllium 1 PKT PO DAILY
Discharge Medications:
1. Fluticasone Propionate NASAL 2 SPRY NU BID
2. Gabapentin 300 mg PO QHS
3. Losartan Potassium 100 mg PO DAILY
4. Levofloxacin 750 mg PO DAILY
5. Acetaminophen 1000 mg PO Q8H:PRN pain
6. Docusate Sodium 100 mg PO DAILY:PRN constipation
7. MetRONIDAZOLE (FLagyl) 500 mg PO Q8H
8. Citracal + D Maximum *NF* (calcium citrate-vitamin D3)
315-250 mg-unit ORAL BID
9. Multivitamins 1 TAB PO DAILY
10. Polyethylene Glycol 17 g PO DAILY
11. Psyllium 1 PKT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary diagnoses: Pneumonia, C. difficile infection
Secondary diagnoses: Hypertension, spinal stenosis, vertigo,
anxiety, sarcoid
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 abdominal pain, nausea, vomiting.
Evaluate for chest pathology.
COMPARISON: ___.
PA AND LATERAL CHEST RADIOGRAPHS: Bilateral lungs are well expanded.
Bilateral reticular nodular opacity similar to the prior examination.
Calcification in the hila may reflect sarcoidosis, unchanged from the prior
examination. The cardiac, mediastinal and hilar contours are unchanged from
the prior examination. There is no evidence of pleural effusion or
pneumothorax. There is a small 7-mm rounded opacity in the left upper lung,
new since ___, 2 days prior.
IMPRESSION:
1. No acute focal consolidation.
2. 7-mm rounded opacity in the left upper lung new since 2 days prior and may
be focus of infection; attention to this region on follow up imaging.
Radiology Report
INDICATION: ___ female with abdominal pain, nausea, vomiting, green
stool with urge to defecate, evaluate for enterocolitis, diverticulitis.
COMPARISON: ___, CT of the chest with contrast, ___.
TECHNIQUE: MDCT axial images were obtained through the abdomen and pelvis
with the administration of IV contrast. Multiplanar reformats were generated
and reviewed.
FINDINGS: Visualized lung bases show mild opacification at the left lung base
(2:80). Visualized heart and pericardium are unremarkable.
The liver, gallbladder, spleen and bilateral adrenal glands appear
unremarkable. The pancreatic duct appears mildly prominent, but improved
compared to the CT of the chest with contrast of ___. Bilateral
kidneys enhance and excrete contrast symmetrically without evidence of
hydronephrosis or renal calculi. Intra-abdominal loops of large and small
bowel are within normal limits.
There is no free air or free fluid within the abdomen. Retroperitoneal and
mesenteric lymph nodes do not meet CT size criteria for pathology.
Intra-abdominal vasculature appears normal in contour, with mild
atherosclerotic calcification involving the abdominal aorta.
CT OF THE PELVIS: There is evidence of sigmoid diverticulosis. There is also
evidence of diverticulosis involving the descending colon. There is no
evidence of colitis. The bladder, distal ureters, rectum and sigmoid colon
appear unremarkable. The uterus appears within normal limits. There is no
free fluid within the pelvis. Pelvic lymph nodes do not meet CT size criteria
for pathology.
Visualized osseous structures show multilevel degenerative changes including
anterolisthesis of L4 on L5. Degenerative vacuum disc phenomenon is noted at
the L3-L4, L4-L5 and L5-S1 disc spaces. Mild irregularity along the T11
vertebral body is unchanged from ___.
IMPRESSION:
1. No definite acute abdominal pathology to explain patient's symptoms.
2. Descending colon and sigmoid diverticulosis without evidence of acute
diverticulitis.
3. Mildly prominent pancreatic duct, but improved from ___. No definite
acute intra-abdominal pathology.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: ABD PAIN
Diagnosed with NAUSEA, OTHER MALAISE AND FATIGUE, FEVER, UNSPECIFIED
temperature: 97.9
heartrate: 90.0
resprate: 16.0
o2sat: 98.0
sbp: 156.0
dbp: 59.0
level of pain: 13
level of acuity: 3.0 | ___ F with hx of HTN, spinal stenosis, vertigo, and anxiety who
presents for nausea, abdominal pain, and dry cough found to have
new opacity concerning for community acquired pneumonia and to
be Cdiff positive.
# Community acquired pnumonia: The patient was found to have a
new R upper lobe opacity compared to a CXR from 2 days prior,
with concerns of possible pneumonia. Clinically, this could be
consistent with her general malaise, low-grade fevers, and
abdominal discomfort. She was administered one dose of IV
ceftriaxone and azithromycin, and switched to PO Levofloxacin on
second day of admission. Throughout this hospitalization, she
remained afebrile without shortness of breath and oxygenating
well on room air. She was discharged with plans to complete a 7
day course of antibiotics.
# Clostridium Difficile: The patient had an episode of soft
stool at home prior to admission, which she brought into the
hospital and was sent for stool studies (C. diff, culture, O&P).
Her C. diff ___ came back positive though the patient
remained afebrile, without abdominal pain/discomfort, and a
normal white blood cell count. Her bowel movements were
infrequent. She was started on PO Flagyl with plans to complete
a 14 day course.
# Hypertension: The patient was maintained on her home dose of
Losartan 100mg PO QD, and her blood pressures remained
well-controlled in 130-140s throughout the hospitalization. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Sulfamethoprim / Tegaderm / Sulfa (Sulfonamide Antibiotics)
Attending: ___
Chief Complaint:
Nausea/Vomiting/Rash
Major Surgical or Invasive Procedure:
None
History of Present Illness:
REASON FOR MICU ADMISSION: hypoxemia, tachycardia
HISTORY OF PRESENT ILLNESS:
___ is a ___ female with PMH significant for relapsed
Hodgkin's lymphoma currently receiving Brentuximab/Bendamustine
(C2D1 = ___ who presents with one day of fevers, rigors and
N/V.
Patient was in her usual state of health until last evening when
she was noted by her mother to be ___ with N/V. Earlier in
the day, patient had received cycle 2 day 1 of
Brentuximab/Bendamustine without issue. She reported to the
nearest emergency room (___) where she was noted to be
febrile to ___, ___ and still with N/V. She then
reportedly developed a erythematous rash beginning on her face
and spreading to her trunk/arms. Mother reports that the rash
developed prior to administration of any antibiotics or
medications. She was given vanc/cefepime at ___. She was then
transferred to ___ for further care.
In the ED, initial vitals: ___, 120, 103/67, 20, 100% RA
- Exam notable for erythematous rash of the face, arms and
trunk. HR went as high as 150s.
- Labs were notable for plts 118, lactate 2.2, Mg 1.2, HCO3 18.
- CXR showed increased perihilar vascular markings. Left sided
port access. No effusions or opacifications.
- Patient was given: 2L IVF, IV Tylenol ___ x1, IV
metoclopramide 10mg x1 and IV Zofran 4mg x1 with mild to
moderate improvement in her symptoms
- Consults: Heme/Onc
On arrival to the MICU, patient reports feeling much better.
Review of systems:
(+) Per HPI
Past Medical History:
PAST ONCOLOGIC HISTORY:
___: CT Torso
reveals extensive supraclavicular and anterior mediastinal
lymphadenopathy, with two non-specific pulmonary nodules
measuring up to 3 mm.
- ___: Right cervical lymph node biopsy reveals classical
Hodgkin Lymphoma, nodular sclerosis subtype.
- ___: Bone Marrow Biopsy reveals normocellular bone marrow
with maturing trilineage hematopoiesis, with no morphologic
evidence of Hodgkin Lymphoma. Cytogenetics: 46,XX[20].
- ___: TTE shows normal LVEF (>55%).
- ___: PET shows marked FDG uptake in a left supraclavicular
lymph node conglomerate and anterior mediastinal lymph node
conglomerate, gocal FDG uptake in the left posterior portion of
the T9 vertebral body, diffuse increased FDG uptake throughout
the bone marrow, and unusual distribution of higher density in
the right breast may be normal breast tissue.
- ___: PFTs demonstrate FEV1 87% of predicted, FEV1/FVC 0.82,
and DLCO corrected for hemoglobin: 90% of predicted.
- ___: C1D1 ABVD.
- ___: MRI of the thoracic spine shows a focal lesion in the
left side of the T9 vertebral body, approximately 2.3 x 1.6 cm
with irregular peripheral edema and enhancement and a
non-enhancing central area.
- ___: EACOPP C1D1 ___
-___ disease (questionable history; likely not truly
VW)
-CAP treated as outpt at age ___
Social History:
___
Family History:
Mother diagnosed with childhood leukemia. Otherwise no family
h/o malignancy.
Physical Exam:
ADMISSION PHYSICAL EXAM:
=========================
Vitals: 99 100s 129/74 95%RA
GENERAL: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear
NECK: supple, JVP not elevated, no LAD
LUNGS: Clear to auscultation bilaterally, no wheezes, rales,
rhonchi
CV: Regular rate and rhythm, normal S1 S2, no murmurs, rubs,
gallops
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: diffuse erythematous rash
NEURO: moving all extremities
DISCHARGE PHYSICAL EXAM:
=========================
Pertinent Results:
ADMISSION LABS:
===============
___ 10:40AM BLOOD WBC-3.2* RBC-4.17 Hgb-13.0 Hct-38.7
MCV-93 MCH-31.2 MCHC-33.6 RDW-13.2 RDWSD-44.4 Plt ___
___ 10:40AM BLOOD Neuts-46 Bands-0 ___ Monos-24*
Eos-0 Baso-0 Atyps-4* ___ Myelos-0 AbsNeut-1.47*
AbsLymp-0.96* AbsMono-0.77 AbsEos-0.00* AbsBaso-0.00*
___ 10:40AM BLOOD Plt Smr-NORMAL Plt ___
___ 10:40AM BLOOD UreaN-10 Creat-0.6 Na-137 K-4.1 Cl-103
HCO3-26 AnGap-12
___ 10:40AM BLOOD ALT-46* AST-37 AlkPhos-67 TotBili-0.2
___ 10:40AM BLOOD TotProt-6.9 Albumin-4.3 Globuln-2.6
Calcium-9.6 Phos-3.4 Mg-1.8
___ 06:03AM BLOOD ___ pO2-73* pCO2-26* pH-7.45
calTCO2-19* Base XS--3
___ 04:59AM BLOOD Lactate-2.2*
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Ondansetron 8 mg PO Q8H:PRN nausea
2. Lactulose 15 mL PO Q8H:PRN constipation
3. Dronabinol 5 mg PO BID
4. Atovaquone Suspension 750 mg PO DAILY
5. LORazepam 0.5 mg PO BID:PRN nausea
6. mometasone 50 mcg/actuation nasal DAILY
7. Acyclovir 400 mg PO Q8H
8. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
9. esomeprazole magnesium 40 mg oral DAILY:PRN heartburn
Discharge Medications:
1. Acyclovir 400 mg PO Q8H
2. Atovaquone Suspension 750 mg PO DAILY
3. Dronabinol 5 mg PO BID
4. esomeprazole magnesium 40 mg oral DAILY:PRN heartburn
5. Lactulose 15 mL PO Q8H:PRN constipation
6. LORazepam 0.5 mg PO BID:PRN nausea
7. mometasone 50 mcg/actuation nasal DAILY
8. Ondansetron 8 mg PO Q8H:PRN nausea
9. OxycoDONE (Immediate Release) ___ mg PO Q4H:PRN pain
Discharge Disposition:
Home
Discharge Diagnosis:
Drug reaction
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: Chest radiograph
INDICATION: History: ___ with hodgkins lymphoma p/w tachycardia and new
oxygen requirement // acute cardiopulmonary process
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph ___
FINDINGS:
Postradiation changes are noted. Cardiomegaly is mild. The lung fields are
clear. A left Port-A-Cath terminates in the low SVC.
IMPRESSION:
No acute cardiopulmonary abnormality.
Radiology Report
INDICATION: History: ___ with hodgkins lymphoma s/p chemo (poss side effect
pneumonitis), here w/ hypotension, tachycardia, fever // PE? Pneumonitis?
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast.
Reformatted coronal, sagittal, thin slice axial images, and oblique maximal
intensity projection images were submitted to PACS and reviewed.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.2 mGy (Body) DLP = 1.8
mGy-cm.
2) Stationary Acquisition 2.7 s, 0.2 cm; CTDIvol = 46.1 mGy (Body) DLP =
9.2 mGy-cm.
3) Spiral Acquisition 3.9 s, 25.1 cm; CTDIvol = 5.7 mGy (Body) DLP = 139.9
mGy-cm.
Total DLP (Body) = 151 mGy-cm.
COMPARISON: ___
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.
Prevascular mediastinal lymphadenopathy is slightly improved compared to the
prior examination, with individual nodes measuring up to 8 mm in short axis
diameter, previously 1 cm. Prominence of soft tissue in the anterior
mediastinum may relate in part to prominence of thymic tissue/thymic rebound.
The thyroid gland appears unremarkable.
There is no evidence of pericardial effusion. There is no pleural effusion.
Minimal ground-glass opacities in the left lower lobe and lingula likely
reflect subsegmental atelectasis; a trace component up superimposed
inflammatory change or atypical infection cannot be excluded. In the left
upper lobe medially, a linearly configured area of ground-glass opacity and
volume loss might reflect subsegmental atelectasis, or postradiation change if
this has been performed. Motion artifact on the prior CT limits comparison
between studies. The airways are patent to the subsegmental level.
Limited images of the upper abdomen show diffuse hypodensity of the hepatic
parenchyma consistent with hepatic steatosis. The imaged portion of the upper
pole of the spleen appears unremarkable.
No lytic or blastic osseous lesion suspicious for malignancy is identified.
IMPRESSION:
1. No evidence of pulmonary embolism or aortic abnormality.
2. Prominence of soft tissue in the anterior mediastinum most likely reflect
thymic hyperplasia/rebound and can be reassessed at followup imaging.
3. Slight interval improvement in mediastinal lymphadenopathy.
4. Minimal subsegmental atelectasis and/or superimposed inflammatory/atypical
infectious changes at the left base and left apex.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Fever, Transfer
Diagnosed with Fever, unspecified
temperature: 102.0
heartrate: 120.0
resprate: 20.0
o2sat: 100.0
sbp: 103.0
dbp: 67.0
level of pain: 5
level of acuity: 2.0 | ___ with PMH of relapsed Hodgkin's lymphoma who is one day s/p
Bendamustine and Brentuximab who presents with fevers, nausea,
vomiting, rash concerning for acute infection vs. drug side
effect.
#Drug Reaction: Patient presented with fever, tachycardia,
tachypnea, with an elevated lactate, which in setting of
infection would be consistent with severe sepsis. She had some
nasal congestion and infected contacts so may have had a viral
illness. She had no evidence of pneumonia or UTI and no other
localizing symptoms. Flu negative. Port appeared uninfected. The
rash and her symptoms resolved quickly however after hydration
and sympotmatic management of sympotms, making this more likely
to be drug side effect, likely from bendamustine. She had no
respiratory compromise or drop in pressure to suggest an
anaphylactic reaction. CTA showed no evidence of PE.
#Respiratory alkalosis - Secondary to tachypnea likely from
reaction to medication
#Elevated lactate - Unlikely from hypoperfusion. Lactic acidosis
is known to occur in lymphoma from anaerobic metabolism.
#Nausea/vomiting -symptomatic control with Zofran, ativan
#Hodgkin's lymphoma - Recurrence now s/p C2 of bendamustine and
brentuximab prior to BEAM auto SCT. She may be able to get
bendamustine again in the future with more
premedication since no anaphylaxis was noted.
Transitional
===========
-follow up with oncology, they will contact you about an
appointment |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
CC: ___
Major Surgical or Invasive Procedure:
None
History of Present Illness:
HPI: The patient is a ___ y/o M with several months of BLE pain
and muscle fasciculations of unclear etiology. He was recently
admitted here with extensive work-up largely unrevealing (please
refer to that discharge summary for further details). He
presented to clinic today for ___ and experienced and
acute
pain episode in the waiting room with associated diaphoresis.
While he stated that he would not have gone to the ED for this,
clinic staff were concerned and referred him to the ED for
evaluation. Neuro saw the patient in the ED and felt that exam
was at baseline, recommended outpatient ___. In the ED, he
also endorsed lightheadedness with standing as well as an
episode
of syncope several weeks ago. Orthostatics were checked and were
positive. He was admitted to medicine for evaluation.
ED Course:
Initial VS: 98.3 ___ 18 98% RA Pain ___
Labs significant for lipase 67. UA with 30 RBC, 14 WBC, few
bacteria.
Imaging: CXR showing no acute cardiopulmonary process.
Meds given:
VS prior to transfer: 98.6 91 154/100 16 100% RA Pain ___
On my exam on the arrival to the floor, the patient described
several months of BLE "electric shock" leg pains that started in
the feet and progressed up to his back. This is associated with
muscle fasciculations / spasms. These symptoms have actually
improved since his recent admission.
Since recent discharge, however, he reports new epigastric pain
(x 2 weeks), which he attributed possibly to NSAIDs he was
taking
for pain. He also endorses ___ days of new spasms in his
shoulders / upper back.
Regarding his syncope, the episode occurred several weeks ago in
the setting of walking from his bedroom to his dtr's room. Had
prodromal darkening of vision. Episode was unwitnessed, but he
does not believe he had a head strike. No further episodes, but
he does note lightheadedness with standing. He does endorse poor
PO intake and 40 lb weight loss since his symptoms began.
Aside from the above symptoms, the patient also endorses
intermittent episodes of diaphoresis, as well as difficulty
concentrating and difficulty focusing his vision, all of which
have been going on for the past few weeks. He also endorses
several weeks of urinary urgency.
ROS: As above. Denies chest pain, heart palpitations, shortness
of breath, cough, vomiting, diarrhea, constipation. The
remainder
of the ROS was negative.
Past Medical History:
Neuropathy of unclear etiology (as described above)
Venous ulcers
S/p appy
Obesity
Pre-Diabetes
History of TB Exposure s/p INH X 9 months
Social History:
___
Family History:
FAMILY HISTORY: Endorses a family history of ___. No
other family history of neurologic disorders.
Physical Exam:
ADMISSION
VS - 98.5 ___ 99%RA Pain ___
GEN - Alert, NAD
HEENT - NC/AT
NECK - Supple
CV - RRR, no m/r/g
RESP - CTA B
ABD - Obese, soft, BS present, diffusely TTP without r/g
EXT - No ___ edema or calf tenderness
SKIN - Scab present on left calf (pt reports that has been there
for a long time), hyperpigmentation of the skin of the BLE's
NEURO -
-- EOMI, PERRL
-- ___ grip strength bilaterally; 4+/5 elbow flexion/extension;
4+/5 shoulder abduction
-- ___ hip flexion, knee extension/flexion, ___
dorsiflexion/plantarflexion
-- 2+ patellar and biceps reflexes bilaterally
-- intermittent muscle fasciculations noted in the BLE's
throughout interview
PSYCH - calm, appropriate
DISCHARGE
VS: 97.6 ___ 99%RA
Gen: sleeping, awaking to voice, then sitting up in bed,
comfortable appearing
Eyes - EOMI
ENT - OP clear, MMM
Heart - RRR no mrg
Lungs - CTA bilaterally
Abd - soft nontender, normoactive bowel sounds
Ext - no edema
Skin - venous stasis changes of legs bilaterally
Vasc - 2+ DP/radial pulses
Neuro - AOx3, ___ strength in lower extremities, hypersensitive
to light touch of feet;
Psych - mildly anxious
Pertinent Results:
ADMISSION
___ 03:25PM BLOOD WBC-8.8 RBC-4.90 Hgb-14.3 Hct-41.9 MCV-86
MCH-29.2 MCHC-34.1 RDW-13.4 RDWSD-41.6 Plt ___
___ 03:25PM BLOOD Glucose-111* UreaN-15 Creat-0.7 Na-140
K-3.6 Cl-103 HCO3-25 AnGap-16
___ 03:25PM BLOOD Albumin-4.2 Calcium-9.5 Phos-4.7* Mg-2.1
___ 03:25PM BLOOD ALT-28 AST-20 AlkPhos-79 TotBili-0.3
DISCHARGE
___ 06:55AM BLOOD WBC-8.6 RBC-4.89 Hgb-14.2 Hct-42.1 MCV-86
MCH-29.0 MCHC-33.7 RDW-13.2 RDWSD-41.3 Plt ___
___ 06:55AM BLOOD Glucose-100 UreaN-12 Creat-0.6 Na-137
K-3.6 Cl-100 HCO3-24 AnGap-17
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. DULoxetine 60 mg PO DAILY
2. Gabapentin 1200 mg PO TID
3. Calcium Carbonate 500 mg PO QID:PRN heartburn
4. Lidocaine 5% Patch 3 PTCH TD QAM back pain
5. Methocarbamol 500 mg PO Q6H:PRN pain, muscle spasm
6. Acetaminophen Dose is Unknown PO Frequency is Unknown
7. Ranitidine 300 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN pain
2. Calcium Carbonate 500 mg PO QID:PRN heartburn
3. DULoxetine 90 mg PO DAILY
RX *duloxetine 30 mg 3 capsule(s) by mouth once a day Disp #*42
Capsule Refills:*0
4. Gabapentin 1200 mg PO TID
5. Methocarbamol 500 mg PO Q6H:PRN pain, muscle spasm
6. Ranitidine 300 mg PO BID
7. lidocaine HCl 3 % topical BID:PRN pain
RX *lidocaine HCl 3 % apply to affected area twice a day
Refills:*0
8. Melatin (melatonin) 3 mg oral QHS:PRN insomnia
this is an over the counter medication to try to help you sleep
Discharge Disposition:
Home
Discharge Diagnosis:
# Orthostatic Hypotension / Neuropathy / Lower Extremity Pain
# Delirium
# Depression
# GERD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with cough // eval for pneumonia
TECHNIQUE: PA and lateral views the chest.
COMPARISON: None.
FINDINGS:
The lungs are clear. The cardiomediastinal silhouette is within normal
limits. No acute osseous abnormalities.
IMPRESSION:
No acute cardiopulmonary process.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: B Leg pain
Diagnosed with Orthostatic hypotension
temperature: 98.3
heartrate: 105.0
resprate: 18.0
o2sat: 98.0
sbp: 164.0
dbp: 104.0
level of pain: 5
level of acuity: 3.0 | This is a ___ year old male with past medical history of venous
insufficiency, recent workup for bilateral lower extremity pain
thought to relate to potential peripheral neuropathy of unknown
etiology, admitted ___ w orthostatic hypotension,
resolving with IV fluids, course complicated by episode of
delirium though to have been precipitated by recent increased
stress and decreased sleep, subsequently ambulating safely, able
to be discharged home with PCP and neurology ___.
# Orthostatic Hypotension / Neuropathy / Lower Extremity Pain -
as documented in prior discharge summary and neurology notes,
patient with peripheral neuropathy of unclear etiology; he
presented with episode of orthostatic hypotension and reported
recent syncopal episode; suspected etiology of syncope was
orthostatic hypotension; he received IV fluids with subsequent
normal orthostatic vital signs. He subsequently revealed
increased stress at home related to marital discord and that he
had only been sleeping < 2 hours per night as a result. He
continued to report ongoing pain and tingling in his lower
extremities, unchanged from his recent admission. He was seen
by the neurology service who recommended outpatient ___
for additional workup and repeat EMG. Stress and lack of sleep
were felt to be a major driver regarding his ongoing symptoms,
and recent reported decreased PO intake (likely the etiology of
his hypovolemia / episode of orthostatic hypotension). At time
of discharge he was able to safely ambulate in the hall today
without issue. Continued home gabapentin, prn Tylenol,
methocarbamol. Trialed on lidocaine cream.
# Delirium - On evaluation by social work and neurology patient
appeared to be responding to internal stimuli and making bizarre
and disorganized statements
clearly awake. Given concern for a primary psychiatric process,
he was seen by psychiatry who felt he had acute encephalopathy
as a result of intense stress and sleep deprivation with
underlying major depressive disorder and anxiety disorder. Case
discussed with neurology who did not believe this was related to
a primary neurologic issue. Psychiatry recommended increasing
duloxetine dose to 90mg daily.
# GERD - continued ranitidine
Transitional Issues
- Discharged home with prescription for increased dose of
duloxetine and trial of lidocaine cream. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: CARDIOTHORACIC
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
Transfer for recurrent RP Bleed s/p failed R Renal aa
embolization and right pleural effusion
Major Surgical or Invasive Procedure:
___
Right pleural pigtail catheter placement
___
Right VATS decortication, evacuation of effusion
History of Present Illness:
___ yo F hx of hep C, hx IVDA, polycystic kidney disease, FMD c/b
(RAS and HTN) w/ recent admission at ___ for angioplasty of
right renal artery c/b by RP bleed (embolized ___ @___)
presented to ___ for right flank and abd pain.
ED course at ___ w/CT showing ?enlarged hematoma
and a large right sided effusion. Patient refused transfer back
to ___, thus transferred to ___ for further evaluation by
___ and thoracic surgery.
In further discussion with patient predominant symptoms of
dyspnea and R sided chest pain, RLQ abd pain. First noted ___
days ago and have progressively worsened. Endorses worsening
pain, occasional lightheadedness w/o syncope, chest pain,
palpitaitons. Denies fever/chills/n/v/myalgias.
ED course also significant for consultations by both thoracic
surgery and ___. Given no active extravasation on in house CT-A,
a multidisciplinary plan was made to hold on ___ intervention,
trend h/h and plan to have thoracics place pigtail cath early am
for symptomatic relief non-urgently.
Past Medical History:
hep C
IVDA
PCKD - Previously managed at ___ s/p angioplasty of right
renal artery c/b by RP bleed (embolized ___ @ ___)
FMD c/b RAS and HTN
HTN
Social History:
___
Family History:
-Father, deceased - ___ Cancer. Unknown if had PCKD.
-Mother, living - also w/FMD w/o PCKD. CVA x2 at ages ___ and
___. Lives in ___.
-Siblings: 1 sister 2 brothers. No medical conditions she's
aware of. They have not been tested for PCKD
-PGF: Cancer
General: no fhx of DM, MI, early sudden cardiac death
Physical Exam:
Vitals- 98.0 PO 137 / 87 L Lying 91 28 96 RA
GENERAL: somewhat cachectic appearing. AOx3, in significant
discomfort.
HEENT: some temporal wasting. PERRLA. EOMI. No conjunctival
pallor or injection, sclera anicteric. Moist mucous membranes,
good dentition. Oropharynx is clear.
NECK: No cervical lymphadenopathy.
CARDIAC: Regular rhythm, normal rate, no murmurs/rubs/gallops.
No JVD.
LUNGS: Left lung fields clear to auscultation. Right upper ___
clear, middle ___ diminished and lower ___ absent breath sounds.
No rhochi or wheezing.
BACK: Skin w/o rashes. tenderness of right flank to light
percussion
ABDOMEN: Clonidine patch from ___ on RLQ abdomen. Normal
bowels sounds, non distended, mild tenderness to RLQ. No
organomegaly.
EXTREMITIES: wtp. No clubbing, cyanosis, or edema, no sign of
atrophy/hypertrophy. Pulses DP/Radial 2+ bilaterally.
SKIN: No evidence of ulcers, rash or lesions suspicious for
malignancy or infection.
NEUROLOGIC: CN2-12 intact.
Labs, Microbiology: reviewed, please see attached
Pertinent Results:
WBC RBC Hgb Hct MCV MCH MCHC RDW RDWSD
Plt Ct
___ 04:55 5.1 4.07 10.6* 33.7* 83 26.0 31.5* 13.5 40.8
365
___ 05:00 7.2 4.34 11.4 35.7 82 26.3 31.9* 13.5 41.1
452*
___ 06:15 5.2 4.17 11.2 34.3 82 26.9 32.7 13.5 40.8
430*
___ 05:20 5.3 4.27 11.3 35.0 82 26.5 32.3 13.6 40.4
414*
___ 10:16 5.6 4.24 11.8 35.4 84 27.8 33.3 14.0 42.2
390
___ 01:00 6.3 4.25 11.4 34.9 82 26.8 32.7 13.8 41.3
423*
Glucose UreaN Creat Na K Cl HCO3 AnGap
___ 04:55 ___ 138 3.5 100 28 14
___ 05:00 ___ 137 4.5 99 25 18
___ 06:15 821 11 0.7 142 4.2 ___
___ 10:16 ___ 140 4.0 ___
___ 01:00 ___ 3.7 ___
ALT AST LD(___) CK(CPK) AlkPhos Amylase TotBili
DirBili
___ 05:20 291*
___ 109* 36 0.7
___ 2:45 pm PLEURAL FLUID RIGHT PLEURAL FLUID.
GRAM STAIN (Final ___:
3+ ___ per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Preliminary): NO GROWTH.
ANAEROBIC CULTURE (Preliminary): NO GROWTH.
FUNGAL CULTURE (Preliminary): NO FUNGUS ISOLATED.
Imaging
___ CTA torso
1. Nonhemorrhagic large right pleural effusion causing near
completely
collapse of the right lung with moderate leftward mediastinal
shift.
2. A large right perinephric hematoma encompasses the right
kidney. There is no evidence of active arterial extravasation.
Renal arteries are patent. No pseudoaneurysm. Metallic
devices, likely related to coil embolization seen in the medial
aspect of the right kidney. There are wedge-shaped infarcts
within the posterior cortex of the right renal interpolar
region.
3. The left kidney is severely atrophic with severe thinning of
the cortical parenchyma and hydronephrosis with foci of
calcification within the dependent portion of the lower pole
calyces. Stranding of fat surrounding the left proximal ureter
as well as ill-defined soft tissue stranding within the
ipsilateral psoas muscle adjacent to the proximal ureter and
enhancing lymph nodes in the left para-aortic region measuring
up to 1 cm in short axis raise suspicion for chronic infection
as an etiology for the above described findings. Comparison
with any prior imaging if available is recommended to ascertain
the exact cause for chronic renal atrophy on the left.
4. The liver demonstrates heterogeneous attenuation however
without delayed phase imaging unable to distinguish between
perfusional variant versus ischemic changes.
5. Mild splenomegaly.
___ CT chest
Interval placement of a right-sided pleural drain. The
right-sided pleural effusion has significantly decreased in size
with decreased mediastinal shift and re-expansion of the right
upper and middle lobes. However, a large right-sided effusion
persists, with collapse of the right lower lobe.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. HydrALAZINE 100 mg PO TID
2. Ferrous Sulfate 325 mg PO DAILY
3. TraZODone 50 mg PO QHS:PRN insomnia
4. Carvedilol 25 mg PO BID
5. amLODIPine 10 mg PO DAILY
6. ClonazePAM 0.5 mg PO BID
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H
RX *acetaminophen 325 mg 2 tablet(s) by mouth every six (6)
hours Disp #*100 Tablet Refills:*1
2. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 capsule(s) by mouth twice a day
Disp #*60 Capsule Refills:*2
3. Milk of Magnesia 30 mL PO Q12H:PRN constipation
4. Nicotine Patch 14 mg TD DAILY
RX *nicotine 14 mg/24 hour 1 once a day Disp #*14 Patch
Refills:*2
5. OxyCODONE (Immediate Release) ___ mg PO Q4H:PRN Pain -
Moderate
RX *oxycodone 5 mg ___ tablet(s) by mouth every four (4) hours
Disp #*50 Tablet Refills:*0
6. Polyethylene Glycol 17 g PO DAILY:PRN no bm for 48h
7. Senna 8.6 mg PO DAILY
RX *sennosides [senna] 8.6 mg 1 tab by mouth once a day Disp
#*30 Tablet Refills:*2
8. amLODIPine 10 mg PO DAILY
9. Carvedilol 25 mg PO BID
10. ClonazePAM 0.5 mg PO BID
11. Ferrous Sulfate 325 mg PO DAILY
12. HydrALAZINE 100 mg PO TID
13. TraZODone 50 mg PO QHS:PRN insomnia
Discharge Disposition:
Home
Discharge Diagnosis:
Right pleural effusion
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: CTA Torso
INDICATION: History: ___ with R pleural effusion, recent RP bleed ___ renal
stenosis procedure // Eval for active bleed, etiology of R pleural effusion
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
arterial 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 0.5 s, 0.5 cm; CTDIvol = 1.5 mGy (Body) DLP = 0.8
mGy-cm.
2) Stationary Acquisition 0.5 s, 0.5 cm; CTDIvol = 1.5 mGy (Body) DLP = 0.8
mGy-cm.
3) Spiral Acquisition 4.9 s, 53.0 cm; CTDIvol = 6.2 mGy (Body) DLP = 328.8
mGy-cm.
4) Stationary Acquisition 2.0 s, 0.5 cm; CTDIvol = 3.2 mGy (Body) DLP = 1.6
mGy-cm.
5) Spiral Acquisition 9.1 s, 71.1 cm; CTDIvol = 6.5 mGy (Body) DLP = 461.5
mGy-cm.
Total DLP (Body) = 793 mGy-cm.
COMPARISON: CT abdomen ___.
Chest film ___.
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, pericardium, and great vessels are within
normal limits. No pericardial effusion is seen.
AXILLA, HILA, AND MEDIASTINUM: The mediastinum is shifted to the left because
of the massive right pleural effusion. No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass.
PLEURAL SPACES: A large nonhemorrhagic right pleural effusion is slightly
hyperdense and may represent the presense of proteinaceous debris, ___ not
in the range of hemorrhagic products.
LUNGS/AIRWAYS: The right lung is near completely collapsed by a right pleural
effusion. The 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:
HEPATOBILIARY: The liver demonstrates heterogeneous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
biliary dilatation. Common bile duct is mildly enlarged measuring 6.0 cm and
tapers towards the ampulla. 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 14.3 cm, without evidence of focal
lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: A large 10.1 x 9.2 cm retroperitoneal perinephric hematoma
encompasses the right kidney, not significantly changed in size since ___. There is no evidence of active extravasation. There are wedge
shaped areas of hypoattenuation of the posterior cortex of the right kidney
compatible with infarcts. A few subcentimeter hypodensities are seen in the
right kidney, too small to characterize, likely simple cysts.
There is severe thinning of the left renal cortical parenchyma with severe
hydronephrosis and multiple foci of calcification within the residual left
renal cortex in the interpolar region as well as the lower pole. The left
ureter is not markedly dilated, etiology for severe left renal atrophy is
unclear based on this scan alone. Stranding of fat surrounding the left
proximal ureter as well as ill-defined soft tissue stranding within the
ipsilateral psoas muscle adjacent to the proximal ureter and enhancing lymph
nodes in the left para-aortic region measuring up to 1 cm in short axis raise
suspicion for chronic infection as an etiology for the above described
findings. Comparison with any prior imaging if available is recommended to
ascertain the exact cause for chronic renal atrophy on the left.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal. There is no free
air.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is
mild free fluid in the pelvis.
REPRODUCTIVE ORGANS: The reproductive organs are unremarkable.
LYMPH NODES: There are multiple enlarged left para-aortic lymph nodes
measuring up to 10 mm in short axis, of questionable etiology.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted. The mesenteric vessels are patent. Embolization of a branch of the
right renal artery is noted. The left renal artery is patent.
BONES AND SOFT TISSUES: There is no evidence of worrisome osseous lesions or
acute fracture. There is an intramuscular lipoma within the right lateral
abdominal wall muscles (series 4, image 167- 190).
IMPRESSION:
1. Nonhemorrhagic large right pleural effusion causing near completely
collapse of the right lung with moderate leftward mediastinal shift.
2. A large right perinephric hematoma encompasses the right kidney. There is
no evidence of active arterial extravasation. Renal arteries are patent. No
pseudoaneurysm. Metallic devices, likely related to coil embolization seen in
the medial aspect of the right kidney. There are wedge-shaped infarcts within
the posterior cortex of the right renal interpolar region.
3. The left kidney is severely atrophic with severe thinning of the cortical
parenchyma and hydronephrosis with foci of calcification within the dependent
portion of the lower pole calyces. Stranding of fat surrounding the left
proximal ureter as well as ill-defined soft tissue stranding within the
ipsilateral psoas muscle adjacent to the proximal ureter and enhancing lymph
nodes in the left para-aortic region measuring up to 1 cm in short axis raise
suspicion for chronic infection as an etiology for the above described
findings. Comparison with any prior imaging if available is recommended to
ascertain the exact cause for chronic renal atrophy on the left.
4. The liver demonstrates heterogeneous attenuation however without delayed
phase imaging unable to distinguish between perfusional variant versus
ischemic changes.
5. Mild splenomegaly.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with RP bleed and right pleural effusion //
interval change post pig tail interval change pre pig tail
IMPRESSION:
Right pigtail catheter is in place. Large pleural effusion on the right has
decreased since the prior study. There is small to moderate pneumothorax.
Left lung is clear. Heart size is top-normal.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with hx of hep C, hx IVDA, polycystic kidney
disease, FMD c/b (RAS and HTN) w/ recent admission at ___ for angioplasty
of right renal artery c/b by RP bleed (embolized ___ @___) presented to
___ for right flank and abd pain found to have recurrent RP bleed
w/o active bleeding on ___ imaging and right pleural effusion, dyspneic
admitted for pig tail catheter placement. // Please evaluate pleural effusion
Please evaluate pleural effusion
IMPRESSION:
Comparison to ___. Minimal decrease in extent of the known right
pleural effusion. An air-fluid level at the right lung apex confirms the
presence of intrapleural air. Mild leftward mediastinal shift. Normal size
of the heart. Normal appearance of the left lung.
Radiology Report
EXAMINATION: CTA CHEST WITH CONTRAST
INDICATION: ___ yo F hx of hep C, hx IVDA, polycystic kidney disease, FMD c/b
(RAS and HTN) w/ recent admission at ___ for angioplasty of right renal
artery c/b by RP bleed (embolized ___ @___) presented to ___
___ for right flank and abd pain found to have recurrent RP bleed w/o
active bleeding on ___ imaging and right pleural effusion, dyspneic admitted
for pig tail catheter placement. // Please evaluate lung and R pleural
effusion
TECHNIQUE: Axial multidetector CT images were obtained through the thorax
after the uneventful administration of intravenous contrast. Reformatted
coronal, sagittal, thin slice axial images, and oblique maximal intensity
projection images were submitted to ___ and reviewed.
DOSE: Acquisition sequence:
1) Spiral Acquisition 9.7 s, 37.2 cm; CTDIvol = 6.9 mGy (Body) DLP = 246.3
mGy-cm.
Total DLP (Body) = 258 mGy-cm.
COMPARISON: CT torso from ___
FINDINGS:
HEART AND VASCULATURE: The thoracic aorta is normal in caliber without
evidence of dissection or intramural hematoma. The heart, pericardium, and
great vessels are within normal limits. Trace pericardial effusion is noted.
AXILLA, HILA, AND MEDIASTINUM: No axillary, mediastinal, or hilar
lymphadenopathy is present. No mediastinal mass. There is interval decreased
mediastinal shift.
PLEURAL SPACES: A right-sided pigtail catheter is noted within a large
pleural effusion, which has significantly decreased in size compared to
previous. Diffusion again demonstrates internal attenuation compatible with
simple fluid. There is a small right-sided pneumothorax.
LUNGS/AIRWAYS: There is interval re-expansion of the right upper and middle
lobes. The right lower lobe remains collapsed. The 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 upper abdomen again demonstrates a partially
visualized right perinephric hematoma. The visualized portions of the left
kidney again demonstrates severe hydronephrosis and thinning of the left renal
cortex.
BONES: No suspicious osseous abnormality is seen.? There is no acute fracture.
IMPRESSION:
Interval placement of a right-sided pleural drain. The right-sided pleural
effusion has significantly decreased in size with decreased mediastinal shift
and re-expansion of the right upper and middle lobes. However, a large
right-sided effusion persists, with collapse of the right lower lobe.
Radiology Report
INDICATION: ___ year old woman with R pleural effusion s/p R VATS decort //
r/o ptx, htx, eval interval change in pleural effusion
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
There has been interval placement of 2 right-sided chest tubes. Interval
decrease in size of the right pleural effusion, now small to moderate in
extent. There is overlying atelectasis in the right mid and lower lung zones.
No discrete pneumothorax is identified and the left lung is grossly clear.
The appearance of the cardiac silhouette is unchanged.
IMPRESSION:
Interval placement of 2 right-sided chest tubes. No discrete pneumothorax
identified.
Interval decrease in size of the right pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with large right pleural effusion, s/p R VATS
decortication and evacuation of pleural effusion // eval for interval change,
please obtain ___ AM eval for interval change, please obtain ___ AM
IMPRESSION:
Compared to chest radiographs ___ through ___.
After pleural drainage procedure, auto before ___, moderate right
pleural effusion persists common despite 2 right thoracostomy tubes. No
pneumothorax. . Right lower lobe atelectasis is severe. Left lung is clear.
Heart size is mildly enlarged. Mediastinum is midline.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with R pleural effusion s/p VAT decortication
// Please evaluate for interval change.Please obtain at 0500, ___ for
likely D/C of chest tubes early AM. Please evaluate for interval
change.Please obtain at 0500, ___ for likely D/C of chest tubes early AM.
IMPRESSION:
In comparison with the study of ___, there is little change.
Bilateral chest tubes are seen on the right following with surgery with no
evidence of pneumothorax. Combination of pleural fluid and volume loss is
seen at the right base.
The left lung is clear. There is mild enlargement of the cardiac silhouette
without appreciable pulmonary vascular congestion.
Radiology Report
INDICATION: ___ year old woman s/p R VATS decortication // R/O PTX post CT
removal
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest radiograph since ___, most recent from ___ at 03:57
FINDINGS:
There has been interval removal of right-sided chest tubes. No evidence of
pneumothorax. Small right pleural effusion. Right consolidative opacities in
the right lower lung field are consistent with expected atelectasis although
could represent pneumonia. Follow-up x-ray is recommended to follow these
opacities. The left lung is clear. Cardiac silhouette is top-normal in size.
Mediastinal and hilar contours are normal.
IMPRESSION:
1. Interval removal of right-sided chest tubes without evidence of
pneumothorax. Small right pleural effusion.
2. Consolidative opacities in the right lower lung field are consistent with
expected atelectasis although could represent pneumonia. Follow-up x-ray is
recommended to follow these opacities.
RECOMMENDATION(S): Follow-up x-ray to follow right lower lung field
opacities.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: R Flank pain, Abd pain, Transfer
Diagnosed with Pleural effusion, not elsewhere classified
temperature: 97.6
heartrate: 90.0
resprate: 18.0
o2sat: 100.0
sbp: 132.0
dbp: 66.0
level of pain: 10
level of acuity: 2.0 | ___ hx of hep C, hx IVDA, polycystic kidney disease, FMD c/b
(RAS and HTN) w/ recent admission at ___ for angioplasty of
right renal artery c/b by RP bleed (embolized ___ @___)
presented to ___ for right flank and abd pain. She
was found to have recurrent RP bleed w/o active bleeding on
___ imaging and right pleural effusion. She was dyspneic and
underwent initial pig tail catheter placement.
Acute issues
#RP Bleed, Right Pleural Effusion: Course began with initial
admission to ___ for balloon angioplasty of right renal
artery stenosis ___ fibromuscular dysplasia. Course complicated
by RP bleed from wire injury(pt reported) then s/p emobolization
___. Presented to ___ ED and eventually transferred to
___ given recurrent bleed w/o active extravasation. No ___
intervention at this time. However, given effusion, she
underwent pigtail catheter placement but her right lung did not
fully reexpand and she was taken to the Operating Room on
___ where she underwent a right VATS decortication. She
tolerated the procedure well and returned to the PACU in stable
condition. She maintained stable hemodynamics and her pain was
controlled with a Dilaudid PCA. Her chest tubes remained on
suction for 48 hours and her chest xray showed almost full
reexpansion of the right lung. Her oxygen saturation on room air
was 97% and her port sites were healing well. Following removal
of her tunes on ___ her post pull chest xray revealed
almost full expansion of the right lung except for a tiny
basilar space. She was converted to oral Oxycodone and Tylenol
and had adequate pain control. Her chest tube sutures remain in
place and will be removed at her post op visit next week and she
was reminded to continue to use her incentive spirometer.
Chronic issues
#Hx IVDU/Substance Abuse Disorder: Per patient at bedside stated
no IVDU for 6 months, however told thoracics fellow most recent
use was 3 months. Patient finished 7 day course of oxycontin and
oxycodone recently and denies any current use. Hep C positive.
HIV negative, RPR negative.
#Hypertension: Secondary to fibromuscular dysplasia
- HydrALAZINE 100 mg PO TID
- Carvedilol 25 mg PO BID
- amLODIPine 10 mg PO DAILY
#Polycystic Kidney Disease: Pt w/known PCKD. Patient has not had
imaging of head to look for berry/sacular aneurysms. No current
headaches or visual symptoms.
- obtain pcp ___ records
- will need MR-A head/neck.
#Insomnia, Anxiety
- TraZODone 50 mg PO QHS:PRN insomnia
- ClonazePAM 0.5 mg PO BID
#Iron Def Anemia
-Ferrous Sulfate 325 mg PO DAILY
TRANSITIONAL ISSUES
=================
- will need MR-A head/neck to look for brain aneurysm given
polycystic kidney disease
Ms. ___ was discharged to home on ___ and will follow
up with Dr. ___ week in the Thoracic Clinic. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: SURGERY
Allergies:
aspirin / penicillin / Fosamax / ciprofloxacin
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
___ ___ percutaneous nephrostomy tube
___ ___ for percutaneous cholecystoscopy tube
___ ex-lap, lysis of adhesions, enteroenterostomy
History of Present Illness:
___ PMH bladder CA s/p pelvic exenteration & ileal conduit c/b
SBO w/ exlap x2, recent C. diff, who presents with abdominal
pain, nausea, vomiting, and diarrhea since ___. She states that
her symptoms changes yesterday evening, when she stopped passing
stool or flatus, and her abdominal pain and nausea worsened. She
presented to the ___ ED for further care. A CT A/P showed a
closed loop small bowel obstruction. ACS was consulted for
surgical management.
Past Medical History:
Bladder Cancer
Hydronephrosis
CVA x2
Anemia
Asthma
Hypertension
Abnormal uterine bleeding
Pelvic carcinoma of unknown primary
Hypothyroidism
Depression
Social History:
___
Family History:
Sister died of cancer in ___, type unknown
Positive for hypertension, diabetes.
Physical Exam:
Admission Physical Exam:
Physical Exam:
Vitals:
98.2F, 117, 148/71, 100% 2LNC
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: No respiratory distress
ABD: Distended, tympanic, diffuse guarding, marked rebound
tenderness. Well functioning urostomy and drain in place.
Ext: No ___ edema, ___ warm and well perfused
Discharge Physical Exam:
GEN: A&O, NAD
HEENT: No scleral icterus, mucus membranes moist
CV: RRR
PULM: No respiratory distress
ABD: Soft, nontender except for intermittently in right lower
quadrant,nondistended, well-healed midline incision, ileal
conduit draining and right percutaneous nephrostomy drainaing
clear yellow urine, percutaneous cholecystostomy draining dark
bilious fluid
Ext: No ___ edema, ___ warm and well perfused
Pertinent Results:
___ 6:00 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 9:48 am STOOL CONSISTENCY: SOFT Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Reported to and read back by ___ (___) @
13:15,
___.
CLOSTRIDIUM DIFFICILE.
Positive for toxigenic C difficile by the Cepheid
nucleic
amplification assay. (Reference
Range-Negative).
___ 9:17 am URINE Source: Kidney.
**FINAL REPORT ___
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL.
IDENTIFICATION AND SENSITIVITIES PERFORMED ON CULTURE #
462-2300P
___.
___ 10:00 am BLOOD CULTURE NEW ALINE 1 OF 2.
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 11:24 am SPUTUM Source: Endotracheal.
**FINAL REPORT ___
GRAM STAIN (Final ___:
<10 PMNs and <10 epithelial cells/100X field.
NO MICROORGANISMS SEEN.
QUALITY OF SPECIMEN CANNOT BE ASSESSED.
RESPIRATORY CULTURE (Final ___: NO GROWTH.
___ 9:50 am URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
PSEUDOMONAS AERUGINOSA. >100,000 CFU/mL.
Piperacillin/Tazobactam sensitivity testing performed
by ___
___.
SENSITIVITIES: MIC expressed in MCG/ML
_________________________________________________________
PSEUDOMONAS AERUGINOSA
|
CEFEPIME-------------- 4 S
CEFTAZIDIME----------- 16 I
CIPROFLOXACIN---------<=0.25 S
GENTAMICIN------------ 8 I
MEROPENEM------------- 0.5 S
PIPERACILLIN/TAZO----- I
TOBRAMYCIN------------ <=1 S
___ 2:32 am PLEURAL FLUID
**FINAL REPORT ___
GRAM STAIN (Final ___:
4+ (>10 per 1000X FIELD): POLYMORPHONUCLEAR
LEUKOCYTES.
NO MICROORGANISMS SEEN.
This is a concentrated smear made by cytospin method,
please refer to
hematology for a quantitative white blood cell count..
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 3:58 pm BILE BILE.
**FINAL REPORT ___
GRAM STAIN (Final ___:
NO POLYMORPHONUCLEAR LEUKOCYTES SEEN.
NO MICROORGANISMS SEEN.
FLUID CULTURE (Final ___: NO GROWTH.
ANAEROBIC CULTURE (Final ___: NO GROWTH.
___ 8:29 am URINE Source: Kidney.
**FINAL REPORT ___
URINE CULTURE (Final ___: NO GROWTH.
==========================================================
RADIOLOGY:
___ CT ABDOMEN/PELVIS:
1. New closed loop small-bowel obstruction with transition point
in the lower pelvis near the ileal conduit and neobladder with
marked dilatation of a cluster of small intestinal loops which
are fluid-filled.. No evidence of intra-abdominal perforation,
fluid collection or abscess.
2. Persistent diffuse circumferential thickening of the
descending, sigmoid colon and the rectum may be related to
chronic colitis with infectious as well as ischemic etiologies
in the differential diagnosis. No evidence for pneumatosis.
3. Status post right percutaneous nephrostomy and double-J
catheter placement with pigtails in the right renal pelvis and
neobladder, unchanged in configuration since ___.
4. Interval decrease in size in hepatic segment 8 hypodensity.
___ ECCHO:
Suboptimal image quality. Normal biventricular cavity sizes with
preserved global biventricular systolic function. No definite
valvular pathology or pathologic flow identified.
___ CTA CHEST:
1. No evidence of pulmonary embolism.
2. Large bilateral pleural effusions with bibasilar atelectasis.
3. Colonic wall edema with mucosal hyperenhancement and loss of
normal
haustra. There is also wall edema and mucosal enhancement
involving multiple small bowel loops. Findings in the colon are
compatible with pseudomembranous colitis. Abnormal findings in
the small bowel may also indicate enteritis.
4. Peripheral areas of hypoenhancement in the right kidney, some
of which are new from prior exam suggestive of renal infarcts.
___ CT ABDOMEN PELVIS:
1. No evidence of active hemorrhage or hematoma in the abdomen
and pelvis.
2. Small increase in right pneumothorax. Right pleural catheter
in stable
position.
___ Bilateral upper extremity ultrasounds:
Of note, there is severely limited visualization of the left
brachial and
basilic veins due to a large known hematoma. Otherwise, no
definite evidence of deep vein thrombosis in the left upper
extremity.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. amLODIPine 10 mg PO DAILY
2. Calcitriol 0.25 mcg PO EVERY OTHER DAY
3. Clopidogrel 75 mg PO DAILY
4. Cyanocobalamin 1000 mcg PO MONTHLY
5. Fentanyl Patch 50 mcg/h TD Q72H
6. Gabapentin 300 mg PO QHS
7. Gabapentin 100 mg PO BID
8. Levothyroxine Sodium 175 mcg PO DAILY
9. OxyCODONE (Immediate Release) ___ mg PO Q8H:PRN Pain -
Moderate
10. Senna 8.6 mg PO BID:PRN constipation
11. Vitamin D ___ UNIT PO 1X/WEEK (___)
12. Vancomycin Oral Liquid ___ mg PO Q6H
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Dronabinol 2.5 mg PO BID
3. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
4. Heparin 5000 UNIT SC BID
may discontinue when ambulatory
5. Insulin SC
Sliding Scale
Fingerstick QACHS
Insulin SC Sliding Scale using REG Insulin
6. LORazepam 0.25 mg PO QHS:PRN insomnia
7. Metoprolol Tartrate 12.5 mg PO Q6H
hold for systolic blood pressure <110, hr,60
8. Pantoprazole 40 mg PO Q24H
9. Polyethylene Glycol 17 g PO BID
10. Sodium Chloride 0.9% Flush ___ mL IV DAILY and PRN, line
flush
11. amLODIPine 10 mg PO DAILY
12. Calcitriol 0.25 mcg PO EVERY OTHER DAY
13. Clopidogrel 75 mg PO DAILY
14. Cyanocobalamin 1000 mcg PO MONTHLY
15. Fentanyl Patch 50 mcg/h TD Q72H
16. Gabapentin 300 mg PO QHS
17. Gabapentin 100 mg PO BID
18. Levothyroxine Sodium 175 mcg PO DAILY
19. OxyCODONE (Immediate Release) ___ mg PO Q8H:PRN Pain -
Moderate
20. Senna 8.6 mg PO BID:PRN constipation
21. Vancomycin Oral Liquid ___ mg PO Q6H
last dose ___. Vitamin D ___ UNIT PO 1X/WEEK (___)
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
Small bowel obstruction
clostridium difficile infection
Urinary tract infection
Pleural effusion
acute cholecystitis
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: ___ year old woman with ex-lap, intubated// ETT, NG, right CVL
placement Contact name: ___: ___
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
IMPRESSION:
The tip of a new right internal jugular central venous catheter projects over
the upper right atrium, approximately 1 cm beyond the cavoatrial junction.
The tip of the endotracheal tube projects 2.1 cm from the carina. The enteric
tube extends to the stomach. A drainage catheter is noted over the right
upper quadrant.
Ill-defined opacities in both lung apices may reflect underlying emphysematous
change. No focal consolidation, pleural effusion or pneumothorax is
identified. The size of the cardiomediastinal silhouette is within normal
limits.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p exlap, intubated// ?interval change
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
IMPRESSION:
NG tube tip isin the stomach. ET tube is in standard position. Right IJ
catheter tip is at the cavoatrial junction.
Cardiomediastinal contours are stable. There is no pneumothorax or enlarging
pleural effusions. There is mild vascular congestion.
Radiology Report
INDICATION: ___ PMH bladder CA s/p pelvic exenteration ileal conduit c/b
SBO w/ exlap x2, recent C. diff, now w/ closed loop SBO of excluded seg bowel
s/p ex-lap, enteroenterostomy with persistent tachycardia unresponsive to
fluid resuscitation// ?pulmonary embolism
TECHNIQUE: Axial multidetector CT images were obtained through the chest,
abdomen and pelvis 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.
Oral contrast was not administered.
DOSE: Acquisition sequence:
1) Stationary Acquisition 1.0 s, 0.5 cm; CTDIvol = 3.0 mGy (Body) DLP = 1.5
mGy-cm.
2) Spiral Acquisition 3.8 s, 29.8 cm; CTDIvol = 11.7 mGy (Body) DLP = 350.1
mGy-cm.
3) Spiral Acquisition 5.0 s, 54.4 cm; CTDIvol = 12.5 mGy (Body) DLP = 681.4
mGy-cm.
Total DLP (Body) = 1,033 mGy-cm.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
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.
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 is not visualized.
There is no evidence of pericardial effusion. There are large bilateral
pleural effusions.
There is atelectasis involving most of the right lower lobe and left lower
lobe. The airways are patent to the subsegmental level.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is mild periportal edema, likely related to volume overload. Scattered
subcentimeter hypodensities in the liver may represent hepatic cysts but are
too small to characterize. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder is distended without
gallstones or wall thickening. There is mild upper abdominal ascites.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: There is a right-sided internal/external nephrostomy tube/ureteral
stent. There is no left-sided hydronephrosis. There are multiple peripheral
hypoenhancing areas within the right kidney suggestive of renal cortical
infarcts. Some of these are new from the prior exam.
GASTROINTESTINAL: Hyperdense material within the stomach may be related to
something ingested by the patient. There is a right lower quadrant ileostomy.
Throughout the colon, there is abnormal wall edema with mucosal hyper
enhancement and loss of normal haustral pattern. There are also multiple
small bowel loops in the pelvis which demonstrate mucosal hyper enhancement
and wall edema.
PELVIS: The urinary bladder is decompressed. There is mild pelvic ascites.
REPRODUCTIVE ORGANS: The uterus is not visualized. No adnexal abnormality is
seen.
LYMPH NODES: No pathologic 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: There is diffuse subcutaneous soft tissue edema.
IMPRESSION:
1. No evidence of pulmonary embolism.
2. Large bilateral pleural effusions with bibasilar atelectasis.
3. Colonic wall edema with mucosal hyperenhancement and loss of normal
haustra. There is also wall edema and mucosal enhancement involving multiple
small bowel loops. Findings in the colon are compatible with pseudomembranous
colitis. Abnormal findings in the small bowel may also indicate enteritis.
4. Peripheral areas of hypoenhancement in the right kidney, some of which are
new from prior exam suggestive of renal infarcts.
Radiology Report
EXAMINATION: Portable chest radiograph
INDICATION: 77W PMH bladder CA s/p pelvic exenteration ileal conduit c/b
SBO w/ exlap x2, recent C. diff, now w/ closed loop SBO of excluded seg bowel
s/p ex-lap, enteroenterostomy now w/ tachycardia and large bilateral pleural
effusions s/p right pigtail placement// right pigtail placement
TECHNIQUE: Portable chest radiograph
COMPARISON: ___ portable chest radiograph
FINDINGS:
The right pigtail catheter tip projects medially over the right posterior
ninth rib. The ET tube and NG tubes have been removed. There is no evidence
of pneumothorax.
The lung volumes are low. There is a layering left-sided pleural effusion,
new from ___. The heart size is normal. There is no pulmonary
vascular congestion or pulmonary edema. The right IJ catheter is in stable
position.
IMPRESSION:
1. Right pigtail catheter tip projects over the posterior ninth rib; there is
no evidence of pneumothorax.
2. Bilateral low lung volumes with small left layering pleural effusion.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with respiratory failure s/p intubation//
intubation, eval ETT placement
IMPRESSION:
In comparison with the earlier study of this date, this and placement of an
endotracheal tube with its tip approximately 3.3 cm above the carina.
Nasogastric tube is now in place with the tip coiled within the upper fundus
of the stomach.
Otherwise, little change in the appearance of the heart and lungs.
Radiology Report
EXAMINATION: CT ABDOMEN AND PELVIS WITHOUT CONTRAST.
INDICATION: ___ year old woman with SBO s/p ex lab, now with GI bleed, septic
shock. Eval for anastomotic leakage, new fluid collection, or source of GI
bleed. PLEASE DO WITH PO CONTAST ONLY, IV CONTRAST NOT NECESSARY// Eval for
anastomotic leakage, new fluid collection, or source of GI bleed. PLEASE DO
WITH PO CONTAST ONLY, IV CONTRAST NOT NECESSARY
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 3.6 s, 56.7 cm; CTDIvol = 14.1 mGy (Body) DLP = 799.7
mGy-cm.
Total DLP (Body) = 800 mGy-cm.
COMPARISON: CTA chest/abdomen/pelvis from earlier same day ___ 02:49
FINDINGS:
LOWER CHEST: There has been interval placement of a posterior right chest
pigtail drainage catheter with its tip looping adjacent to the esophagus
within the azygo-esophageal recess. There has been near complete interval
resolution of a right pleural effusion. The visualized right lung is
re-expanded, with mild atelectasis remaining in the right lower lobe. A
moderate left pleural effusion with associated left lower lobe consolidation
is unchanged. Air bronchograms are seen within the consolidated lungs
bilaterally. Coronary artery calcifications. The tip of a central venous
catheter is seen at the SVC-right atrial junction.
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 moderately distended, similar to prior.
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: An internal-external nephrostomy tube/ureteral stent is noted on the
right, with loops in unchanged position. Previously described renal
parenchymal areas of decreased enhancement were better seen on prior. There
is no hydronephrosis on the left. There is moderate bilateral perinephric fat
stranding. there is no nephrolithiasis.
GASTROINTESTINAL: The stomach is moderately distended with oral contrast.
Esophageal enteric catheter terminates in the gastric fundus. Layering
hypoattenuating and hyperdense material within the gastric fundus is
consistent with ingested material. Small bowel-small bowel anastomosis
sutures are noted in the right lower quadrant, adjacent to an ileostomy. No
evidence of anastomotic leak is seen. Enteric contrast is seen throughout the
small bowel, exiting the ileostomy. No evidence of small bowel obstruction is
identified. There is re-demonstration of diffuse colonic mural thickening and
fat stranding, most consistent with infection.. There is moderate mesenteric
fat stranding likely related to fluid resuscitation and/or colitis.
Transverse colon measures 5.0 cm in diameter, compared with 4.3 cm on prior.
There is no pneumoperitoneum. The appendix is not visualized. Rectal
catheter is in place.
PELVIS: Urinary bladder is not identified. There is mild free pelvic fluid.
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. Surgical clips are noted along
bilateral pelvic sidewalls.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted. There is right femoral catheter in place.
BONES: Degenerative changes are seen in the lumbar spine.
SOFT TISSUES: There is diffuse body wall edema.
IMPRESSION:
1. Status post right lower quadrant ileostomy. No evidence of leak. No
evidence of small-bowel obstruction.
2. Re-demonstration of diffuse, pancolonic wall thickening, most likely
infectious. No pneumoperitoneum. Transverse colon measures 5.0 cm in
diameter.
3. Status post right chest tube placement with near complete resolution of
right pleural effusion.
4. Unchanged moderate left pleural effusion and left lower lobe consolidation.
5. Previously seen areas of decreased enhancement of renal parenchyma are
again seen, which may represent renal infarcts, consider pyelonephritis if
clinically indicated.
Radiology Report
INDICATION: ___ year old woman with ?acalc cholecystitis// perc chole
COMPARISON: CT of the abdomen pelvis ___
PROCEDURE: Ultrasound-guided drainage of the gallbladder.
OPERATORS: Dr. ___, radiology trainee and Dr. ___
___, attending radiologist. Dr. ___ personally
supervised the trainee during the key components of the procedure and reviewed
and agree with the trainee's findings.
TECHNIQUE: The risks, benefits, and alternatives of the procedure were
explained to the patient. After a detailed discussion, informed written
consent was obtained. A pre-procedure timeout using three patient identifiers
was performed per ___ protocol.
The patient was placed in a supine position on the US scan table. Limited
preprocedure ultrasound was performed to localize the gallbladder. Based on
the ultrasound findings an appropriate skin entry site percutaneous
cholecystostomy was chosen. The site was marked. Local anesthesia was
administered with 1% Lidocaine solution.
Using continuous sonographic guidance, ___ Exodus drainage catheter was
advanced via trocar technique into the gallbladder. A sample of fluid was
aspirated, confirming catheter position within the gallbladder. The pigtail
was deployed. The position of the pigtail was confirmed within the
gallbladder via ultrasound.
Approximately 200 cc of thick viscous dark bilious 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 the ICU team.
FINDINGS:
There is a distended gallbladder with mild wall thickening and trace
pericholecystic fluid.
IMPRESSION:
Successful US-guided placement of ___ pigtail catheter into the
gallbladder. Samples was sent for microbiology evaluation.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: 77W PMH bladder CA s/p pelvic exenteration ileal conduit c/b
SBO w/ exlap x2, recent C. diff, now w/ closed loop SBO of excluded seg bowel
s/p ex-lap, enteroenterostomy// please assess fluid status, pulmonary edema,
pleural effusions please assess fluid status, pulmonary edema, pleural
effusions
IMPRESSION:
Comparison to ___. Stable small left pleural effusion with left
basilar atelectasis and retrocardiac atelectasis. Stable correct position of
the monitoring and support devices, including the right-sided chest tube. New
introduction of a feeding tube, the tip projects over the proximal parts of
the stomach, the tube is coiled in the fundus. No new focal parenchymal
changes. Stable appearance of the cardiac silhouette.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p extubation// ?interval change
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
IMPRESSION:
Cardiomediastinal contours are normal. Right IJ catheter tip is in the lower
SVC. There are low lung volumes. Left apical parenchyma opacities have not
improved. Moderate left pleural effusion and adjacent atelectasis are stable.
Minimal opacities in the right base have improved. There is no evident
pneumothorax. Catheter in the right pleura, catheters in the right upper
quadrant are in place. NG tube tip is in the stomach.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old woman with new line// new right PICC 41 ___ ___
Contact name: ___: ___
TECHNIQUE: Single frontal view of the chest
COMPARISON: Chest radiograph ___ at 04:18.
FINDINGS:
The right PICC terminates in the cavoatrial junction. The right IJ catheter
terminates in the low SVC. The enteric tube tip is curled in the upper
abdomen projecting over the region of the gastroesophageal junction.
Right-sided chest tube terminates in the medial aspect of the right lung,
similar to the prior study.
Ill-defined opacities in bilateral lung apices appear unchanged over multiple
studies likely representing pleuroparenchymal scarring. Left basilar
atelectasis and left pleural effusion are stable. Cardiac size is unchanged.
There is no pneumothorax.
IMPRESSION:
The right PICC terminates in the cavoatrial junction and the enteric tube is
curled in the upper abdomen with tip terminating over the region of the
gastroesophageal junction. Otherwise, the study is unchanged compared to the
prior.
Radiology Report
INDICATION: ___ PMH bladder CA s/p pelvic exenteration ileal conduit c/b
SBO w/ exlap x2, recent C. diff, now w/ closed loop SBO of excluded seg bowel
s/p ex-lap, enteroenterostomy now w/ dropping H/H// W/ IV contrastlooking for
source of bleeding/hematoma?
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Spiral Acquisition 3.2 s, 50.7 cm; CTDIvol = 2.4 mGy (Body) DLP = 121.1
mGy-cm.
2) Spiral Acquisition 3.2 s, 50.7 cm; CTDIvol = 9.1 mGy (Body) DLP = 461.7
mGy-cm.
3) Spiral Acquisition 3.2 s, 50.7 cm; CTDIvol = 9.1 mGy (Body) DLP = 461.0
mGy-cm.
4) Stationary Acquisition 2.4 s, 0.5 cm; CTDIvol = 8.1 mGy (Body) DLP = 4.1
mGy-cm.
Total DLP (Body) = 1,048 mGy-cm.
COMPARISON: CT ___
FINDINGS:
LOWER CHEST: There is a right pleural catheter in place. There is a small
right pneumothorax, increased from prior exam. There is right lung base
atelectasis. There is a moderate left pleural effusion with left lung base
atelectasis.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
Subcentimeter hypodensities in the liver may represent hepatic cysts/biliary
hamartomas but are too small to characterize. There is no evidence of
intrahepatic or extrahepatic biliary dilatation. The gallbladder is collapsed
around a percutaneous cholecystostomy tube.
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.
Focal areas of decreased enhancement in the renal cortex bilaterally are less
apparent than on the prior exam. There is no perinephric abnormality.
GASTROINTESTINAL: There is an enteric tube which terminates in the stomach.
The patient has had multiple prior small bowel surgeries. There is no current
evidence of bowel obstruction. There is residual oral contrast in the colon.
Wall thickening and mucosal hyperenhancement in the colon appears mildly
improved although still present in the sigmoid colon and rectum. There is no
evidence of an intraperitoneal or retroperitoneal bleed.
PELVIS: The patient is status post total cystectomy with a loop ileostomy.
There is a small amount of interloop fluid and fluid along the anterior
abdominal wall with enhancement. These findings may be postsurgical.
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 diffuse bony demineralization.
SOFT TISSUES: There is diffuse subcutaneous edema. There are postsurgical
changes in the anterior abdominal wall.
IMPRESSION:
1. No evidence of active hemorrhage or hematoma in the abdomen and pelvis.
2. Small increase in right pneumothorax. Right pleural catheter in stable
position.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 12:18 pm, 5 minutes after
discovery of the findings.
Radiology Report
INDICATION: ___ year old woman with recently accidentally removed R PCN//
Please replace R PCN
COMPARISON: CT abdomen pelvis from ___ and ___..
TECHNIQUE: OPERATORS: Dr. ___ resident and Dr. ___,
___ radiologist performed the procedure. Dr. ___ supervised
the trainee during the key components of the procedure and has reviewed and
agrees with the trainee's findings.
ANESTHESIA: ANESTHESIA: General anesthesia was administered by the
anesthesiology department. Please refer to anesthesiology notes for details.
MEDICATIONS: None
CONTRAST: 15 ml of Optiray contrast.
FLUOROSCOPY TIME AND DOSE: 3.5 min, 14 mGy
PROCEDURE:
1. Right diagnostic antegrade nephrostogram.
2. Right 8 ___, 24 cm nephroureteral stent replacement.
PROCEDURE DETAILS: Following the discussion of the risks, benefits and
alternatives to the procedure, written informed consent was obtained from the
healthcare proxy.The patient was then brought to the angiography suite and
placed prone on the exam table. A pre-procedure time-out was performed per
___ protocol. The right flank was prepped and draped in the usual sterile
fashion.
A Glidewire was advanced through the nephrostomy tract using the ___,
under continuous fluoroscopic guidance. Guidewire was advanced into the
expected region of the renal collecting system and ureter diluted contrast was
injected into the right nephrostomy to confirm catheter position. The image
was stored on PACS. Local anesthesia was administered with instillation of
lidocaine jelly and 1% subcutaneous lidocaine injection. The catheter was cut.
A ___ wire was advanced into the right nephrostomy tube and advanced into
the distal ureter. The stay sutures were cut and the catheter was removed over
the wire. A new 8 ___ nephrostomy catheter was flushed and advanced with
its plastic stiffener over the wire into appropriate position. The wire and
stiffener were removed and the pigtail was formed. Contrast injection
confirmed appropriate positioning. The final image was saved. The catheter was
then flushed, stay sutures applied and the catheter was secured with a Stat
Lock device and sterile dressings. The catheter was attached to a bag for
drainage.
The patient tolerated the procedure well and there were no immediate
post-procedure complications.
FINDINGS:
1. Right antegrade nephrostogram shows delayed contrast drainage into the
ileal conduit.
2. Appropriate final position of Right 8 ___ x 24 cm nephroureteral stent.
IMPRESSION:
Technically successful Right 8 ___ nephroureteral stent replacement.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with PMH bladder CA s/p pelvic exenteration
ileal conduit c/b SBO w/ exlap x2, recent C. diff, now w/ closed loop SBO of
excluded seg bowel s/p ex-lap, enteroenterostomy and chest tube for pleural
effusion, and now pneumothorax, now transitioned to suction// ****To be done
at 2300 please****Evaluate interval changes, CT to suction
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
IMPRESSION:
Small right pneumothorax is probably unchanged. Cardiac size normal. Small
to moderate left pleural effusion and adjacent atelectasis is stable.
Opacities in the right base have minimally increased could be atelectasis or
pneumonia. Right PICC tip is at the cavoatrial junction. Right basal pigtail
catheter is in place. NG tube tip is out of view below the diaphragm
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US
INDICATION: ___ year old woman with PMH bladder CA s/p pelvic exenteration
ileal conduit c/b SBO w/ exlap x2, recent C. diff, now w/ closed loop SBO of
excluded seg bowel s/p ex-lap, enteroenterostomy. Now with left upper
extremity swelling, ecchymosis, pain.// Please evaluate left upper extremity
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the left subclavian vein.
The left internal jugular and axillary veins are patent, show normal color
flow and compressibility. The left brachial, basilic, and cephalic veins are
patent, compressible and show normal color flow and augmentation.
Along the medial left arm is an approximately 7.5 x 1.2 heterogeneous fluid
collection. There is moderate subcutaneous edema within the left upper
extremity.
IMPRESSION:
No evidence of deep vein thrombosis in the left upper extremity.
Moderate subcutaneous edema within the left upper extremity as well as a large
heterogeneous fluid collection tracking along the medial left arm which may
reflect a hematoma.
Radiology Report
EXAMINATION: CHEST (PA AND LAT)
INDICATION: ___ year old woman with R pneumothorax with chest tube now to
waterseal. Please do at 10:30 AM// f/u interval change of pneumothoraxPlease
do at 10:30 AM
TECHNIQUE: Single frontal view of the chest
COMPARISON: ___
IMPRESSION:
Small to moderate left pleural effusion is minimally increased with increasing
adjacent atelectasis. Right lower lobe atelectasis have improved. Cardiac
size is normal. NG tube is coiled in the stomach. Right PICC tip is at the
cavoatrial junction. Right pigtail catheter and catheters in the right upper
abdomen are in place.
Radiology Report
EXAMINATION: Chest Radiograph
INDICATION: ___ year old woman with pneumothorax with CT. Please do at 10:30
AM, re-assess pneumothorax s/p watersea linterval change? Please do at 10:30
AM
TECHNIQUE: AP and Lateral
COMPARISON: Chest radiographs dating back to ___, abdominal and
pelvic CT from ___
FINDINGS:
Right basilar chest tube unchanged in position. Known pneumothorax documented
on abdominal and pelvic CT from ___, is not visible on chest radiographs
dating back to ___. Right PICC ends at the cavoatrial junction. A
moderate left pleural effusion has increased. There is persistent
retrocardiac atelectasis. Abdominal pigtail catheters are in place.
IMPRESSION:
1. No radiographic evidence of pneumothorax. Notably, pneumothorax seen on
prior abdominal and pelvic CT was not visible radiographically.
2. Enlarging left pleural effusion.
Radiology Report
INDICATION: ___ year old woman with pneumo s/p chest tube pigtail dc-ed. 6:30
___ please// re-eval for pneumothorax s/p pigtail dc. 6:30 ___ please
TECHNIQUE: AP and lateral portable chest radiographs
COMPARISON: ___ from earlier in the day
FINDINGS:
The right chest tube has been removed. There is no discrete pneumothorax
identified. The tip of the right PICC line projects over the cavoatrial
junction, unchanged.
The right lung is clear. There is an unchanged moderate layering left pleural
effusion with overlying atelectasis. No left pneumothorax. The size of the
cardiomediastinal silhouette is within normal limits.
IMPRESSION:
Interval removal of the right chest tube. No discrete pneumothorax is
identified.
Radiology Report
EXAMINATION: UNILAT UP EXT VEINS US LEFT
INDICATION: ___ year old woman with upper extremity swelling, concerning for
DVT. Worsening in last 3 days (prior LUE u/s was neg for DVT)// r/o dvt and/or
hematoma
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: Upper extremity ultrasound from ___
FINDINGS:
There is normal flow with respiratory variation in the left subclavian vein.
The left internal jugular and axillary veins are patent, show normal color
flow and compressibility.
There is severely limited visualization of the left brachial and basilic veins
due to a large hematoma measuring 3.3 x 4.6 x 1.5 cm in the medial upper arm.
Given this limitation, the imaged left brachial and basilic veins demonstrate
patency, normal color flow and compressibility. Left cephalic veins are
patent and show normal color flow and augmentation.
IMPRESSION:
Of note, there is severely limited visualization of the left brachial and
basilic veins due to a large known hematoma. Otherwise, no definite evidence
of deep vein thrombosis in the left upper extremity.
Radiology Report
INDICATION: ___ year old woman with s/p ex-lap enteroenterostomy, chronic
c.diff, with abdominal dissension.// ? Fecal impaction vs ileus compare to
prior
TECHNIQUE: Supine and left lateral decubitus abdominal radiograph was
obtained.
COMPARISON: CT abdomen and pelvis ___.
FINDINGS:
Dilated air-filled loops of small and large bowel with multiple air-fluid
levels on left lateral decubitus view consistent with ileus.
There is no free intraperitoneal air.
Osseous structures are unremarkable.
Percutaneous cholecystostomy tube is noted. Skin staples are noted to the
left of the midline. Multiple surgical clips are noted in the pelvis. Suture
line noted in the lower pelvis. A right percutaneous nephroureteral stent is
noted. There are no unexplained soft tissue calcifications or radiopaque
foreign bodies.
IMPRESSION:
Dilated air-filled loops of small and large bowel consistent with ileus.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old woman with s/p exploratory laparotomy, extensive
lysis of adhesions and a side-to-side enteroenterostomy with abdominal
distention no bowel function x7 days and nausea// ?abscess/fluid collection
?obstructions. IV and PO contrast.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence: 1) Spiral Acquisition 3.1 s, 49.7 cm; CTDIvol =
13.3 mGy (Body) DLP = 660.2 mGy-cm. 2) Stationary Acquisition 1.5 s, 0.5 cm;
CTDIvol = 8.4 mGy (Body) DLP = 4.2 mGy-cm. Total DLP (Body) = 664 mGy-cm.
COMPARISON: CT dated ___.
FINDINGS:
LOWER CHEST: Bilateral pleural effusions are seen with associated atelectasis.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
Multiple subcentimeter hypodensities are again seen, too small to characterize
on CT. There is no evidence of intrahepatic or extrahepatic biliary
dilatation. The gallbladder is collapsed around a percutaneous cholecystostomy
tube.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The patient is status post multiple prior small bowel
surgeries, and recent ex lap with side-to-side enteroenterostomy. There is
dilation of the small and large bowel, to the level of the sigmoid colon.
PELVIS: The patient is status post total cystectomy with right-sided
nephrostomy tube. 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: Diffuse bony demineralization is again seen.
SOFT TISSUES: Diffuse subcutaneous edema, consistent with anasarca, and
postsurgical changes in the anterior abdominal wall.
IMPRESSION:
1. Dilation of the small and large bowel is consistent with ileus.
2. Anasarca.
3. Bilateral pleural effusions with associated atelectasis.
Radiology Report
INDICATION: ___ PMH bladder CA s/p pelvic exenteration ileal conduit c/b
SBO w/ exlap x2, recent C. diff, now w/ closed loop SBO of excluded seg bowel
s/p ex-lap, enteroenterostomy// ?interval change
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: Abdominal radiograph ___.
FINDINGS:
Again demonstrated are loops of air-filled dilated large and small bowel,
slightly improved since prior radiograph.
Assessment for free intraperitoneal air is limited on supine radiographs. If
there is clinical concern for pneumoperitoneum, advise upright or left lateral
decubitus radiograph, or cross-sectional imaging.
Osseous structures are unremarkable.
Skin staples are noted along the midline. Surgical staples are noted in the
pelvis. There is re-demonstration of percutaneous cholecystostomy tube and
right percutaneous nephroureteral stent. There are no unexplained soft tissue
calcifications or radiopaque foreign bodies.
IMPRESSION:
Slight interval improvement in dilated loops of small and large bowel.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman s/p xlap with ileus and vomiting with increased
respiratory rate.// ?pulmonary edema, ?effusion
IMPRESSION:
In comparison with the study of ___, there has been placement of a
nasogastric tube that coils in the upper fundus of the stomach. Right
subclavian catheter again extends to the region of the cavoatrial junction.
The left hemidiaphragm is now sharply seen, consistent with improvement in the
left pleural effusion and atelectatic changes. However, there are increasing
atelectatic changes at the right base.
No evidence of appreciable vascular congestion or acute focal pneumonia.
Significant dilatation of gas filled loops of bowel are again seen in the
abdomen.
Radiology Report
INDICATION: ___ year old woman s/p xlap with ileus vomiting s/p ngt
placement.// s/p NGT placement ? ileius, NGT placement
TECHNIQUE: Portable supine abdominal radiograph was obtained.
COMPARISON: Abdominal radiograph ___.
FINDINGS:
Re-demonstration of air-filled dilated loops of small and large bowel,
minimally improved compared to prior radiograph.
Supine assessment limits detection for free air; there is no gross
pneumoperitoneum.
Osseous structures are notable for multilevel degenerative changes of the
lumbar spine and bilateral hips.
NG tube terminates at the gastroesophageal junction and can be advanced
further. Skin staples are again noted to the right of the midline. Surgical
staples are noted in the pelvis. Percutaneous cholecystostomy tube and right
percutaneous nephroureteral stent are again noted.
IMPRESSION:
NG tube terminates in the gastroesophageal junction and should be advanced
further. Re-demonstration of dilated loops of small and large bowel, slightly
improved compared to the day prior.
NOTIFICATION: The findings were discussed with ___, M.D. by ___,
M.D. on the telephone on ___ at 8:57 am, 5 minutes after discovery of
the findings.
Radiology Report
EXAMINATION: VENOUS DUP UPPER EXT UNILATERAL LEFT
INDICATION: ___ year old woman with left upper extremity tenderness and
swelling.// ? DVT
TECHNIQUE: Grey scale and Doppler evaluation was performed on the left upper
extremity veins.
COMPARISON: None.
FINDINGS:
There is normal flow with respiratory variation in the subclavian veins
bilaterally.
The left internal jugular, axillary and brachial veins are patent, show normal
color flow and compressibility. The left basilic and cephalic veins are
patent.
A large hematoma is noted in the superficial tissues of the medial left upper
arm extending from the axilla to the antecubital fossa.
IMPRESSION:
1. No DVT identified in the left arm.
2. Large hematoma extending in the medial left upper arm from the axilla to
the antecubital fossa.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with SBO s/p bowel resection and LOA 35 days
ago, now with chills and sustained tachycardia in 140s// ?acute cardiopulm
processes
TECHNIQUE: Chest single view
COMPARISON: ___
FINDINGS:
Right PICC line tip 2.5 cm above cavoatrial junction. Normal heart size,
pulmonary vascularity. No edema. Trace left pleural effusion, improved.
Bibasilar opacities have resolved since prior. No consolidations. No
pneumothorax. Degenerative arthritis bilateral shoulders.
IMPRESSION:
No acute findings in the chest.
Radiology Report
EXAMINATION: PORTABLE ABDOMEN
INDICATION: ___ year old woman with SBO s/p bowel resection and LOA, now with
chills and sustained HR 150s// ? intraabdominal process
TECHNIQUE: Abdomen single view
COMPARISON: ___
FINDINGS:
Right lateral abdominal percutaneous catheter in place. Right ureteral stent
in place. Surgical clips pelvis. Previously seen distended bowel loops have
resolved. No bowel dilatation today. Few mildly distended bowel loops are
seen. Presumed right lower quadrant stoma. Degenerative changes spine.
IMPRESSION:
No evidence of bowel obstruction.
Radiology Report
EXAMINATION: T-TUBE CHOLANGIO (POST-OP)
INDICATION: ___ year old woman with perc cholecystostomy tube placement on
___// compare to prior study.
TECHNIQUE: Water soluble contrast was hand injected into the pre-existing
cholecystostomy tube. Selected fluoroscopic images were obtained.
DOSE: Acc air kerma: 4 mGy; Accum DAP: 55.37 uGym2; Fluoro time: 02:10
minutes
COMPARISON: CT abdomen and pelvis dated ___.
FINDINGS:
Contrast readily opacified a stone filled gallbladder and the cystic duct,
passing freely into the common bile duct and proximal small bowel. No filling
defects or ductal irregularity were identified.
IMPRESSION:
Patent cystic duct with contrast passing into the small bowel.
Radiology Report
EXAMINATION: CT abdomen pelvis with contrast.
INDICATION: ___ year old woman s/p multiple operations, SBO, exlap,
enterenterostomy, cholangiogram drain, nephrostomy, new abd pain// ? acute
process, biloma?, urinoma? patient has history of bladder cancer (___)
treated with ileal conduit, complicated by renal obstruction resulting in
right PCN. Patient underwent radiation, with subsequent small-bowel
obstructions requiring exploratory laparotomy.
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Stationary Acquisition 3.5 s, 0.5 cm; CTDIvol = 16.9 mGy (Body) DLP =
8.4 mGy-cm.
2) Spiral Acquisition 4.5 s, 49.9 cm; CTDIvol = 6.3 mGy (Body) DLP = 312.6
mGy-cm.
Total DLP (Body) = 321 mGy-cm.
COMPARISON: CT abdomen pelvis dated ___,
___.
FINDINGS:
LOWER CHEST: Trace right lower lobe atelectasis. There is no evidence of
pleural or pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
Small hypodensities scattered throughout the liver too small to accurately
characterize but likely represent cysts or biliary hamartomas. There is no
evidence of intrahepatic or extrahepatic biliary dilatation. The gallbladder
is collapsed around a percutaneous cholecystostomy tube.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions.
ADRENALS: The right and left adrenal glands are normal in size and shape.
URINARY: The kidneys are of normal and symmetric size with normal nephrogram.
There is no evidence of focal renal lesions or hydronephrosis. There is no
perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. The colon and
rectum are within normal limits. The appendix is normal.
PELVIS: Postsurgical changes in the lower pelvis related to cystectomy.
Right-sided nephroureteral stent is in-situ, in appropriate position. A
duplex collecting system is noted in the left kidney. Mild prominence of the
bilateral ureters is unchanged in this patient with known ileal conduit. A
small fluid collection adjacent to the right distal ureter measures 8 x 13 mm,
decreased when compared to the prior study and likely a small urinoma (601:23,
2:59). No focal drainable fluid collection is identified. 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.
SOFT TISSUES: The abdominal and pelvic wall is within normal limits.
Postsurgical changes in the right anterior abdominal wall. Interval decrease
in diffuse anasarca in comparison to the prior study.
IMPRESSION:
1. No acute intra-abdominal process identified.
2. Persistent prominence both ureters in this patient with known ileal
conduit. No focal drainable fluid collection is identified.
3. Post cystectomy, with postsurgical changes in the lower pelvis.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: Abd pain, Tachycardia
Diagnosed with Unspecified intestinal obstruction
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: ua
level of acuity: 1.0 | ___ year old female s/p anterior pelvic exenteration, ileal
ureteral conduit
for poorly differentiated carcinoma of unknown primary on
___. This was complicated by a right ureteral obstruction
resulting in a right PCN. The patient underwent salvage
radiation and subsequent small bowel obstructions requiring
exploratory laparotomy, and recent c. diff infection. She
presented to the hospital on ___ with nausea, vomiting and
abdominal pain. On cat scan imaging she was reported to have a
closed loop bowel obstruction. The Acute care surgery service
was consulted.
Based on the cat scan findings, the patient was taken to the
operating room where she underwent an exploratory laparotomy,
LOA, and entero-enterotomy. For details regarding this
procedure, please refer to the operative report. The patient was
taken to the intensive care unit after the procedure. She
remained intubated. She was noted to have labile pressures
requiring levophed and intravenous fluids. She was started on
flagyl for the reported c.diff.
On ___ she was extubated and resumed home Advair to augment her
pulmonary status. The fentanyl drip was weaned to intermittent
doses of intravenous Dilaudid and the levophed was weaned off.
She reported right upper quadrant pain and right flank pain.
The patient continued with serial abdominal examinations and the
white blood cell count was monitored. To assist with pain
management, the patient resumed her home fentanyl patch. The
Acute pain service was consulted for consideration of an
epidural catheter. Because of her mental status and elevated
INR of 1.6, the pain service were reluctant to place an epidural
catheter and she continued on oral and intravenous home pain
regimen.
After return of bowel function, the ___ tube was
removed and she was advanced to clear liquids. Her vital signs
were stable and she was transferred to the surgical floor.
Over the next two days, her respiratory status declined in the
context of her difficult to control post-operative pain. She was
transferred back to the intensive care unit secondary to
increased O2 requirement. Radiographic imaging of her chest
showed bilateral pleural effusions and a pigtail catheter was
placed in her right chest. On ___, the patient's hematocrit
drifted down and she was transfused 2 units PRBCs, with an
appropriate response. She continued to report abdominal pain.
Cat scan imaging was negative for a post-operative abnormality
but it did show a distended gallbladder. A percutaneous
cholecystostomy tube was placed on ___ to treat presumed
acalculus cholecystitis. The patient's LFT were monitored. The
patient was started on a course of meropenum and cefepime.
On ___, while attempting to remove the right sided pigtail
catheter, the patient's percutaneous nephrostomy tube was
removed. On ___, the patient was taken to ___ for replacement
of the nephrostomy tube. The chest tube remained in place, and
was placed on water-seal. Her antibiotics were narrowed to cipro
for pseudomonas UTI, and tube feedings were restarted, and her
central line access was removed. The patient was again
transferred to the surgical floor for continue management.
The right sided chest tube was placed on water-seal and removed
on ___.
The patient was reported to have purulent material draining from
her abdominal wound and the lower wound staples were removed.
The wound was lightly packed with a dry dressing. The white
blood cell count was monitored. At this time, the patient was
noted have a swelling of the left upper extremity and a
ultrasound was done. No DVT was reported.
The nutritional status of the patient continued to be
sub-optimal. She was evaluated by Speech and Swallow and cleared
for a soft diet. Her oral intake was poor and a PICC line was
placed for TPN. Despite her limited intake, she developed
abdominal distention and vomiting. She was reported to have an
ileus on imaging and was started on a bowel regimen. A
___ tube was placed for bowel decompression and she
was made NPO. After return of bowel function, the ___
tube was removed and the patient's diet was slowly advanced.
Because of caloric depletion, TPN continued along with calorie
counts.
On ___ she had a temperature of ___ F, tachycardic to
130's, and hypotensive with a systolic BP 60's and therefore
transferred to the intensive care unit. PICC line was removed in
setting of sepsis and therefor TPN was discontinued. Patient was
found to have bacteremia with gram negative rods and a e. coli
infection in percutaneous nephrostomy. She was treated initially
with cefepime and flagyl. Once cultures sensitivities were
obtained, she was transitioned to ceftriaxone and a midline was
placed. On ___ she was hemodynamically stable and transferred
back to the surgical floor.
Infectious disease recommended 2 weeks of antibiotic treatment
for bacteremia and an additional week of oral vancomycin for
chronic clostridium difficile infection.
At this point in hospitalization, her remaining issue was
nutritional intake. She was given Dronabinol to stimulate
appetite and family was encourage to bring foods of from. The
patient appetite and caloric intake improved with these
interventions.
In preparation for discharge, the patient was evaluated by
physical therapy who recommended discharge to rehab.
At the time of discharge, the patient was doing well, afebrile
and hemodynamically stable. The patient was tolerating a diet,
making adequate urine, and pain was well controlled. The patient
received discharge teaching and follow-up instructions with
understanding verbalized and agreement with the discharge plan.
Rehab stay anticipated <30 days. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Mr. ___ is a ___ yo man with CAD s/p anterior MI s/p CABG
(LIMA-LAD, SVG-RPDA, SVG-D1), iCM (LVEF 25%), A Fib on warfarin,
VT s/p ICD in ___ who presented with hypotension in the setting
of A Fib with RVR and recent cystoscopy.
Major Surgical or Invasive Procedure:
Extraction of retained foley catheter (___)
RIJ placement and removal
History of Present Illness:
Mr. ___ is a ___ old with CAD s/p anterior MI ___ s/p
CABG (LIMA-LAD, SVG-RPDA, SVG-D1), iCM (LVEF 25%), afib on
warfarin, VT s/p ICD in ___, CML, and hx of prostate cancer s/p
brachytherapy, who presented with hematuria following
cystoscopy,
developed afib w/ RVR and hypotension requiring ICU admission.
The patient reports he has been followed by urology for several
years following a traumatic foley insertion a couple years ago.
He had a routine cystoscopy two days prior to presentation
evaluating for scar tissue, which he reports was overall normal.
Following the procedure, he developed a small amount of
hematuria
which became significant and associated with clots yesterday. He
also describes mild abdominal pain and mild dysuria. No
increased
urinary frequency, urinary retention, flank pain, fever, chills,
chest pain, shortness of breath, cough, nausea, vomiting, and
diarrhea. He has been taking his Coumadin daily without missing
doses.
Past Medical History:
Hypertension
Hyperlipidemia
CAD s/p anterior MI s/p CABG x3 (LIMA to LAD, SVG to PDA, SVG to
D1) ___
S/p ___ ICD placement in ___
Ischemic cardiomyopathy (LVEF 25%)
Atrial fibrillation
Gout
Prostate cancer s/p brachytherapy (___)
Erectile dysfunction
Skin cancers
Diverticulosis
Chronic myeloid leukemia
Cataract
Social History:
___
Family History:
Mother deceased at ___ years old from myocardial infarction;
brother deceased at ___ years old from myocardial infarction;
brother deceased at ___ years old from sudden death.
Physical Exam:
Admission physical exam:
Vitals: Temp 99.1 BP 112/74 on levophed HR 107 RR 30 95% on RA
GEN: Elderly male in NAD. Lying comfortably in bed.
HEENT: Conjunctiva clear, PERRL, MMM. Oropharynx clear.
NECK: Supple, right IJ line in place with mild bleeding around
site.
LUNGS: Normal respiratory effort. CTAB without wheezes, rales or
rhonchi.
HEART: Irregularly irregular rhythm, tachycardic. Normal S1 and
S2. No murmurs, rubs or gallops.
ABD: Abdomen soft, mildly distended, mild TTP over suprapubic
region. No rebound or guarding.
GU: No CVA TTP bilaterally. Foley catheter with minimal bloody
output.
EXTREMITIES: Warm, well perfused. No ___ edema or erythema.
SKIN: Warm, dry. No rashes.
NEURO: Alert and interactive. CN II-XII grossly intact. Moves
all
extremities.
Discharge physical exam:
VSS 98.3 PO ___ 18 99 RA
GENERAL: Alert and in no apparent distress
EYES: sclera anicteric, pupils equally round
ENT: Ears and nose without visible erythema, masses, or trauma.
Oropharynx without visible lesion, erythema or exudate
CV: Irreg irregular, nl S1, S2, ___ systolic murmur, no JVD, ICD
L chest wall
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 fullness or tenderness to palpation;
EXT: Lower ext warm without edema,
SKIN: No rashes or ulcerations noted
NEURO: AOx3, CN II-XII intact, ___ strength all ext
PSYCH: appropriate affect
Pertinent Results:
Admission labs:
___ 02:20PM BLOOD WBC-7.1 RBC-3.38* Hgb-9.7* Hct-30.4*
MCV-90 MCH-28.7 MCHC-31.9* RDW-17.0* RDWSD-54.9* Plt ___
___ 02:20PM BLOOD ___ PTT-38.9* ___
___ 02:20PM BLOOD Glucose-134* UreaN-41* Creat-1.8* Na-139
K-4.6 Cl-102 HCO3-23 AnGap-14
___ 10:47PM BLOOD Digoxin-0.9
___ 11:01PM BLOOD Lactate-2.8*
Discharge labs:
___ 08:49AM 19.6* INR 1.8*
___ 06:17AM BLOOD WBC-6.7 RBC-3.00* Hgb-8.4* Hct-26.7*
MCV-89 MCH-28.0 MCHC-31.5* RDW-17.6* RDWSD-55.8* Plt ___
___ 06:49AM BLOOD WBC-6.5 RBC-2.93* Hgb-8.2* Hct-26.2*
MCV-89 MCH-28.0 MCHC-31.3* RDW-17.4* RDWSD-56.4* Plt ___
___ 07:22AM BLOOD WBC-7.9 RBC-2.99* Hgb-8.3* Hct-26.0*
MCV-87 MCH-27.8 MCHC-31.9* RDW-17.2* RDWSD-53.1* Plt ___
___ 06:17AM BLOOD Plt ___
___ 06:17AM BLOOD ___
___ 06:17AM BLOOD Glucose-108* UreaN-38* Creat-1.8* Na-143
K-4.2 Cl-105 HCO3-23 AnGap-15
___ 06:49AM BLOOD Glucose-128* UreaN-41* Creat-2.0* Na-142
K-4.4 Cl-106 HCO3-24 AnGap-12
___ 07:22AM BLOOD ALT-44* AST-33 AlkPhos-119 TotBili-1.6*
___ 04:31PM BLOOD CK-MB-9 cTropnT-0.18*
___ 11:07AM BLOOD CK-MB-9 cTropnT-0.20*
___ 06:17AM BLOOD Calcium-8.4 Phos-3.6 Mg-2.0
___ 03:55AM BLOOD Hapto-159
___ 08:20PM BLOOD O2 Sat-59
___ 07:34AM BLOOD O2 Sat-87
___ 08:09AM BLOOD freeCa-1.10*
___ 12:07PM BLOOD freeCa-1.14
Other notable:
Trop 0.2 -> 0.18
Hapto 159, LDH 260
PTH 142
Dig 0.9
Lact 2.8 -> 6.3 -> 1.6
UA (___): mod bld, neg nit, lg ___, 30 prot, >182 RBCs, 176
WBCs, few bact
BCx (___): neg x 2
UCx (___): E.coli >100K
_________________________________________________________
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:
========
- Renal ultrasound (___):
1. The bladder is only minimally distended and cannot be fully
assessed on the current study. Within this limitation, there is
no sonographic evidence of clot within the bladder.
2. No hydronephrosis.
3. There is trace perihepatic free fluid.
4. Prostate is suboptimally evaluated, but appears markedly
heterogeneous in echogenicity. Clinical correlation is
recommended.
- CXR (___):
1. Stable cardiomegaly without evidence of pulmonary vascular
congestion.
2. No evidence of focal consolidation.
- CT A/P with contrast (___):
1. Foley catheter in place within a partially decompressed
urinary bladder, which contains slightly increased density
consistent with blood products.
2. Small to moderate fluid within the pelvis, as well as trace
perihepatic and perisplenic ascites. No rim enhancing fluid
collections identified.
3. Small right pleural effusion and trace left pleural effusion
with adjacent bibasilar atelectasis.
4. Minimally complex cyst in the left upper renal pole measuring
3.3 cm and containing a thin internal septation, compatible with
Bosniak II.
5. Cholelithiasis without evidence of acute cholecystitis.
6. Diverticulosis without evidence for acute diverticulitis.
- CXR (___):
1. Interval placement of a right internal jugular central venous
catheter, with tip extending to the mid SVC.
2. No evidence of pneumothorax.
- TTE (___):
Severe global LV systolic dysfunction, with areas of relative
akinesis, lateral wall contracts best. Dilated RV with severe
dysfunction. Can not exclude LV apical thrombus (images 53, 54).
Probable moderate mitral regurgiation. Severe tricuspid
regurgitation. At least moderate pulmonary hypertension, likely
underestimated.
- TTE (___):
Compared with the prior TTE (images reviewed) of ___,
contrast administration suggests no apical left ventricular mass
as possibly suggested in the prior images. The degrees of mitral
and tricuspid regurgitation may be similar but focused / limited
views preclude full comparison.
___ 08:49AM BLOOD WBC-7.0 RBC-3.13* Hgb-8.8* Hct-28.2*
MCV-90 MCH-28.1 MCHC-31.2* RDW-18.1* RDWSD-57.8* Plt ___
___ 08:49AM BLOOD WBC-7.0 RBC-3.13* Hgb-8.8* Hct-28.2*
MCV-90 MCH-28.1 MCHC-31.2* RDW-18.1* RDWSD-57.8* Plt ___
___ 08:49AM BLOOD Neuts-74.8* Lymphs-12.6* Monos-8.3
Eos-2.3 Baso-0.7 Im ___ AbsNeut-5.25 AbsLymp-0.88*
AbsMono-0.58 AbsEos-0.16 AbsBaso-0.05
___ 08:49AM BLOOD ___
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Multivitamins W/minerals 1 TAB PO DAILY
2. Tasigna (nilotinib) 300 mg oral BID
3. Allopurinol ___ mg PO DAILY
4. Atorvastatin 40 mg PO QPM
5. Calcitriol 0.25 mcg PO 3X/WEEK (___)
6. Vitamin D 1000 UNIT PO DAILY
7. Digoxin 0.125 mg PO EVERY OTHER DAY
8. Fluticasone Propionate NASAL 1 SPRY NU BID
9. Metoprolol Succinate XL 50 mg PO QHS
10. Quinapril 10 mg PO DAILY
11. Torsemide 60 mg PO DAILY
12. Warfarin 2 mg PO 3X/WEEK (___)
13. Warfarin 1 mg PO 4X/WEEK (___)
Discharge Medications:
1. Cefpodoxime Proxetil 200 mg PO Q12H Duration: 1 Day
Take on ___
RX *cefpodoxime 200 mg 1 tablet(s) by mouth twice a day Disp #*2
Tablet Refills:*0
2. Allopurinol ___ mg PO DAILY
RX *allopurinol ___ mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*3
3. Atorvastatin 40 mg PO QPM
4. Calcitriol 0.25 mcg PO 3X/WEEK (___)
5. Digoxin 0.125 mg PO EVERY OTHER DAY
6. Fluticasone Propionate NASAL 1 SPRY NU BID
7. Metoprolol Succinate XL 50 mg PO QHS
8. Multivitamins W/minerals 1 TAB PO DAILY
9. Quinapril 10 mg PO DAILY
10. Tasigna (nilotinib) 300 mg oral BID
11. Torsemide 60 mg PO DAILY
12. Vitamin D 1000 UNIT PO DAILY
13. Warfarin 1 mg PO 4X/WEEK (___)
14. Warfarin 2 mg PO 3X/WEEK (___)
___
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
Urinary tract infection
Gross hematuria
Sepsis with septic shock
Chronic systolic heart failure
Atrial fibrillation
Coronary artery disease
CML
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION: RENAL U.S. PORT
INDICATION: History: ___ with hematuria s/p cystoscopy, no pain// Bladder
clots
TECHNIQUE: Grey scale and color Doppler ultrasound images of the kidneys were
obtained.
COMPARISON: CT dated ___.
FINDINGS:
There is no hydronephrosis, stones, or masses bilaterally. There are multiple
bilateral simple renal cysts, the largest on the right measuring up to 3.7 cm
in the upper pole and the largest on the left measuring up to 3.2 cm in the
lower pole. Normal cortical echogenicity and corticomedullary differentiation
are seen bilaterally.
Right kidney: 9.9 cm
Left kidney: 10.1 cm
The bladder is only minimally distended and can not be fully assessed on the
current study, though there is no evidence of clots.
There is trace perihepatic free fluid noted.
The prostate gland is not well-visualized, though measures approximately 3.2 x
3.1 x 3.0 cm with prostate volume of 15.1 cc. The visualized portions appear
heterogeneous.
IMPRESSION:
1. The bladder is only minimally distended and cannot be fully assessed on the
current study. Within this limitation, there is no sonographic evidence of
clot within the bladder.
2. No hydronephrosis.
3. There is trace perihepatic free fluid.
4. Prostate is suboptimally evaluated, but appears markedly heterogeneous in
echogenicity. Clinical correlation is recommended.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with hypoxia. Evaluation for infection, edema.
TECHNIQUE: Chest AP portable upright
COMPARISON: Comparison to prior chest radiograph from ___.
FINDINGS:
Median sternotomy wires are intact and well aligned. Cardiac device projects
over the left upper chest wall, with leads extending to the right atrium and
right ventricle. Few surgical clips project over the upper mediastinum.
Stable enlargement of the cardiac silhouette, without vascular congestion. No
evidence of focal consolidation. No pleural effusion or pneumothorax is seen.
IMPRESSION:
1. Stable cardiomegaly without evidence of pulmonary vascular congestion.
2. No evidence of focal consolidation.
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ with hematuria, hypotension and tachycardia, s/p cystoscopy.
Evaluation for signs of 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) Stationary Acquisition 7.5 s, 0.5 cm; CTDIvol = 72.2 mGy (Body) DLP =
36.1 mGy-cm.
2) Spiral Acquisition 6.5 s, 51.1 cm; CTDIvol = 17.8 mGy (Body) DLP = 906.4
mGy-cm.
Total DLP (Body) = 943 mGy-cm.
COMPARISON: Comparison to CT abdomen/pelvis from ___.
FINDINGS:
LOWER CHEST: Small right pleural effusion and trace left pleural effusion with
adjacent bibasilar atelectasis. No pericardial effusion.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic or
extrahepatic biliary dilatation. The gallbladder appears decompressed and
contains hyperdense gallstones. Trace perihepatic ascites.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal size and attenuation throughout, without
evidence of focal lesions. Small amount of perisplenic ascites.
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 minimally complex cyst at the left upper renal pole measuring 3.3
cm (2:27, 601:38), containing a thin internal septation, compatible with
___ II. There is a 3.4 cm simple cyst at the right upper pole. Few
additional subcentimeter hypodensities are too small to characterize, likely
compatible with simple cysts. There is no evidence of hydronephrosis. There
is no perinephric abnormality.
GASTROINTESTINAL: The stomach is unremarkable. Small bowel loops demonstrate
normal caliber, wall thickness, and enhancement throughout. Diverticulosis of
the sigmoid colon is noted, without evidence of wall thickening and fat
stranding.
PELVIS: The urinary bladder is decompressed with a Foley catheter in place.
Slightly increased density within the bladder lumen is consistent with blood
products. Air within the bladder is consistent with history of
instrumentation. There is moderate free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate contains numerous brachytherapy seeds.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy. Few
mildly prominent retroperitoneal lymph nodes are not pathologically enlarged
by CT size criteria. There is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. Moderate atherosclerotic
disease is noted. Air within the bilateral common femoral veins, likely
compatible with instrumentation.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
Moderate multilevel degenerative change of the lumbar spine. A sclerotic
focus within the left humeral head is consistent with a bone island.
Unchanged appearance of a bone island within the lateral aspect of the left
tenth rib (02:27).
SOFT TISSUES: A left inguinal hernia containing fat is noted.
IMPRESSION:
1. Foley catheter in place within a partially decompressed urinary bladder,
which contains slightly increased density consistent with blood products.
2. Small to moderate fluid within the pelvis, as well as trace perihepatic and
perisplenic ascites. No rim enhancing fluid collections identified.
3. Small right pleural effusion and trace left pleural effusion with adjacent
bibasilar atelectasis.
4. Minimally complex cyst in the left upper renal pole measuring 3.3 cm and
containing a thin internal septation, compatible with Bosniak II.
5. Cholelithiasis without evidence of acute cholecystitis.
6. Diverticulosis without evidence for acute diverticulitis.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: History: ___ with CVL placement. Evaluation for CVL placement.
TECHNIQUE: Chest AP portable upright
COMPARISON: Comparison to multiple prior chest radiographs, most recently
from ___.
FINDINGS:
Median sternotomy wires are intact and well aligned. Cardiac device projects
over the upper left chest wall, with pacer leads extending to the right atrium
and right ventricle. Few surgical clips project over the upper mediastinum.
Interval placement of a right internal jugular central venous catheter, with
tip projecting over the mid SVC. Stable enlargement of the cardiac
silhouette. No definite evidence of focal consolidation. No pleural effusion
or pneumothorax.
IMPRESSION:
1. Interval placement of a right internal jugular central venous catheter,
with tip extending to the mid SVC.
2. No evidence of pneumothorax.
Gender: M
Race: WHITE
Arrive by WALK IN
Chief complaint: Hematuria
Diagnosed with Hematuria, unspecified, Anemia, unspecified, Tachycardia, unspecified
temperature: 98.2
heartrate: 84.0
resprate: 18.0
o2sat: 95.0
sbp: 131.0
dbp: 74.0
level of pain: 4
level of acuity: 2.0 | ___ man with history of CAD s/p CABG, ischemic
cardiomyopathy (LVEF 25%), VT s/p ICD, atrial fibrillation on
warfarin, prostate cancer s/p brachytherapy, CML on nilotinib
who presented with gross hematuria after routine outpatient
cystoscopy s/p traumatic foley placement with retained urethral
foreign body s/p extraction and CBI initiation, with course c/b
shock, suspected septic due to UTI, and atrial fibrillation with
RVR, called out of FICU ___, s/p successful voiding trial with
improvement in hematuria treated with IV Vanc/Cefepime from
___ transitioned to Ceftriaxone until discharge and
continued on Cefpodoxime to complete course of antibiotics
ending on ___. He will follow-up with urology for outpatient
evaluation and continue on Coumadin for atrial fibrillation.
# Shock, presumed septic, now resolved, due to
# Urinary tract infection:
Developed shock in setting of gross hematuria, traumatic foley
placement, and retained urethral foreign body s/p extraction.
Suspect urinary source with UCx growing pan-S E.coli. CXR
without pneumonia, and blood cultures without growth to date.
Likely some component from baseline systolic heart failure, but
no compelling evidence for cardiogenic shock. Briefly required
phenylephrine in the FICU via RIJ, weaned off with IVFs. He was
treated broadly with Vancomycin/Cefepime initially (___),
transitioned CTX based on culture results with plan to complete
course of antibiotics until ___, continued on Ceftriaxone
IV while hospitalized and transitioned to Cefpodoxime on
discharge.
# Gross hematuria:
# Prostate cancer s/p brachytherapy:
P/w gross hematuria after routine outpatient cystoscopy.
Underwent traumatic Foley placement in the ED c/b retained
catheter and clots (extracted by urology) and development of
UTI/sepsis as above. Two way coude was placed with initiation of
CBI, with improvement in hematuria. Underwent a successful
voiding trial on ___. Monitored in house until INR therapeutic
on coumadin with no further episodes of frank hematuria with
clots. He will f/u with outpatient urology (scheduled for ___.
# Anemia:
Chronic anemia likely multifactorial due to CKD, AoCD,
nilotinib. Acute component secondary to gross hematuria in
setting of anticoagulation. Transfused 1 unit pBRC on ___ and
Hb subsequently stable. Hgb 8.8 on discharge.
# Thrombocytopenia:
Chronic, stable, suspect secondary to nilotinib, continued this
admission. Plt wnl on d/c.
# Transaminitis/hyperbilirubinemia:
Developed mild transaminitis and hyperbilirubinemia on ___,
likely secondary to shock, which downtrended with management as
above.
# Atrial fibrillation:
CHADs2vasc = 4. Developed RVR in setting of suspected septic
shock as above, improved with treatment of infection. Warfarin
initially held for hematuria (did not require reversal), resumed
at home dosing on ___ without bridging. Home metoprolol and
digoxin were continued.
INR 1.8 on discharge on the 1 mg of warfarin 4 times a week, and
2 mg the other three days. Will need INR check ___.
# Ischemic cardiomyopathy (LVEF 25%):
# VT S/p ICD:
As above, developed shock that was presumed septic in setting of
UTI, without evidence of frank cardiogenic shock. Home torsemide
and ACE were initially held in setting of volume resuscitation
and subsequently resumed. Home metoprolol was continued.
Torsemide was restarted and on discharge, ACE was resumed on
discharge. He will f/u with his outpatient cardiologist, Dr.
___. Dry weight on discharge 70.67 kg (155.8 lb)
# CAD s/p anterior MI s/p CABG:
# NSTEMI, type II:
Patient with elevated troponin on admission in setting of CKD.
Suspect mild demand in setting of sepsis and atrial fibrillation
as above. Downtrended. Home statin was continued. Of note,
patient is not on an ASA in setting of warfarin use. Deferred
consideration of ASA to outpatient cardiologist Dr. ___.
# Chronic kidney disease stage III:
Recent baseline around 1.8-2.2, now stable at baseline. Renal
ultrasound on ___ without hydronephrosis. Home calcitriol and
vitamin D were continued. Cr 1.8 on discharge.
- continue calcitriol and vitamin D
# Hypertension:
As above, initially required pressor for shock, weaned off with
fluids and treatment of infection. Home metoprolol was continued
and home torsemide subsequently resumed.
# Hyperlipidemia:
Continued home statin.
# CML:
Continued home nilotinib. F/u with Dr. ___ on ___
# Gout:
Continued home allopurinol, renally dosed. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
telaprevir / Nafcillin / vancomycin
Attending: ___.
Chief Complaint:
L-sided abd pain 10 days s/p splenic embolization
Major Surgical or Invasive Procedure:
none
History of Present Illness:
HISTORY OF PRESENT ILLNESS: ___ with chronic HCV presents as a
transfer from an OSH in ___ for evaluation for a splenic
laceration s/p coil embolization. She presented to a hospital in
___ on ___ due to syncope in the bathroom, one week
after tripping and falling while attempting to catch a bus. She
reports she fell on her left side injuring her left rib cage and
hitting her head. She felt well overall and decided not to seek
medical care. She thereafter left to go ___ for vacation
(Hepatitis C support convention, also to visit a friend with
liver transplant) and had a syncopalepisode in the bathroom,
prompting her admission. While there, undergone splenic ___
embolization after a hematoma was discovered on a CT of her
abdomen. She then decided to come here for further care, got on
a plane, and was even upgraded to business class.
Also, of note The patient was discharged to rehab on nafcillin
after having a bacteremia and a reaction to vancomycin, and was
discharged home after she completed that course. Her last
injection was on ___.
In the ED, initial VS were:5 99.7 98 146/77 18 96%
-Patient was seen by transplant team in the ED, who recommended
to obtain OSH records especially discharge summary to determine
need for admission. If requires admission, recommend admission
to medicine/hepatology (Hep C cirrhosis). No active surgical
issues at this time. Discussed with Dr. ___
attending.
- Labwork was significant for
136 103 7
---------<115
4.2 25 0.5
ALT/AST ___ AP 108 Tbili 0.9 Alb 3.1
WBC 10.3
HCT 37.7
VS prior to transfer were:99.3 70 18 140/70 98% ra
On arrival to the floor,98.6 145/87 HR 90 RR 18 97%RA. She felt
well, other than pain in her abdomen over her spleen.
REVIEW OF SYSTEMS:
reprted having some fevers up to 102 recently, but not in the
past day,Denies headache, vision changes, rhinorrhea,
congestion, sore throat, cough, chest pain, nausea, vomiting,
diarrhea, constipation, BRBPR, melena, hematochezia, dysuria,
hematuria.
Past Medical History:
HEPATITIS C CIRRHOSIS
HYPOTHYROIDISM
DEPRESSION
OBESITY
MIGRAINE HEADACHES
PERIPHERAL EDEMA
*S/P ADJ GASTRIC BAND (VG) & HIATAL HERNIA REPAIR ___
s/p hystorectomy due to excessive vaginal bleeding and
?precanerous condition
ANEMIA
AFIB CHADS risk score 0
Social History:
___
Family History:
Family History: husband also has hep C, but patient had Hep C
prior to meeting husband.
Physical Exam:
ADMISSION PE:
VS T 98.7 BP 126/85 HR 80 RR 18 O2Sat 93RA
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, rales at bases, otherwise CTAB no wheezes,
rhonchi
CV Irregular rate normal S1/S2, no mrg
ABD soft Tender esp in L upper quadrant, but also more
diffusely, ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, 2+ pitting edema, no c/c
NEURO CNs2-12 intact, motor function grossly normal, gait
appeared grossly norml, no asterixis
SKIN no ulcers or lesions
DISCHARGE PE:
VS 94.5 BO 132/61 HR 82 RR 20 99RA
GEN Alert, oriented, no acute distress
HEENT NCAT MMM EOMI sclera anicteric, OP clear
NECK supple, no JVD, no LAD
PULM Good aeration, rales at bases, otherwise CTAB no wheezes,
rhonchi
CV Irregular rate normal S1/S2, no mrg
ABD soft Decreased, diffuse tenderness esp in L upper quadrant,
ND normoactive bowel sounds, no r/g
EXT WWP 2+ pulses palpable bilaterally, 2+ pitting edema, no c/c
NEURO CNs2-12 intact, motor function grossly normal, gait
appeared grossly norml, no asterixis
SKIN no ulcers or lesions
Pertinent Results:
ADMISSION LABS:
___ 03:00PM BLOOD WBC-10.3# RBC-3.64* Hgb-11.6* Hct-37.7
MCV-104* MCH-31.8 MCHC-30.7* RDW-17.4* Plt ___
___ 03:00PM BLOOD Neuts-77.1* Lymphs-9.3* Monos-11.2*
Eos-1.8 Baso-0.7
___ 03:00PM BLOOD ___ PTT-36.5 ___
___ 03:00PM BLOOD Glucose-115* UreaN-7 Creat-0.5 Na-136
K-4.2 Cl-103 HCO3-25 AnGap-12
___ 03:00PM BLOOD ALT-10 AST-29 AlkPhos-108* TotBili-0.9
___ 06:10AM BLOOD GGT-28
___ 03:00PM BLOOD Albumin-3.1*
DISCHARGE LABS:
___ 07:00AM BLOOD WBC-11.0 RBC-3.53* Hgb-11.4* Hct-35.7*
MCV-101* MCH-32.2* MCHC-31.8 RDW-16.9* Plt ___
___ 07:00AM BLOOD Plt ___
___ 07:00AM BLOOD Glucose-74 UreaN-6 Creat-0.5 Na-134 K-4.5
Cl-103 HCO3-23 AnGap-13
___ 07:00AM BLOOD ALT-10 AST-49* AlkPhos-92 TotBili-1.0
___ 07:00AM BLOOD Calcium-8.0* Phos-2.7 Mg-1.5*
CT ABD/PELVIS WITH CONTRAST ___:
. Splenic enlargement compared to prior likely secondary to an
intracapsular
hematoma and liquification status post embolization. Minimal
amount of
residual enhancing splenic tissue is noted. Superinfection is
not excluded,
although lack of a thickened and enhancing rim would make this
less likely.
There is no evidence of extracapsular extension.
2. Cirrhosis with a mild amount of ascites.
3. Bilateral pleural effusions, small on the right and moderate
on the left,
with lobar collapse in the left lower lung.
4. Gastric band.
Medications on Admission:
Preadmission medications listed are correct and complete.
Information was obtained from Patient.
1. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) unknown
Oral daily
2. Docusate Sodium 100 mg PO BID
3. Venlafaxine XR 150 mg PO DAILY
4. Levothyroxine Sodium 100 mcg PO DAILY
5. Multivitamins 1 TAB PO DAILY
6. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
7. Spironolactone Dose is Unknown PO PRN leg swelling
8. Ciprofloxacin HCl 500 mg PO Q12H s/p splenic embolization
9. MetRONIDAZOLE (FLagyl) 500 mg PO TID s/p splenic embolization
Discharge Medications:
1. Docusate Sodium 100 mg PO BID
2. Levothyroxine Sodium 100 mcg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. Venlafaxine XR 150 mg PO DAILY
5. Ciprofloxacin HCl 500 mg PO Q12H s/p splenic embolization
to be taken through ___
RX *ciprofloxacin 500 mg 1 tablet(s) by mouth twice daily Disp
#*40 Tablet Refills:*0
6. MetRONIDAZOLE (FLagyl) 500 mg PO TID s/p splenic embolization
to be taken through ___
RX *metronidazole 500 mg 1 tablet(s) by mouth every 8 hours Disp
#*60 Tablet Refills:*0
7. Acetaminophen 650 mg PO Q8H pain
do not take more than 2 grams total per day
RX *acetaminophen 650 mg 1 tablet(s) by mouth every eight (8)
hours Disp #*30 Tablet Refills:*0
8. Calcium 500 + D *NF* (calcium carbonate-vitamin D3) 1 tab
ORAL DAILY
9. Senna 1 TAB PO BID:PRN constipation
RX *senna 8.6 mg 1 tab(s) by mouth twice daily Disp #*60 Tablet
Refills:*0
10. Polyethylene Glycol 17 g PO DAILY
RX *Miralax 17 gram/dose 17 g(s) by mouth daily Disp #*1 Bottle
Refills:*0
11. OxycoDONE (Immediate Release) ___ mg PO Q6H:PRN pain
Duration: 14 Days
RX *oxycodone 5 mg ___ tablet(s) by mouth every 6 hours Disp
#*30 Tablet Refills:*0
12. Spironolactone 0 mg PO PRN leg swelling
Discharge Disposition:
Home
Discharge Diagnosis:
splenic laceration status post splenic artery embolization
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with HCV cirrhosis, status post splenic
rupture three weeks prior and splenic artery embolization, now with continuing
pain, assess for phlegmon.
COMPARISONS: CT abdomen and pelvis from ___ dated
___.
TECHNIQUE: MDCT-acquired axial images were obtained from the dome of the
liver to the pubic symphysis after the uneventful administration of 130 mL of
Omnipaque. Oral contrast was also administered. Coronal and sagittal
reformations were provided and reviewed.
DLP: 587.69 mGy-cm.
CHEST: The visualized lung bases demonstrate bilateral pleural effusions,
small on the right and moderate sized on the left. There is left lower lobar
atelectasis seen within the left lung and adjacent compressive atelectasis
seen on the right. There are no pulmonary nodules or masses. The visualized
portion of the heart is top normal in size, and there is no pericardial
effusion.
ABDOMEN: A nodular contour to the liver is compatible with known diagnosis of
hepatitis C cirrhosis. The gallbladder is normal, and there is no
intrahepatic biliary ductal dilatation. The adrenal glands are normal. The
kidneys enhance symmetrically and excrete contrast without hydronephrosis.
Streak artifact from splenic artery embolization limits complete evaluation of
the pancreas, although to the extent visualized, it appears normal. A gastric
band is present with its port in the left anterior subcutaneous tissues. The
small and large bowel are normal without evidence of bowel wall thickening.
There is a trace amount of intra-abdominal ascites. There is no free air.
The spleen is enlarged, measuring 18 cm in the craniocaudal dimension which
has increased slightly from prior. Embolization coils are seen at the splenic
hilum within the renal artery. There is a large subcapsular
hematoma/liquified splenic tissue with minimal residual enhancing splenic
tissue. There is no evidence for extracapsular extension.
PELVIS: Free fluid from the abdomen is noted in the posterior cul-de-sac.
The bladder, rectum and sigmoid are normal. The uterus and adnexa are not
definitively identified. There is no inguinal or pelvic sidewall
lymphadenopathy.
BONES: There are no suspicious osseous lesions. A sclerotic focus seen in
the posterior portion of the right iliac wing likely represents a bone island.
Degenerative changes of the lower lumbar spine are marked by disc space
narrowing and vacuum phenomenon seen between L3-L4.
IMPRESSION:
1. Splenic enlargement compared to prior likely secondary to an intracapsular
hematoma and liquification status post embolization. Minimal amount of
residual enhancing splenic tissue is noted. Superinfection is not excluded,
although lack of a thickened and enhancing rim would make this less likely.
There is no evidence of extracapsular extension.
2. Cirrhosis with a mild amount of ascites.
3. Bilateral pleural effusions, small on the right and moderate on the left,
with lobar collapse in the left lower lung.
4. Gastric band.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: SPLENIC LAC
Diagnosed with SPLEEN PARENCHYMA LACER, UNSPECIFIED FALL
temperature: 99.7
heartrate: 98.0
resprate: 18.0
o2sat: 96.0
sbp: 146.0
dbp: 77.0
level of pain: 5
level of acuity: 3.0 | Assessment/Plan: ___ ___ witness with PMHx s/p HCV
cirrhosis completed full treatment, in Afib now presenting with
abd s/p splenic embolisation
#Abdominal Pain - Pt recently sustained a traumatic splenic
laceration in early ___ s/p mechanical fall in trying
to catch a bus. She was unaware of the laceration until she
became lightheaded and passed out a few weeks later. She was
brought to an OSH in ___ where she was found to be anemic and
the splenic lacerations were identified on CT. She underwent
splenic embolization at OSH on ___. Of note, she did
not receive any blood products, because she is a ___
witness. Even though she was anemic s/p bleed from splenic lac
at ___, when she was admitted to ___ her HCTs were stable at
38.4. Per pt, decision was made to undergo splenic embolization
over surgery bc of her religous reasons for not getting blood.
Pain was controlled with acetaminophen 650mg Q8h standing and
oxycodone 5mg PO q6h prn pain. Repeat CT was performed to assess
for evidence of phlegmon that could rupture and leading to
bleeding. CT results revealed a stable hematoma around the
spleen. Transplant surgery was consulted in the event there were
findings requiring repeat intervention. Pt was hemodynamically
stable throughout stay, with pain control improving. Pt was
discharged with close follow-up with her PCP and hematologist.
To prevent constipation with pain medications, pt was discharged
on an aggressive bowel regimen.
# Splenic artery embolization: Pt was continued on
flagyl/ciprofloxacin which was started at OSH for a total course
of 28d to prevent splenic abscess. Patient should also be
assessed for vaccinations against encapsulated organisms once
she is a spleniC (e.g. pneumovax, HIB vaccination, and N.
meningitides vaccine).
#S/P multiple Falls - First fall sounds like it was
purelymechanical as she denies chest pain, sob, palpitations,
lightheadedness. The subsequent falls were likely ___ to anemia
and lightheadedness. While at ___ her hct has been stable. ___
worked with her to ensure that she was steady on her feet.
#Elevated alk pos: Alk phos was marginally elevated at 108,
which was trending down from a month prior. It was likely
elevated for multiple reasons including her recent splenic
embolization and HCV cirrhosis.
# HEP C cirrhosis - Pt completed her therapy for HCV and her
most recent viral load undetectable. While she was hospitalized,
we limited acetaminophen for pain control to <2g/day. Pt had
grade 4 cirrhosis by biopsy from ___. She completed a total
of 48 weeks of treatment which included telepavir completed on
___, interferon, and ribavarin. Per prior notes, most recent
HCV viral load in ___ was undetectable.
# Afib: currently irregularly irregular. CHADS risk score = 0,
thus does not need anticoagulation and not symptomatic per
patient
# Hypothyroidism - stable and continued on home levothyroxine
per endocrinology note from labs on ___. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: NEUROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___
Chief Complaint:
Fall and left-sided weakness
Major Surgical or Invasive Procedure:
___ Percutaneous endoscopic gastrostomy tube placement
History of Present Illness:
The patient is a ___ gentleman with past medical history
significant for hypertension and CLL in remission recently
completed chemo, history of prior hypertensive stroke ___ years
ago with residual right foot drop who presents as an outside
hospital transfer for further evaluation of IPH.
Briefly, per wife patient and wife were just about to go to do
errands, he was walkign to the car with his walker when he
noticed he forgot something in the house. He walked back to the
house without his walker. His wife was walking behind him. He
was
walking very fast so she told him to slow down and when he
turned
around he suddenly fell and hit his head. She states that prior
to this he was in his usual states of health. he has residual
left sided weakness from a stroke ___ years ago and a known right
foot drop. He was getting ___ and speech therapy (at baseline
does not speak very clear) after a fall in ___. Since then
he walks with a cane. He is independent of ADL's. The wife
denies
any complains of headache, altereted mental status, or new neuro
defcits. In fact she ___ that ___ was just there earlier stating
how well he was doing.
No recent fevers or unexplained weight loss.
After the fall she called she EMS. Per there report the patient
reportedly had expressive aphasia, left-sided neglect, and left
upper and left lower extremity weakness. He was brought to ___ where his blood pressure was noted to be 144/77 heart
rate 63 satting on room air. CT head showed a right basal
ganglia
bleed with intraventricular extension. He was given 1 g of
Keppra and transferred to ___ for further
evaluation. Upon arrival to ___'s vitals were
Blood pressure 142/73 heart rate 65 satting 100% on room air.
GCS was 14. Plts 57, INR 1.3
He has a hx of leukemia and had his last chemo in ___.
He has completed chemo.
Past Medical History:
Prior stroke ___ years ago with residual right foot drop
Hypertension
CLL with remission and then recurrent skin leukemia
Social History:
Married. Used to work as ___. Lives with
wife.
Walks with a walker. Smoked in past, etoh occasionally, no
illicit drugs.
- Modified Rankin Scale:
[] 0: No symptoms
[] 1: No significant disability - able to carry out all usual
activities despite some symptoms
[] 2: Slight disability: able to look after own affairs without
assistance but unable to carry out all previous activities
[x] 3: Moderate disability: requires some help but able to walk
unassisted
[] 4: Moderately severe disability: unable to attend to own
bodily needs without assistance and unable to walk unassisted
[] 5: Severe disability: requires constant nursing care and
attention, bedridden, incontinent
[] 6: Dead
Family History:
Unknown
Physical Exam:
ADMISSION EXAMINATION
=====================
Vitals: T: 97.8 P: 65 r: 16 BP: 142/73 SaO2: 100% room air
- General: Awake, cooperative, NAD.
- HEENT: NC/AT
- Neck: Supple
- Pulmonary: no increased WOB
- Cardiac: well perfused
- Abdomen: soft, nontender, nondistended
- Extremities: no edema, pulses palpated
- Skin: no rashes or lesions noted.
Neurologic:
-Mental Status: Alert, not oriented to time or place, says he is
___ and that it is ___. Unable to relate history.
Inattentive unable to name ___ backward without difficulty.
Unable to name, decreased verbal fluency, intact comprehension.
Speech was not dysarthric. Able to follow both midline and
appendicular commands. reagrds examiner on rigth and left side.
-Cranial Nerves:
I: Olfaction not tested.
II: PERRL 3 to 2mm and brisk. VFF to confrontation.
III, IV, VI: Mild right gaze preference but able to cross
midline
easily.
V: Facial sensation intact to light touch.
VII: mild left lower facial droop
VIII: Hearing intact to finger-rub bilaterally.
IX, X: Palate elevates symmetrically.
XI: ___ strength in trapezii and SCM bilaterally.
XII: Tongue protrudes in midline.
-Motor: Normal bulk, tone throughout. No adventitious movements,
such as tremor, noted. No asterixis noted. LUE drift.
Patient did not fully participate in confrontational exam but
was
able to move all 4 extremities antigravity.
Right upper and right lower extremity 5 out of 5, except for RLE
distally. LUE ___, LLE 4+/5.
-Sensory: No deficits to light touch, pinprick throughout.
Difficult to assess for extinction.
-Coordination: No dysmetria on finger to nose bilaterally
-Gait: Deferred
DISCHARGE EXAMINATION
=====================
Vitals: Temp: 97.3 (Tm 98.1), BP: 154/75 (148-173/72-82), HR:
61
(56-61), RR: 20 (___), O2 sat: 100% (95-100), O2 delivery: RA
General: awake, cooperative, NAD
HEENT: resolving forehead and lateral periorbital hematoma, no
scleral icterus noted, MMM
Pulmonary: breathing comfortably, no tachypnea or increased WOB
Cardiac: skin warm, well-perfused
Abdomen: soft, ND
Extremities: symmetric, no edema
Neurologic:
-Mental Status: Awake, alert, oriented to place (hospital) but
not city or time. Mildly inattentive. Language is sparse though
fluent with intact comprehension. Able to follow both midline
and appendicular commands.
-Cranial Nerves: PERRL. EOMI without nystagmus. Subtle R NLFF.
Palatal elevation symmetric. Hearing intact to conversation.
Tongue protrusion in midline.
-Motor: Limited by motor impersistence, full on left and at
least 4+/5
throughout RUE/RLE aside from R TA, chronically ___ from foot
drop.
-Sensory: Symmetric to LT.
-DTRs: ___.
-Coordination: Deferred.
Pertinent Results:
___ 05:16AM BLOOD WBC-8.1 RBC-2.91* Hgb-9.3* Hct-28.5*
MCV-98 MCH-32.0 MCHC-32.6 RDW-14.4 RDWSD-50.3* Plt Ct-56*
___ 05:16AM BLOOD Glucose-88 UreaN-15 Creat-0.7 Na-144
K-3.7 Cl-112* HCO3-21* AnGap-11
___ 05:16AM BLOOD Calcium-8.0* Phos-2.7 Mg-1.9
___ 05:50AM BLOOD %HbA1c-4.8 eAG-91
___ 05:50AM BLOOD Triglyc-73 HDL-25* CHOL/HD-5.3 LDLcalc-93
___ 5:41 am STOOL CONSISTENCY: NOT APPLICABLE
Source: Stool.
**FINAL REPORT ___
C. difficile DNA amplification assay (Final ___:
Negative for toxigenic C. difficile by the Cepheid nucleic
acid
amplification assay..
(Reference Range-Negative).
___ 3:15 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 3:15 pm BLOOD CULTURE
**FINAL REPORT ___
Blood Culture, Routine (Final ___: NO GROWTH.
___ 2:32 pm URINE Source: Catheter.
**FINAL REPORT ___
URINE CULTURE (Final ___:
ENTEROCOCCUS FAECALIS. 10,000-100,000 CFU/mL.
SENSITIVITIES: MIC expressed in
MCG/ML
_________________________________________________________
ENTEROCOCCUS FAECALIS
|
AMPICILLIN------------ <=2 S
NITROFURANTOIN-------- <=16 S
TETRACYCLINE---------- =>16 R
VANCOMYCIN------------ <=0.5 S
___ 5:43 ___ CTA HEAD W&W/O C & RECONS; CTA NECK W&W/OC &
RECONS
1. Slight increase in moderate amount of intraventricular blood
described
above. Of note, on CTA there is evidence a potential spot sign
in the region of the right lateral ventricle occipital horn
raising concern for potential active bleeding.
2. Redemonstrated evidence of intraparenchymal extension blood
just superior to right lateral ventricle temporal horn in the
region of the basal ganglia where there is mild surrounding
vasogenic edema.
3. Evidence of mild-to-moderate white matter small vessel
disease.
4. Small old infarct abutting the body of the right caudate
nucleus.
5. Extensive cervical lymphadenopathy likely correlates with the
patient's
history of CLL.
6. A 2 mm left upper lobe pulmonary nodule for which no imaging
follow-up is recommended in low risk patients. High-risk
patients may receive an optional follow-up CT in 12 months per
the ___ criteria.
7. Couple thyroid nodules measuring up to 1.4 cm for which no
follow-up
imaging is recommended.
___ 8:00 ___ MR HEAD W & W/O CONTRAST
1. Stable hematoma in the right basal ganglia and medial
temporal lobe with stable surrounding edema and stable
intraventricular extension.
2. Several small foci of contrast enhancement within the basal
ganglia and
medial temporal lobe portions of the hematoma, without
peripheral masslike
enhancement outside the margins of the hematoma, are of
uncertain clinical
significance. Follow-up imaging is needed to exclude an
underlying mass.
3. Extensive supratentorial white matter and pontine signal
abnormalities,
nonspecific but likely sequela of small vessel disease. Small
chronic
infarcts within bilateral corona radiata, left centrum
semiovale, and left
pons.
___ 10:01 AM VIDEO OROPHARYNGEAL SWALLOW
Penetration with thin liquids and nectar thick liquids without
aspiration.
Medications on Admission:
1. Aspirin EC 81 mg PO DAILY
2. Potassium Chloride 20 mEq PO DAILY
3. Spironolactone 25 mg PO DAILY
4. Metoprolol Tartrate 50 mg PO BID
Discharge Medications:
1. Lisinopril 20 mg PO DAILY
2. Aspirin EC 81 mg PO DAILY
3. Metoprolol Tartrate 50 mg PO BID
4. Potassium Chloride 20 mEq PO DAILY
Hold for K > 4
5. Spironolactone 25 mg PO DAILY
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
1. Right basal ganglia intraparenchymal hemorrhage
2. Dysphagia s/p PEG placement
3. Hypertension
4. E. faecalis UTI
Discharge Condition:
Mental Status: Confused - sometimes.
Level of Consciousness: Alert and interactive.
Activity Status: Out of Bed with assistance to chair or
wheelchair.
Followup Instructions:
___
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ with fall. Evaluate for acute thoracic process.
TECHNIQUE: Chest PA and lateral
COMPARISON: Chest x-ray ___, performed at an outside facility.
FINDINGS:
The heart size is normal. A right-sided Port-A-Cath terminates in the right
atrium. Mild bibasilar atelectasis. Otherwise, the lungs are clear. No
pleural effusion or pneumothorax. A deformity of the left seventh posterior
rib is likely chronic.
IMPRESSION:
Mild bibasilar atelectasis. No focal consolidations or pneumothorax.
Radiology Report
EXAMINATION: CTA HEAD AND CTA NECK Q16 CT NECK
INDICATION: History: ___ with right basal ganglia hemorrhagic stroke// avm,
aneurysm
TECHNIQUE: Contiguous MDCT axial images were obtained through the brain
without contrast material. Subsequently, helically acquired rapid axial
imaging was performed from the aortic arch through the brain during the
infusion of intravenous contrast material. Three-dimensional angiographic
volume rendered, curved reformatted and segmented images were generated on a
dedicated workstation. This report is based on interpretation of all of these
images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 10.0 s, 17.0 cm; CTDIvol = 48.8 mGy (Head) DLP =
829.0 mGy-cm.
2) Stationary Acquisition 0.5 s, 1.0 cm; CTDIvol = 3.7 mGy (Head) DLP = 3.7
mGy-cm.
3) Stationary Acquisition 5.5 s, 1.0 cm; CTDIvol = 41.1 mGy (Head) DLP =
41.1 mGy-cm.
4) Spiral Acquisition 9.8 s, 37.5 cm; CTDIvol = 37.9 mGy (Head) DLP =
1,361.1 mGy-cm.
Total DLP (Head) = 2,263 mGy-cm.
COMPARISON: CT head without contrast ___.
FINDINGS:
CT HEAD WITHOUT CONTRAST:
There has been a slight increase in the moderate amount of blood pooling
within the temporal and occipital horns of the right lateral ventricle with
the temporal horn being slightly expanded, as before. New trace amount of
blood is also present within the left lateral ventricle occipital horn.
Redemonstrated is intraparenchymal extension of blood just superior to the
right lateral ventricle temporal horn in the region of the basal ganglia where
there is mild surrounding vasogenic edema.
There is mild-to-moderate subcortical and periventricular white matter
hypoattenuation compatible with small vessel disease. Abutting the body of
the right caudate nucleus is a small old infarct (03:27).
The visualized portion of the paranasal sinuses, mastoid air cells, and middle
ear cavities are clear. The visualized portion of the orbits are unremarkable.
CTA HEAD:
There is evidence of a spot sign within the occipital the right lateral
ventricle (7:301). 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 are atherosclerotic calcifications of the intracranial vertebral
arteries as well as of the origin and mid right cervical vertebral artery.
The carotid and vertebral arteries and their major branches appear otherwise
normal with no evidence of stenosis or occlusion. There is no evidence of
internal carotid stenosis by NASCET criteria.
OTHER:
There is a 2 mm left upper lobe pulmonary nodule adjacent to the major fissure
(07:12). There are a couple bilateral thyroid nodules measuring up to 1.4 cm
in the left thyroid lobe. There are several prominent and enlarged nodes
involving nearly all cervical stations. Largest lymph node is present within
the right submandibular station measuring 1.2 x 2.6 cm in greatest axial
___.
IMPRESSION:
1. Slight increase in moderate amount of intraventricular blood described
above. Of note, on CTA there is evidence a potential spot sign in the region
of the right lateral ventricle occipital horn raising concern for potential
active bleeding.
2. Redemonstrated evidence of intraparenchymal extension blood just superior
to right lateral ventricle temporal horn in the region of the basal ganglia
where there is mild surrounding vasogenic edema.
3. Evidence of mild-to-moderate white matter small vessel disease.
4. Small old infarct abutting the body of the right caudate nucleus.
5. Extensive cervical lymphadenopathy likely correlates with the patient's
history of CLL.
6. A 2 mm left upper lobe pulmonary nodule for which no imaging follow-up is
recommended in low risk patients. High-risk patients may receive an optional
follow-up CT in 12 months per the ___ ___ criteria.
7. Couple thyroid nodules measuring up to 1.4 cm for which no follow-up
imaging is recommended.
RECOMMENDATION(S): Thyroid nodule. No follow up recommended.
Absent suspicious imaging features, unless there is additional clinical
concern, ___ College of Radiology guidelines do not recommend further
evaluation for incidental thyroid nodules less than 1.0 cm in patients under
age ___ or less than 1.5 cm in patients age ___ or older.
Suspicious findings include: Abnormal lymph nodes (those displaying
enlargement, calcification, cystic components and/or increased enhancement) or
invasion of local tissues by the thyroid nodule.
___, et al, "Managing Incidental Thyroid Nodules Detected on Imaging: White
Paper of the ACR Incidental Findings Committee". J ___ ___
12:143-150.
NOTIFICATION: The findings were discussed with ___, M.D. by ___
___, M.D. on the telephone on ___ at 12:32 pm, 10 minutes after
discovery of the findings.
Radiology Report
EXAMINATION: MR HEAD W AND W/O CONTRAST T___ MR HEAD
INDICATION: ___ year old man with intraventricular hemorrhage. Evaluate for
underlying mass.
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: CT head without contrast from ___.
CTA head and neck from ___.
FINDINGS:
No significant change in the parenchymal hematoma centered within the basal
ganglia and extending into the medial right temporal lobe, with stable
surrounding edema, compared to the earlier same-day CT. Extension of
hemorrhage into the temporal and occipital horns of the right lateral
ventricle, and occipital horn of left lateral ventricle, is stable. Temporal
horn of the right lateral ventricle remains compressed. The remainder of the
ventricular system is mildly prominent, unchanged, which may be due to global
parenchymal volume loss. There is commensurate mild prominence of the sulci.
The above described parenchymal hematoma demonstrates isointensity to minimal
hyperintensity on precontrast T1 weighted images. No postcontrast T1 weighted
images were performed due to technical air. Postcontrast MP RAGE images
demonstrate small foci of contrast enhancement within the lentiform nucleus as
well as medial temporal portions of the hematoma. Diffusion-weighted images
demonstrate patchy signal abnormality throughout the parenchymal hematoma,
which may in part be related to susceptibility artifact, without evidence for
slow diffusion outside the margins of the hematoma.
Extensive bilateral T2/FLAIR hyperintensities in the subcortical, deep, and
periventricular white matter of the cerebral hemispheres, as well as in the
bilateral pons, are nonspecific but likely sequela of chronic small vessel
ischemic disease in this age group. There are several chronic infarcts in the
right corona radiata, left frontal corona radiata and centrum semiovale, and
left pons.
2 mm rounded focus of relatively low signal (but not flow void) to the right
of the distal basilar artery flow void on image 8:7 is likely artifactual, as
no abnormality is seen on this location on the ___ CTA. The major
intracranial vascular flow voids are otherwise grossly preserved. Dural
venous sinuses appear patent on postcontrast MP RAGE images.
There is mild mucosal thickening of the ethmoid air cells and maxillary
sinuses.
IMPRESSION:
1. Stable hematoma in the right basal ganglia and medial temporal lobe with
stable surrounding edema and stable intraventricular extension.
2. Several small foci of contrast enhancement within the basal ganglia and
medial temporal lobe portions of the hematoma, without peripheral masslike
enhancement outside the margins of the hematoma, are of uncertain clinical
significance. Follow-up imaging is needed to exclude an underlying mass.
3. Extensive supratentorial white matter and pontine signal abnormalities,
nonspecific but likely sequela of small vessel disease. Small chronic
infarcts within bilateral corona radiata, left centrum semiovale, and left
pons.
RECOMMENDATION(S): Follow up MRI with and without contrast to assess for
resolution of contrast enhancement at the site of the right basal
ganglia/medial temporal lobe hematoma.
Radiology Report
EXAMINATION: CT HEAD W/O CONTRAST Q111 CT HEAD
INDICATION: ___ year old man with R BG IPH w/ ?spot sign// Assess for
progression of hemorrhage
TECHNIQUE: Contiguous axial images of the brain were obtained without
contrast.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 11.0 s, 18.7 cm; CTDIvol = 48.8 mGy (Head) DLP =
911.9 mGy-cm.
2) Sequenced Acquisition 3.0 s, 5.1 cm; CTDIvol = 48.8 mGy (Head) DLP =
248.7 mGy-cm.
Total DLP (Head) = 1,175 mGy-cm.
COMPARISON: CTA head and neck ___ at 17:45
FINDINGS:
There has been minimal discernible change with minimal redistribution in the
intraparenchymal hemorrhage in the region of right basal ganglia with
breakthrough in layering into the temporal and occipital horns of the right
lateral ventricle and occipital horn of the left lateral ventricle.
Surrounding vasogenic edema is also similar to prior. No discernible midline
shift. Basal cisterns remain patent.
There is unchanged hypodensity adjacent to the body of the right caudate
nucleus, likely prior lacune. Mild-to-moderate subcortical, periventricular,
and deep white matter hypodensities are similar to prior and likely represent
sequela of chronic microvascular ischemic disease.
There is no evidence of fracture. The visualized portion of the paranasal
sinuses, mastoid air cells, and middle ear cavities are clear. The visualized
portion of the orbits are unremarkable.
IMPRESSION:
Essentially unchanged intraparenchymal hemorrhage with only minimal
redistribution in the region of the right basal ganglia with breakthrough and
layering into the temporal and occipital horns of the right lateral ventricle
and occipital horn left lateral ventricle. Similar surrounding vasogenic
edema. No discernible midline shift. Basal cisterns remain patent.
Radiology Report
INDICATION: ___ year old man with new dobhoff// Eval tube location
TECHNIQUE: Portable frontal view of the chest/abdomen.
COMPARISON: Chest radiograph ___.
IMPRESSION:
There has been interval placement of a Dobhoff tube with the last image
demonstrating the tip in the proximal gastric body, satisfactory. Right-sided
port is unchanged, satisfactory. There is mild cardiomegaly and unfolding of
the thoracic aorta. Hilar contours are preserved. There is minimal bibasilar
atelectasis. The visualized lung fields are otherwise clear. There is no
large effusion or appreciable pneumothorax.
Radiology Report
INDICATION: ___ year old man with R BG IPH// Check NGT
TECHNIQUE: Frontal abdominal radiographs were obtained.
COMPARISON: None
FINDINGS:
The enteric tube tip projects over the left upper quadrant presumably within
the stomach.
The bowel gas pattern is unremarkable with gas seen in nondistended loops of
large and small bowel.
Partially visualized lower chest demonstrates no focal consolidation. The
bony structures are unremarkable.
IMPRESSION:
1. The enteric tube tip projects over the left upper quadrant presumably
within the stomach.
2. The right chest wall Port-A-Cath tip projects over the distal right atrium.
3. Nonspecific and nonobstructive bowel gas pattern.
Radiology Report
INDICATION: ___ year old man with R IPH, dysphagia// 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: 4 minutes and 51 seconds
COMPARISON: None
FINDINGS:
There is penetration with thin liquids and nectar thick liquids without
aspiration.
IMPRESSION:
Penetration with thin liquids and nectar thick liquids without aspiration.
Please note that a detailed description of dynamic swallowing as well as a
summative assessment and recommendations are reported separately in a
standalone note by the Speech-Language Pathologist (OMR, Notes, Rehabilitation
Services).
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: CVA, Transfer
Diagnosed with Traum hemor right cerebrum w/o loss of consciousness, init, Other fall on same level, initial encounter
temperature: 97.8
heartrate: 65.0
resprate: 16.0
o2sat: 100.0
sbp: 142.0
dbp: 73.0
level of pain: 0
level of acuity: 2.0 | ___ man with history notable for HTN, prior hypertensive
infarct, and CLL s/p ___ transferred from OSH after
presenting with left-sided weakness, found to have right basal
ganglia IPH on CT. Follow-up MRI did not demonstrate
microhemorrhages suggestive of underlying CAA as etiology of
hemorrhage, raising suspicion for hypertension (particularly in
light of persistent hypertension noted during the admission)
rather than trauma as the proximal cause of the IPH. Note was
made on MRI, however, of several small foci of contrast
enhancement within the basal ganglia and medial temporal lobe
portions of the hematoma potentially concerning for an
associated mass, for which repeat MRI with and without contrast
is recommended for further evaluation.
Subsequent course complicated by dysphagia s/p uncomplicated PEG
placement as well as E. faecalis UTI treated with a seven-day
course of ampicillin. HTN managed with captopril (transitioned
to lisinopril prior to discharge) as well as home metoprolol and
spironolactone. Chronic thrombocytopenia again noted during the
admission, with subcutaneous heparin held for platelet levels <
50,000.
TRANSITIONAL ISSUES
1. Ongoing blood pressure monitoring and titration of
antihypertensives.
2. Follow up MRI brain with and without contrast as above within
the next three months.
3. Ongoing speech therapy and assessment of swallow function.
4. Periodic monitoring of platelet counts.
5. Optional follow-up chest CT in 12 months for incidental
pulmonary nodule noted on CTA.
AHA/ASA Core Measures for Intracerebral Hemorrhage
1. Dysphagia screening before any PO intake? (X) Yes - () No
2. DVT Prophylaxis administered? (X) Yes - () No
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 (verbally or
written)? (X) Yes - () No
5. Assessment for rehabilitation and/or rehab services
considered? (X) Yes - () No |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
spironolactone / metoprolol
Attending: ___.
Chief Complaint:
dyspnea
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/PMHx COPD, dCHF/sCHF (EF ___ ___ CRT ___, presents
with shortness of breath x several days, much worse today. Said
at baseline, she is ually able to walk around the house and get
chores done all day without feeling short of breath. However,
today she had a very difficult time breathing.
She denies any recent illnesses, or associated fevers or cough.
Also denies any sick contact.
Of note, patient's lisinopril dose was increased from 5 to 10mg
a few months ago. Otherwise, no recent change in medications.
In the ED initial vitals were: 97.6 88 115/78 22 100% 15L. She
initially triggered for a desat into 70's.
- Labs were significant for K 5.5, creatinine 1.5, BNP 1765,
trop <.01.
- Patient was given albuterol, ipratropium and prednisone
Vitals prior to transfer were: 97.5 77 94/60 18 94% RA
On the floor, patient reports she pretty much feels back to her
baseline.
Past Medical History:
- CAD ___ NSTEMI ___ (60% RCA lesion)
- Severe non-ischemic dilated cardiomyopathy
- Chronic systolic (LVEF ___ and diastolic CHF
- LBBB with ventricular mechanical dys-synchrony
- 3+ Mitral Regurgitation
- COPD
- Hypertension
- Hypercholesterolemia
- ICD (epicardial lead implanted ___
Social History:
___
Family History:
DMII and HTN in multiple family members. No FH kidney disease,
cancer, stroke.
Physical Exam:
PHYSICAL EXAM ON ADMISSION:
===========================
Vitals - T:97.8 BP:129/68 HR:83 RR:18 02 sat:94RA
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs, PMI laterally
displaced. Device in good position with no surrounding erythema
LUNG: Inspiratory crackles throughout, most prominent at bases
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
PHYSICAL EXAM ON DISCHARGE:
==========================
Vitals: 97.4 94/61 69 18 95% on RA
I/O: ___
weight 66.8 kg
GENERAL: NAD
HEENT: AT/NC, EOMI, PERRL, anicteric sclera, pink conjunctiva,
patent nares, MMM, good dentition, nontender supple neck, no
LAD, no JVD
CARDIAC: RRR, S1/S2, no murmurs, gallops, or rubs, PMI laterally
displaced. Device in good position with no surrounding erythema
LUNG: Inspiratory crackles throughout, most prominent at bases
ABDOMEN: nondistended, +BS, nontender in all quadrants, no
rebound/guarding, no hepatosplenomegaly
EXTREMITIES: moving all extremities well, no cyanosis, clubbing
or edema
PULSES: 2+ DP pulses bilaterally
NEURO: CN II-XII intact
SKIN: warm and well perfused, no excoriations or lesions, no
rashes
Pertinent Results:
LABS ON ADMISSION:
=====================
___ 05:30AM GLUCOSE-247* UREA N-36* CREAT-1.6* SODIUM-139
POTASSIUM-4.8 CHLORIDE-93* TOTAL CO2-28 ANION GAP-23*
___ 05:30AM CALCIUM-10.3 PHOSPHATE-2.6* MAGNESIUM-2.3
___ 05:30AM WBC-5.6 RBC-4.41 HGB-13.1 HCT-38.6 MCV-88
MCH-29.6 MCHC-33.8 RDW-13.1
___ 05:30AM PLT COUNT-244
___ 11:30PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-6.0
LEUK-LG
___ 11:30PM URINE RBC-3* WBC-15* BACTERIA-FEW YEAST-NONE
EPI-4
___ 11:30PM URINE HYALINE-20*
___ 09:49PM ___ PO2-42* PCO2-58* PH-7.38 TOTAL
CO2-36* BASE XS-6
___ 09:49PM LACTATE-1.6
___ 09:49PM O2 SAT-73
___ 09:40PM GLUCOSE-166* UREA N-35* CREAT-1.5* SODIUM-133
POTASSIUM-5.5* CHLORIDE-92* TOTAL CO2-30 ANION GAP-17
___ 09:40PM cTropnT-<0.01
___ 09:40PM proBNP-1765*
___ 09:40PM WBC-7.8 RBC-4.87 HGB-14.1 HCT-41.7 MCV-86
MCH-28.9 MCHC-33.7 RDW-12.9
___ 09:40PM NEUTS-56.7 ___ MONOS-7.6 EOS-7.5*
BASOS-0.9
___ 09:40PM PLT COUNT-277
___ 09:40PM ___ PTT-28.4 ___
LABS ON DISCHARGE:
==================
___ 05:44AM BLOOD WBC-13.2* RBC-4.59 Hgb-13.5 Hct-39.4
MCV-86 MCH-29.4 MCHC-34.2 RDW-13.0 Plt ___
___ 05:44AM BLOOD Plt ___
___ 05:44AM BLOOD Glucose-84 UreaN-55* Creat-1.4* Na-135
K-3.4 Cl-92* HCO3-31 AnGap-15
___ 05:44AM BLOOD Calcium-9.7 Phos-3.6 Mg-2.3
PERTINENT LABS:
==============
NONE
MICROBIOLOGY:
=============
___ 10:25 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 10:00 am BLOOD CULTURE
Blood Culture, Routine (Pending):
__________________________________________________________
___ 1:10 am BLOOD CULTURE
Blood Culture, Routine (Preliminary):
PROBABLE MICROCOCCUS SPECIES.
Isolated from only one set in the previous five days.
Aerobic Bottle Gram Stain (Final ___:
GRAM POSITIVE COCCI IN CLUSTERS.
Reported to and read back by ___ (___) 4:35AM
___.
__________________________________________________________
___ 9:40 pm BLOOD CULTURE
Blood Culture, Routine (Pending):
STUDIES:
========
CXR ___:
As compared to the previous radiograph, no relevant change is
noted. The size of the cardiac silhouette has slightly
increased, caused by LS a inspiratory air Ford. There is no
evidence of pneumonia, pulmonary edema or pleural effusions. The
pacemaker leads are constant in position.
CXR ___:
Left chest wall pacer defibrillator has leads terminating in the
right atrium and right ventricle as well as epicardial leads on
the left
ventricle. The lungs are slightly hyperexpanded with flattening
of the
hemidiaphragms similar to the prior study. The heart is not
enlarged. The mediastinal and hilar contours are normal. There
is no pleural effusion or pneumothorax. There is no focal
airspace opacity to suggest pneumonia and no evidence of
pulmonary edema.
IMPRESSION: No acute cardiopulmonary abnormality. No evidence
of pneumonia or pulmonary edema.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
2. Carvedilol 25 mg PO BID
3. Colchicine 0.6 mg PO DAILY
4. Digoxin 0.125 mg PO EVERY OTHER DAY
5. Fluticasone Propionate 110mcg 2 PUFF IH BID
6. Lisinopril 10 mg PO DAILY
7. Pravastatin 80 mg PO DAILY
8. Torsemide 60 mg PO DAILY
9. Aspirin 81 mg PO DAILY
Discharge Medications:
1. Albuterol 0.083% Neb Soln 1 NEB IH Q6H:PRN shortness of
breath
2. Aspirin 81 mg PO DAILY
3. Carvedilol 25 mg PO BID
4. Colchicine 0.6 mg PO DAILY
5. Digoxin 0.125 mg PO EVERY OTHER DAY
6. Pravastatin 80 mg PO DAILY
7. Torsemide 60 mg PO DAILY
8. Fluticasone-Salmeterol Diskus (250/50) 1 INH IH BID
RX *fluticasone-salmeterol [Advair Diskus] 250 mcg-50 mcg/Dose
one puff inh twice a day Disp #*1 Disk Refills:*0
9. Fluticasone Propionate 110mcg 2 PUFF IH BID
10. PredniSONE 40 mg PO DAILY Duration: 1 Day
RX *prednisone 20 mg two tablet(s) by mouth daily Disp #*2
Tablet Refills:*0
11. Lisinopril 5 mg PO DAILY
RX *lisinopril 5 mg one tablet(s) by mouth daily Disp #*30
Tablet Refills:*0
12. Tiotropium Bromide 1 CAP IH DAILY
RX *tiotropium bromide [Spiriva with HandiHaler] 18 mcg one cap
inh daily Disp #*30 Capsule Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
ACUTE DIAGNOSES:
1. COPD exacerbation
2. CHF exacerbation
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 CHF and COPD exacerbation and new cough
// pneumonia, edema, effusion
COMPARISON: ___.
IMPRESSION:
As compared to the previous radiograph, no relevant change is noted. The size
of the cardiac silhouette has slightly increased, caused by LS a inspiratory
air Ford. There is no evidence of pneumonia, pulmonary edema or pleural
effusions. The pacemaker leads are constant in position.
Radiology Report
EXAMINATION: CHEST (PORTABLE AP)
INDICATION: ___ year old woman with severe constipation and dropping Hct //
NGT placement
COMPARISON: ___
IMPRESSION: FINDINGS:
As compared to the previous radiograph, the size of the cardiac silhouette has
minimally decreased and the lung volumes have minimally increased, likely
reflecting a stronger inspiratory effort Ford. There is no evidence of
pneumonia. No pulmonary edema. No pleural effusions. Unchanged course of the
pacemaker leads. On the current radiograph. There is no evidence for
nasogastric tube placement.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dyspnea, Hypoxia
Diagnosed with OBSTRUCTIVE CHR. BRONCHITIS,WITH ACUTE EXACERBATION
temperature: 97.6
heartrate: 88.0
resprate: 22.0
o2sat: 100.0
sbp: 115.0
dbp: 78.0
level of pain: 0
level of acuity: 2.0 | ___ w/PMHx COPD, dCHF/sCHF (EF ___ ___ CRT ___, presents
with shortness of breath x several days consistent with COPD
___ CHF exacerbation.
#COPD Exacerbation: Precipitating factor unclear but most likely
cardiac given report of palpitation by pt and crackles on exam.
Infectious cause less likely as no systemic systems such as
fever, cold symptoms, or CXR findings. Pt was treated with
prednisone 40mg x5 days, last dose ___, in addition to nebulizer
treatments. Advair and tiotropium were added to her home
regimen.
#Palpitations: Pt reported palpitations x1 month, raising
concern for ICD malfunction. She has been self dosing carvedilol
for such symptoms. EP was consulted for device interrogation.
Her Device battery is at RRT (recommended replacement time).
However, pt expressed reluctance in replacing the battery. She
has an appointment with Dr. ___ on ___ and this will be
discussed further during that visit.
#Systolic (EF 15%) and Diastolic CHF ___ CRT: Pt presented with
worsening dyspnea and dry cough. She has been self dosing
torsemide at home. She reports non-compliance with her diet and
Na use x1 month. Exam was notable for crackles in the lungs but
no JVD or peripheral edema. Diuresis regimen included additional
torsemide doses (___), lasix 60mg IV, and metolazone 2.5mg.
-Continue home beta blocker, digoxin
- torsemide dose may be adjusted as appropriate in discretion of
PCP ___ cardiologist |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: UROLOGY
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
ABDOMINAL PAIN
Major Surgical or Invasive Procedure:
1. Cystoscopy.
2. Left ureteroscopy.
3. Left ureteral stent placement.
4. Basket extraction of stone
History of Present Illness:
___ yo F with CAD, asthma, metastatic colon cancer undergoing
chemotherapy, who presented to the ED with abdominal pain 2 days
prior and was found to have a 2 mm UVJ stone on CT scan. Pain
was controlled and she was discharged with pain medications and
flomax. She presented to the ED today with cough and weakness.
CXR was negative for pneumonia. She was afebrile and
hemodynamically stable, without leukocytosis or evidence of ___,
dirty UA. In this setting urology was consulted and the patient
was admitted for observation in the ED for IVF and pain control.
Additionally, she recieved IV ceftriaxone in the ED.
When the patient was seen, her pain was much improved ___
located in her left flank, radiating to left groin. Little
nausea, but feeling hungry. No vomiting. She denied
f/c/n/v/hematuria, urgency, frequency, and dysuria. She denies
passing any stones overnight.
Past Medical History:
PMH:
Metastatic colon cancer
CAD s/p Stent ___
HTN
Asthma
PSH:
Ex lap, right colectomy, LOA, umbilical hernia repair ___
Chole
Hysteroscopy with diagnostic D&C
Port placement
ONCOLOGIC HISTORY:
-___: Fe-deficiency anemia. Colonoscopy revealed a partially
obstructing and bleeding 5-cm mass, biopsied adenocarcinoma.
-___: Right hemicolectomy and hernia repair. Pathology T3,
N1, M0 stage III with 1 out of 18 lymph nodes positive.
-___: Completed 12 cycles FOLFOX adjuvant chemotherapy.
-___: Rising CEA to 5.8. CT showed interval development of
bilateral pulmonary nodules, an ill-defined focus of increased
enhancement involving segment VI of liver, increase in size of
nodal mass at the base of the mesentery, and interval
development of paraaortic-retroperitoneal adenopathy.
___: Retroperitoneal node biopsy confirmed metastatic colon.
___: FOLFOX started.
___: Leucovorin and bolus infusional ___ were dose reduced
by 25% with cycle 2 Day 15.
___: CT showed interval decrease in size and number of
bilateral pulmonary nodules, mesenteric and nodal mass and
retroperitoneal lymphadenopathy.
___: Oxaliplatin was discontinued from FOLFOX with cycle 9
due to neuropathy.
___: CT showed progression of disease and she was begun on
Irinotecan.
.
OTHER PMHx:
CAD, s/p MI and stent ___.
HTN
Hyperlipidemia
Asthma
Cesarean section
Cholecystectomy
Social History:
___
Family History:
Brother died of MI at ___. No other FHx of CAD or sudden death.
Denies family history of kidney stones, bladder/kidney cancer.
Physical Exam:
WDWN female, NAD, AVSS
Abdomen soft, nt/nd
___ speaking, pleasant, cooperative
No lower extremity pitting/edema
Pertinent Results:
___ 6:36 pm URINE Site: NOT SPECIFIED
ADDED TO HOLD ___.
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 8:30 am URINE
**FINAL REPORT ___
URINE CULTURE (Final ___:
MIXED BACTERIAL FLORA ( >= 3 COLONY TYPES), CONSISTENT
WITH SKIN
AND/OR GENITAL CONTAMINATION.
___ 06:00AM BLOOD WBC-4.6 RBC-3.90* Hgb-10.3* Hct-31.5*
MCV-81* MCH-26.3* MCHC-32.6 RDW-16.3* Plt ___
___ 04:55PM BLOOD WBC-5.0 RBC-3.93* Hgb-10.6* Hct-33.5*
MCV-85 MCH-26.9* MCHC-31.6 RDW-15.4 Plt ___
___ 05:30AM BLOOD WBC-6.3 RBC-3.91* Hgb-10.8* Hct-33.3*
MCV-85 MCH-27.5 MCHC-32.3 RDW-15.6* Plt ___
___ 04:55PM BLOOD Neuts-43.4* Lymphs-44.1* Monos-5.6
Eos-6.5* Baso-0.5
___ 05:30AM BLOOD Neuts-40.7* Lymphs-46.8* Monos-6.3
Eos-5.7* Baso-0.7
___ 06:00AM BLOOD Glucose-147* UreaN-7 Creat-0.6 Na-142
K-3.9 Cl-108 HCO3-28 AnGap-10
___ 04:55PM BLOOD Glucose-95 UreaN-8 Creat-0.5 Na-143 K-3.5
Cl-108 HCO3-30 AnGap-9
___ 05:30AM BLOOD Glucose-126* UreaN-12 Creat-0.7 Na-141
K-3.6 Cl-108 HCO3-24 AnGap-13
___ 05:43AM BLOOD Lactate-1.0
Medications on Admission:
benzonatate 100 mg capsule (One) Capsule(s) by mouth three
times a day as needed for cough
codeine-guaifenesin 100 mg-10 mg/5 mL Liquid
5 ml(s) by mouth three times a day as needed for cough
diphenoxylate-atropine 2.5 mg-0.025 mg tablet
1 (One) Tablet(s) by mouth every four (4) to six (6) hours as
needed for chemotherapy related diarrhea ICD: 153.9 (colon
cancer)
fluticasone 50 mcg Spray, Suspension puffs in each nostril
daily fluticasone [Flovent Diskus] 250 mcg Disk with Device
puff inhaler twice daily
metoprolol succinate 50 mg Tablet Sustained Release 24 hr
1 Tablet(s) by mouth twice a day
montelukast 10 mg Tablet Tablet(s) by mouth once daily
naproxen 375 mg tablet tablet(s) by mouth Twice a day
omeprazole 20 mg capsule,delayed ___ Capsule(s) by
mouth once daily
oxycodone 5 mg tablet Tablet(s) by mouth every 6 hours as
needed for pain
prochlorperazine maleate 10 mg Tablet
1 (One) Tablet(s) by mouth every six (6) hours as needed for
nausea
salmeterol [Serevent Diskus] 50 mcg Disk with Device puff
inhaler twice daily
valsartan [Diovan] 160 mg tablet (One) Tablet(s) by mouth
daily
zopidem 5 mg tab (One) Tab by mouth at bedtime as needed for
insomnia
aspirin 81 mg Tablet, Delayed Release (E.C.)1 Tablet(s) by
mouth once daily
loperamide [Anti-Diarrhea] 2 mg tablet -2 tablet(s) by mouth
PRN diarrhea
loratadine 10 mg Tablet (One) Tablet(s) by mouth once a day
magnesium oxide-Mg AA chelate [Mg-Plus-Protein] 133 mg tablet
3 (Three) Tablet(s) by mouth three times a day Take with meals
acetaminophen [Tylenol]
albuterol sulfate [ProAir HFA] 90 mcg HFA Aerosol Inhaler puff
QID prn Camptosar * patient unable to identify actual drug
name *
taken every ___ as directed
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain or fever
2. Benzonatate 100 mg PO TID:PRN cough
3. Diphenoxylate-Atropine 1 TAB PO Q6H:PRN diarrhea
for chemotherapy related diarrhea
4. Docusate Sodium 100 mg PO BID
5. Fluticasone Propionate NASAL 1 SPRY NU DAILY
6. Guaifenesin-CODEINE Phosphate 5 mL PO Q8H:PRN cough
7. Metoprolol Succinate XL 50 mg PO DAILY
8. Montelukast Sodium 10 mg PO DAILY
9. Omeprazole 20 mg PO DAILY
10. Salmeterol Xinafoate Diskus (50 mcg) 1 INH IH Q12H
11. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain greater
than 4
12. Valsartan 160 mg PO DAILY
13. Zolpidem Tartrate 5 mg PO HS insomnia
14. Aspirin 81 mg PO DAILY
Resume when the ureteral stent is removed or your are advised
by your PCP/Urologist
15. Prochlorperazine 10 mg PO Q6H:PRN nausea
16. Naproxen 375 mg PO Q12H:PRN pain
17. Loratadine *NF* 10 mg Oral DAILY ALLERGIC RHINITIS
18. CAMPTOSAR
Resume this medication as directed.
19. RETURN TO WORK NOTE
You may return to work without restrictions effective ___.
Please excuse her absence from work since ___.
20. F/U APPT WORK NOTICE
Ms. ___ will return to clinic during the week of ___ for
her post-hospitalization follow-up appointment. Date is to be
determined. Please excuse her absence from work.
21. Loperamide 2 mg PO QID:PRN diarrhea
22. magnesium oxide-Mg AA chelate *NF* 399 mg Oral TID
Three 133mg tablets (399mg total)taken three times per day.
23. Cephalexin 500 mg PO Q6H Duration: 5 Days
Discharge Disposition:
Home
Discharge Diagnosis:
Left 2 mm ureterovesical junction stone.
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Cough.
TECHNIQUE: PA and lateral views of the chest.
COMPARISON: Chest radiograph ___ and CT torso ___.
FINDINGS:
Left-sided Port-A-Cath tip terminates within the proximal right atrium,
unchanged. Lung volumes are low. Mild enlargement of cardiac silhouette is
unchanged. The aorta remains mildly tortuous. There is crowding of the
bronchovascular structures, but no overt pulmonary edema is visualized. Known
nodules within both lower lobes are better depicted on the prior CT. There is
minimal streaky atelectasis in both lung bases. No focal consolidation,
pleural effusion or pneumothorax is present. Cholecystectomy clips are
demonstrated in the right upper quadrant of the abdomen. There are no acute
osseous abnormalities.
IMPRESSION:
Mild bibasilar atelectasis. Known bilateral lower lobe pulmonary nodules are
better depicted on the prior CT.
Radiology Report
INDICATION: History of a 2-mm left ureterovesicular stone. Left-sided stent
placement.
COMPARISON: CT abdomen and pelvis from ___.
FINDINGS: Five spot fluoroscopic images were obtained without a radiologist
present. Images demonstrate the passage of a wire through the left ureter, and
a subsequent successful placement of a left-sided stent. Please refer to the
intraoperative report for further details.
Gender: F
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by WALK IN
Chief complaint: ?PNEUMONIA
Diagnosed with CALCULUS OF KIDNEY
temperature: 98.4
heartrate: 85.0
resprate: 20.0
o2sat: 98.0
sbp: 130.0
dbp: 73.0
level of pain: 10
level of acuity: 3.0 | Ms. ___ was admitted to Urology service after ED observation
and in anticipation of going to the OR for surgical intervention
for her uteral stone. She was taken from the ED to the
preoperative holding area and subsequently to the cystoscopy
suite after consent obtained with ___ interpreter. No
concerning intraoperative events occurred; please see dictated
operative note for details.
The patient received perioperative antibiotic prophylaxis. The
patient was transferred to the floor from the PACU in stable
condition. On POD0, pain was well controlled post-operatively
and she was provided with pneumoboots and incentive spirometry
for prophylaxis and home medications were resumed. On POD1, the
patient ambulated, basic metabolic panel and complete blood
count were checked and heart healthy diet was advanced as
tolerated. The remainder of the hospital course was relatively
unremarkable. The patient was discharged in stable condition,
eating well, ambulating independently, voiding without
difficulty, and
with pain control on oral analgesics. The patient was given
explicit instructions to follow-up in clinic in approximately
one week for ureteral stent removal. Urine cultures at time of
discharge were negative but with mixed flora suggestive of
contamination. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Lisinopril / Ertapenem / diltiazem / iv contrast
Attending: ___.
Chief Complaint:
chest pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
___ with medical history of CAD ___ RCA stent ___, HFpEF ___
porcine MVR (___), anti-cardiolipin antibody and paroxysmal
atrial fibrillation ___ MAZE and PVI on warfarin and flecainide,
mild aortic stenosis, broncho-alveolar carcinoma, seizures, CKD,
and prior stroke, who presents with substernal chest pain
radiating to the left that woke her up from sleep.
Patient states she woke up at 3AM with chest discomfort. SSCP
radiating to left shoulder. Mild nausea and diaphoresis. Pain
worsened over the night prompting presentation to ED. No
palpitations, cough or SOB. Chest pain was exertional and
associated with lightheadedness with walking. She reports that
she thinks she has had similar chest pain before. No recent
fevers, chills. Endorses ___ numbness.
Of note, Had a stroke years ago, has short term memory loss. Has
been in intermittent atrial fibrillation since MVR/Maze.
Followed by ___ but transitioning to Dr. ___.
ED COURSE
In the ED intial vitals were: 97.6 126 141/85 16 98% RA. She was
noted to be in AF with RVR.
EKG: atrial fibrillation, without ischemic changes.
Labs/studies notable for: H/H 9.1/___, platelets 131. Chemistries
notable for BUN 61, Cr 2.5, (last Cr 2.5 in ___. INR 1.7, Trop
<0.01 x2.
Patient was given: ASA and morphine immediately. She then
converted to NSR with improvement in symptoms. Pain decreased to
a five.
Vitals on transfer: 98.4 71 101/54 17 96% RA.
On the floor... she denies chest pain, dyspnea,
lightheadedness, dizziness. Endorses feeling lightheaded and
short of breath during exercise stress test which was aborted
due to hypotension/ tachyarrythmia and possible ECG changes.
Past Medical History:
1. CAD RISK FACTORS: +hypertension, +dyslipidemia, -diabetes
2. CARDIAC HISTORY:
- CABG: None
- PERCUTANEOUS CORONARY INTERVENTIONS: CAD ___ RCA stent (___)
___ angina, but no occlusions on cath
- PACING/ICD: None
3. OTHER PAST MEDICAL HISTORY:
- Atrial fibrillation on warfarin, ___ cardioversion and
unsuccessful ablation ___, now in NSR on flecainide
- mitral stenosis / mitral regurgitation, ___ porcine valve ___
years ago
- HTN
- HFpEF
- + anti-cardiolipin antibody with prior DVT on lifelong
warfarin goal INR 2.5-3.5
- hyperlipidemia
- CKD
- CVA ___: R facial droop/speech arrest, followed by a TIA
- seizure disorder (temporal lobe; confusional episodes, stable
on keppra)
- asbestos exposure
- bronchoalveolar carcinoma ___ Right VATS/RLL wedge resection
on ___ with clean margins (has stable recurrence on follow-up
imaging)
- anemia
- alopecia
- gout
- vein ligation and stripping x 2
Social History:
___
Family History:
Mother with CAD, type 2 DM. Father with CAD.
Physical Exam:
======================
ADMISSION PHYSICAL EXAM
======================
VS: 98.2 161/77 71 18 97%RA
GENERAL: WDWN sitting up in bed in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple with JVP of 8 cm.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. ___ systolic murmur best heard at ___.
No thrills, lifts.
LUNGS: No chest wall deformities, scoliosis or kyphosis. Resp
were unlabored, no accessory muscle use. Mild bibasilar crackles
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e. No femoral bruits.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
.
.
======================
DISCHARGE PHYSICAL EXAM
======================
Weight on admission: 63.1kg
Weight on discharge: 62.0kg
Vitals: 97.7, 102/65, 64, 16, 100% RA
Tele: Sinus, First degree AV block (PR prolongation not new). No
alarms
I/O's not recorded
GENERAL: WDWN sitting up in bed in NAD. Oriented x3. Mood,
affect appropriate.
HEENT: NCAT. Sclera anicteric. PERRL, EOMI. Conjunctiva were
pink, no pallor or cyanosis of the oral mucosa. No xanthelasma.
NECK: Supple.
CARDIAC: PMI located in ___ intercostal space, midclavicular
line. RR, normal S1, S2. ___ systolic murmur best heard at ___.
No thrills, lifts.
LUNGS: CTAB no w/r/r
ABDOMEN: Soft, NTND. No HSM or tenderness.
EXTREMITIES: No c/c/e.
SKIN: No stasis dermatitis, ulcers, scars, or xanthomas.
PULSES: Distal pulses palpable and symmetric
Pertinent Results:
ADMISSION LABS:
==============
___ 06:05AM BLOOD WBC-6.0 RBC-2.98* Hgb-9.1* Hct-28.0*
MCV-94 MCH-30.5 MCHC-32.5 RDW-15.6* RDWSD-53.1* Plt ___
___ 06:05AM BLOOD Neuts-73.7* Lymphs-14.7* Monos-9.3
Eos-1.5 Baso-0.5 Im ___ AbsNeut-4.41 AbsLymp-0.88*
AbsMono-0.56 AbsEos-0.09 AbsBaso-0.03
___ 06:05AM BLOOD ___ PTT-43.2* ___
___ 06:05AM BLOOD Glucose-110* UreaN-61* Creat-2.5* Na-138
K-3.9 Cl-102 HCO3-23 AnGap-17
___ 12:07PM BLOOD cTropnT-<0.01
___ 06:05AM BLOOD cTropnT-<0.01
IMAGING/STUDIES:
=================
CXR ___
1. No definite acute cardiopulmonary process.
2. Grossly stable bibasilar interstitial markings and calcified
pleural plaques.
ETT ___
___ yo woman with HL and HTN, h/o CAD and ___ stent
of RCA in ___, HFpEF, h/o atrial tachycardia, flutter and
fibrillation ___ MAZE in ___, PVI and CTI ablation in ___ and
now on flecainide was referred to evaluate an atypical chest
discomfort after presenting to the ED in PAT/PAF at ~ 125 bpm.
The patient completed 7 minutes of a Gervino protocol
representing a fair exercise tolerance; ~ ___ METS.
Although the patient was near fatigue, the exercise test was
stopped due to increasing atrial irritability accompanied with
shortness of breath. The patient denied any chest, back, neck or
arm discomforts during the procedure. No lightheadedness or
palpitations were reported. While in the atrial tachycardia,
0.5-1 mm horizontal ST segment depression was noted in leads I,
inferiorly and in V6. In addition, 0.5-1 mm ST segment elevation
was noted in aVR. At 13 minutes of recovery, and following the
administration of 2.5 mg Lopressor IV, sinus rhythm was noted
with resolution of ST segment changes. The rhythm was sinus with
frequent nonsustained runs of PAT noted in exercise and
throughout recovery; rates ~ 115-120 bpm. Rare isolated VPBs.
The blood pressure response to exercise was flat.
IMPRESSION: Test stopped due to increasing atrial irritability
accompanied by increasing shortness of breath. ST segment
changes noted in the setting of the tachyarrhythmia; see above.
Blunted blood pressure response to exercise. Fair exercise
tolerance.
Nuclear Perfusion ___:
Normal myocardial perfusion study. No significant change from
myocardial perfusion study ___.
Stress ___:
IMPRESSION: Frequent atrial irritability with frequent
nonsustained
runs of PAT noted at rest and throughout the procedure; similar
rhythm noted on floor. No anginal symptoms or ischemic ST
segment changes. Appropriate hemodynamic response to the
Persantine infusion. Nuclear report sent separately.
Medications on Admission:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 325 mg PO DAILY
3. Flecainide Acetate 50 mg PO Q12H
4. LeVETiracetam 750 mg PO BID
5. Metoprolol Succinate XL 12.5 mg PO DAILY
6. Rosuvastatin Calcium 40 mg PO QPM
7. Warfarin 5 mg PO DAILY16
8. Calcium Carbonate 500 mg PO DAILY
9. Furosemide 40 mg PO DAILY
Discharge Medications:
1. Allopurinol ___ mg PO DAILY
2. Aspirin 81 mg PO DAILY
3. Calcium Carbonate 500 mg PO DAILY
4. Furosemide 40 mg PO DAILY
5. LeVETiracetam 750 mg PO BID
6. Metoprolol Succinate XL 12.5 mg PO DAILY
7. Rosuvastatin Calcium 40 mg PO QPM
8. Acetaminophen ___ mg PO Q6H:PRN pain/fever
9. Amiodarone 200 mg PO BID
RX *amiodarone 200 mg 1 tablet(s) by mouth twice a day Disp #*60
Tablet Refills:*3
10. Warfarin 7.5 mg PO DAILY16
Discharge Disposition:
Home
Discharge Diagnosis:
Primary:
Unstable angina
Anticardiolipin antibody syndrome
Secondary:
Paroxysmal atrial fibrillation
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ female with chest pain, evaluate for widened
mediastinum or pneumothorax.
TECHNIQUE: Single upright AP chest radiograph
COMPARISON: Prior chest radiographs dated ___ and chest CT dated
___. .
FINDINGS:
Bilateral calcified pleural plaques are unchanged compared with multiple prior
studies. Bibasilar interstitial markings are also unchanged or slightly
decreased consistent with chronic interstitial lung disease. There is no
pleural effusion, pneumothorax, or focal consolidation. The cardiomediastinal
silhouette is stable. Chain sutures in the right mid lung are related to
prior right lower lobe wedge resection.
IMPRESSION:
1. No definite acute cardiopulmonary process.
2. Grossly stable bibasilar interstitial markings and calcified pleural
plaques.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Chest pain, Nausea, L Shoulder pain
Diagnosed with Other chest pain
temperature: 97.6
heartrate: 126.0
resprate: 16.0
o2sat: 98.0
sbp: 141.0
dbp: 85.0
level of pain: 6
level of acuity: 2.0 | ___ with CAD, HFpEF, pAF on Coumadin for anti-cardiolipin (INR
goal 2.5-3.5), MR ___ porcine valve replacement ___, known
multifocal lung adenocarcinoma, seizure disorder, gout who
presents with chest pressure/dyspnea at rest and aborted stress
test due to atrial irritability and dyspnea. She underwent
persantine MIBI test inpatient which showed no perfusion
defects.
While awaiting P-MIBI she was maintained on heparin gtt given
anti-phospholipid syndrome and prior stroke. After perfusion
study complete and determined no plan for cardiac
catheterization she was restarted on coumadin. She was kept
inpatient while her Coumadin was restarted on heparin bridge
given her anticardiolipid syndrome with prior TIA. She was not a
candidate for lovenox bridge given her renal function. She is
being discharged on a dose of 7.5mg daily with plan for INR
check ___
Electrophysiology saw her regarding her paroxysmal atrial
fibrillation and her antiarrhythmic plan. Flecainide carries a
mortality risk in patients with CAD and therefore she was
transitioned to amiodarone. Her baseline TSH/FT4 were normal
(4.9/1.1). LFTs normal.
She is being discharged with ___ of hearts monitor for
further characterization of her paroxysmal afib versus other
arrhythmias.
# Orthostatic hypotension
- positive orthostats; pt states this is chronic
- consider this problem prior to starting nitrates
- fall precautions
# Hyperlipidemia- She was continued on rosuvastatin 40mg qHS
# Gout- She was continued on allopurinol ___ daily
# Seizures- she was continued on home Keppra 750mg BID
# Anti-cardiolipin antibody
-INR goal 2.5-3.5 with Coumadin as per above
-bridge heparin gtt as per above
# Lung adenocarcinoma
-stable, undergoing outpatient 6 month surveillance
======================
TRANSITIONAL ISSUES
======================
-STOPPED flecainide
-STARTED amiodarone 200mg BID
-DECREASED aspirin to 81mg daily (to reduce risk of bleeding)
-NEEDS TO F/U with primary care doctor and cardiology as
scheduled
-DISCHARGED WITH ___ cardiac monitoring for 30 days
-discharge weight: 62kgs
-full code
-HCP: ___ (husband) ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
SOB and chest pain
Major Surgical or Invasive Procedure:
none
History of Present Illness:
Mr. ___ is a ___ yo M with recently diagnosed neuroendocrine
tumor of the lung, stage IV with mets to skin and brain who is
admitted with increasing shortness of breath and chest pain.
Describes the chest pain as a constant dull ache in his chest
since last night at 10 pm. He took his morphine ___ at home
which relieved the pain enough for him to sleep but it recurred
this am so he called the ambulance. He says that the pain is
not worse with activity or eating, although he has not been
having much of an appetite and has lost weight. He does have
paroxsymal nocturnal dyspnea and orthopnea. His EKG shows
diffuse ST elevations, not in a vascular territory and his
troponins are negative x 1.
In the ED, his blood pressure was in the ___ systolic and they
performed a CTA chest to eval for PE. There was no PE, no
evidence of pneumonia, but progression of the cancer with
encasement of pulmonary arteries, pulmonary veins, SVC, and left
atrium. He had started chemo ___ with carboplatin/etoposide
every 3 weeks and the oncology team does not think there is
anything else to do for him since he already got the chemo. He
was scheduled to get XRT to his whole brain for mets, but this
has not happened yet.
On arrival to the MICU, he is uncomfortable but saturating well.
Past Medical History:
Past Medical History:
- metastatic neuroendocrine tumor of lung, stage IV, metastatic
to brain and skin, started chemo ___
- alcoholic hepatitis with admission ___ with intoxication
- anemia
- GI bleed, gastritis, most recent endoscopy in ___
- HLD
- right tibial ORIF ___
- chronic bilateral leg pain s/p accident and surgeries in ___
- multiple falls
- depression
Oncologic history:
- ___: CXR with mediastinal LAD when admitted with alcohol
intoxication.
- ___: new liver lesions on RUQ ultrasound.
- ___: admitted for tender head and neck nodes which
initially appeared in early ___ on the chin, then
submandibular and pre-auricular bilaterally with large one of
anterior neck. He had night sweats and a 45 lb weight loss in
___. In mid ___, developed severe headaches and falls. LP
this admission with negative cytology. Chest CT showed massive
mediastinal LAD with 17cm RLL lung mass and LUL pulmonary
nodules. Neck CT identified multiple subcutaneous nodules with
central necrosis and large nodule abutting right jugular vein
and
invading neighboring structures. Brain MRI with 1cm lesion from
falx and 7mm cerebellar lesion.
- ___: right cervical lymph node biopsy with metastatic
large
cell neuroendocrine carcinoma c/w lung primary.
- ___: Initiated treatment w ___
Social History:
___
Family History:
no h/o cancer, mother and father passed away with DM
Physical Exam:
Vitals: T: 97.9, BP: 114/57, P: 80, R: 18, O2: 100% 2LNC
General: Alert, oriented, no acute distress
HEENT: Sclera anicteric, MMM, oropharynx clear, EOMI, PERRL,
vascular mass on the left jaw bone
Neck: supple, JVP not elevated
CV: Regular rate and rhythm, normal S1 + S2, no murmurs, rubs,
gallops
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
Abdomen: soft, non-tender, non-distended, bowel sounds present,
no organomegaly
GU: no foley
Ext: cachectic, warm, well perfused, 2+ pulses, no clubbing,
cyanosis or edema
Neuro: CNII-XII intact, ___ strength in all extremities, grossly
normal sensation, gait deferred, finger-to-nose intact
Pertinent Results:
Admission labs:
___ 05:33AM BLOOD WBC-9.7 RBC-3.26* Hgb-10.2* Hct-30.6*
MCV-94 MCH-31.2 MCHC-33.2 RDW-13.5 Plt ___
___ 05:33AM BLOOD Glucose-119* UreaN-12 Creat-0.4* Na-130*
K-4.3 Cl-97 HCO3-22 AnGap-15
___ 05:33AM BLOOD ___ BCx x 2 - pending
Imaging:
CXR ___
Right lower lobe opacity is likely a combination of tumor
infiltration, atelectasis, and infection cannot be rule out.
This area will be further evaluated on the subsequent CT
angiogram.
CTA Chest ___:
1. No evidence of pulmonary embolism or acute aortic syndrome.
2. Large infiltrative right hilar lung mass with extension into
the
mediastinum, much progressed from the prior study.
3. The mass causes compression of the right pulmonary artery,
obliteration of the right pulmonary veins, narrowing of the
right mainstem and lobar bronchial branches, and likely
endobronchial invasion at these locations.
4. Diffuse infiltration of the right lower lobe with probable
malignant
effusion.
5. Extensive mediastinal and bilateral axillary lymph node
metastases.
6. Lytic metastases of the right fifth and sixth anterior ribs.
DISCHARGE LABS
___ 01:34AM BLOOD WBC-6.8 RBC-3.25* Hgb-10.2* Hct-30.4*
MCV-94 MCH-31.5 MCHC-33.7 RDW-13.6 Plt ___
___ 03:33PM BLOOD Glucose-97 UreaN-10 Creat-0.4* Na-129*
K-3.5 Cl-100 HCO3-21* AnGap-12
___ 01:34AM BLOOD CK-MB-22* MB Indx-25.9* cTropnT-<0.01
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. Multivitamins 1 TAB PO DAILY
2. Pantoprazole 40 mg PO Q12H
3. traZODONE 25 mg PO HS:PRN insomnia
4. BusPIRone 20 mg PO BID
5. Citalopram 20 mg PO DAILY
6. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
7. Acetaminophen 1000 mg PO BID
8. Guaifenesin-CODEINE Phosphate ___ mL PO HS:PRN cough
9. Morphine Sulfate ___ 15 mg PO Q4H:PRN pain
10. Ondansetron 8 mg PO Q8H:PRN nausea
11. Prochlorperazine ___ mg PO Q6H:PRN nausea
Discharge Medications:
1. Acetaminophen 1000 mg PO Q8H pain
2. BusPIRone 20 mg PO BID
RX *buspirone 10 mg 2 tablet(s) by mouth twice a day Disp #*28
Tablet Refills:*0
3. Citalopram 20 mg PO DAILY
RX *citalopram 20 mg 1 tablet(s) by mouth daily Disp #*30 Tablet
Refills:*0
4. Morphine Sulfate ___ 7.5 to 15 mg PO Q2H:PRN Pain, Dyspnea
RX *morphine 15 mg ___ tablet(s) by mouth q2h:PRN Disp #*84
Tablet Refills:*0
5. Ondansetron 8 mg PO Q8H:PRN nausea
RX *ondansetron 8 mg 1 tablet(s) by mouth q8h:PRN Disp #*21
Tablet Refills:*0
6. Pantoprazole 40 mg PO Q12H
RX *pantoprazole 40 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*14 Tablet Refills:*0
7. traZODONE 25 mg PO HS:PRN insomnia
RX *trazodone 50 mg 0.5 (One half) tablet(s) by mouth qHS:PRN
Disp #*14 Tablet Refills:*0
8. Guaifenesin ___ mL PO Q6H:PRN cough
RX *guaifenesin 100 mg/5 mL ___ mL by mouth q6h:PRN Disp #*1
Unit Refills:*0
9. Multivitamins 1 TAB PO DAILY
10. Bisacodyl 10 mg PO/PR DAILY:PRN constipation
11. Prochlorperazine ___ mg PO Q6H:PRN nausea
RX *prochlorperazine maleate 5 mg ___ tablet(s) by mouth q6h:
PRN Disp #*28 Tablet Refills:*0
12. Nicotine Patch 21 mg TD DAILY
13. Morphine SR (MS ___ 15 mg PO Q12H
RX *morphine 15 mg 1 tablet(s) by mouth every twelve (12) hours
Disp #*14 Tablet Refills:*0
14. Filgrastim 300 mcg SC Q24H Duration: 5 Days
15. Lorazepam 0.5 mg PO Q4H:PRN anxiety
RX *lorazepam 0.5 mg 1 tablet(s) by mouth q4h:PRN Disp #*42
Tablet Refills:*0
16. Guaifenesin-CODEINE Phosphate ___ mL PO HS:PRN cough
RX *codeine-guaifenesin 100 mg-10 mg/5 mL ___ mL by mouth
qHS:PRN Disp #*1 Unit Refills:*0
Discharge Disposition:
Home With Service
Facility:
___
Discharge Diagnosis:
metastatic large cell neuroendocrine carcinoma of the lung
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: ___ man with a history of lung cancer presenting with chest
pain.
COMPARISONS: Comparison is made with a chest radiograph dated ___,
for ___, medical record number ___, clip number ___.
FINDINGS: There is a hazy, heterogeneous opacity in the right lower lobe
which may represent infection, tumor infiltration, atelectasis, or a
combination of all three. Widening of the mediastinum is caused by the
patient's known malignancy. The left lung and upper right lung are mostly
clear. There is no pneumothorax. A right pleural effusion is undoubtedly
present.
IMPRESSION: Right lower lobe opacity is likely a combination of tumor
infiltration, atelectasis, and infection cannot be rule out. This area will
be further evaluated on the subsequent CT angiogram.
Radiology Report
HISTORY: ___ man with lung cancer presenting with chest pain and
shortness of breath. Evaluate for pulmonary embolism.
COMPARISONS: Chest CT from ___.
TECHNIQUE: MDCT-acquired axial images of the chest were obtained in the early
arterial phase during rapid injection of 100 mL of Omnipaque intravenous
contrast material. Coronal and sagittal reformats as well as oblique maximal
intensity projection images provided and reviewed.
DLP: 472.14 mGy-cm.
FINDINGS: There are no pulmonary arterial filling defects to suggest presence
of pulmonary embolism. Thoracic aorta is of normal caliber without
dissection.
There is a large heterogeneously enhancing mass originating in the right lower
lung and infiltrating throughout the upper and lower mediastinum. There are
areas of low density, suggestive of necrosis. The mass partially compresses
the right main pulmonary artery and its branches. The superior vena cava is
partially infiltrated and compressed. The posterior branches of the right
pulmonary vein are obliterated. The mass causes compression of the left
atrium. There is narrowing of the right main stem bronchus as well as the
lobar branches as they traverse through the mass. There are soft tissue
protuberances into the lobar branches of the right bronchus concerning for
endobronchial invasion (2:60). There is more diffuse tumor infiltration into
the right lower lobe parenchyma as well as an accompanying moderate right
pleural effusion, likely malignant given the proximity of the tumor. There is
a component of atelectasis in the right lower lobe as well.
Likely much of the mass is also comprised of malignant lymph nodes. There is
lymph node metastasis to the left axillary station with the largest measuring
2.4 x 2.0 cm (2:34). The largest lymph node in the right axilla measures 1.5
x 1.6 cm (2:16).
Limited evaluation of the upper abdomen reveals pathologically enlarged
paraesophageal lymph node at the hiatus measuring 1.8 x 1.4 cm (2:99). There
is a small hiatal hernia.
There are metastases to the right anterior fifth and sixth ribs with soft
tissue expansion and lytic destruction (2:68, 602B:13). There are no
concerning lesions in the spine.
IMPRESSION:
1. No evidence of pulmonary embolism or acute aortic syndrome.
2. Large infiltrative right hilar lung mass with extension into the
mediastinum, much progressed from the prior study.
3. The mass causes compression of the right pulmonary artery, obliteration of
the right pulmonary veins, narrowing of the right mainstem and lobar bronchial
branches, and likely endobronchial invasion at these locations.
4. Diffuse infiltration of the right lower lobe with probable malignant
effusion.
5. Extensive mediastinal and bilateral axillary lymph node metastases.
6. Lytic metastases of the right fifth and sixth anterior ribs.
Gender: M
Race: HISPANIC/LATINO - PUERTO RICAN
Arrive by AMBULANCE
Chief complaint: R/O STEMI
Diagnosed with CHEST PAIN NOS, SHORTNESS OF BREATH, SECONDARY NEUROENDOCRINE TUMOR OF OTHER SITES
temperature: nan
heartrate: nan
resprate: nan
o2sat: nan
sbp: nan
dbp: nan
level of pain: nan
level of acuity: nan | Mr. ___ is a ___ yo M with newly diagnosed neuroendocrine
tumor of the lung which is metastatic to brain and skin who
presented with chest pain and was found to have progression of
his cancer encasing the pulm artery, pulm veins, SVC, and left
atrium.
# Chest pain and SOB: These symptoms are likely from the
progression of his lung cancer which is very aggressive and
invasive to the medastinal structures including bronchi and
vasculature. Per oncology, increased symptoms may also be
secondary to inflammation from recent initiation of
chemotherapy. CTA was negative for PE and there is no clinical
evidence of pneumonia. Negative troponins and pattern on EKG
more consistent with diffuse myocarditis or pericarditis from
the tumor invasion rather than a vascular territory. Outpatient
oncologist (Drs ___ documented very clear
discussion with the patient and family that his cancer was
aggressive and life expectancy was on the order of weeks on
___. Per radiation oncology, no benefit to chest or whole
brain XRT at this time. Palliative care was consulted. Morphine
dosing increased to help with pain and dyspnea. Per discussions
with the patient and his family, code status was changed to
DNR/DNI and decision made to send him home with hospice.
# Hyponatremia: Na 128-130 during hospitalization, did not
improve with IV fluids. Urine electrolytes suggestive of SIADH
with urine Na 199, urine osmolality 645, likely secondary to his
malignancy.
# Chronic pain: from prior falls and accident. Used morphine ___
at home. The patient was transitioned to home with hospice.
# H/o depression and EtOH use: social work and pall care
involved.
# Code status: DNR/DNI, home with hospice
# HCP: daughter, ___ ___ cell, ___
Transitional issues
- blood cultures pending at time of DC, no growth to date |
Name: ___ ___ No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Codeine / Lisinopril
Attending: ___.
Chief Complaint:
Chief Complaint: dyspnea
.
Reason for MICU transfer: need for NIPPV
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms ___ is a ___ with h/o COPD/asthma, not on home O2, HTN,
who p/w COPD/asthma exacerbation. For the last 2 days, she has
had symptoms of a URI including subjective fever and a cough.
Her grandchildren have recently been sick. She was seen at ___
today and given a Z-pack and 60mg prednisone. A CXR showed mild
hyperinflation of the lungs, without consolidation. These
interventions did not improve her symptoms and she presented to
the ED.
.
PFTs per Atrius records last done ___, show FEV1 65%
predicted, FVC 83% predicted, FEV1/FVC 64% (Gold stage II COPD).
.
In the ED, initial vitals 97.7, 96, 157/91, 18, 100% on 6L O2.
Labs notable for hct 55, normal d-dimer, VBG 7.30/51/86. ___
___ showed no infiltrate, hyperinflated lungs. She was given
solumedrol 125mg IV, Duonebs x2, magnesium, and Ativan 2mg IV
x1. After Ativan she appeared tired, so NIPPV was started ___
FiO2 40%. Vitals prior to transfer: 98, 132/79, 24, 98% non
invasive.
.
On arrival to the MICU, pt on NIPPV and transitioned to NRB. Pt
reports breathing more difficult on a NRB. She reports symptoms
started 3 days ago after spending time with her sick
grandchildren 4 days ago. She reports dry cough, myalgias -
mostly back pain. She reports some pain below L breast in
transport (less so than back pain) which she thinks is from
coughing so much. She reports feeling hot and cold at home but
did not measure temp; no rigors. She reports rhinorrhea and
tickle in her throat as well. She reports she has not been
hospitalized for COPD/asthma in the past. She did NOT get her
flu shot this year.
.
Review of systems:
(+) Per HPI. Otherwise negative.
.
Past Medical History:
- COPD/asthma
- HTN
- depression
- former smoker (quit ___
Social History:
___
Family History:
+ colon cancer
Physical Exam:
ADMISSION EXAM
==============
Vitals: 97.9, ___, 29, 100% on ___
General- middle aged black woman, sitting up in moderate
respiratory distress
Neck- supple
CV- regular, tachy at 100s, no appreciable murmurs
Lungs- poor air entry diffusely with diffuse expiratory wheezes,
accessory muscle use, speaks in short sentences
Abdomen- soft, non-tender, non-distended
GU- +foley
Ext- warm, well perfused, no ___ edema
DISCHARGE EXAM
==============
VS: AVSS
Gen: NAD, comfortable
HEENT: OP clear, no lesions, MMM
CV: RRR, no murmur
Lungs: good air movement, no accessory muscle use, no crackles,
some faint expiratory wheezing diffusely
Abd: soft, NT, ND, NABS
Ext: WWP, no edema
GU: No Foley
.
Pertinent Results:
ADMISSION LABS
==============
___ 03:43AM BLOOD WBC-10.0 RBC-6.03* Hgb-17.3* Hct-54.8*
MCV-91 MCH-28.7 MCHC-31.6 RDW-13.0 Plt ___
___ 03:43AM BLOOD Neuts-80.3* Lymphs-9.3* Monos-9.4 Eos-0.4
Baso-0.6
___ 04:18AM BLOOD ___ PTT-33.2 ___
___ 03:43AM BLOOD Glucose-126* UreaN-7 Creat-0.6 Na-135
K-4.1 Cl-100 HCO3-24 AnGap-15
___ 03:43AM BLOOD ALT-21 AST-22 CK(CPK)-178 AlkPhos-67
TotBili-0.1
___ 03:43AM BLOOD CK-MB-5 cTropnT-<0.01
___ 02:59AM BLOOD Calcium-9.1 Phos-3.5 Mg-2.3
___ 03:43AM BLOOD D-Dimer-495
___ 04:51AM BLOOD ___ pO2-86 pCO2-51* pH-7.30*
calTCO2-26 Base XS--1
___ 11:30AM BLOOD Lactate-0.9
___ 04:51AM BLOOD O2 Sat-95
.
DISCHARGE LABS
===========
___ 07:20AM BLOOD WBC-12.3* RBC-5.54* Hgb-16.0 Hct-49.4*
MCV-89 MCH-28.9 MCHC-32.4 RDW-13.1 Plt ___
___ 07:20AM BLOOD Glucose-81 UreaN-10 Creat-0.5 Na-138
K-3.1* Cl-97 HCO3-32 AnGap-12
___ 07:20AM BLOOD Calcium-9.1 Phos-3.2 Mg-2.1
.
PERTINENT LABS
==========
___ Erythropoietin < 1 (Low)
___ Alpha-1-antitrypsin 153 (WNL)
.
MICROBIOLOGY
===========
___ MRSA screen - NEGATIVE
___ DFA for influenza - CANCELLED
___ Rapid respiratory viral screen - POSITIVE for INFLUENZA
A
___ Sputum culture - POOR SAMPLE
___ C. diff - NEGATIVE
.
IMAGING STUDIES
===============
___ CHEST (PA & LAT)
FINDINGS:
No focal consolidation, pleural effusion, pneumothorax, or
pulmonary edema is detected. The lungs are hyperinflated, with
worsening of diaphragmatic flattening bordering on inversion.
Heart and mediastinal contours are within normal limits.
IMPRESSION:
Increased lung hyperinflation.
.
___ PCXR
FRONTAL VIEWS OF THE CHEST: The lungs are clear but remain
hyperinflated. There is no pleural effusion, pneumothorax or
focal airspace consolidation. The heart size is normal. The
mediastinal and hilar structures are unremarkable.
.
Radiology Report
HISTORY: ___ female with acute dyspnea.
COMPARISON: ___.
TECHNIQUE: Frontal and lateral chest radiographs were obtained.
FINDINGS:
No focal consolidation, pleural effusion, pneumothorax, or pulmonary edema is
detected. The lungs are hyperinflated, with worsening of diaphragmatic
flattening bordering on inversion. Heart and mediastinal contours are within
normal limits.
IMPRESSION:
Increased lung hyperinflation.
Reported to ___ by ___ by phone at 7:36 a.m. on
___ after attending radiologist review.
Radiology Report
HISTORY: Increased sputum, evaluate for pneumonia.
COMPARISON: Chest radiographs ___ and ___.
FRONTAL VIEWS OF THE CHEST: The lungs are clear but remain hyperinflated.
There is no pleural effusion, pneumothorax or focal airspace consolidation.
The heart size is normal. The mediastinal and hilar structures are
unremarkable.
Gender: F
Race: BLACK/AFRICAN AMERICAN
Arrive by AMBULANCE
Chief complaint: Dyspnea, Asthma exacerbation
Diagnosed with RESPIRATORY ABNORM NEC
temperature: 97.7
heartrate: 96.0
resprate: 18.0
o2sat: 100.0
sbp: 157.0
dbp: 91.0
level of pain: 0
level of acuity: 3.0 | ___ yo F with history of COPD and reactive airway disease
(asthma), hypertension who presented with impending hypercarbic
respiratory failure attributed to influenza infection causing an
asthma vs. COPD exacerbation.
.
#) Influenza, COPD/asthma exacerbation: Patient presented in
moderate respiratory distress with accessory muscle use and poor
air entry on exam. She required non-invasive positive pressure
ventilation initially but weaned to supplemental oxygen over the
course of her ICU stay. The trigger for this exacerbation was
most certainly influenza A (she had no been vaccinated this
year) and she was started on oseltamavir on admission (___) for
a planned 10-day course given her severe presentation. She also
received standing nebulizer treatments, corticosteroids and
azithromycin for a component of COPD and asthma exacerbation.
Given her youth, relatively low pack-year for smoking, we
obtained an alpha-1 antitrypsin level, which was reassuring. Her
PFTs in ___ documented an obstrutive ventilatory deficit with
severe asthma. She remained dyspnea with exertion following
transfer to the floor, but overall was much improved. She was
weaned off supplemental O2 successfully. She requested a
nebulizer machine, which we were able to obtain. She will
complete a short steroid taper on discharge.
.
#) Elevated hematocrit: Hematocrit 54.8 on admission. As high as
45% back in ___. Polycythemia ___ should be considered in
women with this hematocrit, though secondary polycythemia is
also a possibility given her pulmonary disease. However, her
lack of oxygenation issues supports a primary cause. Epo level
was low. LFTs were reassuring. She should be referred to
Hematology for further work-up.
.
#) HTN: Held her home carvedilol initially given her
bronchospastic airway disease and risk of beta-blocker induced
bronchospasm. Resumed her amlodipine for BP control once she
clinically stabilized. Carvedilol is being re-started on
discharge.
. |
Name: ___. Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Penicillins / Compazine
Attending: ___
Chief Complaint:
chest tightness
Major Surgical or Invasive Procedure:
Cardiac cath ___
History of Present Illness:
___ with RCA stenosis on medical management, hypothyroidism, and
bipolar disorder presenting with chest tightness and dizziness.
Has been experiencing intermittent chest tightness of the right
side for months for which she is followed by ___ cardiology.
She developed ___ chest tightness ___ that has been
persistent. Complicated by further dizziness and
lightheadedness while shopping today, as if she "was about to
pass out". Her
symptoms improved with rest and SL nitro, but returned within
minutes. SL nitro was able to relieve repeat symptoms. Came to
___ ED for evaluation given concern. Endorses concomitant
palpitations, but no SOB, pleurisy, abdominal pain, fevers, or
chills.
In the ED initial vitals were:
98.2F, 72, 119/63, 20, 96% on RA, ___ pain
Past Medical History:
1. CARDIAC RISK FACTORS
- Hypertension
- Dyslipidemia
2. CARDIAC HISTORY
- CAD
3. OTHER PAST MEDICAL HISTORY
- Osteopenia
- Hypothyroidism
- bipolar disorder
- Positive PPD in ___ s/p 4 months of rifampin
- TAH/BSO (___)
- L. neck mass
Social History:
___
Family History:
No family history of early MI, arrhythmia, cardiomyopathies, or
sudden cardiac death.
Physical Exam:
ADMISSION PHYSICAL EXAM:
24 HR Data (last updated ___ @ ___)
Temp: 97.7 (Tm 97.7), BP: 99/60, HR: 65, RR: 18, O2 sat:
93%,
O2 delivery: RA, Wt: 132.05 lb/59.9 kg
GENERAL: Older appearing woman sitting in NAD. Pleasant and
cooperative.
HEENT: PERRL, non-erythematous oropharynx.
NECK: No JVD
CV: RRR, SEM best heard at ___
PULM: CTAB in anterior fields, mild mid-inspiratory crackles ___
at the bases with mild improvement with cough.
Abdomen: Soft, NTND
EXT: No ___ edema
NEURO: AAOx3
DISCHARGE PHYSICAL EXAM:
Afebrile, BP 90-100s/60s, HR 60-70s, O2 96 on RA
GENERAL: Pleasant and cooperative. In no acute distress.
HEENT: PERRL, non-erythematous oropharynx. Dry mucous membranes.
NECK: No JVD
CV: RRR, SEM best heard at ___
PULM: CTAB in anterior fields, mild mid-inspiratory crackles ___
at the bases with mild improvement with cough.
Abdomen: Soft, NTND
EXT: No ___ edema
Pertinent Results:
ADMISSION LABS:
___ 01:10PM BLOOD WBC-7.0 RBC-4.10 Hgb-12.3 Hct-37.8 MCV-92
MCH-30.0 MCHC-32.5 RDW-13.3 RDWSD-45.2 Plt ___
___ 01:10PM BLOOD Neuts-52.4 ___ Monos-11.2 Eos-4.9
Baso-0.4 Im ___ AbsNeut-3.66 AbsLymp-2.17 AbsMono-0.78
AbsEos-0.34 AbsBaso-0.03
___ 01:10PM BLOOD Glucose-93 UreaN-23* Creat-0.8 Na-132*
K-9.6* Cl-102 HCO3-21* AnGap-9*
___ 06:04PM BLOOD CK(CPK)-127
___ 01:10PM BLOOD cTropnT-<0.01
___ 06:04PM BLOOD CK-MB-2
___ 06:04PM BLOOD cTropnT-<0.01
___ 06:27AM BLOOD CK-MB-2 cTropnT-<0.01
DISCHARGE LABS
___:27AM BLOOD WBC-5.2 RBC-4.34 Hgb-12.9 Hct-38.7 MCV-89
MCH-29.7 MCHC-33.3 RDW-13.0 RDWSD-42.7 Plt ___
___ 06:27AM BLOOD Glucose-89 UreaN-17 Creat-0.6 Na-138
K-4.3 Cl-105 HCO3-23 AnGap-10
___ 06:27AM BLOOD Calcium-8.7 Phos-3.3 Mg-2.1
REPORTS:
___ CHEST XRAY: NO ACUTE PROCESS
___ CARDIAC CATH: The left main, left anterior descending,
circumflex and right coronary artery have no angiographically
significant coronary abnormalities. Complications: There were no
clinically significant complications.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Divalproex (EXTended Release) 500 mg PO DAILY
2. QUEtiapine Fumarate 200 mg PO QHS
3. Vitamin D 1000 UNIT PO DAILY
4. Alendronate Sodium 70 mg PO QSUN
5. Atorvastatin 40 mg PO QPM
6. Citalopram 30 mg PO DAILY
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies
8. Isosorbide Mononitrate (Extended Release) 60 mg PO DAILY
9. Levothyroxine Sodium 50 mcg PO DAILY
10. Metoprolol Succinate XL 25 mg PO DAILY
11. Naproxen 500 mg PO Q12H
12. Nitroglycerin SL 0.3 mg SL Q5MIN:PRN chest pain
13. Aspirin 81 mg PO DAILY
14. ClonazePAM 0.5 mg PO Q8H:PRN anxiety
15. amLODIPine 5 mg PO DAILY
Discharge Medications:
1. amLODIPine 2.5 mg PO DAILY
RX *amlodipine 2.5 mg 1 tablet(s) by mouth once a day Disp #*30
Tablet Refills:*0
2. Alendronate Sodium 70 mg PO QSUN
3. Atorvastatin 40 mg PO QPM
4. Citalopram 30 mg PO DAILY
5. ClonazePAM 0.5 mg PO Q8H:PRN anxiety
6. Divalproex (EXTended Release) 500 mg PO DAILY
7. Fluticasone Propionate NASAL 2 SPRY NU DAILY:PRN allergies
8. Levothyroxine Sodium 50 mcg PO DAILY
9. Metoprolol Succinate XL 25 mg PO DAILY
10. Naproxen 500 mg PO Q12H
11. QUEtiapine Fumarate 200 mg PO QHS
12. Vitamin D 1000 UNIT PO DAILY
Discharge Disposition:
Home
Discharge Diagnosis:
Primary Diagnosis:
Chest tightness, ruled out cardiac etiology
Secondary Diagnoses:
Hypothyroidism
Bipolar disease
Depression
Osteopenia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
EXAMINATION:
Chest: Frontal and lateral views
INDICATION: History: ___ with chest pain// An etiologies for CP?
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: ___
FINDINGS:
Minimal basilar atelectasis is seen. There is no focal consolidation. No
pleural effusion or pneumothorax is seen. The cardiac and mediastinal
silhouettes are unremarkable. Anterior wedging of a vertebral body at the
thoracolumbar junction is again seen, similar to prior.
IMPRESSION:
No acute cardiopulmonary process.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: Chest pain, Dizziness
Diagnosed with Unstable angina, Dizziness and giddiness, Athscl heart disease of native coronary artery w/o ang pctrs
temperature: 98.2
heartrate: 72.0
resprate: 20.0
o2sat: 96.0
sbp: 119.0
dbp: 63.0
level of pain: 5
level of acuity: 2.0 | ___ with ___ stress with inducible inferior/posterior
ischemia concerning for RCA stenosis, treated with medical
management, hypothyroidism, and bipolar disorder presenting with
chest tightness and dizziness, s/p cardiac cath ___
showing no CAD.
CORONARIES: No angiographically apparent coronary artery disease
PUMP: EF >55%
RHYTHM: NSR
=============
ACTIVE ISSUES:
=============
#Chest tightness
Presented with chest tightness that occurred at rest. Troponins
negative. ECG with normal sinus rhythm, global t wave
flattening, no ST elevations or depression. Given full dose
aspirin. Taken to cath lab and found to have no CAD. On
discharge, stopped patient's imdur, SL nitro and aspirin. Chest
tightness had resolved at time of discharge. Likely MSK in
origin.
#Lightheadedness, dizziness
Likely ___ to hypovolemia. On day of discharge, given 500cc IV
fluid bolus.
===============
CHRONIC ISSUES:
===============
#HYPERTENSION
Patient was taking imdur, metoprolol, and amlodipine at home
prior to admission. Discontinued imdur on discharge. Per chart
review, it looks like outpatient cardiologist had stopped
patient's amlodipine ___ concern for lower extremity swelling.
She indicates she continued to take it. On exam in the hospital,
she has no lower extremity swelling. Will discharge her out on
amlodipine 2.5mg daily which can be discontinued in outpatient
setting if she develops any lower extremity swelling or her
blood pressures normalize. BPs 100s/60s on discharge.
#BACK PAIN
- Treated with lidocaine patch and tylenol
#HYPOTHYROIDISM
- Continued levothyroxine
#BIPOLAR DISORDER
- Continued divalproex, quetiapine
#DEPRESSION
- Continued citalopram
#OSTEOPENIA
- Next alendronate dose due ___, Continued vitamin D |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Atenolol / Diltiazem / Lisinopril / Verapamil
Attending: ___.
Chief Complaint:
Chest Pain
Major Surgical or Invasive Procedure:
Coronary Angiography (___) - Placement of BMS x1 to LAD
History of Present Illness:
Mr. ___ is a ___ with hx CAD (single vessel coronary artery
disease, LAD w/ 40% stenosis after the diagonal, proximal D1 w/
90% stenosis; s/p Cath in ___ (first PCI with BMS to D1
complicated by acute closure requiring 2 additional BMS stents),
HTN, frequent GI bleeding who prevents following acute onset CP,
SOB, and elevated blood pressures.
Pt. has been in her usual state of health until the last few
weeks where she has been noting increasing DOE. Evening prior
to admission, pt. developed sharp left-sided non-pleuritic chest
pain. Pain radiates to her jaw and left arm. No recent fevers,
chills, cough, or abdominal pain. Also denies any
lightheadedness, dizziness, or new ___ swelling. Pt. took her
blood pressures on day of admission and noted them to be
extremely elevated to 240/110. Patient had pharmacol MIBI
stress test 2 days ago at ___ that was negative.
Of note, pt's previous ischemic pain in ___ consistent with
mid scapular back pain for months. Following chest pain and
positive stress test, pt. had cath which showed 40% LAD
stenosis, 90% D1 stenosis. She received BMS to D1 which was c/b
acute D1 closure requring emergent recatheterization and 2
additional BMS. Pt's post intervention course over the next
several years was complicated by several GI bleeding events in
the setting of ongoing anticoagulation on plavix (plavix later
discontinued). Pt. also unable to take many typical cardiac
medications given intolerances to beta blockers (bradycardia/ ?
complete heart block), statins (muscle pain), ACEi (cough),
Plavix (GIB), and some type of intolerance to ___.
In the ED, initial VS were 98.0, 250/97 (similar to pressures
she had been reading at home), 100, 18, 100% on RA. Pt. had
negative guaiac. Labs were notable for trop elevation 0.07 to
0.15. Pt. was thought to be low-probability for PE, therefore a
d-dimer was sent which returned positive. CTA was then done
which was negative for PE. Pt. was given heparin gtt and full
dose aspirin.
Pt. was taken directly from the ED to the cath lab where pt. was
noted to have 90% mid LAD lesion which was successfully corssed
with BMS stent. Pt. was started on ticagrelor. Post-cath, pt.
c/o pleuritic substernal chest pain radiating to the back. Exam
revealed reproducible chest pain consistent with musculoskeletal
injury. Pain improved with fentanyl bolus.
On review of systems, she denies any prior history of stroke,
TIA, deep venous thrombosis, pulmonary embolism, bleeding at the
time of surgery, cough, hemoptysis, black stools or red stools.
She denies recent fevers, chills or rigors. All of the other
review of systems were negative.
Cardiac review of systems is notable for absence of chest pain,
orthopnea, ankle edema, palpitations, syncope or presyncope.
Pt. does endorse dyspnea on exertion, paroxysmal nocturnal
dyspnea.
Past Medical History:
CAD (single vessel coronary artery disease, LAD w/ 40% stenosis
after the diagonal, proximal D1 w/ 90% stenosis; s/p Cath in
___ (first PCI with BMS to D1 complicated by acute closure
requiring 2 additional BMS stents; pt. previously on plavix but
d/c'ed given GI bleeds)
Hypertension
EP study ___ d/t bradycardia
GERD
H Pylori ___
Lower GI bleed r/t diverticulitis
Hx. of Polyps
Mild obstructive sleep apnea (dx/ by sleep study ___
Hypothyroid
Hx. of Pneumonia
Pernicious anemia
Osteoporosis
Chronic headaches
Depression
Hx. of intermittent blurry vision-unclear etiology
Eye surgery for growth
Social History:
___
Family History:
Father died of an MI at age ___. Mother died at age ___. Brother
suffered a stroke
Physical Exam:
ADMISSION PHYSICAL EXAMINATION:
===================================
VS: 98.1, 68, 150/77,, 18, 100% on RA
General: Lying flat, awake/alert, NAD
HEENT: NCAT, EOMI, oropharynx clear
Neck: Supple, no JVD
CV: RRR, S1/S2, no murmurs, rubs, gallops, or clicks;
tenderness to palpation on the costochondro joints left of the
sternum
Lungs: Anterior fields CTAB
Abdomen: Soft, NT, ND, +BS
Ext: WWP, ___ adiposity but no ___ edema
Neuro: ___, SILT, A/O x3
Pulses: RP and DP 2+ bilaterally
DISCHARGE PHYSICAL EXAMINATION:
===================================
PHYSICAL EXAMINATION:
VS: 98.4, 74, 140/75, 22, 100% on RA
General: NAD
HEENT: NCAT, EOMI, oropharynx clear
Neck: Supple, no JVD
CV: RRR, S1/S2, no murmurs, rubs, gallops, or clicks
Lungs: CTAB, no wheezes, rales, or rhonchi
Abdomen: Soft, NT, ND, +BS
Ext: WWP, no ___ edema
Neuro: ___, SILT, A/O x3
Pulses: RP and DP 2+ bilaterally
Pertinent Results:
ADMISSION LABS
==============
___ 03:35AM BLOOD WBC-8.6 RBC-4.86 Hgb-14.0 Hct-41.5 MCV-85
MCH-28.8 MCHC-33.7 RDW-12.9 Plt ___
___ 03:35AM BLOOD Neuts-58.0 ___ Monos-5.6 Eos-2.3
Baso-0.5
___ 03:35AM BLOOD Glucose-122* UreaN-18 Creat-0.8 Na-138
K-6.4* Cl-101 HCO3-24 AnGap-19
NOTABLE LABS
===============
___ 03:35AM BLOOD D-Dimer-560*
___ 03:35AM BLOOD cTropnT-0.07*
___ 11:15AM BLOOD cTropnT-0.15*
___ 09:33PM BLOOD CK-MB-6 cTropnT-0.23*
___ 06:20AM BLOOD CK-MB-5 cTropnT-0.22* proBNP-1790*
DISCHARGE LABS
==============
___ 06:20AM BLOOD WBC-8.8 RBC-4.53 Hgb-12.8 Hct-39.3 MCV-87
MCH-28.2 MCHC-32.6 RDW-13.4 Plt ___
___ 06:20AM BLOOD Glucose-100 UreaN-15 Creat-0.6 Na-141
K-3.9 Cl-107 HCO3-23 AnGap-15
STUDIES
===========
CXR (___): IMPRESSION: Normal chest radiograph.
CTA CHEST (___): IMPRESSION: 1. No acute process.
Specifically, there is no pulmonary embolus or aortic pathology.
2. Minimal bibasilar bronchiectasis evident.
RIGHT FEMORAL VASCULAR ULTRASOUND (___): Prelim Normal
CATH (___): COMMENTS:
Selective coronary angiograpy of this right dominant system
revealed:
1. LMCA - mild disease
2. LAD - 99% mid LAD lesion patent prior diagona
3. Lcx - mild disease
4. RCA - no significant disease
Successful ___ stenting of the mLAD.
Angioseal closure of the RFA access site.
The patient left the lab free of angina and in stable condition.
FINAL DIAGNOSIS:
1. Single vessel ___ arteries arteries, s/p bare-metal
stenting.
2. Normal ventricular function.
3. Aspirin and Brillinta daily
4. Wean off nitroglycerin to imdur for blood pressure control
Radiology Report
INDICATION: Chest pain, evaluate for cardiopulmonary process.
COMPARISON: Comparison is made to chest radiograph performed ___.
FINDINGS: Frontal and lateral chest radiographs demonstrate unremarkable
cardiomediastinal and hilar contours. Lungs are clear. No pleural effusion
or pneumothorax is present.
IMPRESSION: Normal chest radiograph.
Radiology Report
INDICATION: Chest pain, elevated D-dimer, evaluate for pulmonary embolism.
COMPARISON: Comparison is made to CT chest performed ___.
TECHNIQUE: Intravenous contrast was administered and arterial phase imaging
was acquired. Coronal, sagittal and oblique reformats were provided.
FINDINGS:
CTA CHEST: The pulmonary vasculature is well opacified and without filling
defect to suggest embolus. The aorta contains minimal atherosclerotic
calcifications but is otherwise unremarkable. Dense atherosclerotic
calcifications are noted within the left anterior descending artery without
aneurysm. Heart size is normal and with a small physiologic pleural effusion.
CT CHEST: There is no supraclavicular, axillary, mediastinal or hilar
lymphadenopathy. Airways are patent to the subsegmental level with mild
bronchiectasis and bronchial wall thickening in the lower lung bases.
Evaluation of the pulmonary parenchyma is limited due to expiratory phase
imaging and motion. Within this limitation, no opacification concerning for
pneumonia is identified. No solid pulmonary nodules evident. No pleural
effusion or pneumothorax identified.
Limited assessment of the upper abdomen demonstrates a small hiatal hernia.
No fracture is identified. No suspicious lytic or blastic lesions present.
IMPRESSION:
1. No acute process. Specifically, there is no pulmonary embolus or aortic
pathology.
2. Minimal bibasilar bronchiectasis evident.
Radiology Report
INDICATION: Status post catheterization via right femoral artery with bruit.
Assess for pseudoaneurysm.
COMPARISON: No prior study available for comparison.
FINDINGS: No pseudoaneurysm, dissection, stenosis, femoral venous thrombosis,
superficial soft tissue hematoma or edema identified.
IMPRESSION: Normal examination.
Gender: F
Race: OTHER
Arrive by WALK IN
Chief complaint: Chest pain
Diagnosed with CHEST PAIN NOS, RESPIRATORY ABNORM NEC
temperature: 98.0
heartrate: 100.0
resprate: 18.0
o2sat: 95.0
sbp: 250.0
dbp: 97.0
level of pain: 6
level of acuity: 2.0 | BRIEF SUMMARY STATEMENT: Mr. ___ is a ___ with hx CAD
(single vessel coronary artery disease, LAD w/ 40% stenosis
after the diagonal, proximal D1 w/ 90% stenosis; s/p Cath in
___ (first PCI with BMS to D1 complicated by acute closure
requiring 2 additional BMS stents), HTN, hx. of GI bleeding who
presents following acute onset CP and SOB found to have
hypertensive urgency and NSTEMI. Pt. had coronary angiography
which revealed 90% lesion in mid LAD, s/p placement 1 BMS. Pt.
tolerated the procedure well. She had notable bruit at femoral
access site. Preliminary read of ultrasound revealed no evidence
of AV fistula, pseudo aneurysm or other complication. She was
chest pain free at time of discharge.
ACTIVE ISSUES
================
# NSTEMI: Pt. presented with acute onset CP and SOB found to be
with significantly elevated blood pressures. Cardiac enzymes
sent which revealed troponin elevation. Given pt's known
coronary artery disease, pt. was taken for coronary angiography
where she was found to have a 90% lesion in mid LAD. One BMS
was placed across this lesion. Pt. was loaded with ticagrelor
and told to continue ticagrelor for a limited 7 day course given
her previous history of GI bleed. Pt. was then told to
transition to plavix for approximately ___ weeks given placement
of BMS. She was also initiated on crestor 5mg daily.
# Hypertensive Urgency: Pt's elevated blood pressures were self
limited and improved without medication. Given her significant
history of anti-hypertensive intolerance and allergy, initiation
of BP meds were deferred at this time. This was communicated to
pt's outpatient cardiologist. Outpatient regimen will be
considered if BPs remain elevated.
CHRONIC ISSUES
================
# GERD: Pt. was started on ranitidine for GI protection in
setting of ongoing aspirin, anti-plt therapy, and her hx. of GI
bleed.
# Mild obstructive sleep apnea (dx/ by sleep study ___: Pt.
diagnosed with OSA on ___ sleep study. Pt should be seen as
outpatient for possible CPAP.
# Hypothyroid: No current therapy. Continue monitoring as an
outpatient.
# Pernicious anemia: Continue on vitamin B12 supplementation
TRANSITIONAL ISSUES
======================
# Ticagrelor and Plavix: Pt. should continue with ticagrelor
through ___. Following termination of ticagrelor, pt. should
start on plavix on ___. This should continue for at least 4
weeks. Total duration to be discussed with ___. cardiologist
Dr ___
# Pt. started on crestor 5mg daily on this admission (unable to
tolerate higher doses)
# Pt. scheduled to have TTE as an outpatient per Dr. ___
# Began ranitidine for GI protection in setting of ongoing
anti-plt therapy and previous GI bleed
# CODE: Full, confirmed
# CONTACT: Carmalina (daughter, HCP, ___ |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Percocet
Attending: ___.
Chief Complaint:
abdominal pain
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Ms. ___ is a ___ with h/o recurrent pancreatitis of
unknown etiology c/b pancreatic pseudocyst formation and rupture
who now presents with abdominal pain. The patient reports that
her pain began 2 days prior to admission while placing A/C units
in the window. She noticed ___ back pain as if someone put a
fist through her back. She thought is was muscular in etiology,
but when she got home from her daughters, she developed nausea
and mid/epigastric abdominal pain consistent with her
pancreatitis flares. SHe went to bed that night and the next
morning tried to eat some toast with some tea and her pain
became ___ and she had increased nausea without vomiting. She
took some tylenol and advil without benefit and she made herself
NPO. On the morning of admission, she tried to work from home
hoping the pain would improve, but it was persistent so she came
to the ED for further evaluation. She also reports some mild
loose BM the day of admission. Not watery or bloody, just
loose.
In addition over the last few days, she has had increased
vaginal itching and whitish discharge.
In the ED, initial vs were: 97.3 71 162/87 16 98% RA. Labs were
remarkable for lipase 362, Hgb 16, UA w/ large leuk (12 WBC) few
bacteria. Patient was given ceftriaxone 1gm for possible UTI
and morphine 5mg x3 for pain control. Also given zofran 4mg IV
x2 and metoclopramide 10mg IV x1 for nausea. CT abdomen/pelvis
was performed which showed Stranding along the second and third
portions of the duodenum may be duodenitis, however, given
elevated lipase inflammation may be secondary to pancreatitis.
Patient was given 2L NS. Vitals on Transfer: 98.2 70 128/70 16
97%
On the floor, patient pain is better controlled, but with nausea
and vomiting.
Review of sytems:
(+) Per HPI
(-) Denies fever, chills, night sweats, recent weight loss or
gain. Denies headache, sinus tenderness, rhinorrhea or
congestion. Denies cough, shortness of breath. Denies chest pain
or tightness, palpitations. Denies constipation. Denies
arthralgias or myalgias.
Past Medical History:
Exploratory laparotomy (___)
External drainage of pancreatic pseudocyst (___)
? Gallstone pancreatitis in ___ although recurrent episodes
after cholecystectomy and no evidence of stones on imaging.
Chronic pancreatitis of the tail of the pancreas evident on
imaging
Obesity
Splenic vein thrombus
Laparoscopy ccy (___)
C-section x2 (remote past)
Diabetes Mellitus
Social History:
___
Family History:
Notable for PBC and Sjogren's in mother.
Sister with multiple sclerosis
Father with CAD and DM
Physical Exam:
admission
Vitals: T: 97.7 BP: 127/78 P: 77 R: 12 O2: 94% RA, FSG: 282
General: Alert, oriented, in moderate distress ___ nasuea
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, distant heart sounds, normal S1 +
S2, no murmurs, rubs, gallops
Abdomen: soft, tender in epigastric area with no gaurding with
mid/deep palpation, non-distended, bowel sounds present,
Organomegaly difficult to assess given body habitus
Ext: Warm, well perfused, 2+ pulses, no clubbing, cyanosis or
edema, varicosities of the lower extremity
Neuro: CN II-XII intact, strenght and sensation intact on
extremities, gait deferred
.
discharge
VS: 97.4 74 106/59 18 96%RA
I/O: NPO 150 IVF | 550 UOP BMx1
General: Alert, oriented, in moderate distress ___ nasuea
HEENT: Sclera anicteric, MMM, oropharynx clear
Neck: supple, no LAD
Lungs: Clear to auscultation bilaterally, no wheezes, rales,
ronchi
CV: Regular rate and rhythm, distant heart sounds, no m/r/g
Abdomen: soft, minimally tender in epigastric area with no
gaurding with mid/deep palpation, non-distended, bowel sounds
present
Ext: Warm, well perfused
Neuro: A&Ox3
Pertinent Results:
admission
___ 03:11PM BLOOD WBC-10.6# RBC-5.38 Hgb-16.3* Hct-46.8
MCV-87 MCH-30.3 MCHC-34.7 RDW-13.5 Plt ___
___ 03:11PM BLOOD Glucose-174* UreaN-11 Creat-0.8 Na-140
K-4.1 Cl-101 HCO3-28 AnGap-15
___ 03:11PM BLOOD ALT-33 AST-26 AlkPhos-110* TotBili-1.2
___ 03:11PM BLOOD Albumin-4.8
___ 07:10AM BLOOD Calcium-8.5 Phos-3.5 Mg-2.1
.
STUDIES:
CT ABD/PELVIS ___
1. Stranding along the second and third portions of the duodenum
may be duodenitis, however, given elevated lipase inflammation
may be secondary to pancreatitis.
2. Chronic splenic vein thrombosis.
3. Splenomegaly.
.
discharge
___ 07:20AM BLOOD WBC-5.5 RBC-4.09* Hgb-12.7 Hct-36.4
MCV-89 MCH-31.0 MCHC-34.8 RDW-13.4 Plt ___
___ 07:20AM BLOOD Glucose-133* UreaN-8 Creat-0.7 Na-141
K-4.0 Cl-108 HCO3-24 AnGap-13
___ 07:20AM BLOOD Calcium-8.9 Phos-3.0 Mg-1.8
Radiology Report
INDICATION: History of pancreatitis complicated by pancreatic pseudocyst with
severe epigastric abdominal pain. Evaluate for acute pancreatic pathology.
COMPARISON: MR abdomen ___. CT abdomen and pelvis ___. MRCP ___.
TECHNIQUE: Contiguous helical MDCT images were obtained through the abdomen
and pelvis after administration of 150 mL of Omnipaque IV contrast.
Multiplanar axial, coronal, and sagittal images were generated.
TOTAL BODY DLP: 991.98 mGy-cm.
FINDINGS:
The lung bases are clear. The heart is not enlarged and there is no
pericardial effusion.
CT ABDOMEN: There is fatty infiltration of the liver without focal lesions or
intrahepatic biliary duct dilation. The gallbladder has been surgically
removed. The spleen measures 14.3 cm. The portal vein is patent; however,
there is chronic splenic vein thrombosis. The adrenal glands are
unremarkable. The kidneys excrete contrast promptly and symmetrically. There
is no hydronephrosis.
Stranding along the second and third portions of the duodenum may be related
to duodenitis, however, given elevated lipase, inflammation may be secondary
to acute pancreatitis. The pancreas is somewhat atrophic. No drainable fluid
collection is seen. The colon and appendix are within normal limits.
The intra-abdominal vasculature is unremarkable. There is no retroperitoneal
or mesenteric lymph node enlargement by CT size criteria. There is no
ascites, free air, or abdominal wall hernias.
PELVIC CT: The urinary bladder and terminal ureters are normal. There is no
pelvic wall or inguinal lymph node enlargement. There is no pelvic free
fluid.
OSSEOUS STRUCTURES: There are no focal lytic or blastic lesions suspicious
for malignancy.
IMPRESSION:
1. Stranding along the second and third portions of the duodenum may be
duodenitis, however, given elevated lipase, inflammation may be secondary to
pancreatitis.
2. Splenomegaly and chronic splenic vein thrombosis.
3. Hepatic steatosis.
Gender: F
Race: WHITE
Arrive by WALK IN
Chief complaint: EPIGASTRIC PAIN
Diagnosed with ACUTE PANCREATITIS
temperature: 97.3
heartrate: 71.0
resprate: 16.0
o2sat: 98.0
sbp: 162.0
dbp: 87.0
level of pain: 10
level of acuity: 2.0 | Ms. ___ is a ___ with h/o recurrent pancreatitis of
unknown etiology c/b pancreatic pseudocyst formation and rupture
who now presents with abdominal pain and recurrent pancreatitis.
.
# Acute on Chronic Pancreatitis: Patient with recurrent flare
of her pancreatitis over the last 2 days. Her last flare
requiring hospitalization was ___. There continues to
be no clear etiology of her symptoms. She last had her MRCP 4
months ago and given her acute symptoms, and is not due for
repeat MRCP so we did not perform. Patient maintained on pain
control, IVF, and NPO status initially with gradual advancing of
diet. Patient did well and was discharged home with plan to
follow up in primary care.
.
# Chronic Splenic Vein Thrombosis: Patient with known chronic
splenic vein thrombosis. Likely secondary to recurrent
inflammation from pancreatitis flares. Monitored patient for
signs/symptoms of bleeding from gastric varices.
.
# Diabetes: Held metformin while in house given poor PO intake
and risk for ___ and possible need for further contrast studies.
Maintained on ISS. Discharged back on home metformin.
.
# Yeast infection: Patient noted to have UA with 12 WBC but
asymptomatic. Thereafter on history/physical noted to have
signs/symptoms of vulvovaginal candidiasis. It is likely this
may have contributed to WBC in urine. Treated patient with
fluconazole IV (given NPO status).
. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
Dilaudid
Attending: ___.
Chief Complaint:
vomiting, R abd pain
Major Surgical or Invasive Procedure:
None.
History of Present Illness:
___ year old male with HIV (on ART, last CD4 1200) presenting
with acute onset vomiting and right sided abdominal pain that
woke him up from sleep on the day of admission at 12AM ___.
The patient endorses copious yellow vomiting. He has also been
experiencing diarrhea. He experiences nausea, vomiting and
abdominal pain on a nearly daily basis (4 out of 7 days of the
week). He takes Zofran for nausea and oxycodone for pain. He
also takes and herbal supplement buscapina for nausea. His
symptoms acutely worsened over the last 24 hours. He denies
fevers or sick contacts. Of note, he is s/p cholecystectomy and
appendectomy. No history of kidney stones. He denies recent
travel. He own 2 dogs, 1 cat and 1 parakeet.
Regarding his GI history the patient has known NAFLD. He has a
history of acute hepatitis (secondary acetaminophen/viral
illness), pancreatitis and chronic RUQ abd pain/n/v/d. He smokes
marijuana daily for nausea. He is s/p cholecystectomy and
appendectomy. An EGD in ___ showed mild mucosal abnormalities
in the stomach and duodenum, biospies were normal. He underwent
a liver biopsy in ___ which showed evidence of toxic
metabolic injury and stage I fibrosis. tTg negative, quant gold
negative (___) and ___ negative in the past.
In the ED intial vitals were: 96.6 68 136/79 18 95% RA
- Labs were significant for: WBC 15 (75%N), Hct 45, plt 429
- Patient was given: Zofran, IVFs, morphine
- CTU: no acute abdominal process
- RUQ: unremarkable
- Admit for abdominal pain
- Vitals prior to transfer were: 97.9 68 113/75 14 97% RA
On the floor, pt reports continued abdominal pain in the RUQ,
which has not improved. Nausea which is somewhat improved.
Review of Systems:
(+) per HPI
Past Medical History:
NAFLD
HIV on HAART
Seizures
Type II diabetes
CAD s/p MI
Migraine
Anxiety
History of acute hepatitis/pancreatitis
Colonoscopy and EGD in ___ for HIV surveillence
PAST SURGICAL HISTORY:
S/p cholecystectomy
S/p appendectomy
Social History:
___
Family History:
Father: deceased, ___
Mother: healthy
Sister: S/p hysterectomy
No children
Uncle dx with colon and lung cancer
Physical Exam:
ADMISSION PHYSICAL EXAM:
Vitals- 97 118/60 62 16 98% RA
General- middle aged male in moderate amount of pain, occasional
grunting
HEENT- b/l periorbital edema, PERRL conjunctiva normal,
anicteria sclerae
Neck- supple, no LAD
Lungs- CTA bilaterally
CV- RRR, S1/S2 normal, no MRG
Abdomen- +BS, soft, diffusely tender, no rebound or rigidity,
voluntary guarding
GU- no performed
Ext- WWP, trace lower extremity edema
Neuro- CNII-XII intact, ___ upper and lower extremity strength
DISCHARGE PHYSICAL EXAM:
Vitals- Tm 98.1, 68, 103/61, 96 on RA
General- middle aged male lying in bed in NAD but appears
fatigued
HEENT- no periorbital edema, PERRL conjunctiva normal, anicteria
sclerae
Neck- supple, no LAD
Lungs- CTA bilaterally
CV- RRR, S1/S2 normal, no MRG
Abdomen- +BS, soft, nontender, no rebound or rigidity, voluntary
guarding
GU- no performed
Ext- WWP, no lower extremity edema
Neuro- CNII-XII intact, ___ upper and lower extremity strength
Pertinent Results:
==========================
LABS ON ADMISSION
==========================
___ 04:40PM BLOOD WBC-15.0*# RBC-4.59* Hgb-14.6 Hct-45.0
MCV-98 MCH-31.8 MCHC-32.5 RDW-14.3 Plt ___
___ 04:40PM BLOOD Neuts-75.3* ___ Monos-3.5 Eos-0.2
Baso-0.6
___ 04:40PM BLOOD Glucose-126* UreaN-13 Creat-0.9 Na-139
K-4.1 Cl-104 HCO3-20* AnGap-19
___ 04:40PM BLOOD Albumin-4.3
___ 04:40PM BLOOD ALT-37 AST-39 AlkPhos-122 TotBili-0.4
___ 04:40PM BLOOD Lipase-13
___ 04:47PM BLOOD Lactate-2.9*
___ 10:23PM BLOOD Lactate-1.4
___ 04:40PM BLOOD cTropnT-<0.01
==========================
LABS ON DISCHARGE
==========================
___ 06:50AM BLOOD WBC-6.6 RBC-4.11* Hgb-13.2* Hct-41.4
MCV-101* MCH-32.2* MCHC-32.0 RDW-14.5 Plt ___
___ 06:50AM BLOOD ___ PTT-31.3 ___
___ 06:50AM BLOOD Glucose-134* UreaN-14 Creat-0.8 Na-138
K-4.0 Cl-103 HCO3-22 AnGap-17
___ 06:50AM BLOOD Calcium-8.8 Phos-4.7* Mg-2.0
___ 06:50AM BLOOD ALT-136* AST-63* AlkPhos-170* TotBili-0.6
==========================
OTHER RESULTS
==========================
___ 04:40PM BLOOD ALT-37 AST-39 AlkPhos-122 TotBili-0.4
___ 06:00AM BLOOD ALT-88* AST-140* AlkPhos-104 TotBili-0.7
___ 06:00AM BLOOD ALT-102* AST-140* AlkPhos-130 TotBili-0.4
___ 06:00AM BLOOD ALT-157* AST-211* AlkPhos-150*
TotBili-1.0
___ 06:10AM BLOOD ALT-213* AST-159* AlkPhos-159*
TotBili-0.8
___ 06:40AM BLOOD ALT-193* AST-124* AlkPhos-180*
TotBili-1.0
___ 06:50AM BLOOD ALT-136* AST-63* AlkPhos-170* TotBili-0.6
___ 06:00AM BLOOD HBsAg-NEGATIVE HBsAb-POSITIVE
HBcAb-NEGATIVE IgM HBc-NEGATIVE IgM HAV-NEGATIVE
___ 06:00AM BLOOD HCV Ab-NEGATIVE
___ 06:00AM BLOOD ASA-NEG Ethanol-NEG Acetmnp-NEG
Bnzodzp-NEG Barbitr-NEG Tricycl-NEG
___ 02:00PM URINE bnzodzp-NEG barbitr-NEG opiates-POS
cocaine-NEG amphetm-NEG mthdone-NEG
___ MRCP -
IMPRESSION:
1. No obstructive biliary stones are noted. The patient is
status post
cholecystectomy with the common bile duct measuring up to 8 mm
which is within
normal limits post-cholecystectomy.
2. Fat replacement throughout the pancreas and more than
expected for the
patient's age. Mild fibrosis of the pancreatic parenchyma which
raises the
concern for a form of chronic pancreatitis.
3. No fat deposition within the liver. No cirrhotic changes
noted within the
liver. No splenomegaly.
CXR ___
IMPRESSION: No pneumonia.
CXR ___
FINDINGS:
Lungs are clear. Cardiac silhouette is normal in size.
Mediastinal contours unremarkable. There is no pleural effusion,
pneumothorax or pulmonary edema. There is no free air.
IMPRESSION: No evidence of acute cardiopulmonary process.
RUQ U/S ___
FINDINGS:
The liver is of normal echogenicity without any focal lesions or
intra or extrahepatic biliary dilatation. The common bile duct
measures 6 mm. The main portal vein is patent with normal
hepatopetal flow. The patient is status post cholecystectomy.
The head of the pancreas is unremarkable however the tail and
body are obscured by bowel gas. Limited views of the right
kidney are unremarkable and demonstrate no hydronephrosis. The
spleen is
normal in size measuring 12.4 cm. IMPRESSION: Unremarkable right
upper quadrant ultrasound. No evidence of biliary dilatation.
CTU ___
FINDINGS:
Lung bases demonstrate minimal dependent atelectasis and
scarring. There are stable sub 4 mm bibasilar lower lobe
nodules. Cardiac apex unremarkable. The liver is hypodense
compatible with hepatic steatosis. Patient status post
cholecystectomy. Noncontrast appearance of the spleen, pancreas,
adrenal glands, bilateral kidneys, small bowel are all within
normal limits. There is
scattered diverticulosis without any evidence of acute
diverticulitis of the large bowel. The appendix is not seen.
The bladder, rectum, prostate are all within normal limits.
There are bilateral fat containing inguinal and umbilical
hernias. There is no lymphadenopathy in the pelvis. No
suspicious osseous lesions are present. Old left rib fracures
noted. IMPRESSION: 1. No evidence of acute intra-abdominal
process 2. Fatty liver, diverticulosis, bilateral fat containing
inguinal hernias.
EKG ___
NSR, no acute ST/T wave changes
Medications on Admission:
The Preadmission Medication list may be inaccurate and requires
futher investigation.
1. ALPRAZolam 1.5 mg PO TID
2. benazepril 10 mg oral daily
3. BusPIRone 15 mg PO BID
4. Divalproex (EXTended Release) 500 mg PO DAILY
5. ATRIPLA (efavirenz-emtricitabin-tenofov) ___ mg oral
daily
6. Gabapentin 400 mg PO TID
7. NIFEdipine CR 30 mg PO DAILY
8. Ondansetron 4 mg PO DAILY:PRN nausea
9. OxycoDONE (Immediate Release) ___ mg PO DAILY:PRN headache
10. Aspirin 81 mg PO DAILY
Discharge Medications:
1. ALPRAZolam 1.5 mg PO TID
RX *alprazolam 0.5 mg 3 tablet(s) by mouth three times daily
Disp #*42 Tablet Refills:*0
2. Aspirin 81 mg PO DAILY
RX *aspirin 81 mg 1 tablet,delayed release (___) by mouth
daily Disp #*14 Tablet Refills:*0
3. BusPIRone 15 mg PO BID
4. Divalproex (EXTended Release) 500 mg PO DAILY
5. Gabapentin 400 mg PO TID
RX *gabapentin 400 mg 1 capsule(s) by mouth three times per day
Disp #*42 Capsule Refills:*0
6. NIFEdipine CR 30 mg PO DAILY
7. Docusate Sodium 100 mg PO BID
Do not take if stools are loose.
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice daily Disp
#*60 Capsule Refills:*0
8. ATRIPLA (efavirenz-emtricitabin-tenofov) ___ mg oral
daily
9. benazepril 10 mg ORAL DAILY
10. Omeprazole 20 mg PO DAILY
11. Ondansetron 4 mg PO DAILY:PRN nausea
RX *ondansetron 4 mg 1 tablet,disintegrating(s) by mouth every 8
hours Disp #*42 Tablet Refills:*0
12. OxycoDONE (Immediate Release) ___ mg PO DAILY:PRN headache
RX *oxycodone 5 mg 1 tablet(s) by mouth every 6 hours Disp #*28
Tablet Refills:*0
13. Polyethylene Glycol 17 g PO DAILY
Do not take if stools are loose.
RX *polyethylene glycol 3350 [Miralax] 17 gram 1 packet by mouth
daily Disp #*1 Box Refills:*0
14. Senna 8.6 mg PO BID
Do not take if stools are loose.
RX *sennosides [senna] 8.6 mg 1 tablet by mouth twice daily Disp
#*60 Tablet Refills:*0
15. Outpatient Lab Work
LFT (AST, ALT, AlkPhos, TBili)
___
FAX TO: ___. ___: ___ Fax:
___
Discharge Disposition:
Home
Discharge Diagnosis:
Diagnosis:
Nausea/Vomiting
Secondary diagnoses:
HIV on ART
NAFLD
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
HISTORY: Tenderness to palpation. Question free air.
COMPARISON: ___.
FINDINGS:
Lungs are clear. Cardiac silhouette is normal in size. Mediastinal contours
unremarkable. There is no pleural effusion, pneumothorax or pulmonary edema.
There is no free air.
IMPRESSION:
No evidence of acute cardiopulmonary process.
Radiology Report
HISTORY: History of right upper quadrant pain and tenderness. Status post
cholecystectomy.
COMPARISON: CT abdomen from ___.
FINDINGS:
The liver is of normal echogenicity without any focal lesions or intra or
extrahepatic biliary dilatation. The common bile duct measures 6 mm. The
main portal vein is patent with normal hepatopetal flow. The patient is
status post cholecystectomy. The head of the pancreas is unremarkable however
the tail and body are obscured by bowel gas. Limited views of the right
kidney are unremarkable and demonstrate no hydronephrosis. The spleen is
normal in size measuring 12.4 cm.
IMPRESSION:
Unremarkable right upper quadrant ultrasound. No evidence of biliary
dilatation.
Radiology Report
HISTORY: Right upper quadrant pain.
COMPARISON: ___.
Technique: CT of the abdomen and pelvis without IV or oral contrast.
FINDINGS:
Lung bases demonstrate minimal dependent atelectasis and scarring. There are
stable sub 4 mm bibasilar lower lobe nodules. Cardiac apex unremarkable. The
liver is hypodense compatible with hepatic steatosis. Patient status post
cholecystectomy. Noncontrast appearance of the spleen, pancreas, adrenal
glands, bilateral kidneys, small bowel are all within normal limits. There is
scattered diverticulosis without any evidence of acute diverticulitis of the
large bowel. The appendix is not seen.
The bladder, rectum, prostate are all within normal limits. There are
bilateral fat containing inguinal and umbilical hernias. There is no
lymphadenopathy in the pelvis.
No suspicious osseous lesions are present. Old left rib fracures noted.
IMPRESSION:
1. No evidence of acute intra-abdominal process
2. Fatty liver, diverticulosis, bilateral fat containing inguinal hernias.
Radiology Report
HISTORY: ___ man with cough, coarse breath sounds, leukocytosis.
Evaluate for pneumonia.
COMPARISON: Multiple prior radiographs of the chest dated ___ and
___.
FINDINGS:
Frontal and lateral radiographs of the chest demonstrate hyperexpanded and
clear lungs. The cardiomediastinal and hilar contours are unremarkable.
There is no pneumothorax, pleural effusion, or consolidation.
IMPRESSION: No pneumonia.
Radiology Report
HISTORY: History of increasing abdominal pain. Evaluate for obstruction.
COMPARISON: CT from ___.
FINDINGS: Upright and supine frontal abdominal radiographs show an
unremarkable bowel gas pattern without evidence of obstruction or bowel
dilation. Moderate amount of stool is noted in the right colon, and there is
no evidence of pneumatosis or intraperitoneal free air. Cholecystectomy
surgical clips are seen within the right upper quadrant. The bony structures
are unremarkable. Atelectasis or scarring is seen in the left lung base.
IMPRESSION: Unremarkable bowel gas pattern without evidence of obstruction.
Moderate amount of stool in the right colon.
Radiology Report
HISTORY: Non-alcoholic fatty liver disease status post cholecystectomy, now
with abnormal LFTs and right upper quadrant pain, concern for biliary
pathology.
COMPARISON: This examination is compared to prior CT abdomen and pelvis from
___ and prior CTU from ___.
TECHNIQUE: Multisequential, multiplanar MRI of the abdomen was performed pre
and post the uneventful administration of 8 mL of Gadavist intravenous
contrast. In addition, the patient was administered 1 cc of Gadavist mixed
with 50 cc of water P.O. prior to the examination.
FINDINGS:
There is no fat deposition within the liver. There is no nodularity of the
liver to suggest cirrhosis. There is no splenomegaly and no intra-abdominal
varices are noted. The spleen appears unremarkable. There is a 15 mm
accessory spleen noted. In segment VIII of the liver, there is a
subcentimetric area of hyperenhancement on arterial images without
corresponding abnormality on other sequences, most likely representing a
perfusion anomaly. There are no suspicious liver lesions.
There is fat interdigitation seen throughout the pancreas which is slightly
more than expected for the patient's age. In addition, there is lower signal
intensity diffusely throughout the pancreatic parenchyma on the arterial
phase, which may be related to pancreatic fibrosis and raises concern for a
form of chronic pancreatitis. There is no pancreatic duct dilatation.
There has been prior cholecystectomy noted. The common bile duct measures up
to 8 mm which is within normal limits in patient with prior cholecystectomy.
Areas of hypointense signal noted within the common bile duct are related to
artifact. There are no obstructive stones visualized.
There is no intrahepatic bile duct dilatation. The adrenal glands, spleen and
kidneys appear unremarkable. Incidental note is made of an accessory left
hepatic artery, which appears dominant.
There is no upper intra-abdominal lymphadenopathy. The bone marrow signal
intensity is within normal limits.
IMPRESSION:
1. No obstructive biliary stones are noted. The patient is status post
cholecystectomy with the common bile duct measuring up to 8 mm which is within
normal limits post-cholecystectomy.
2. Fat replacement throughout the pancreas and more than expected for the
patient's age. Mild fibrosis of the pancreatic parenchyma which raises the
concern for a form of chronic pancreatitis.
3. No fat deposition within the liver. No cirrhotic changes noted within the
liver. No splenomegaly.
Findings were discussed with Dr. ___ at 11:15 a.m. on ___, two hours after discovery of the findings.
Gender: M
Race: OTHER
Arrive by WALK IN
Chief complaint: RUQ abdominal pain, Vomiting
Diagnosed with ABDOMINAL PAIN RUQ, VOMITING, ASYMPTOMATIC HIV INFECTION
temperature: 96.6
heartrate: 68.0
resprate: 18.0
o2sat: 95.0
sbp: 136.0
dbp: 79.0
level of pain: 8
level of acuity: 3.0 | ___ year old gentleman with PMH of DMII, NAFLD, anxiety, CAD
s/p MI, and HIV on HAART admitted with acute onset vomiting and
right sided abdominal pain. for one day. His LFTs and lipase
were initially normal on admission, but his LFTs gradually
uptrended on subsequent days. Abdominal imaging including CT,
RUQ U/S and MRCP were unrevealing. Viral hepatitis serologies
were negative this admission. Tox screen was also negative this
admission. He has no history of sick contacts or abnormal food
intake, though he was born in ___ and travels back to see
family on occasion. His HIV is well controlled with a CD4 count
of 1100 in ___. An opportunistic infection was felt to be
less likely due to his robust CD4 count. Of note, he is
followed by GI for NAFLD, chronic abdominal pain/nausea, and a
history of pancreatitis. An EGD in ___ showed gastritis with
normal biopsies.
Symptoms resolved with supportive care including IVF,
anti-emetics, and pain control. HIs LFTs also downtrended
without intervention. Acute complaints were felt to likely be
due to viral gastroenteritis with associated liver inflammation
as no other source of hepatobiliary pathology was identified.
Chronic symptoms may be related to post-cholecystectomy
syndrome, an IBS varient, hyperemesis variant, or possibly
gastroparesis. Pt. was advised to follow-up with his outpatient
gastroenterologist for continued management of chronic symptoms.
Throughout the admission, pt. was continued on his home HAART,
divalproex, anti-anxiety, and anti-hypertensive medications. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: M
Service: MEDICINE
Allergies:
No Known Allergies / Adverse Drug Reactions
Attending: ___.
Chief Complaint:
sore throat
Major Surgical or Invasive Procedure:
None
History of Present Illness:
Mr. ___ is a ___ without significant past medical history
who is admitted with several months of fever and sore throat
found to be neutropenic and thrombocytopenic.
Patient first developed sore throat and fever in ___,
and he was treated for Strep throat with penicillin. Since that
episode, he reports several intermittent bouts of recurrent
strep throat, fevers, and malaise that would last for several
days at a time before improving. He notes two such episodes in
___, last being two weeks ago which improved with Tylenol and
Sudafed.
Yesterday morning, patient again awoke with a markedly sore
throat. He also noted rigors/sweats, headache, sore back, and
orthostasis. He stayed in bed all day, and presented to
___ this morning. There, he was found to have
pancytopenia, with WBC 0.5 (0 neutrophils), Plt 22. He was given
Toradol, PCN, decadron, and 2L of fluid. He was transferred to
___ for further evaluation.
In the ED, initial VS were t 96.7 HR 90 BP 113/65 RR 18 O2
100%RA.
Labs were notable for WBC 0.3 (20%N, 75%L), HCT 35.7, PLT 15,
Uric acid 3.1, Na 135, K 3.9, Cr .0.8, lactate 1.6, ALT 12, AST
9, ALP 51, LDH 209, TBili 0.5, Alb 3.9, Fibrinogen 670, INR 1.2.
CT neck with contrast showed enlargement of the left palantine
tonsil without abscess. CXR showed no acute process. Bone marrow
biopsy was performed and patient was given 2g cefepime, 1mg po
Ativan, 1L NS, 1g IV vancomycin, 4mg IV morphine, and APAP prior
to transfer to ___ for further management. VS prior to transfer
were T 102.2, HR 102, BP 134/84, RR 18, O2 100%RA.
On arrival to the floor, patient reports significant anxiety.
He notes sore throat and odynophagia as above. He denies any
bleeding or significant bruising. No new rashes or joint pains.
No nausea, vomiting, or abdominal pain. He has been constipated
for a few days. No new joint pains or swelling. No travel
outside of ___, and no significant outdoor activity or
bug bites. He drinks ___ days per week, ___ beers. A few times a
month he will binge drink up to 5 beers. Reports much heavier
alcohol use several years ago. He smokes marijuana about 2x per
week, no other current illicit drugs. However, he does have a
history of daily IV heroin use, reports being clean ___ years. He
was incarcerated for almost ___ years, and was released in ___.
Sexually active with one female partner; doesn't use condoms.
About ___ female partners in the last year. Per report, he also
had a WBC at OSH of 1.7 in ___.
Past Medical History:
History of IVDU
Social History:
___
Family History:
Paternal grandfather with stroke in ___, parents alive and in
good health. denies family history of malignancy or hematologic
disorder.
Physical Exam:
ADMISSION PHYSICAL EXAM
=======================
VS: 100.8 112-120/60-68 ___ RA
GENERAL: Pleasant well appearing young male in no acute distress
HEENT: PERRL. EOMI. Enlarged L tonsil with exudates/tonsiliths.
Cervical lymphadenopathy b/l. No supraclavicular, axillary
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: Appears in no respiratory distress, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly
EXT: Warm, well perfused, no lower extremity edema
PULSES: 2+ radial pulses, 2+ ___ pulses, 2+ DP pulses
NEURO: Alert, oriented, CN II-XII intact, motor and sensory
function grossly intact
SKIN: No significant rashes
DISCHARGE PHYSICAL EXAM
=======================
VS: 98.6 (98.0-98.3) 126/76 (110-126/50-80) 83 (78-102) 20
96-99% RA
I/O: 1680/BRP
GENERAL: Pleasant well appearing young male in no acute distress
HEENT: Enlarged L tonsil (reduced in size on ___,
nonerythematous or exudative, but 1 petechaie on L soft palate
and also petechaie on L buccal mucosa (resolved on ___.
CARDIAC: Regular rate and rhythm, no murmurs, rubs, or gallops
LUNG: No increase work of breathing, clear to auscultation
bilaterally, no crackles, wheezes, or rhonchi
ABD: Normal bowel sounds, soft, nontender, nondistended, no
hepatomegaly, no splenomegaly
EXT: Warm, well perfused, no lower extremity edema
NEURO: Alert, oriented, CN II-XII intact
SKIN: No significant rashes
Pertinent Results:
ADMISSION LABS
========================
___ 01:15PM PLT SMR-RARE PLT COUNT-15*
___ 01:15PM HYPOCHROM-NORMAL ANISOCYT-1+ POIKILOCY-1+
MACROCYT-NORMAL MICROCYT-NORMAL POLYCHROM-NORMAL OVALOCYT-1+
___ 01:15PM NEUTS-20* BANDS-2 LYMPHS-75* MONOS-0 EOS-0
BASOS-0 ATYPS-3* ___ MYELOS-0 AbsNeut-0.07* AbsLymp-0.23*
AbsMono-0.00* AbsEos-0.00* AbsBaso-0.00*
___ 01:15PM WBC-0.3* RBC-4.14* HGB-12.2* HCT-35.7* MCV-86
MCH-29.5 MCHC-34.2 RDW-11.4 RDWSD-34.9*
___ 01:15PM HAPTOGLOB-300*
___ 01:15PM ALBUMIN-3.9 URIC ACID-3.1*
___ 01:15PM ALT(SGPT)-12 AST(SGOT)-9 LD(LDH)-209 ALK
PHOS-51 TOT BILI-0.5
___ 01:15PM GLUCOSE-157* UREA N-9 CREAT-0.8 SODIUM-135
POTASSIUM-3.9 CHLORIDE-104 TOTAL CO2-20* ANION GAP-15
___ 01:30PM LACTATE-1.6
___ 04:02PM URINE RBC-1 WBC-3 BACTERIA-FEW YEAST-NONE
EPI-0 RENAL EPI-<1
___ 04:02PM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-1000 KETONE-NEG BILIRUBIN-NEG UROBILNGN->12 PH-7.0
LEUK-NEG
___ 04:02PM URINE bnzodzpn-NEG barbitrt-NEG opiates-NEG
cocaine-NEG amphetmn-NEG oxycodn-NEG mthdone-NEG
___ 09:22PM ___
___ 04:29PM ___ PTT-24.1* ___
___ 09:22PM HBsAg-Negative HBs Ab-Negative HBc
Ab-Negative
___ 09:22PM HIV Ab-Negative; HIV, CMV, EBV, parvovirus
B19 VLs all negative
MICROBIOLOGY
========================
Blood cx x2 (___): No growth (final)
Urine cx (___): No growth (final)
Urine cx (___): No growth (final)
IMAGING
========================
CHEST (PA & LAT) (___):
IMPRESSION:
No acute cardiopulmonary process.
CT NECK W/CONTRAST (___):
IMPRESSION:
1. Asymmetric enlargement of the left palatine tonsil without
peritonsillar abscess.
2. Bilateral cervical adenopathy.
CT Torso (___):
IMPRESSION:
1. No worrisome lymphadenopathy in the abdomen or pelvis.
2. Mild splenomegaly.
3. Moderate colonic fecal loading.
4. Please see the separately submitted report of the same day CT
Chest for
findings above the diaphragm.
CARDIAC STUDIES
========================
TTE (___):
IMPRESSION:
The left atrium and right atrium are normal in cavity size. No
atrial septal defect is seen by 2D or color Doppler. The
estimated right atrial pressure is ___ mmHg. Left ventricular
wall thickness, cavity size and regional/global systolic
function are normal (LVEF >55%). The estimated cardiac index is
normal (>=2.5L/min/m2). Tissue Doppler imaging suggests a normal
left ventricular filling pressure (PCWP<12mmHg). Right
ventricular chamber size and free wall motion are normal. The
diameters of aorta at the sinus, ascending and arch levels are
normal. The aortic valve leaflets (3) appear structurally normal
with good leaflet excursion and no aortic stenosis or aortic
regurgitation. No masses or vegetations are seen on the aortic
valve. The mitral valve appears structurally normal with trivial
mitral regurgitation. There is no mitral valve prolapse. No mass
or vegetation is seen on the mitral valve. No vegetation/mass is
seen on the pulmonic valve. There is no pericardial effusion.
IMPRESSION: No echocardiographic evidence of endocarditis or
pathologic flow. Normal biventricular cavity sizes with
preserved global and regional biventricular systolic function.
PATHOLOGY
========================
Bone Marrow Biopsy (___)
PATHOLOGY:
MARKEDLY HYPOCELLULAR BONE MARROW WITH RARE ERYTHROPOIETIC
ISLANDS AND
SPARSE LYMPHOID INFILTRATE, PLASMA CELLS AND STROMAL CELLS,
CONSISTENT
WITH MARROW APLASIA. SEE NOTE.
NOTE: In the abscence of an obvious toxic exposure, such as
medications, chemicals or infections, the findings are
consistent with aplastic anemia.
CYTOGENETICS REPORT:
FISH: NO EVIDENCE of REARRANGEMENT of RUNX1 or ETV6. No evidence
of interphase bone marrow cells with rearrangement of the ETV6
gene or the RUNX1 gene. Uncultured cells for fluorescence in
situ hybridization (FISH) analysis with the ___ Molecular
ETV6(TEL)/RUNX1(AML1) dual color probe set: SpectrumOrange
directly labeled probe for the RUNX1 gene on ___
and SpectrumGreen directly labeled probe for exons 1A-4 on the
telomeric 5' end of the ETV6 gene. This probe combination
detects the ETV6/RUNX1 gene rearrangement seen in pediatric
B-lymphoblastic leukemia. It also detects other rearrangements
of ETV6 and RUNX1 as well as copy number abnormalities of these
gene regions.
FINDINGS: A total of 200 interphase nuclei were examined with
the ETV6(TEL)/RUNX1(AML1) dual color probe set and fluorescence
microscopy. 200 cells (100%) had 2 red signals and 2 green
signals. 0 cells (0%) had 3 red signals and 2 green signals. 0
cells (0%) had 2 red signals and 3 green signals. Normal cut-off
values for this probe set include: 84% for a normal 2 red and 2
green signal pattern, 1% for a 3 red and 2 green signal pattern,
and 1% for a 2 red and 3 green signal pattern. nuc
ish(ETV6,RUNX1)x2[200]
FLOW CYTOMETRY REPORT
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: Kappa, Lambd,
and CD antigens
2,3,4,5,7,8,10,11c,13,14,16,19,20,24,33,34,38,45,56,64, and 117.
RESULTS:
10-color analysis with linear side scatter vs. CD45 gating is
used to evaluate lymphocytes, blasts and plasma cells.
75% of total acquired events are evaluable non-debris events.
The viability of the analyzed non-debris events, done by 7-AAD
is 92%.
CD45-bright, low side gated lymphocytes comprise 86% of total
analyzed events B cells comprise 14% of lymphoid gated events,
are polyclonal, and do not express aberrant antigens.
T cells comprise 64% of lymphoid gated events, and express
mature lineage antigens CD3, CD5, CD2; a minor subset (3%) have
dim, variable loss of CD7 (nonspecific finding). T cells have a
helper cytotoxic ratio of 0.7. There is an expanded population
of double-negative (CD4-, CD8-) cells comprising 6% of CD3(+) T
cells. CD56(+), CD3(-) natural killer cells are 22% of gated
lymphocytes. These co-express CD2 and CD7. No abnormal events
are identified in the "blast gate." Blast cells comprise <1% of
total analyzed events.
INTERPRETATION
Nonspecific T cell dominant lymphoid profile; diagnostic
immunophenotypic features of involvement by leukemia or lymphoma
are not seen in specimen.
Correlation with clinical, morphologic (see separate pathology
report ___ and other ancillary findings is recommended.
Flow cytometry immunophenotyping may not detect all abnormal
populations due to topography, sampling or artifacts of sample
preparation.
Peripheral blood (___):
FLOW CYTOMETRY REPORT- Peripheral blood
FLOW CYTOMETRY IMMUNOPHENOTYPING
The following tests (antibodies) were performed: CD antigens
14,15,24,45,59, 235a, FLAER.
RESULTS:
A high sensitivity paroxysmal nocturnal hemoglobinuria panel is
performed.
INTERPRETATION
Flow cytometric quantitation of glycosylphosphatidylinositol
(GPI) using fluorescent Aerolysin (FLAER) and CD24 or CD14 on
granulocytes and monocytes, respectively, and quantitation of
the GPI-anchored antigens CD59 on erythrocytes did not
demonstrate the presence of a PNH clone. There is no phenotypic
support for a diagnosis of paroxysmal nocturnal hemoglobinuria
(PNH). These results should be correlated with all available
clinically and laboratory data.
PERTINENT & DISCHARGE LABS
========================
___ 04:37PM BLOOD IgG-618* IgA-<5* IgM-147
___ 06:25AM BLOOD PEP-NO SPECIFI IgG-571* IgA-<5* IgM-135
IFE-NO MONOCLO
___ 12:00AM BLOOD WBC-3.8* RBC-3.04* Hgb-8.8* Hct-26.1*
MCV-86 MCH-28.9 MCHC-33.7 RDW-12.2 RDWSD-37.4 Plt Ct-20*
___ 12:00AM BLOOD Neuts-29.3* Lymphs-56.8* Monos-12.0
Eos-0.0* Baso-0.0 NRBC-1.1* Im ___ AbsNeut-1.10*
AbsLymp-2.13 AbsMono-0.45 AbsEos-0.00* AbsBaso-0.00*
___ 12:00AM BLOOD Hypochr-1+ Anisocy-1+ Poiklo-1+
Macrocy-NORMAL Microcy-1+ Polychr-OCCASIONAL Ovalocy-1+
Schisto-OCCASIONAL Tear Dr-OCCASIONAL
___ 12:00AM BLOOD Plt Smr-VERY LOW Plt Ct-20*
___ 12:00AM BLOOD Glucose-128* UreaN-35* Creat-0.8 Na-138
K-4.2 Cl-99 HCO3-30 AnGap-13
___ 12:00AM BLOOD ALT-50* AST-11 LD(LDH)-228 AlkPhos-33*
TotBili-0.3
___ 12:00AM BLOOD Albumin-3.1* Calcium-8.6 Phos-4.9* Mg-1.7
___ 08:57AM BLOOD Cyclspr-357
PENDING LABS
========================
___ 16:40: anti-IgA pending
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. This patient is not taking any preadmission medications
Discharge Medications:
1. Acetaminophen 650 mg PO Q6H:PRN Pain - Mild
2. Acyclovir 400 mg PO Q12H
RX *acyclovir 400 mg 1 tablet(s) by mouth every twelve (12)
hours Disp #*28 Tablet Refills:*0
3. Aluminum-Magnesium Hydrox.-Simethicone ___ mL PO QID:PRN
indigestion
RX *alum-mag hydroxide-simeth 200 mg-200 mg-20 mg/5 mL 1 cup by
mouth twice a day Refills:*0
4. CycloSPORINE (Neoral) MODIFIED 200 mg PO Q12H
For aplastic anemia, ICD10 D61.9.
RX *cyclosporine modified [Neoral] 100 mg 2 capsule(s) by mouth
every twelve (12) hours Disp #*56 Capsule Refills:*0
5. CycloSPORINE (Neoral) MODIFIED 50 mg PO Q12H
For aplastic anemia. ICD10 D61.9.
RX *cyclosporine modified [Neoral] 25 mg 2 capsule(s) by mouth
every twelve (12) hours Disp #*56 Capsule Refills:*0
6. Docusate Sodium 100 mg PO BID
RX *docusate sodium 100 mg 1 tablet(s) by mouth twice a day Disp
#*28 Tablet Refills:*0
7. PredniSONE 10 mg PO DAILY Duration: 7 Doses
Start: After 20 mg DAILY tapered dose
This is dose # 3 of 3 tapered doses
RX *prednisone 10 mg 1 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
8. PredniSONE 40 mg PO DAILY Duration: 5 Doses
Start: Tomorrow - ___, First Dose: First Routine
Administration Time
This is dose # 1 of 3 tapered doses
RX *prednisone 10 mg 4 tablet(s) by mouth once a day Disp #*5
Tablet Refills:*0
RX *prednisone 10 mg 4 tablet(s) by mouth once a day Disp #*20
Tablet Refills:*0
9. PredniSONE 20 mg PO DAILY Duration: 7 Doses
Start: After 40 mg DAILY tapered dose
This is dose # 2 of 3 tapered doses
RX *prednisone 10 mg 2 tablet(s) by mouth once a day Disp #*7
Tablet Refills:*0
RX *prednisone 10 mg 2 tablet(s) by mouth once a day Disp #*14
Tablet Refills:*0
10. QUEtiapine Fumarate 12.5 mg PO BID:PRN anxiety, nausea
RX *quetiapine 25 mg 0.5 (One half) tablet(s) by mouth twice a
day Disp #*28 Tablet Refills:*0
11. Senna 8.6 mg PO BID:PRN constipation
RX *sennosides [senna] 8.6 mg 1 tab by mouth twice a day Disp
#*28 Tablet Refills:*0
12. Simethicone 40-80 mg PO QID:PRN Flatulence/Bloating
RX *simethicone [Gas Relief] 80 mg 1 tab by mouth four times a
day Disp #*56 Tablet Refills:*0
Discharge Disposition:
Home
Discharge Diagnosis:
PRIMARY DIAGNOSES
=================
Aplastic Anemia
Tonsillitis
Neutropenic fever
IgA Deficiency
Transaminitis
Steroid-induced hyperglycemia
Discharge Condition:
Mental Status: Clear and coherent.
Level of Consciousness: Alert and interactive.
Activity Status: Ambulatory - Independent.
Followup Instructions:
___
Radiology Report
INDICATION: ___ with likely acute leukemia, weakness. Evaluate for mass or
pneumonia.
TECHNIQUE: Chest: Frontal and Lateral
COMPARISON: None.
FINDINGS:
The lungs are clear without focal consolidation. No pleural effusion or
pneumothorax is seen. The cardiac and mediastinal silhouettes are
unremarkable.
IMPRESSION:
No acute cardiopulmonary process.
Radiology Report
EXAMINATION: NECK CT WITH CONTRAST
INDICATION: ___ male with left-sided necrotizing tonsil.
TECHNIQUE: Contiguous axial images obtained through the neck after the
administration of intravenous contrast. Coronal and sagittal reformats were
reviewed.
DOSE: Total DLP (Body) = 432 mGy-cm.
COMPARISON: None.
FINDINGS:
The parotid glands and submandibular glands are unremarkable. There is a 3 mm
nodule in the left thyroid lobe.
There is bilateral cervical adenopathy, specifically involving level 2
bilaterally. On the left a level 2 lymph node measures 2.0 x 1.4 cm. On the
right, a level-II lymph node measure up to 1.5 x1.3 cm. Other scattered
smaller not pathologically enlarged lymph nodes are identified at additional
levels along the internal jugular chain bilaterally.
There is asymmetric enlargement of the left palatini tonsil with respect to
the right. There is no evidence of peritonsillar abscess. The aerodigestive
tract appears normal. Included paranasal sinuses and mastoids are essentially
clear besides mild mucosal thickening in the maxillary sinuses. .
Vascular structures in the neck are grossly unremarkable.
Included intracranial structures appear normal.
No focal suspicious osseous lesion identified.
IMPRESSION:
Asymmetric enlargement of the left palatine tonsil without peritonsillar
abscess.
Bilateral cervical adenopathy.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with picc // s/p r 44cm dl picc ___ ___
Contact name: ___: ___
TECHNIQUE: Chest single view
COMPARISON: ___ 14:46
FINDINGS:
New right PICC line tip near cavoatrial junction. Lungs are clear. Normal
heart size, pulmonary vascularity.
IMPRESSION:
New right PICC line
Radiology Report
INDICATION: ___ year old man with newly diagnosed aplastic anemia and IgA
deficiency. // Please evaluate for any lymphadenopathy/lymphoma. Thanks
TECHNIQUE: Single phase split bolus contrast: MDCT axial images were acquired
through the abdomen and pelvis following intravenous contrast administration
with split bolus technique.
Oral contrast was administered.
Coronal and sagittal reformations were performed and reviewed on PACS.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
2) Stationary Acquisition 16.7 s, 0.2 cm; CTDIvol = 284.8 mGy (Body) DLP =
57.0 mGy-cm.
3) Spiral Acquisition 10.7 s, 69.4 cm; CTDIvol = 18.7 mGy (Body) DLP =
1,285.1 mGy-cm.
Total DLP (Body) = 1,344 mGy-cm.
COMPARISON: None.
FINDINGS:
LOWER CHEST: Please refer to separate report of CT chest performed on the same
day for description of the thoracic findings.
ABDOMEN:
HEPATOBILIARY: The liver demonstrates homogenous attenuation throughout.
There is no evidence of focal lesions. There is no evidence of intrahepatic
or extrahepatic biliary dilatation. The gallbladder is within normal limits.
PANCREAS: The pancreas has normal attenuation throughout, without evidence of
focal lesions or pancreatic ductal dilatation. There is no peripancreatic
stranding.
SPLEEN: The spleen shows normal attenuation throughout, without evidence of
focal lesions. The spleen is mildly enlarged measuring up to 14.4 cm (05:58).
A 2 cm accessory spleen is incidentally noted (5:63).
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 with moderate colonic fecal loading. The
appendix is normal.
PELVIS: The urinary bladder and distal ureters are unremarkable. There is no
free fluid in the pelvis.
REPRODUCTIVE ORGANS: The prostate and seminal vesicles are normal.
LYMPH NODES: There is no retroperitoneal or mesenteric lymphadenopathy by CT
size criteria. There is no pelvic or inguinal lymphadenopathy.
VASCULAR: There is no abdominal aortic aneurysm. No atherosclerotic disease
is noted.
BONES: There is no evidence of worrisome osseous lesions or acute fracture.
SOFT TISSUES: An umbilical hernia containing fat is noted.
IMPRESSION:
1. No worrisome lymphadenopathy in the abdomen or pelvis.
2. Mild splenomegaly.
3. Moderate colonic fecal loading.
4. Please see the separately submitted report of the same day CT Chest for
findings above the diaphragm.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ male with newly diagnosed aplastic anemia and IgA
deficiency, evaluate for lymphadenopathy or lymphoma.
TECHNIQUE: Multidetector helical scanning of the chest was coordinated with
intravenous infusion of nonionic iodinated contrast agent and reconstructed as
contiguous 5 mm and 1.25 mm thick axial, 2.5 mm thick coronal and
parasagittal, and 8 mm MIP axial images.
DOSE: Acquisition sequence:
1) Sequenced Acquisition 0.5 s, 0.2 cm; CTDIvol = 9.3 mGy (Body) DLP = 1.9
mGy-cm.
2) Stationary Acquisition 16.7 s, 0.2 cm; CTDIvol = 284.8 mGy (Body) DLP =
57.0 mGy-cm.
3) Spiral Acquisition 10.7 s, 69.4 cm; CTDIvol = 18.7 mGy (Body) DLP =
1,285.1 mGy-cm.
Total DLP (Body) = 1,344 mGy-cm.
** Note: This radiation dose report was copied from CLIP ___ (CT ABD AND
PELVIS WITH CONTRAST)
COMPARISON: None
FINDINGS:
NECK, THORACIC INLET, AXILLAE: The visualized thyroid contains small
hypodense thyroid nodules, not meeting ACR criteria for further evaluation.
Supraclavicular and axillary lymph nodes are not enlarged. A left
supraclavicular lymph node measures 6 mm in short axis (5:6).
MEDIASTINUM: Mediastinal lymph nodes are not enlarged.
HILA: Hilar lymph nodes are not enlarged. A right hilar lymph node measures
up to 9 mm in short axis (6:117).
HEART: The heart is not enlarged and there is no coronary arterial
calcification. There is no pericardial effusion.
VESSELS: Vascular configuration is conventional. Aortic caliber is normal.
The main, right, and left pulmonary arteries are normal caliber. A right PICC
terminates in the right atrium.
PULMONARY PARENCHYMA: There is no evidence of infection or malignancy. There
is no emphysema.
AIRWAYS: The airways are patent to the subsegmental level bilaterally.
PLEURA: There is no pleural effusion.
CHEST WALL AND BONES: There is no worrisome lytic or sclerotic lesion.
Multilevel degenerative changes are absent.
UPPER ABDOMEN: Please see separately submitted Abdomen and Pelvis CT report
for subdiaphragmatic findings.
IMPRESSION:
1. No lymphadenopathy by CT criteria. A single borderline right hilar lymph
node measures 9 mm in short axis, attention on follow-up imaging is
recommended.
2. Please see separately submitted Abdomen and Pelvis CT report for
subdiaphragmatic findings.
Radiology Report
EXAMINATION: DX CHEST PORTABLE PICC LINE PLACEMENT
INDICATION: ___ year old man with recent PICC line placement with intermittent
arrhythmia and episode of pleuritic chest discomfort // Please evaluate PICC
line placement and any acute processes
TECHNIQUE: Chest single view
COMPARISON: ___ 16:42
FINDINGS:
Right PICC line tip low SVC. Lungs are clear. Normal heart size, pulmonary
vascularity.
IMPRESSION:
Right PICC line tip low SVC.
Radiology Report
INDICATION: ___ year old man with newly diagnosed aplastic anemia w/ PICC
line. // Please re-evaluate placement of PICC line
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of the right PICC line projects over the mid SVC, mildly retracted
since the prior radiograph. No focal consolidation, pleural effusion or
pneumothorax identified. The size of the cardiomediastinal silhouette is
within normal limits.
IMPRESSION:
Mild interval retraction of the right PICC line, the tip now projecting over
the mid SVC.
Clear lungs.
Radiology Report
INDICATION: ___ year old man with aplastic anemia on IV abx // Assess for
PICC placement
TECHNIQUE: AP portable chest radiograph
COMPARISON: ___
FINDINGS:
The tip of the right PICC line projects over the mid SVC.
No pleural effusion or pneumothorax identified. New haziness along the contour
of the right hemidiaphragm may reflect a new small effusion or atelectasis.
IMPRESSION:
The tip of the right PICC line projects over the mid SVC.
New haziness along the contour of the right hemidiaphragm may reflect a small
effusion or atelectasis.
Gender: M
Race: WHITE
Arrive by AMBULANCE
Chief complaint: Abnormal labs
Diagnosed with Other pancytopenia
temperature: 96.7
heartrate: 90.0
resprate: 18.0
o2sat: 100.0
sbp: 113.0
dbp: 65.0
level of pain: 2
level of acuity: 3.0 | ___ with history of polysubstance abuse (reportedly clean for ___
years), presented with with pharyngitis, pancytopenia found to
have newly diagnosed severe aplastic anemia. Also noted to have
IgA deficiency. He started immunosuppressive therapy with AtG
(___) and cyclosporine (___). His tonsillitis was treated
with cefepime (___) and clinda (___) until clinical
improvement and counts recovered with ANC>500. Course
complicated by methylprednisolone induced hyperglycemia, of
which ___ was consulted for management, which resolved after
cessation of steroids. Donor search was initiated for possible
bone marrow transplant in the future if patient relapses.
#Aplastic Anemia
BMBx confirming severe aplastic anemia. Vital studies negative.
Suspect immune related. Patient was started on ATG/cyclosporine
(D1: ___ and cyclosporine (___) with goal cyclosporine
level 200-250. Patient tolerated ATG without major
complications, although did experience some transaminitis (see
below). Patient was also treated with course of
methylprednisolone (Day 5: ___ to Day 14: ___. He was started
on acyclovir for prophylaxis. Voriconazole was started for
fungal prophylaxis, but was held in the setting of transaminitis
(see below). Patient's course was complicated by
thrombocytopenia, and he required platelet transfusions, which
he will likely need to continue in the outpatient setting.
Patient was discharged on cyclosporine, prednisone 3 week taper
(to end on ___, and acyclovir, with plan to restart
fluconazole as outpatient.
#Tonsillitis/Neutropenic fever
Patient with neutropenia, sore throat, and swollen exudative
tonsils. No abscess on CT of neck. Patient was treated with
Cefepime (___), Clinda (___), s/p Vancomycin
(___). Antibiotics were discontinued with evidence of
clinical improvement and when counts recovered with ANC>500.
#IgA Deficiency
Likely congenital as pt reports having frequent sinopulmonary
infections as a child. CT torso negative for lymphadenopathy,
but has mild splenomegaly of 14.4cm. Anti-IgA pending at time of
discharge.
#Steroid induced hyperglycemia
Patient with elevated FSBG in setting of methylprednisolone.
___ was consulted for further management. Hyperglycemia was
very mild and controlled with sliding scale insulin that
eventually resolved after cessation of steroids.
#Transaminitis:
Likely in the setting of voriconazole, ATG, and atovaquone, with
ALT peaking in 200s and AST in the 200s. Voriconazole and
atovaquone were discontinued, and following conclusion of ATG
therapy, ALT/AST downtrended. ALT/AST ___ on ___ at time of
discharge on ___.
#Polysubstance abuse: Reports clean from IVDU for several years.
Denies known EtOH withdrawal but has history of heavy drinking.
Also with tobacco abuse. Tox screen negative on admission.
Patient was agreeable to a sober pain management plan. Offered
patient nicotine patch/lozenge, although pt declined.
TRANSITIONAL ISSUES
========================
- Please consider starting fluconazole ppx for patient upon
discharge in the setting of his immunosuppression with recent
ATG therapy as well as ongoing cyclosporine and prednisone
therapy. Pt had been on voriconazole, but this was held in the
setting of transient transaminitis that was likely ___ to
combination of ATG therapy, voriconazole, and atovaquone.
- Patient received pentamidine for PCP ___ (Day 1:
___, in the setting of transaminitis as discussed above. His
next dose will be due on ___.
- Patient was started on cyclosporine as inpatient as discussed
above, with goal range 200-250. On day of discharge, ___,
cyclosporine level 389, and dose was decreased from 550mg daily
to 500mg daily. Please recheck cyclosporine level at outpatient
appointment on ___.
- Patient required intermittent platelet transfusions during
hospital course, and will likely need regular transfusions as an
outpatient.
- Patient was started on three week prednisone taper following
conclusion of methylprednisolone therapy, to end on ___.
- Patient has anti-IgA antibody pending at time of discharge. |
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:
___ year old male with history of cryptogenic cirrhosis s/p liver
transplant, CKD, and recurrent self-resolving febrile illnesses,
here with fever. Patient and family report that he has been
having fevers ~q6 weeks without clear source. Fever began again
yesterday, tmax of 101.2. He complains of chills and diffuse
myalgias, similar to previous episodes of fever. No focal
symptoms. Reports he has leg pains which are chronic but make it
difficult for him to walk. ROS positive for dysuria and urinary
urgency, which started yesterday.
No other focal symptoms.
In the ED, initial vitals were 100.6 115 112/61 18 98% RA
Labs notable for: negative UA; Cr 1.8 (at baseline), LFTs wnl
CXR and RUQ u/s were unremarkable.
Past Medical History:
- Cholangitis c/b citrobacter bacteremia in ___
- Cryptogenic cirrhosis s/p transplant ___
- Hiatal hernia
- GERD
- Esophageal dismotility
- Prostate cancer s/p prostatectomy and penile prosthesis
- Depression
- Chronic kidney disease with baseline creatinine 1.3-3.0
- History of pancreatic cyst (monitored with MRCP)
- Hypertension
- Hypertriglyceridemia
Social History:
___
Family History:
No family history of liver disease, diabetes, or premature CAD.
Physical Exam:
ADMISSION PHYSICAL EXAM:
VS: 99.3 120/57 104 20 97%RA
General: NAD. Well-appearing. Very pleasant. Appears younger
than stated age.
HEENT: PERRL. EOMI. dry MMs
Neck: JVP not elevated
CV: RRR. ___ holosystolic murmur heard best at left sternal
border
Lungs: CTAB
Abdomen: NT/ND. +BS. Diffusely audible abdominal bruit.
Ext: No edema
Neuro: A&Ox3. No focal deficits. No asterixis
Skin: warm and well-perfused.
DISCHARGE PHYSICAL EXAM:
VS: 98.2 120/68 87 20 99% RA
General: Walking around the room, in NAD
HEENT: PERRL. EOMI, MMM
Neck: JVP not elevated
CV: RRR. ___ holosystolic murmur heard best at left sternal
border
Lungs: CTAB
Abdomen: Non-distended, mildly tender in the RUQ, +BS.
Ext: No edema
Neuro: A&Ox3. No focal deficits. No asterixis
Skin: warm and well-perfused.
Pertinent Results:
Admission Labs:
___ 06:59PM BLOOD WBC-11.8* RBC-3.37* Hgb-10.1* Hct-30.4*
MCV-90 MCH-30.0 MCHC-33.3 RDW-14.1 Plt ___
___ 06:59PM BLOOD Neuts-75.9* Lymphs-14.5* Monos-6.8
Eos-2.7 Baso-0.1
___ 07:22PM BLOOD ___ PTT-29.3 ___
___ 06:59PM BLOOD Glucose-130* UreaN-26* Creat-1.8* Na-137
K-4.6 Cl-100 HCO3-25 AnGap-17
___ 06:59PM BLOOD ALT-22 AST-21 AlkPhos-156* TotBili-0.3
___ 06:59PM BLOOD Lipase-26
___ 06:59PM BLOOD Albumin-4.3
___ 07:44PM BLOOD rapmycn-6.6
___ 07:14PM BLOOD Lactate-1.4
Urine:
___ 08:30PM URINE Color-Yellow Appear-Clear Sp ___
___ 08:30PM URINE Blood-NEG Nitrite-NEG Protein-30
Glucose-NEG Ketone-NEG Bilirub-NEG Urobiln-NEG pH-5.5 Leuks-NEG
___ 08:30PM URINE RBC-1 WBC-1 Bacteri-NONE Yeast-NONE Epi-0
Micro:
___ 6:59 pm BLOOD CULTURE R AC.
Blood Culture, Routine (Pending):
___ 8:30 pm URINE
**FINAL REPORT ___
URINE CULTURE (Final ___: <10,000 organisms/ml.
___ 6:55 pm Immunology (CMV)
CMV Viral Load (Pending):
___ 07:44PM BLOOD rapmycn-6.6
___ 06:20AM BLOOD rapmycn-PND
IMAGING:
CXR ___:
No acute cardiopulmonary process.
RUQ U/S: ___:
1. Patent hepatic vasculature, similar to the prior exams.
Evaluation of the right hepatic artery is somewhat limited due
to patient cooperation, though it is patent with a normal
waveform.
2. Normal echogenicity of the transplanted liver.
3. Pneumobilia again seen. No biliary duct dilation.
4. Limited evaluation of the common bile duct stents due to
overlying bowel gas. Stents not seen
CT Abd/Pelvis w/ contrast ___:
1. No evidence of posttransplant lymphoproliferative disease.
2. Transplanted liver, with pneumobilia within left lobe of the
liver. Biliary stents in appropriate position. Mild intrahepatic
biliary ductal dilatation of the left lobe of the liver. Even
though there is no query biliary ductal enhancement or
thickening, possibility of cholangitis is raised. Clinical
correlation is recommended.
3. No lymphadenopathy.
4. Please refer to the CT chest from the same day for complete
details on
thoracic findings.
CT Chest: ___:
Subtle patchy areas of ground-glass changes along the peripheral
aspects of upper and lower lobes of the lung are nonspecific,
and may simply relate to atelectasis, however differential
considerations would include prior scarring given the
parenchymal changes on prior study from ___ and
infectious/inflammatory etiologies including atypical organisms.
Continued followup is recommended.
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Fish Oil (Omega 3) 1000 mg PO BID
2. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. mycophenolate sodium 360 mg Oral BID
5. Sirolimus 1.5 mg PO DAILY
6. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
7. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
8. Ursodiol 300 mg PO BID
9. Polyethylene Glycol 17 g PO DAILY:PRN constipation
Discharge Medications:
1. Fish Oil (Omega 3) 1000 mg PO BID
2. Lansoprazole Oral Disintegrating Tab 30 mg PO DAILY
3. Multivitamins 1 TAB PO DAILY
4. mycophenolate sodium 360 mg Oral BID
5. Polyethylene Glycol 17 g PO DAILY:PRN constipation
6. Sirolimus 1.5 mg PO DAILY
7. Sulfameth/Trimethoprim SS 1 TAB PO DAILY
8. TraMADOL (Ultram) 50 mg PO Q4H:PRN pain
9. Ursodiol 300 mg PO BID
Discharge Disposition:
Home
Discharge Diagnosis:
Fever
Discharge Condition:
Mental Status: Clear and coherent.
Activity Status: Ambulatory - Independent.
Level of Consciousness: Alert and interactive.
Followup Instructions:
___
Radiology Report
EXAM: Chest frontal and lateral views.
CLINICAL INFORMATION: Fever.
___.
TECHNIQUE: Frontal and lateral views of the chest.
FINDINGS: Frontal and lateral views of the chest were obtained. There is
elevation of the right hemidiaphragm with overlying atelectasis. No definite
focal consolidation is seen. There is no pleural effusion or pneumothorax.
Cardiac and mediastinal silhouettes are unremarkable. Tubular structure is
seen projecting over the upper abdomen on the lateral view.
IMPRESSION: No acute cardiopulmonary process.
Radiology Report
INDICATION: Status post liver transplant, here with fever. Evaluate
transplant.
COMPARISONS: Liver ultrasound from ___. Liver ultrasound from
___. CT of the abdomen and pelvis from ___.
TECHNIQUE: Grayscale, Doppler and spectral ultrasound images were acquired
through the right upper quadrant.
FINDINGS: The patient is status post a liver transplant. The transplant is
normal in shape and contour. There is normal echogenicity. No focal hepatic
lesions are identified. Again, there is pneumobilia, which is not unexpected
in the presence of biliary stents. There is no biliary duct dilation. Due to
overlying bowel gas, the hepatic hilum is not well evaluated and the stents in
the common bile duct are not visualized. The gallbladder is surgically
absent.
The main hepatic artery, right hepatic artery and left hepatic artery are
patent with normal arterial waveforms. Evaluation of the right hepatic artery
and its resistive index is somewhat limited due to patient cooperation. The
resistive indices in the main and left hepatic arteries are normal, measuring
0.52 and 0.42, respectively. These are not significantly changed from the
prior exam.
The main, right and left portal veins are patent. The right, middle and left
hepatic veins are patent.
The spleen is normal measuring 8.9 cm. The pancreas is not well evaluated due
to overlying bowel gas. Limited views of the right kidney are normal without
hydronephrosis. There is no ascites on this limited right upper quadrant
ultrasound.
IMPRESSION:
1. Patent hepatic vasculature, similar to the prior exams. Evaluation of the
right hepatic artery is somewhat limited due to patient cooperation, though it
is patent with a normal waveform.
2. Normal echogenicity of the transplanted liver.
3. Pneumobilia again seen. No biliary duct dilation.
4. Limited evaluation of the common bile duct stents due to overlying bowel
gas. Stents not seen
Radiology Report
EXAMINATION: CT ABD AND PELVIS WITH CONTRAST
INDICATION: ___ year old man s/p liver transplant presenting with recurrent
fevers. Rule out post-transplant lymphoproliferative disease.
TECHNIQUE: Axial CT images of the abdomen and pelvis were obtained with
intravenous and oral contrast. Sagittal and coronal reformats were prepared.
DLP: 849.99 mGy-cm
COMPARISON: Prior abdominal ultrasound from ___, MRCP from ___ and CT abdomen pelvis from ___.
FINDINGS:
ABDOMEN:
Please refer to the CT chest from the same day for complete details on
thoracic findings.
The transplanted liver demonstrates homogeneous enhancement. There is evidence
of pneumobilia, predominate within the left lobe of the liver. Biliary stents
are identified, in appropriate position. Mild intrahepatic biliary ductal
dilatation is identified in the left lobe of the liver. Adrenal glands,
spleen, pancreas are within normal limits. Both kidneys demonstrate symmetric
enhancement and excretion of contrast. No focal renal lesions are identified.
No hydronephrosis. No retroperitoneal or mesenteric lymphadenopathy.
Visualized hepatic and portal veins are patent. Caliber of abdominal aorta is
within normal limits. Mild atheromatous calcification is identified at the
origin of celiac artery, SMA and renal arteries. No ascites. The stomach is
unremarkable. Caliber of small bowel is within normal limits. No significant
diverticulosis.
PELVIS:
Mildly distended urinary bladder is unremarkable. Patient is status post
prostatectomy. Penile prosthesis is identified. No significant pelvic free
fluid. No inguinal or pelvic lymphadenopathy.
OSSEOUS STRUCTURES:
No focal osteolytic or osteoblastic lesions are identified. Mild multilevel
degenerative changes of the thoracic and lumbar spine are evident.
IMPRESSION:
1. No evidence of posttransplant lymphoproliferative disease.
2. Transplanted liver, with pneumobilia within left lobe of the liver. Biliary
stents in appropriate position. Mild intrahepatic biliary ductal dilatation of
the left lobe of the liver. Even though there is no query biliary ductal
enhancement or thickening, possibility of cholangitis is raised. Clinical
correlation is recommended.
3. No lymphadenopathy.
4. Please refer to the CT chest from the same day for complete details on
thoracic findings.
Radiology Report
EXAMINATION: CT CHEST W/CONTRAST
INDICATION: ___ man status post liver transplant presenting with
recurrent fevers. Rule out posttransplant lymphoproliferative disease.
TECHNIQUE: Axial CT images of the chest were obtained with intravenous
contrast. Sagittal and coronal reformats were prepared.
DLP: 849.99 mGy-cm
COMPARISON: Chest radiograph from ___ and CT chest, abdomen and
pelvis from ___.
FINDINGS:
No axillary, supraclavicular, mediastinal or hilar lymphadenopathy. Small
subcentimeter mediastinal lymph nodes are identified. Cardiac size is within
normal limits. No pericardial pleural effusions are identified. Caliber of
pulmonary artery and thoracic aorta are within normal limits. No focal soft
tissue abnormality. The subdiaphragmatic cyst structures are described in
detail on the CT abdomen study from the same day.
Subtle patchy areas of ground-glass changes are identified along the
peripheral aspects of the upper and lower lobes (02:15, 18, 21, 27, 35, 41).
No evidence of consolidation. No bronchiectasis. No obstructing
tracheobronchial lesions.
OSSEOUS STRUCTURES:
No suspicious focal osseous lesions are identified. Mild degenerative changes
of the thoracic and lumbar spine are evident.
IMPRESSION:
Subtle patchy areas of ground-glass changes along the peripheral aspects of
upper and lower lobes of the lung are nonspecific, and may simply relate to
atelectasis, however differential considerations would include prior scarring
given the parenchymal changes on prior study from ___ and
infectious/inflammatory etiologies including atypical organisms. Continued
followup is recommended.
Please refer to CT abdomen/pelvis from the same day for complete details on
abdominal/pelvic findings.
Gender: M
Race: PORTUGUESE
Arrive by WALK IN
Chief complaint: Fever, TRANSPLANT
Diagnosed with FEVER, UNSPECIFIED
temperature: 100.6
heartrate: 115.0
resprate: 18.0
o2sat: 98.0
sbp: 112.0
dbp: 61.0
level of pain: 5
level of acuity: 2.0 | Mr. ___ is a ___ year old male with history of cryptogenic
cirrhosis s/p liver transplant, cholangitis, CKD, and recurrent
mild febrile illnesses, who presents with fevers.
# Fevers: Patient with fever to 101.2 at home. On the night of
admission his Tmax was 99.6. He did not have a recurrence of his
fevers for the rest of his hospital stay. Workup with RUQ US,
blood and urine cultures was unrevealing. CMV viral load pending
on discharge. CT scan did not reveal evidence of abscess or
PTLD. However, the radiographic possibility of cholangitis was
raised. Clinically, there was low suspicion for cholangitis with
normal LFTs, no leukocytosis, no fevers, and negative cultures.
He had mild diffuse abdominal pain, which patient stated was his
baseline. He is scheduled for close follow up in the liver
clinic for further monitoring.
# Liver transplant: S/p transplant in ___ for cryptogenic
cirrhosis. RUQ u/s on admission in the ED unremarkable. LFTs
were within normal limits during his hospital stay without
evidence of graft dysfunction. He was continued on home
Cellcept, sirolimus, ursodiol, and Bactrim. Sirolimus levels WNL
on admission, but pending on discharge.
# CKD: Thought to be ___ prior cyclosporine toxicity. Creatinine
at baseline during his stay.
# Holosystolic murmur: Consistent w/ mitral regurgitation. No
previous documentation of murmur and last TTE w/o significant
valvular disease. Unlikely to be related to current
presentation. Blood cultures negative. Consider outpatient TTE
to evaluate etiology of murmur.
# Abdominal bruit: Heard diffusely throughout abdomen. No
palpable/pulsatile mass. CT scan notable for normal caliber of
abdominal aorta. |
Name: ___ Unit No: ___
Admission Date: ___ Discharge Date: ___
Date of Birth: ___ Sex: F
Service: MEDICINE
Allergies:
Clozapine / Phenothiazines
Attending: ___.
Chief Complaint:
some bleeding from trach
Major Surgical or Invasive Procedure:
none
History of Present Illness:
___ w/chronic trach ___ laryngeal cancer s/p exploration and
tracheal tube change on ___ by ENT presents from nursing
facility due to frank blood coming from the trachea tube. Pt
reports sore throat and pain at the top of the lung.
In ED Respiratory therapy evaluated inner cannula and found no
concern. Clear mucus suctioned out of the tube, no blood seen.
ENT evaluation found trauma to carina from repeated deep
suctioning. Pt anxious and insistant on suctioning in the ED.
However ENT recommended to avoid deep suctioning. Pt developed a
fever up to ___ given vanc/cefepime. ativan given for anxiety.
On arrival to the floor pt reports pain is unchanged. No fevers
prior to ED visit.
ROS: +as above, otherwise reviewed and negative
Past Medical History:
1. Stage ___ Cancer s/p resection, chemotherapy and
radiation
2. Schizophrenia.
3. Crohn's disease.
4. Coronary artery disease status post MI in her mid ___.
5. Hypertension.
6. Neurogenic bladder.
7. Hyperlipidemia.
8. Back pain.
9. COPD.
Social History:
___
Family History:
One sister. Father had heart disease. Cousin with breast
cancer
Physical Exam:
Vitals: T:afeb BP:113/72 P:78 R:18 O2:96% on 50%trach mask
PAIN: 6
General: nad
Lungs: clear
CV: rrr no m/r/g
Abdomen: bowel sounds present, soft, nt/nd PEG tube site c/d/i
Ext: no e/c/c
Skin: no rash
GU: Foley present, chronic
Neuro: alert, follows commands
Pertinent Results:
___ 10:18AM WBC-8.0 RBC-4.37# HGB-11.0* HCT-36.1 MCV-83
MCH-25.2* MCHC-30.5* RDW-15.0
___ 10:18AM NEUTS-81.7* LYMPHS-12.2* MONOS-4.0 EOS-1.8
BASOS-0.2
___ 10:18AM PLT COUNT-494*
___ 10:18AM GLUCOSE-147* UREA N-20 CREAT-0.5 SODIUM-138
POTASSIUM-7.0* CHLORIDE-98 TOTAL CO2-32 ANION GAP-15
___ 12:10PM K+-4.5
___ 10:18AM URINE RBC-1 WBC-2 BACTERIA-FEW YEAST-NONE
EPI-0
___ 10:18AM URINE 3PHOSPHAT-MANY
___ 10:18AM URINE MUCOUS-RARE
___ 10:18AM URINE BLOOD-NEG NITRITE-NEG PROTEIN-TR
GLUCOSE-NEG KETONE-NEG BILIRUBIN-NEG UROBILNGN-NEG PH-8.5*
LEUK-LG
___ 10:18AM URINE COLOR-Yellow APPEAR-Hazy SP ___
CXR: Tracheostomy is seen. A rebreather mask obscures part of
the left upper lung. There is a small right-sided pleural
effusion. There is some atelectasis at the lung bases. There
is no focal consolidation or signs of overt pulmonary edema
CT Neck FINDINGS: There is a tracheostomy. There is no soft
tissue gas within the neck or definite swelling. There are
severe degenerative changes of the cervical spine with loss of
intervertebral disc height at multiple levels and some reversal
of the normal cervical lordosis. If there is high concern for
soft tissue abnormalities, would recommend a CT scan or MRI.
The lung apices are clear
Medications on Admission:
The Preadmission Medication list is accurate and complete.
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
3. Aspirin 81 mg PO DAILY
4. Atenolol 25 mg PO DAILY
5. Atorvastatin 10 mg PO HS
6. Docusate Sodium (Liquid) 100 mg PO BID
7. Glycopyrrolate 1 mg PO TID
8. Guaifenesin-CODEINE Phosphate 5 mL PO BID:PRN cough
9. LOPERamide 2 mg PO QID:PRN loose stools
10. Magnesium Citrate 300 mL PO DAILY:PRN constipation
11. OLANZapine 6.25 mg PO DAILY
12. Ondansetron 4 mg PO Q8H:PRN nausea
13. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
14. Senna 17.2 mg PO BID:PRN constipation
15. TraZODone 25 mg PO Q12H:PRN anxiety/insomnia
16. Omeprazole 20 mg PO BID
17. Guaifenesin-CODEINE Phosphate 5 mL PO BID
18. Acetylcysteine Inhaled For interventional pulmonary use
only 5 mL NEB Q6H
Discharge Medications:
1. Acetaminophen 325-650 mg PO Q6H:PRN pain
2. Albuterol 0.083% Neb Soln 1 NEB IH Q6H
3. Aspirin 81 mg PO DAILY
4. Atenolol 25 mg PO DAILY
5. Atorvastatin 10 mg PO HS
6. Docusate Sodium (Liquid) 100 mg PO BID
7. Glycopyrrolate 1 mg PO TID
8. Guaifenesin-CODEINE Phosphate 5 mL PO BID:PRN cough
9. Guaifenesin-CODEINE Phosphate 5 mL PO BID
10. LOPERamide 2 mg PO QID:PRN loose stools
11. Magnesium Citrate 300 mL PO DAILY:PRN constipation
12. OLANZapine 6.25 mg PO DAILY
13. Omeprazole 20 mg PO BID
14. Ondansetron 4 mg PO Q8H:PRN nausea
15. OxycoDONE (Immediate Release) 5 mg PO Q6H:PRN pain
16. Senna 17.2 mg PO BID:PRN constipation
17. TraZODone 25 mg PO Q12H:PRN anxiety/insomnia
Discharge Disposition:
Extended Care
Facility:
___
Discharge Diagnosis:
bleeding from trach
chronic trach and peg status
Discharge Condition:
does not speak
writes down to communicate
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
STUDY: AP chest, ___.
CLINICAL HISTORY: Patient with possible right neck soft tissue infection.
Evaluate for apical pneumothorax.
FINDINGS: Comparison is made to prior radiographs from ___.
___ is seen. A rebreather mask obscures part of the left upper lung.
There is a small right-sided pleural effusion. There is some atelectasis at
the lung bases. There is no focal consolidation or signs of overt pulmonary
edema.
Radiology Report
STUDY: Neck soft tissues, ___.
CLINICAL HISTORY: Patient with laryngeal stenosis. Evaluate for soft tissue
neck infection.
FINDINGS: There is a tracheostomy. There is no soft tissue gas within the
neck or definite swelling. There are severe degenerative changes of the
cervical spine with loss of intervertebral disc height at multiple levels and
some reversal of the normal cervical lordosis. If there is high concern for
soft tissue abnormalities, would recommend a CT scan or MRI. The lung apices
are clear.
Gender: F
Race: WHITE
Arrive by AMBULANCE
Chief complaint: TRACH EVAL
Diagnosed with PNEUMONIA,ORGANISM UNSPECIFIED, OTHER HEMOPTYSIS, TRACHEOSTOMY STATUS
temperature: 97.8
heartrate: 100.0
resprate: 25.0
o2sat: 96.0
sbp: 150.0
dbp: 103.0
level of pain: 13
level of acuity: 2.0 | ASSESSMENT AND PLAN: ___ w/chronic trach ___ laryngeal cancer
s/p exploration and tracheal tube change on ___ by ENT presents
from nursing facility with trauma from too much deep suctioning
at ___ causing mild tracheitis
Tracheitis: likely due to repetitive suctioning and recent
procedure. Resolved. ENT advised no use of antibiotics and
avoidance of frequent deep suctioning, use of cough training and
pulmonary toliet. Patient only had one episode of low grade
fever in the ED and did not receive antibiotics once she was
admitted to the floor. She remained on her usual cough meds and
humidified trach mask to keep secretions wet to be able to cough
up. She should f/u with ENT, Dr. ___ in 4 weeks.
Schizophrenia/Anxiety: cont home meds
CAD: cont home meds
neurogenic bladder: maintain foley, UA negative, culture urine
grew 10k proteus, not treated
FEN: tube feeds
I communicated discharge plans on ___ Dr. ___ ___ |